RB 151 
 
 BBK 
 
 1 
 
 ssse 
 
 ili i i 
 
 ^m 
 
 m 
 
 SSS 
 
 srshf 
 
 m 
 
 eaDs 
 
 m| 
 
 HI 
 
 &S$ 
 
 mSSm 
 
 1M1 
 
 HI 
 
 |8& 
 
 
 
 m 
 
 HH 
 
 B88 
 
 K 
 
 Sign 
 
 18111 
 
 MS 
 
 ffi 
 
 TC 
 
! 
 
 .. - 
 
 o 
 
 
 > V <9 V * Y * ° 
 
 
 
 w* . 
 
 
 
 
 & °-» A <^ 
 
 
 
 
 t. 
 
 
 
 
 
 

 
 
 /^ 
 
 
 <^ 'o , 
 
 
 
 o .0 , s * * 
 
 "V 
 
 o V ^ 
 
 \k- \~ 
 
 \^ * • ■ • ° « 
 
 ^^ 
 
 
 - v 
 
 
 
 
 
 
 ' • • ' 
 
 
 ,0- 
 
 
 
 
 
 ^, \ 
 
 
 
 
 
 
 
 ?%, 
 
 
 
 
 
 
 
 
 * 
 
 • 
 
 
 
 
 ,• 
 
 J> 
 
 
 
 
 
 
 
 
 
 
 • 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 0* 
 
 
 
 
 

 [Price 25 Cents 
 
 A COMMON HUMORAL FACTOR 
 OF DISEASE AND ITS BEAR- 
 ING ON THE PRACTICE 
 OF MEDICINE 
 
 Being a Deductive Investigation Into the Primary Cau- 
 sation, Meaning, Mechanism and Rational Treatment, 
 Preventive and Curative, of the Paroxysmal Neu- 
 roses (Migraine, Asthma, Angina Pectoris, 
 Epilepsy, Etc.), Bilious Attacks, Gout, 
 Catarrhal and Other Affections,High 
 Blood-Pressure, Circulatory, 
 Renal and Other 
 Degenerations. 
 
 BY 
 FRANCIS EVERARD HARE, M. D, 
 
 LONGMANS, GREEN & CO. 
 
 [Copyright, 1905, by F. E HareI 
 
LIBRARY of CONGRESS 
 Two Copies Received 
 
 FEB 13 1905 
 
 Couyngnt tniry 
 CLASS A XXc. Hn 
 
 / cs^rt r 
 
 COPY 9. 
 
 
>v 
 
 I* 
 
 A COMMON 
 HUMORAL FACTOR OF DISEASE 
 
 INTRODUCTION. 
 
 The argument contained in this work, proceeds, from the 
 consideration of physiological metabolic processes, to the elucida- 
 tion of processes which we are accustomed to regard as patho- 
 logical : it is, therefore, in the main deductive, not inductive. Such 
 an inquiry is of necessity severely hampered by the existing pov- 
 erty of exact chemical knowledge of normal metabolism. But there 
 is no reason for regarding it as hopeless. For, by a bolder use of 
 the imagination, than is usually considered scientific from an in- 
 ductive standpoint, it is possible to frame provisional hypotheses, 
 which may be brought thereafter to the test of clinical experience. 
 Many such hypotheses were tested in this way, and. being found 
 inconsistent with established clinical facts, were abandoned. 
 
 Although we are accustomed to speak of deduction and induc- 
 tion as distinct and separate methods of inquiry, yet in practice 
 the two are almost invariably used in combination, or rather 
 alternately. The investigations, herein pursued, are no exception 
 to this rule. Though I have for the most part tried to follow 
 deductive lines, yet induction sometimes takes precedence ; and, 
 indeed, my starting-point was a clinical observation which long 
 remained unexplained. 
 
 In the year 1889, 1 happened to prescribe for a travelling 
 acquaintance. This gentleman was a resident of tropical China: 
 he was in good general health, but for some years had been 
 increasing considerably in weight: he was about forty years of 
 age and weighed between fifteen and sixteen stone. The treat- 
 ment prescribed was directed against the increasing corpulence : 
 
it consisted in a diet scale which largely excluded fats, carbo- 
 hydrates, and saccharine alcoholic drinks, throwing the onus of 
 nutrition in the main upon proteids. I lost sight of this patient 
 until 1891, when I met him in the North of Scotland. He then 
 informed me that he had ever since practically adhered to the 
 plan of diet I had prescribed, not on account of the obesity, for 
 he had fallen in weight to between eleven and twelve stone, but 
 because he had quite ceased to suffer from periodic headaches. 
 1 then elicited for the first time that he had suffered from violent 
 headaches since early boyhood : that the attacks had recurred at 
 intervals of a month, three weeks, or a fortnight ; and that, having 
 tried many physicians and numerous drugs without relief, he had 
 ceased to seek advice on their account. His description of the 
 attacks, from which he used to suffer, left me in no doubt that 
 they were typically migrainous ; but. so imbued was T at that 
 time with the teaching that migraine was a primary — usually a 
 hereditary — disorder of the brain, that T reflected little on the 
 case. I regarded the cessation of the headaches as a coincidence, 
 or as resulting, in a sort of general way, from change of climate 
 and habits. It was not until an almost identical result occurred in 
 a second case, that I began to suspect a direct casual relation 
 between the food supply and this particular variety of 'primary 
 neurosis.' 
 
 In the second case, the patient has suffered for many years 
 from typical hemicrania. commencing with usual symptoms and 
 ending in bilious. vomiting: the attacks recurred with great regu- 
 larity every fortnight. He had abandoned hope of getting rid 
 of his 'bilous attacks:' indeed, he regarded them as salutary ; but 
 he wished to have his weight reduced. He was dieted accord- 
 ingly as in the previous case. In three or four months, he had 
 attained the desired reduction in weight : he then returned to his 
 usual diet. The attacks of migraine ceased absolutely from the 
 day on which he commenced dietetic treatment: they returned 
 within a fortnight after the cessation of treatment, and they con- 
 tinued to recur thenceforward with their old regularity. No other 
 alteration in his habits had been made: although he took but 
 little exercise at any time, his general health remained excellent. 
 as it had always been. 
 
 Such results appeared inexplicable, except on the hypothesis 
 thai migraine, in these cases at least, was a food disease. It 
 
seemed as if something, derived from the ordinary food supply., 
 remained unassimilated by the tissues and accumulated in the 
 blood, inducing, at regular intervals, a kind of salutary explosion. 
 And, since the alteration in diet, which conferred immunity from 
 the attacks, consisted of an increase of the nitrogenous, with a 
 decrease of the carbonaceous, intake, it seemed reasonable to 
 ascribe to the latter the source of the accumulation. 
 
 This idea, however, was manifestly out of harmony with 
 accepted views as to the destination of the carbonaceous portion 
 of the food in the organism. The carbonaceous portion of the 
 food consists of the fats, carbohydrates, and two-thirds of the 
 proteid : the nitrogenous portion, on the other hand, is nearly 
 all found in the remaining third of the proteid. Now it seems to 
 be always assumed that the former either undergoes rapid oxida- 
 tion by the tissues, or is rapidly assimilated by them and laid down 
 mainly in the form of fat ; and that it is something derived from 
 the latter which alone is capable of accumulating in the blood. 
 
 There remained the possibility that these commonly accepted 
 views were incorrect ; and the possibility of such a fundamental 
 error having crept in, was supported by several considerations. 
 In particular, it was admitted that the known carbonaceous con- 
 tents of normal blood (sugar, fat, glycogen, etc.) were liable to 
 wide physiological variations : there was nothing to show that 
 other carbonaceous compounds were not normally present ; and it 
 was felt that the amount of work, done upon the chemistry of the 
 plasma, was insufficient to justify a position of absolute negation 
 with regard to the possibility of carbonaceous material accumu- 
 lating in the blood to a pathological degree. 
 
 Accordingly, it was determined to reconsider the whole posi- 
 tion ab initio, and to adopt provisionally the hypothesis that car- 
 bonaceous material might, in certain circumstances, accumulate 
 in the blood to an ultra-physiological degree, such accumulation 
 constituting a primary cause of pathological action. To the blood- 
 state supposed to eventuate, the term 'hyperpyraemia' (Gr. 
 pureia=iue\) was applied. The term implies a condition in which 
 the contained fuel or carbonaceous matter, whatever its exact 
 chemical composition, is in excess of the capacity of the organism 
 for physiological disposal, whether by katabolism (combustion 
 or oxidation) or by anabolism and storage (fat- formation, etc.). 
 Conformably with this use of the term hyperpyraemia, we may 
 
speak of the physiological condition of the blood, in which the 
 contained fuel or carbonaceous matter is capable of purely physio- 
 logical disposal, as one of 'pyraemia' ; and, in accordance with 
 the view that the fuel, or carbonaceous matter in the blood, may 
 fluctuate within physiological limits, we may speak of high and 
 low degrees, or grades, of pyraemia. 
 
 Were it excusable to mention this crude, and possibly prema- 
 ture, attempt at a medical generalisation in the same breath with 
 the greatest scientific generalisation of the nineteenth century, 
 the argument for hyperpyraemia might be compared, in some 
 respects, with Darwin's argument for the theory of natural selec- 
 tion. Darwin's scientific imagination led him early in his career 
 to conceive his great theory. Provisional at first, the theory of 
 natural selection soon ceased to be so, for it was found to correlate 
 and explain an enormous number of accredited, but isolated and 
 unexplained, biological observations.' Further, the truth of the 
 theory was confirmed by the fact that the theory pointed out the 
 way to a further series of observations, altogether new. 
 
 The theory of hyperpyraemia, as already said, was suggested 
 by a few therapeutic observations. It was at first purely pro- 
 visional ; but it rapidly ceased to be so when seriously entertained ; 
 for it was found to correlate and explain a large number of 
 isolated clinical observations, otherwise inexplicable, or, at any 
 rate, unexplained. Further, it was found (1) to indicate before- 
 hand the direction in which such observations were to be sought, 
 and (2) to discover what seem to me 1 to be an altogether new 
 series of observations. An example or two will serve to make 
 this clear. 
 
 1. If migraine depends upon hyperpyraemia, and is, as we 
 shall argue, a conservative 'explosion' adapted to clear the blood 
 from the carbonaceous accumulation, it follows that conditions, 
 whether physiological or pathological, which are hostile to hyper- 
 pyraemia, will be capable of relieving or dispersing migraine 
 
 1 I have determined to refrain from claiming priority with regard to 
 any of the observations in this work. It is true many of the contained 
 observations seem to me, and, I doubt not, will seem to others, entirely 
 new; yet the prolonged use in medicine of the almost exclusively inductive 
 method has resulted in the collection of such a mass of clinical observations, 
 that a large number of these are now forgotten: this is especially true of 
 such as have hitherto led to the establishment of no principle. The more 
 one looks into the literature of the past, the more one becomes convinced 
 of this, so that it seems Over bold to claim any observation as new. 
 
paroxysms. We shall argue that physical exercise and absti- 
 nence from food tend to reduce, or disperse, hyperpyraemia ; and, 
 on searching through Edward Liveing's classic work on 'Migraine 
 and Sick-headache,' many examples of the salutary influence of 
 both conditions upon recurring migraine paroxysms are to be 
 found. Again, migraine and asthma have long been known to 
 be capable of alternation, or mutual substitution, in the same 
 individual. The obvious inference is that asthma also depends 
 upon hyperpyraemia. If so, asthma, equally with migraine, 
 should be relievable, or dispersable, by physical exercise and 
 abstinence from food; and, on searching through Hyde Salter's 
 classic work 'On Asthma,' numerous instances of the salutary 
 influence of both conditions upon this affection are to be found. 
 
 2. Hyperpyraemia, we shall argue, is of necessity incom- 
 patible with pyrexia of any severity or duration. Hence both 
 asthma and migraine should remain in abeyance during pyrexia. 
 On searching through medical literature, plenty of cases may 
 be found in which asthma ceased during pyrexia. Hitherto I 
 have failed to find the same recorded of migraine ; but any one 
 can satisfy himself that the cessation of migraine during pyrexia 
 is almost invariable. However, whether the latter is a new 
 observation or not, what I am especially anxious to point out, 
 is that, so far is I am concerned, the inverse relations of both 
 migraine and asthma to pyrexia, .were in the first place pure 
 deductions from the theory of hyperpyraemia, which deductions 
 led up later to the discovery of the facts. One more illustration. 
 If asthma depends upon hyperpyraemia, then the supervention 
 of obesity should be capable of relieving asthma. This 
 deduction prompted search for such a result — a search which 
 ended in the discovery of Berkhart's three cases (§ 323). And 
 so with the majority of observations, some apparently new, 
 many obviously old, deduction preceded and observation suc- 
 ceeded. It is this consideration, more than any other, which 
 has served to convince me of the fundamental truth of the 
 theory of hyperpyraemia. 
 
 The argument for hyperpyraemia is therefore cumulative: 
 it depends for its strength, both upon the number of well- 
 accredited clinical and experimental facts which it explains, 
 and upon the number of apparently new observations, all 
 capable of independent proof, which it has facilitated. These 
 
facts and observations, taken together, are extremely numerous ; 
 and probably not a tithe of them are included in this work. 
 
 In that it will convey some idea of the scope of the work, it 
 may be advantageous to refer here to a few of the more familiar 
 physiological and pathological problems which the theory of 
 hyperpyraemia seems capable of solving. 
 
 1. It will hardly be disputed that there is an old-standing 
 and widespread, though vague, impression, both within and 
 without the medical profession, that dyspeptic conditions are 
 in a sense conservative, in that persons, so affected, are rela- 
 tively less liable than others to become the victims of certain 
 other and graver diseases : it is, at any rate, freely admitted 
 that some constitutional diseases, such for example as gout, are 
 commonly acquired by the aid of a sound stomach (Ewart). 
 Under the theory of hyperpyraemia, these conceptions become 
 definite and explicit. 
 
 2. Physical exercise is widely recognised as an almost 
 essential factor in physiological health : its influence in pre- 
 venting, and even dispersing, a host of minor ailments, such as 
 dyspepsia, biliousness, bilious attacks, headaches, and nervous- 
 nesses, is unquestioned ; and many authors have pointed out 
 that, under its influence, formal attacks of migraine, asthma, 
 epilepsy, gout, etc., may be greatly modified, if not altogether 
 abolished. I do not think any satisfactory explanation of the 
 therapeutic influence of physical exercise has been offered ; but 
 if, as is maintained in this work, hyperpyraemia enters as a 
 factor into all the above-mentioned departures from health, 
 then a simple and complete explanation is to hand : exercise 
 operates by dispersing hyperpyraemia through greatly increasing 
 the combustion of carbon and the consequent output of carbonic 
 acid. 
 
 3. It is generally admitted that extreme leanness, unless it 
 has been attained deliberately as in training, is incompatible 
 with perfect health ; and that increasing deposit of fat goes 
 hand in hand with convalescence from disease and with 
 improving health. It has also been observed that the develop- 
 ment of obesity has. in some cases, replaced a long-standing 
 recurrent neurosis or other recurrent affection, such as gout. 
 No explanation oi am of these facts has been offered, but thee 
 are all readily explicable on the theory of hyperpyraemia. For, 
 
in the process of fat-formation, carbonaceous material is with- 
 drawn from the blood, thus relieving hyperpyraemia, upon which 
 many forms of depraved health, recurrent neurosis, gout, etc., 
 can be shown by independent evidence to depend : the process 
 of fat-formation thus becomes an actual factor in, rather than 
 a mere index of, the improvement in general health. 
 
 The temperaments of the lean and fat are in general 
 antagonistic. Lean persons tend to be physically active and 
 energetic, if not fidgety and irritable : fat persons tend to be 
 physically inactive and placid, if not lazy and indifferent. We 
 commonly assume that the temperament determines the state 
 of nutrition — that inactivity leads to corpulence, restlessness, to 
 the opposite. The theory of hyperpyraemia does not exclude 
 this sequence of cause and effect ; but it suggests that, in some 
 cases, the sequence is reversed — that many lean persons, being 
 deficient in the capacity to form fat, are constrained, in order 
 to avert hyperpyraemia, to depend upon constant exercise, a 
 necessity not experienced by persons of an obese tendency. 
 
 4. The meaning of menstruation has yet to be elucidated. 
 Under the theory of hyperpyraemia and all that it involves, 
 menstruation depends upon a tendency to continuous accumu- 
 lation of carbonaceous material in the blood. This accumula- 
 tion results from a retardation of combustion — a reduction of 
 the specific coefficient of heat production — introduced at 
 puberty by the evolution of ovarian activity : it is demanded 
 by the preponderatingly anabolic functions of the mature 
 female: it is devoted to the anabolism of the offspring; or, 
 in the absence of conception, it is discharged at regularly 
 recurring intervals during the menstrual process. 
 
 This conception of the causation and meaning of menstrua- 
 tion explains the occurrence of vicarious menstruation : the 
 antagonism, complete or incomplete, between menstruation 
 on the one hand, and on the other, pregnancy, lactation, hard 
 physical exercise, exposure to cold climates, obesity, fever, 
 diabetes, haemorrhage, and other conditions: the 'normal' 
 symptoms of menstruation : the variations in the excretion of 
 carbonic acid, urea and uric acid, which have been observed 
 at puberty, each menstrual period, and the menopause: the 
 well-known tendency for the attacks of many paroxysmal dis- 
 orders, such as migraine, asthma, epilepsy and gout, together 
 
with numerous minor ailments, to group themselves around 
 each menstrual epoch : the accentuation of all such disorders 
 which supervenes on the suppression of the flow; and the 
 special tendency for many of them to commence at the period 
 of puberty, to be increased in severity at the menopause, and to 
 disappear thereafter. 
 
 5. The salutary influence of pregnancy. It is an old obser- 
 vation that some women enjoy perfect health only during preg- 
 nancy. This is readily understood when we come to realise 
 (1) that, during pregnancy, hyperpyraemia is less probable than 
 at other times; and (2) that a very large number of common 
 ailments, as well as many more or less formal paroxysmal 
 affections, have hyperpyraemia for an essential factor. Cases 
 are recorded in which long-standing recurrent migraine, asthma, 
 epilepsy, and even mania, have remained in complete abeyance 
 during pregnancy. 
 
 6. Nearly all sufferers believe that recurrent bilious attacks 
 and paroxysmal affections, such as migraine, asthma, epilepsy, 
 and gout, are in a sense salutary, in that each attack is apt to 
 be succeeded by a period of considerably improved general 
 health and comfort. So widely recognised was the salutary 
 influence of an acute gouty paroxysm at the commencement of 
 the nineteenth century, that deliberate endeavors were not 
 infrequently made to precipitate attacks. Conformable with 
 these facts, is the observation that, in many cases the attacks 
 of these paroxysmal disorders tend to be severe in proportion 
 to their in frequency, and conversely. 
 
 All the observations, contained in the above paragraphs, 
 are explicable on the theory of hyperpyraemia, but not, I think, 
 upon any other. The affections, referred to, depend upon 
 hyperpyraemia and are themselves adapted to disperse this 
 blood-state: though pathological, they are conservative but not 
 necessarily salutary. 
 
 7. The phenomena termed 'alternation of the neuroses,' 
 'neurosal transformations or metamorphoses,' have attracted 
 much attention and speculation. Recurrent paroxysmal dis- 
 orders, such as migraine, asthma, epilepsy, gastralgia, paroxysmal 
 mania, and many other less definite nervous affections, have 
 been observed to be susceptible of mutual replacement in the 
 same individual at different periods of his life. Such alterna- 
 
 10 
 
tions have been explained on the theory of accumulation and 
 discharge of nerve energy : it has been supposed that nerve 
 energy accumulates and that the paroxysmal affections, referred 
 to, are manifestations of the discharge of this accumulated 
 nerve energy. This explanation might appear sufficient, were 
 it not for the fact that the 'alternation of neuroses' is but a 
 portion of a much longer series of alternations : almost any of 
 the above conspicuously nervous disorders may be replaced by 
 very numerous processes, such as gout and pyrexia, affections 
 in which the nervous element is inconspicuous and seemingly 
 of secondary importance. This far longer series of alterna- 
 tions is explicable only on the theory of hyperpyraemia. This 
 theory retains the ideas of accumulation and discharge, but not 
 as applied to nerve energy : instead, it applies these ideas to 
 the fuel, or carbonaceous material, which is the source of all 
 energy, nervous and other, but which is as yet unconverted 
 into energy of any kind: further, it locates the accumulation 
 in the blood and regards the recurrent paroxysmal affections in 
 question as conservative manoeuvres, adapted to relieve the blood 
 of its accumulated load. 
 
 8. The attacks of the paroxysmal affections, we are con- 
 sidering, exhibit a remarkable preference for the small hours 
 of the morning. Asthma, epilepsy, angina pectoris, gastralgia, 
 gout, and other allied affections, are all especially prone to arise 
 between midnight and about five in the morning. This is a 
 fact which has been long observed, but for which, so far as I 
 am aware, no definite tenable explanation has ever been offered. 
 
 On the theory that these affections depend upon hyper- 
 pyraemia, their special predilection for these hours is susceptible 
 of a simple explanation. For, other things equal or approxi- 
 mately so, carbonaceous accumulation will tend to vary 
 inversely with the rate of combustion and the output of carbonic 
 acid ; and it is during the small hours that the rate of com- 
 bustion and the output of carbonic acid sink to the minimum. 
 
 9. Many paroxysmal affections, whether prominently ner- 
 vous, such as migraine, or other, such as gout, have been 
 treated with more or less success by plans of diet which are 
 seemingly opposed to each other in nature and effect. 
 
 Haig strongly recommends for migraine a diet in which 
 the proteid intake is largely reduced and drawn in the main 
 
 11 
 
from milk and cheese : he lays no stress upon the necessity of 
 restricting the purely carbonaceous intake. Plans somewhat 
 similar are commonly accepted as the best for gout. On the 
 other hand, both migraine and gout may be treated by the 
 Salisbury diet, which consists almost exclusively of lean meat 
 and hot water: in this plan, the purely carbonaceous intake is 
 almost abolished, the proteid intake considerably increased. 
 
 Either plan has been attended with more or less success ; 
 and this upon a superficial view is difficult to explain. But it 
 will not, I think, be by any means impossible to show that 
 both these apparently divergent methods join in one common 
 tendency — namely, a tendency to the reduction of hyper- 
 pyraemia. 
 
 10. A condition of unrelieved, or inadequately relieved, 
 hyperpyraemia fully explains the almost interminable list of 
 symptoms variously ascribed to lithaemia, the gouty, arthritic 
 or herpetic diathesis, larvaceous, irregular, abarticular, sup- 
 pressed or concealed gout, arthritism, uricacidaemia, etc. For 
 it will be pointed out that all conditions, dietetic, hygienic, 
 therapeutic, physiological or pathological — amongst the last 
 notably acute articular gout — which are capable theoretically 
 of dispersing the hypothetic state of hyperpyraemia, have been 
 observed, in different cases, to abolish, temporarily at least, the 
 whole train of morbid manifestations referred to. 
 
 11. Finally, the theory of hyperpyraemia seems to shed a 
 new light upon the retention and excretion of uric acid, and 
 upon the pathological potentialities of this compound, limiting 
 these potentialities, for the most part, to true articular gout, 
 the morbid affections dependent on urolithiasis and calculus, 
 and certain forms of renal degeneration. 
 
 The problems and observations in the above eleven para- 
 graphs are but a few of the large number which seem to me 
 explicable on the theory of hyperpyraemia. I have selected 
 them because of their importance and because they are prob- 
 ably amongst those which are most familiar to students of 
 contemporary medicine. To attempt anything further would 
 be out of place at the present stage of this work. 
 
 But, besides offering a rational explanation of numerous 
 medical problems and observations, the theory of hyperpyraemia 
 seems to form a fundamental bond of union, hitherto missing. 
 
 12 
 
between many of the theories of individual diseases, which 
 have been best received by the medical profession, and which 
 have stood the test of time — it seems to stand behind and 
 complement, not in any way to contravene, many of the less 
 comprehensive generalisations, already accepted or favourably 
 regarded. Thus it will be found to be almost wholly consistent 
 with, and perhaps to lend additional confirmation to, the fol- 
 lowing: 
 
 The theory that the energy of muscular action is supplied 
 by the carbonaceous portions of the food ; and that function, 
 whether katabolic or anabolic, is dominated by the nitrogenous 
 supply : both Bernard's and Pavy's views as to the glycogenic 
 function of the liver in so far as these views are not mutually 
 antagonistic : Marey's law of the inverse relation between 
 blood-pressure and pulse-rate : MollendorfT's theory of the 
 mechanism of migraine : the vaso-motor theories of the 
 mechanism of asthma as set forth by Sir Andrew Clark and 
 others: Moxon's theory, and vaso-motor theories generally, of 
 the mechanism of an epileptic fit: Xorhnagel's theory of 
 functional angina pectoris : Raymond's theory of local syncope : 
 the influence of hereditary or acquired pathological habit in 
 perpetuating the recurrence of paroxysmal nervous disorders : 
 Garrod's theory of gout, and Roberts's quadriurate theory : the 
 humoral (usually termed toxic) conception of insanity, of 
 many functional nervous disorders, and of many dermatoses : 
 George Johnson's theory of the stop-cock action of the arte- 
 rioles as applied to high blood-pressure, renal cirrhosis, etc.: 
 Cohnheim's theory as to the meaning of the high blood-pressure 
 in degenerative diseases of the kidney ; and many more. 
 
 Finally, and to my mind most important of all, because 
 fundamental, the theory of hyperpyraemia constitutes a tangible 
 basis for the conception of the conservative principle of disease 
 — of the vis medicatrix nature? — which has been held by 
 practically all philosophic physicians from Hippocrates down- 
 wards: it implies, indeed, a considerable extension of this 
 conservative principle. 
 
 The theory of hyperpyraemia is consistent with, and 
 explanatory and confirmatory of, a smaller conception, subor- 
 dinate to, but constituting an integral portion of, the larger 
 conception of the conservative principle of disease : this 
 
 13 
 
subordinate conception, held by Jonathan Hutchinson, Harry 
 Campbell and others, is to the effect that physiological and 
 pathological action differ from each other in degree, rather 
 than in kind, and graduate by insensible gradations into each 
 other. It will be admitted that physiological action is fully, 
 and on all occasions, conservative in nature ; and we shall, I 
 think, come to believe, from a study of the theory of hyper* 
 pyraemia, that pathological action is, for the most part, but an 
 exaggeration or modification of physiological action, equally 
 'purposive,' though less accurately adaptive, and therefore less 
 economical, more damaging, and perhaps as a rule less 
 successful. 
 
 14 
 
CHAPTER I 
 , §§ 1—36 
 
 Metabolism — Nitrogenous metabolism: nitrogenous equilibrium: nitrog- 
 enous katabolism and excretion : nitrogenous anabolism and accretion : 
 improbability of a nitrogenous accumulation in the blood — Carbona- 
 ceous metabolism : carbonaceous katabolism and excretion : car- 
 bonaceous anabolism and accretion : probability of a carbonaceous 
 accumulation in the blood — The steam engine analogy — The problem 
 of a physiological diet : deductive investigation : inductive investigation : 
 harmonization of the results of deductive and inductive investigation — 
 Summary. 
 
 § 1. An enquiry into the possibility of an accumulation of 
 carbonaceous material in the blood, whereby there arises the 
 humoral condition we have termed hyperpyraemia, may be 
 conveniently commenced with a brief survey of what is known 
 or conjectured concerning the metabolism of the chief food- 
 stuffs, namely, proteids, carbohydrates and fats. All three 
 contain carbon in varying proportions: proteid alone contains 
 nitrogen. The carbohydrates and fats, though differing widely 
 in their mode of digestion and absorption and in their sub- 
 sequent course through the circulation, present so much 
 similarity in metabolism, that we may frequently speak of 
 r them as one, under the term carbonaceous food-stuffs. Follow- 
 ing the usual custom, the digestive changes of food-stuffs will 
 be excluded from the scope of the expression metabolism 
 (Schafer) i 1 metabolism will include only those changes which 
 occur subsequent to absorption. 
 
 § 2. Metabolism comprises two fundamentally distinct 
 processes, namely, anabolism or assimilation, and katabolism 
 or dissimilation : these, though distinct, may be concurrent in 
 the one cell. Whether, however, the fresh food-material on 
 reaching the cell is invariably in the first place built up into 
 the substance of the cell, or whether, under certain conditions, 
 the fresh food-material may be split by the agency of the cell, 
 but outside its proper substance or bioplasm — whether, in 
 short, anabolism of food-stuffs invariably precedes their katab- 
 
 1 Text-book of Physiology, Schafer, vol. i. p. 868. 
 15 
 
olism — seems at present not fully determined. It is probable 
 that, in the case of the proteid food-stuffs, such antecedent 
 anabolism may occur; but 'it 1 is not probable that the non- 
 proteid materials (fat, carbohydrate, gelatin) of the food 
 become, after assimilation, built up into bioplasm, and, 
 although they are undoubtedly taken into cell protoplasm, 
 they can hardly be regarded as forming constituent parts of ' 
 the molecules of its bioplasm. In this sense, therefore, they 
 are outside, although in contact with, the bioplasm of the 
 tissues' (Schafer). In summing up upon these questions. 
 Schafer* says : — 'The phenomenon of contact changes is . . . 
 too universal to be denied. Since this is so, the most reason- 
 able view to be taken of the matter appears to be one which 
 supposes that metabolism may occur both as a splitting up 
 and oxidation of the molecules of living tissue or bioplasm 
 and as a splitting up and oxidation both of unorganized proteid 
 and of non-proteid materials outside, but in contact with, the 
 molecules of bioplasm. Such a view ... is consistent with 
 all the known facts, and is . . . readily applicable to the 
 phenomena, both of animal and vegetable metabolism.' What 
 is, however, certain is that, in all cases, the metabolic changes, 
 whether anabolic, or katabolic, in the apported food-material, 
 whether proteid or non-proteid, occur through the active 
 agency of the cell or of its bioplasm. This fact is of essential 
 importance from the standpoint of the theory of hvperpyraemia. 
 
 NITROGENOUS METABOLISM. 
 
 § 3. It is a fundamental biological fact that all structures, 
 manifesting energy of any kind (muscles, nerves, gland cells, 
 floating cells, seminal and ovarian cells, etc.), are nitrogenous. 
 The same is true of the non-cellular digestive fluids, which 
 prepare the food for absorption into the blood. This con- 
 stancy of nitrogen implies the necessity of nitrogen wherever 
 function has to be performed (Parkes). 
 
 But the performance of function involves nitrogenous 
 waste from destruction of tissue proteid. This is clearly seen 
 
 1 Text-book of Physiology, Schafer, vol. i. p. 898 ' lb. pp. 898, B99 
 
 16 
 
during inanition. Schafer 1 says : — 'The amount of urea in the 
 urine, during a fasting period of not too long duration, is 
 probably a definite measure of the necessary destruction of 
 tissue proteid which goes on within the body. . . . Such 
 destruction occurs in spite of the fact that there is still plenty 
 of non-nitrogenous material (fat) able to be drawn upon.' 
 
 This essential continuous waste of nitrogen can only be 
 replaced by proteid food — in other words, the anabolism of 
 bioplasm is possible only from nitrogen supplied in the form 
 of proteid. Though other food-stuffs such as gelatin contain 
 nitrogen, yet they are unable to replace proteid in this respect. 
 Consequently, the satisfactory performance of function depends 
 upon the supply of proteid. Parkes 2 says : — Tf the nitrogen 
 be cut off from the body, the various functions languish. . . . 
 If it is wished to increase the manifestations of the energies of 
 the various organs, more nitrogen must be supplied' ; and it 
 must be supplied, as just stated, in the form of proteid. The 
 above generalized statement is true within certain limits, 
 whether the functions concerned consist mainly of anabolism 
 or of katabolism. 
 
 § 4. Nitrogenous equilibrium. — Since, as we have seen, 
 the continued katabolism of tissue proteid is essential to the 
 performance of function and therefore to life, it follows that 
 continued anabolism of tissue proteid is no less essential. 
 When the processes of proteid katabolism and proteid anabo- 
 lism are evenly balanced, and when, consequently, the output 
 of urea is practically equivalent to the intake of proteid, the 
 body is said to be in nitrogenous equilibrium. 
 
 The proteid intake, necessary for the maintenance of this 
 equilibrium, varies with a number of circumstances. If, dur- 
 ing total deprivation of food, an amount of proteid, exactly 
 equal to the loss of tissue proteid as estimated by the urea 
 excretion, is given, the loss of tissue proteid is restricted, but 
 not abolished. 'The whole 3 of the nitrogen of the added pro- 
 teid appears in the urine as urea, and in addition there is a 
 certain amount, although not as much as during complete 
 starvation, of tissue nitrogen still present in the urine. In 
 order to keep up nitrogenous equilibrium, Voit found that it 
 
 1 Text-book of Physiology, vol. i. pp. 888, 889. 
 
 2 Practical Hygiene, 1891, p. 242. 
 
 3 Text-book of Physiology, vol. vi. p. 891, Schafer. 
 
 17 
 
was necessary to give two and a half times as much proteid 
 as the animal had metabolized during fasting. This result 
 ... is due to the fact that the ingestion of proteid food 
 directly excites the tissues to increased metabolic activity so 
 that tissue proteid itself still becomes split up. . . . Xon-proteid 
 substances do not produce this effect. On the contrary, the 
 giving of gelatin, carbohydrates and fat has ... a sparing 
 effect upon proteid metabolism and tends to diminish the 
 amount of tissue proteid which is becoming broken down' 
 (Schafer). Nitrogenous equilibrium can be produced with 
 a far smaller amount of proteid, provided that, for the amount 
 removed, an adequate quantity of any of these food-stuffs is 
 added to the diet. 
 
 Tf 1 to a starving animal, instead of what would appear to 
 be just a sufficient amount of proteid, an excess be given, a 
 point is at length reached at which the building up process 
 exceeds the breaking down, and the tissues, and therefore the 
 body generally, gain in weight. This increase in body weight, 
 due to the laying on of tissue, proceeds to a certain point with 
 any constant amount of added proteid, until a balance between 
 the N laid on and the N lost is struck, when a condition of 
 N-equilibrium is again obtained. A further increase of pro- 
 teid food will now again produce an increase of tissue and of 
 body weight, until again a condition of N-equilibrium is estab- 
 lished. And this may apparently be carried up to the limit 
 of the power of digestion of the animal for proteid food, so 
 that ultimately fifteen times as much proteid may be metab- 
 olised as in the condition of inanition. On the other hand, 
 diminution of the amount of proteid food tends in the same 
 way to gradually establish N-equilibrium on a lower level, and 
 with a diminished body weight ; the animal losing flesh until 
 such equilibrium becomes established, and then maintaining 
 itself, provided the N ingested be constant, at a constant but 
 lower level of N-equilibrium. In short "N-equilibrium is pos- 
 sible with the most different amounts of proteid in the food" 
 (Schafer). 
 
 § 5. Nitrogenous katabolism and excretion. — The view 
 is commonly accepted that proteid consists of two parts, 
 namely (1) a nitrogenous part, which is discharged in the form 
 1 Text-book of Physiology, Schafer, vol. i. pp. S9i. 892. 
 
 18 
 
of urea; and (2) a non-nitrogenous or carbonaceous (fatty or 
 carbohydrate) part, which may be utilized as fuel by the 
 tissues, or stored therein — which may, in short, behave like the 
 carbonaceous food-stuffs 1 (Foster). Now there is reason to 
 think that the primary katabolism or splitting of proteid into 
 these two parts is quite unconnected with the process of oxida- 
 tion. For, as Schafer points out on the authority of Voit, 'in 2 
 a dog fed with proteid, the urea was found by Feder to make 
 its appearance in the urine within fourteen hours after feeding, 
 whereas the removal of the remainder of the proteid molecule 
 in the form of carbon dioxide and water did not occur for 
 twenty-four hours after, so that the splitting of the proteid 
 molecule must have occurred at one time and its complete 
 oxidation at another.' Further, were nitrogenous katabolism 
 an oxidative process in ordinary circumstances, we should 
 expect that muscular exercise would materially increase nitrog- 
 enous excretion ; and this, as we shall see, is not the case, 
 except perhaps when the carbonaceous portion of the diet is of 
 insufficient caloric value, 3 and in prolonged starvation when 
 the tissue stores of purely carbonaceous material have been 
 exhausted 4 (Schafer). 
 
 Except in the case of the loss of nitrogenous material 
 which occurs with the menstrual flow, nitrogenous katabolism 
 precedes and determines nitrogenous excretion. This applies 
 to urea which constitutes by far the greater part of the waste 
 nitrogen of the body, and which, as Voit has shown, 5 is ex- 
 creted in direct proportion to the amount of proteid ingested." 
 
 Stewart 7 says : — 'Within the limits of nitrogenous equili- 
 brium, which is the normal state of the healthy adult, the body 
 lives up to its income of nitrogen : it lays by nothing for the 
 future. In the actual pinch of starvation, the organism be- 
 comes suddenly economical. When a plentiful supply of 
 proteid is presented to the starving tissues, they pass at once 
 from extreme frugality to luxury : some flesh may be put on for 
 
 1 Text-book of Physiology, Foster, 1895, pp. 789, 801, 811. 
 
 2 Text-book of Physiology, p. 894. 
 
 3 lb. vol. vi. pp. 913, 914. 
 
 4 lb. p. 889. 
 
 6 lb., Schafer, vol. i. p. 892. 
 
 9 The excretion of uric acid will be considered at a later stage of this 
 work (Chapter XV). 
 
 7 Manual of Physiology, 1899, p. 457. 
 
 19 
 
a short time, some nitrogen may be stored up; but the tissues 
 soon pitch their wants to the new scale of supply and spend 
 their proteid income as freely as they receive it.' Hence we 
 may infer that nitrogenous katabolism, and therefore nitrog- 
 enous excretion, is largely determined by supply. This may 
 be regarded as the first great law of nitrogenous katabolism 
 and excretion. 
 
 § 6. A second law of nitrogenous katabolism and excretion 
 is that, in ordinary circumstances, they are 'nearly 1 inde- 
 pendent of muscular work, that is to say, the quantity of 
 nitrogen excreted by a man on a given diet, is practically the 
 same whether he rests or works' (Stewart). Foster says:* 
 — 'We have no evidence of any nitrogenous waste at all as the 
 result of a contraction' [of muscle] ; 'and indeed . . . the 
 study of the waste products of the body as a whole, leads 
 us to believe that the energy of the work done by the muscles 
 of the body comes from the potential energy of the carbon 
 compounds and not of the nitrogen compounds at all.' Pro- 
 fessor J. Bauer says: 3 — 'It has been proved, chiefly through 
 the researches of Voit. that the consumption or metabolism 
 of albumen in the body is not raised in the least by the most 
 laborious efforts; it is the non-nitrogenous materials only 
 whose consumption is increased by activity. This fact is in 
 no way opposed to the matter of experience, that the body 
 requires a more liberal supply of albumen during hard labour ; 
 it rather tends to counteract false conclusions from these 
 results of experience and to make the connection clear. There 
 can of course be no doubt that a labourer requires for the 
 performance of a hard task powerfully developed and well- 
 nourished muscles — that is, a large proportion of albuminous 
 tissue in the body, for the maintenance of which a correspond- 
 ing amount of albuminous food is necessary, as all experience 
 of intense bodily activity goes to show.' 
 
 § 7. We may, I think, formulate a third law to the effect 
 that, in ordinary circumstances — that is, so long as there is 
 available a sufficiency of purely carbonaceous material — nitrog- 
 enous katabolism and excretion are independent of external 
 
 1 Manual of Physiology, Stewart, L899, p. 457. 
 
 2 Text-book of Physiology, 1895, p. 103. 
 
 3 Ziemssen's I land-booh of General Therapeuties, 1885, vol. i. p. i.">4 
 
 20 
 
temperature. Parkes 1 says of the influence of high air tem- 
 perature : — 'The urea is lessened as shown by experiments in 
 hot seasons at home and during voyages (Dr. Forbes Watson 
 and Dr. Becher).' But he adds : 2 — Tt is probable that this is 
 simply from lessened food.' Similarly, it might fairly be 
 presumed that any increase of urea excretion under cold 
 weather results from increased food. In both cases, the food 
 variations would refer to nitrogenous, especially proteid, food. 
 
 § 8. The general conclusions, to be drawn from a consider- 
 ation of these three laws of nitrogenous katabolism and 
 excretion, would be (1) that except in the special circum- 
 stances of a deficiency of purely carbonaceous material, the 
 organism does not draw to any extent upon proteid to supply 
 energy, whether as force or heat; and (2) that, with the same 
 limitations, nitrogenous katabolism and excretion are mainly 
 determined by supply. 
 
 § 9. Nitrogenous anabolism and accretion. — Just as 
 nitrogenous katabolism for the most part precedes and deter- 
 mines nitrogenous excretion, so nitrogenous anabolism is a 
 necessary condition of nitrogenous accretion. Under increased 
 nitrogenous anabolism, there is a disturbance of nitrogenous 
 equilibrium in a direction opposed to what occurs under 
 increased nitrogenous katabolism, that is, the nitrogenous 
 output falls below the nitrogenous intake. 
 
 Increased nitrogenous anabolism and accretion occur under 
 the following, amongst other, conditions : — 
 
 1. During the period of physiological growth of the organ- 
 ism, whether, (1) as a parasite in utero, (2) as an ecto-parasite 
 during lactation, or (3) subsequently, as an independent being. 
 While it is certain a priori that, under these conditions, the 
 output of nitrogen is below the intake, the fact has been 
 demonstrated experimentally in the case of utero-gestation. 
 Thus Reprev 3 has shown, from metabolic experiments on 
 rabbits and dogs, that 'during pregnancy the organism absorbs 
 more from the food and rejects less than during periods of 
 sexual rest.' The katabolism 'of nitrogen decreases and less 
 is excreted in the urine. Nitrogen is stored up in the body. 
 In other words, the processes of assimilation are intensified, 
 
 1 Practical Hygiene, 1891, p. 402. 2 lb. 
 
 8 Digest of Metabolism Experiments, Atwater and Langworthy, p. 344. 
 
 21 
 
while those of excretion are diminished. Less urea and 
 phosphates are excreted during pregnancy than under normal 
 conditions. The amount diminishes as pregnancy advances.' 
 
 2. During the development in size of an individual tissue 
 from increased use, for example, muscle from increased exer- 
 cise, as in the case of cardiac hypertrophy from increased per- 
 ipheral resistance. We have already seen that it is impossible, 
 in ordinary circumstances, by increasing muscular contraction 
 to increase nitrogenous katabolism and excretion ; but the 
 evidence, that it is easy, by this means, to increase nitrogenous 
 anabolism and accretion, seems to me irrefutable. 
 
 3. In repair, during recovery from loss of tissue proteid, 
 whether such loss has arisen from deficient proteid income, 
 as in starvation or partial starvation ; or whether it has oc- 
 curred through the pathologically exaggerated nitrogenous 
 katabolism of pvrexia or possibly other morbid conditions 
 (§ 104). 
 
 4. To some extent, as we have seen (§ 4), as a consequence 
 of the ingestion of proteid in excess of the amount necessary 
 for the maintenance of nitrogenous equilibrium. 
 
 § 10. On taking a comprehensive survey of the above- 
 mentioned conditions under which nitrogenous anabolism and 
 accretion are increased as regards nitrogenous katabolism and 
 excretion, we can hardly fail to be impressed by the idea that 
 the metabolic variation is for the most part determined by the 
 demand for new tissue. In the first two examples, the demand 
 is manifestly created by a superadded or an increased physio- 
 logical function. In the third, the demand results from an 
 abnormal or pathological expenditure of the nitrogenous cap- 
 ital of the body. In the fourth only, is there any question as 
 to the dominant influence of demand: in this case it would 
 appear at first sight as if supply were the determining factor. 
 But, even here, we cannot I think finally exclude the influence 
 of an increase of function. We have seen that an increase of 
 proteid stimulates the tissues to increased katabolism; and it 
 is open for us to assume that such increased antecedent katab- 
 olism in the presence of a plentiful supply, is the real deter- 
 mining factor of the succeeding increased anabolism and 
 accretion. 
 
 But, be thai as it may. we shall have to admit that in the 
 
great majority of cases, while a due supply of fresh proteid 
 is essential, nitrogenous anabolism and accretion are not 
 determined by the supply, but by the demand for fresh tissue, 
 whether this has been created by an additional or increased 
 function or by an exaggerated waste. 
 
 § 11. Improbability of a nitrogenous accumulation in 
 the blood. — We have arrived at the conclusions that nitrog- 
 enous katabolism and excretion depend mainly on supply, 
 nitrogenous anabolism and accretion, mainly on demand. 
 Now it seems to me that these laws of nitrogenous metabolism 
 — if they may be so designated — afford a strong a priori argument 
 against the probability of an accumulation of nitrogenous 
 material occurring in the blood. For it would seem, on the 
 one hand, that the organism experiences no difficulty in get- 
 ting rid of superfluous nitrogen, but that, on the other, some- 
 thing of a struggle is involved in the retention of such nitrogen 
 as is essential. Hence nitrogen, which fails to be anabolised 
 and accreted, is discharged by an automatic mechanism. 
 
 These remarks apply only to the metabolism of proteid and 
 to the excretion of urea. The metabolism of nucleo-proteid 
 and the excretion of uric acid, will be referred to at a later 
 stage of this work. 
 
 CARBONACEOUS METABOLISM. 
 
 § 12. The subject of carbonaceous metabolism will be con- 
 sidered in some detail in Chapters III to VI inclusive. Mean- 
 while, it will be convenient to refer to some of its leading 
 feature's in order to contrast them with nitrogenous metab- 
 olism. 
 
 Carbonaceous metabolism presents an almost complete 
 contrast to nitrogenous metabolism. The purely carbonaceous 
 food-stuffs cannot be said to be essential to the organism, 
 since proteid is a complete food and will alone continue to 
 support life indefinitely. Again, unlike proteid, the purely 
 carbonaceous food-stuffs have no power to increase the meta- 
 bolic activity of the tissues; on the contrary, fat and carbo- 
 hydrates, as we have seen, have a sparing effect upon proteid 
 katabolism and tend to diminish the amount of tissue proteid 
 which is being broken down. Further, it goes without saying 
 
 23 
 
that the purely carbonaceous food-stuffs have a sparing effect 
 upon the katabolism of the fixed carbonaceous tissues. 
 
 § 13. Carbonaceous katabolism and excretion. — Unlike 
 the primary katabolism of proteid, carbonaceous katabolism 
 consists essentially of a process of slow combustion or oxida- 
 tion : as a result, oxygen is absorbed and carbonic acid given 
 out. 
 
 Except in the case of the loss of carbonaceous material 
 which occurs with the menstrual flow, carbonaceous katab- 
 olism precedes and determines carbonaceous excretion. In 
 this, the katabolism and excretion of carbon and nitrogen 
 agree. But, as we have seen, nitrogenous katabolism is 
 largely determined by nitrogenous supply. This does not 
 hold of carbonaceous katabolism. Stewart 1 points out that 
 'although the consumption of fat is to a certain extent in- 
 creased with the supply of fat or fat-producing food, there is 
 by no means the same prompt adjustment of expenditure to 
 income in the case of carbon, as in the case of nitrogen.' 
 In other words, carbonaceous katabolism and excretion do not 
 depend, except within certain narrow limits, upon carbona- 
 ceous supply. This may be regarded as a first law of 
 carbonaceous katabolism and excretion. 
 
 § 14. Again, in contrast with nitrogenous katabolism and 
 excretion, is a second law of carbonaceous katabolism and 
 excretion, namely, that they are largely dependent on physical 
 exercise. Foster 2 says : — 'One hour's hard labour will increase 
 fivefold the quantity of carbonic acid given off within the 
 hour.' Parkes 3 gives the observations of Pettenkofer and Voit 
 on this point in the following table : 
 
 Weight of man experimented 
 upon, 60 kilos=132 lb. avoir. 
 
 Absorption of 
 Oxygen in 
 grammes. 
 
 Elimination in grammes of 
 
 Carbon 
 Dioxide 
 
 Water 
 
 Urea. 
 
 Rest day 
 Work day 
 
 708.9 
 954.5 
 
 911.5 
 
 1,284.2 
 
 828.0 
 2,042.1 
 
 37.2 
 37.0 
 
 Excess on work day 
 (with exception of urea) 
 
 245.6 
 
 372.7 
 
 1,214.1 
 
 -0.2 
 
 Tn other words, during the working day . . . 
 
 1 Manual of Physiology. L899, p. 461. 
 
 1 Text-book of Physiology, L895, p. S44. 
 
 8 Parkes' Practical Hygiene, 1891, p. .'570. 
 
 5,751 grains 
 
 •>l 
 
or 13.15 ounces of carbon dioxide in excess were evolved. 
 Expressing this as carbon, an excess of 1,568 grains or 3.58 
 ounces, were eliminated on the work day. There was an 
 excess of oxidation of carbon equal to 41 per cent., and it must 
 be remembered that the so-called "work day" included a period 
 of rest : the work was done only during the working hours, 
 and was not excessive' (Parkes). 
 
 § 15. In further contrast with nitrogenous katabolism and 
 excretion, is a third law of carbonaceous katabolism and excre- 
 tion, namely, that they vary widely with the external tempera- 
 ture. Foster says : * — 'Within a lower and higher limit, cold 
 increases and heat diminishes the bodily metabolism, as shown 
 by the increased or diminished consumption of oxygen and 
 production of carbonic acid as the temperature falls or rises.' 
 
 § 16. But there is a fourth law of carbonaceous katabolism 
 and excretion — and herein carbonaceous and nitrogenous 
 katabolism and excretion are found to be in agreement — 
 namely that they depend largely upon the nitrogenous — that 
 is the proteid — supply. Foster points out that proteid food 
 augments the whole metabolism of the body, hurrying on the 
 destruction, not only of proteid, but of carbon, food: in other 
 words, proteid increases the excretion of carbonic acid, as well 
 as the excretion of urea. This is in accordance with the view 
 we have adopted, that all katabolic changes in apported food 
 material occur through the active agency, and constitute 
 functions, of the nitrogenous bioplasm (§ 2) ; and that function 
 generally is increased with the supply of proteid. The power 
 of proteid to increase the katabolism and excretion of the 
 purely carbonaceous food-stuffs, is of extreme importance 
 from the standpoint of the theory of hyperpyraemia. 
 
 § 17. The general conclusions to be drawn from a consider- 
 ation of these four laws of carbonaceous katabolism and excre- 
 tion, would be (1) that, in ordinary circumstances, the 
 organism is accustomed to draw upon the purely carbonaceous 
 food-stuffs, fats and carbohydrates, to supply energy, whether 
 as force or heat; and (2) that carbonaceous katabolism and 
 excretion are mainly determined by the exercise of function. 
 
 § 18. Carbonaceous anabolism and accretion. — Just as 
 
 1 Text-book of Physiology, 1895, p. S53. 
 
 2 Text-book of Physiology, 1895, p. 884. 
 
 25 
 
carbonaceous katabolism for the most part precedes and deter- 
 mines carbonaceous excretion, so carbonaceous anabolism is, 
 with some possible exceptions to be afterwards considered 
 (§ 126), a necessary condition of carbonaceous accretion. 
 
 Carbonaceous anabolism and accretion concern mainly fat- 
 formation. Later (§§ 125 to 135) I shall argue that fat-forma- 
 tion depends fundamentaMy upon two factors, namely (1) 
 a margin of carbonaceous material in the blood over and above 
 the amount which is being utilized as fuel; and (2) a vital or 
 active construction capacity on the part of the bioplasm of 
 some of the nitrogenous tissues, which construction capacity 
 depends, as do all functions, upon the supply of proteid in the 
 food (§12?). 
 
 Now the capacity to construct fat is always present in some 
 degree in a physiological condition of the organism. Hence, 
 in ordinary circumstances, fat-formation will be determined by 
 the margin of carbonaceous material in the blood, that is, by 
 the supply. In general terms, then, we may conclude that 
 carbonaceous anabolism and accretion do not depend upon 
 demand, but upon supply. 
 
 § 19. Probability of a carbonaceous accumulation in 
 the blood. — We have arrived at the conclusions that carbona- 
 ceous katabolism and excretion do not depend (except slightly) 
 upon supply, but upon the exercise of function ; and that carbona- 
 ceous anabolism and accretion do not depend upon demand, but 
 upon supply and upon a vital construction capacity on the part 
 of some of the nitrogenous tissues. Now it seems to me that 
 these laws of carbonaceous metabolism — if they may be so 
 designated — afford a strong a priori argument in favour of the 
 probability of an accumulation of carbonaceous material occur- 
 ring in the blood in some circumstances. For, on the one hand, 
 the exercise of the functions, force-production and heat- 
 production, which mainly determine carbonaceous katabolism 
 and excretion, is largely dependent on conditions, such as 
 physical exercise and exposure to cold, which are more or less 
 voluntary or accidental; and, on the other hand, the capacity 
 for fat-construction may, as we shall see (§ 237), be conspicu- 
 ously inadequate. Hence carbonaceous material, which is 
 superfluous through a retardation of combustion from deficient 
 physical exercise or from hot weather, will not of necessity 
 
 26 
 
fully undergo anabolism and accretion ; neither will carbona- 
 ceous material, which fails to be anabolised and accreted, be 
 of necessity discharged, as in the case of superfluous nitroge- 
 nous material, by an automatic mechanism. It would seem, 
 indeed, that, in the case of nitrogen, accretion alone demands 
 something of a struggle on the part of the organism, whereas 
 in the case of carbon, something of a struggle is demanded by 
 both excretion and accretion. 
 
 These views are not in accordance with current medical 
 thought. We are accustomed to argue as if fat-formation were 
 on all occasions adequate to the requirements of the organism — 
 as if carbonaceous material in the blood, in excess of the 
 fuel requirements of the tissues, were, ipso facto, stored extra- 
 vascularly as fat, and also to some extent as glycogen. This 
 optimistic assumption has arisen, as seems to me, through our 
 laying insufficient stress upon the constructive capacity of the 
 tissues in fat-formation ; and its disproval is one of the main 
 objects of this work. 
 
 THE STEAM ENGINE ANALOGY. 
 
 § 20. The preceding conclusions were originally largely 
 suggested by the old analogy between the human organism and 
 the steam engine. This, as Robert Hutchinson ' says, 'is a 
 rather threadbare and not altogether accurate analogy, but it is 
 perhaps the best that can be found. The building material of 
 food' (proteid) 'corresponds to the metal of which the engine 
 is constructed, the energy producers' (the non-nitrogenous, or 
 purely carbonaceous, food-stuffs) 'to the fuel which is used to 
 heat the boiler. Where the body differs from the engine is 
 that it is able to use part of the material of its construction' 
 (the carbonaceous part of the proteid) 'for fuel also.' 
 
 We are often warned that it is easy to push the analogy of 
 the steam engine too far : it is seldom suggested that it is 
 possible to err in the opposite direction. And yet it may be 
 that, hitherto, an over-timidity, arising through a too con- 
 scientious adherence to the severely inductive method of inves- 
 
 1 Food and Dietetics, 1900, p. 2. 
 
 27 
 
tigation, has unduly restricted us in the use of analogical 
 methods in general and of the steam engine analogy in par- 
 ticular. 
 
 For this analogy seems to me much more complete than is 
 commonly claimed. In both the steam, and the human, 
 engine, there is in general a practical equilibrium of building 
 material : in neither, is there carried any store of such material 
 beyond what is in daily use: accretion in either occurs only 
 when such is in actual demand. In the steam engine, the waste 
 of building material is determined in the main by friction — at 
 least it depends upon function and is not directly dependent on 
 combustion or oxidation. In the human engine also, it depends 
 upon function and, with an apparent exception, is not directly 
 dependent on combustion or oxidation. This apparent 
 exception occurs when, in consequence of a deficiency of its 
 accustomed fuel, the organism exercises its capacity for 
 burning its building material. On the other hand, fuel in 
 both cases is apt to be stored in advance : its expenditure in 
 both is strictly proportionate to the energy developed, whether 
 as force or heat; and accretion may occur in the absence of 
 any immediate . demand — it is apt to occur, indeed, in inverse 
 proportion to the immediate demand. 
 
 There is a further resemblance which, to my mind, is of 
 extreme importance in practical medicine. It will be 
 admitted that a well-constructed, large and therefore heavy, 
 engine has a capacity for combustion, and therefore for the 
 development of energy, which is not possessed by a smaller 
 one — that the possible energy is largely proportionate to the 
 amount of building material. The same is true of the human 
 organism : the capacity for combustion, and therefore for the 
 development of energy, is largely proportionate to the amount 
 of anabolised proteid or bioplasm ; and it is possible, as we 
 have seen, to increase this anabolised proteid by increasing, 
 under proper conditions, the supply of proteid in the food. 
 Such conditions commonly include the creation of the demand 
 for fresh tissue through the exercise of function, as. for 
 example, systematic muscular contractions (§ 9). But, as we 
 have seen (§ Hi), the mere increase of proteid intake, though 
 it may not result in an increase of anabolised proteid. increases 
 the rate <>\ combustion. 
 
 88 
 
THE PROBLEM OF A PHYSIOLOGICAL DIET. 
 
 § 21. Our knowledge of physiological metabolism, meagre 
 as it is, is sufficient to suggest that considerable variations 
 in the quantity and constitution of the diet should be made in 
 accordance with the variations in external conditions and work, 
 inseparable from modern civilized life. In an attempt to solve 
 the problem of a physiological diet, we may proceed in either 
 of two fundamentally different ways. We may proceed by 
 deduction from what we know of physiological metabolism ; and 
 we may proceed by induction from observations of the food 
 customs of mankind in various environments. 
 
 § 22. Deductive investigation. — Since exposure to cold 
 largely increases the expenditure of carbon in response to the 
 increased demand for heat-production, we should infer that, 
 under conditions, such as the approach of winter or a change 
 of residence from a low to a high latitude, we ought to 
 increase considerably the carbonaceous or fuel intake. And, 
 since physical exercise largely increases the expenditure of 
 carbon in response to the increased demand for force-pro- 
 duction, we should infer that, under conditions such as a 
 change from a sedentary to a laborious occupation, a similar 
 addition to the food should be made. A fortiori, under 
 conditions involving an increased demand for both heat and 
 force production such as a change from a sedentary occupation 
 in a low latitude to a laborious occupation in a high latitude, 
 it is clear that the addition to the carbonaceous or fuel intake 
 would be urgent. 
 
 § 23. The converse of the above would necessarily follow. 
 Under conditions, involving diminished exposure to cold or 
 diminished physical exercise, we should infer the propriety of 
 a considerable diminution of the carbonaceous or fuel intake ; 
 and, a fortiori, under conditions involving a diminution of 
 both sources of expenditure. Conformably, Robert Hutchinson 
 says: 1 — 'Compared with the diet of muscular labour . . . the 
 diet for mental work should be small. The reduction should 
 probably affect the carbohydrates and fats more than proteid, 
 for it is the two former . . . which tend to be specially made 
 use of as muscle foods. . . . Hence it is, that it is far easier 
 
 1 Food and the Principles of Dietetics, 1900, p. 43. 
 
 29 
 
for a man who is performing bodily labour to be a vegetarian, 
 than for one who is engaged in mental work.' 
 
 § 24. The variations in the nitrogenous or proteid intake, 
 which should on physiological grounds be made in accordance 
 with variations of external conditions or personal habits, are 
 less clear. In the steam engine, the capacity for combustion 
 will depend, inter alia, upon the size and strength of the 
 furnace; and, if these qualities are to be assured, the supply of 
 building material must not be stinted. So it is, perhaps, with 
 the human engine. The capacity for combustion will depend. 
 inter alia, upon the bulk and nutrition of the nitrogenous 
 tissues, especially the muscles ; and to assure these qualities, 
 a due supply of proteid is essential. Hence it may be 
 argued that, in an environment or with personal habits which 
 entail rapid combustion, an ample supply of proteid is 
 demanded. But manifestly such supply will not be propor- 
 tionate to the combustion as in the case of fuel supply. 
 
 § 25. But there is another side to the question. External 
 heat involves a diminished demand for heat-production and, 
 consequently, a diminished combustion. But the development 
 of energy, whether as heat or force, is not the only object of 
 combustion. Combustion is also adapted, as we shall see later 
 (§ 107 to 109), to clear the blood of superfluous carbonaceous 
 material. Hence it may be argued that the diminished com- 
 bustion, which results from the diminished demand for heat- 
 production due to external heat, may lead, in some cases, to a 
 deleterious accumulation of carbonaceous material in the blood ; 
 and that this tendency is best met by an increased supply of 
 proteid which, as we have seen, has the power of stimulating 
 the nitrogenous tissues to increased combustion (§ 1(5). 
 
 § 2(>. So also in the case of the diminished combustion 
 which results from the diminished demand for force-production 
 due to sedentary habits. It may be argued that, here also. 
 there is demanded the stimulating influence of an increased 
 proteid supply upon the oxidising nitrogenous tissues in order 
 to compensate for the absence of physical exercise. In con- 
 formity with this, is, I think, an observation of Clifford Allbutt. 
 This author says: — 'I am always assured by brain workers, 
 and I share the prejudice, that for them also a somewhat liberal 
 
 diet is required.' ' 
 
 1 System of Medicine, vol. v. p. 845, 
 
 30 
 
It must be admitted that the theoretical indications for 
 varying the proteid supply are complex, if not conflicting. On 
 the whole, it would seem that, while a certain minimum is 
 essential, the variations, demanded in accordance with varia- 
 tions of environment and personal habits, are much less than 
 in the case of the purely carbonaceous food-stuffs. 
 
 The objections to the deductive method of investigating the 
 problem of a physiological diet, consist in the seeming lack of 
 complete harmony which exists between the conclusions so 
 arrived at, on the one hand, and observation of the food 
 customs of mankind and the experience of the medical 
 profession on the other. This subject will be returned to 
 presently. 
 
 § 27. Inductive investigation. — Sir William Roberts 2 
 says : — 'The science of dietetics must, I apprehend, be mainly 
 based and built up on an observation and a study of the 
 practices and customs of mankind in regard to their food, 
 rather than upon a priori data supplied by physiology. In, 
 the case of the lower animals, we assume that each creature 
 selects from the nutrient materials within its reach those articles 
 which are most suited to its well-being and are best fitted to 
 promote its success in the struggle for existence, and that it is 
 guided in this selection by an almost unerring instinct. This, 
 like other instincts, is now explained by biologists as con- 
 sisting essentially in an inherited experience, which has been 
 gradually accumulated through a long line of ancestors, and 
 is transmitted by heredity to the descendants. Accordingly, 
 when we see an animal feeding on a particular kind of food, 
 we conclude without hesitation that that food is, of all the 
 nutrient materials accessible to it, the best adapted for the 
 special wants of its economy. But we know that man, in 
 regard to his bodily functions, is subject to the same laws as 
 those which govern the life of the lower animals. And we 
 cannot doubt that in the formation of his dietetic habits, man 
 is guided by the same kind of instincts as those which guide 
 the rest of the animal creation in the choice of their food. 
 
 'The generalised food-customs of mankind are therefore not 
 to be viewed as random practices adopted to please the palate 
 or to gratify an idle or vicious appetite. These customs must 
 
 2 Digestion and Diet, 1891, pp. 96, 97. 
 
 31 
 
be regarded as the outcome of profound instincts, which corre- 
 spond to important wants of the human economy. They are 
 the fruit of a colossal experience, accumulated by countless 
 millions of men through successive generations. They have 
 the same weight and significance as other kindred facts of 
 natural history, and are fitted to yield to observation and study, 
 lessons of the highest scientific and practical value.' 
 
 § 28. I have given this long quotation partly because of 
 the eminence of the writer and of the weight which his 
 teachings undoubtedly carry, but chiefly because the wide- 
 spread adoption of such exclusively inductive views are, in my 
 opinion, very largely responsible for the confusion which 
 admittedly prevails at the present day in the science of 
 dietetics. The optimistic assumption that the food-customs 
 of the civilized races of mankind are almost of necessity 
 physiological, seems to me unfortunate, as well as untenable. 
 It is unfortunate because it practically precludes food as a 
 • primary factor of disease, and thus closes the door at the out- 
 set upon investigation in this direction. By excluding supply, 
 it throws into undue prominence disorder of function, whether 
 hereditary, congenital, or acquired in many incidental ways, 
 as the original starting-point of pathological action : this 
 source of fallacy seems to permeate modern pathology, but is, 
 I think, especially conspicuous in disorders of the digestive 
 system. The optimistic assumption, just referred to, is unten- 
 able because it depends upon the further assumption that 
 civilized man and the lower animals are subject in equal 
 decrees to the law of natural selection — an assumption the truth 
 of which cannot, in my opinion, be maintained. 
 
 § 29. Harry Campbell * points out that 'the essential 
 purpose of instinct and reason is to regulate the environment 
 of the individual, to surround him by such conditions as are 
 best suited to his existence' ; that 'man and brutes stand out 
 in bold contrast in that reason is the chief means of the one, 
 instinct of the other'; and further that instinct though 'the 
 most perfect possible guide.' is fully operative only in the pres- 
 ence of a stable environment. 
 
 Now it is admitted that, in the course of ages, owing to the 
 stability of their environment, animals have developed an 
 
 1 Causation of Disease, Chap. TI. 
 
 on 
 
almost unerring instinct with regard to the selection of their 
 food. The same is true doubtless of primitive man, and 
 probably also to a less extent of contemporary human races 
 whose environment has undergone little alteration through 
 long periods. It is probable for example that the primitive 
 Asiatic 1 'took to rice eating not from desire but from the 
 scarcity of animal food' (Hueppe) : and that, through the 
 operation of the law of natural selection, the modern Asiatic now 
 lives upon an approximately physiological diet. 
 
 It cannot, I think, be upheld that instinct, operating 
 through natural selection, has exercised a preponderating 
 influence on the formation of the present food customs of 
 Western civilized man. Instinct, as already stated, is fully 
 operative only under a stable environment; and civilization 
 implies an ever-changing environment. Further, the growth 
 of reason, in itself an essential cause of the unstable environ- 
 ment, tends to blur the precision of instinct. Hence civilized 
 man has come to depend largely, if not mainly, on the former. 
 But reason, though doubtless far better adapted to a changing 
 environment, is, as argued by Harry Campbell," 'a far less 
 perfect guide than instinct' under a stable environment. For 
 'in order that reason shall on all occasions give a correct 
 result, two things are necessary, man must be acquainted with 
 every natural law, and he must be gifted with perfect reasoning 
 power.' Now, whatever may happen in the future, it is 
 certain that such conditions are unattainable now. Conse- 
 quently, we might perhaps regard the present in the light of 
 an 'evolutionary interregnum' — an interregnum succeeding the 
 despotic reign of instinct and preceding that of reason in its 
 full development. 
 
 Hence, it must, I think, be admitted that, into our present 
 civilized food customs, there have entered many factors in 
 addition to the operation of natural selection. Amongst these, 
 we shall have to include greatly increased accessibility to a 
 variety of food-stuffs through advancing knowledge in the 
 science and art of manufacture and through increased facilities 
 of transport, cultivated tastes, sentimentalism, fashion and 
 many more. If this is true, then we may have in our present 
 
 1 Prof. Ferdinand Hueppe in Brit. Med. Journ., 1901, March 2. 
 
 2 Causation of Disease, pp. 192 et seq. 
 
 33 
 
food customs a primary factor of disease possessing vast 
 potentialities. 
 
 Conformably, we shall find that practically all the affections, 
 which we are ascribing in this work to hyperpyraemia, are 
 more or less peculiar to civilized, especially to highly civilized, 
 man: and they are comparatively absent from man in a 
 savage state; and that they are unknown in the lower animals, 
 except perhaps in such domesticated varieties as have come 
 largely under the civilized human environment. Hence we 
 shall have to regard hyperpyraemia as largely a result of 
 civilization or of the evolutionary interregnum implied in the 
 development of civilization. Moebius has said: — 'The tendency 
 to headache is a part of the degeneration which is inseparable 
 from civilization.' Xow headaches — at any rate, recurrent 
 sick-headaches — are amongst the commonest of all the mani- 
 festations of hyperpyraemia; and if we might use the term 
 'degeneration' to cover conditions which depend upon inade- 
 quately rapid adaptation to the ever-changing environment of 
 civilization, then the view held by Moebius would include the 
 view preferred in this work. 
 
 § 30. Harmonization of the results of deductive 
 AND inductive investigation.— The conclusions we have 
 reached by deduction from physiology are supported to some 
 extent by observation of the food customs of mankind. Thus 
 in the Arctic Zone the Esquimaux live largely upon fat, the most 
 concentrated form of purely carbonaceous, or fuel, food. Xor 
 are there wanting examples of races inhabiting hot climates 
 —the aborigines of Northern Australia, the Indians of parts 
 of South America — who live largely upon flesh, the main 
 source of proteid. And Schafer 1 states that 'it has been 
 observed by Tiegel that the Japanese rickshaw runners con- 
 sume rice in large quantities and at frequent intervals during 
 their periods of work, whereas on off days, they live mainly 
 on a flesh diet. 5 
 
 § 31. Consistent with these observations is the experi< 
 of a minority of the profession (of which I am one) that 
 proteid is practically as essential in a hot climate and under 
 sedentary conditions of life as under the opposite circum- 
 stances; but that, under both external heat and diminished 
 
 1 'Text-hook of Physiology, vol. i. p. 915. 
 
 3 1 
 
physical exercise, the purely carbonaceous food-stuffs should be 
 largely reduced ; and conversely. 
 
 § 32. On the other hand, our physiologically deduced con- 
 clusions are seemingly in conflict with other observations. 
 Many Asiatic races, such as the natives of India, Java, parts 
 of China, and the South Sea Islands, take comparatively little 
 proteid and live very largely on carbohydrates, such as rice, 
 sago and fruit. 
 
 § 33. Consistent with, perhaps largely based upon, the 
 latter series of observations, is, I think, the opinion of the 
 majority of the medical profession upon dietetics. It is held 
 that, under increased heat, meat should be largely eschewed, 
 the carbohydrates somewhat increased ; and that meat, except 
 in small amount, is an improper food for those whose occupa- 
 tion is sedentary. The last is a deep-rooted and old-standing 
 conviction, dating from long before the time when Liebig 
 formulated his theory (now exploded) 1 that the functional 
 activity of the nitrogenous tissues involved a proportionate waste 
 of the structural elements of those 'tissues, and necessitated a 
 corresponding consumption of nitrogenous material to replace 
 that loss' (Yeo). Indeed the influence of this conviction may 
 be traced in the Old Testament. Further, it seems to be 
 the general view that one class of the purely carbonaceous or 
 purely fuel foods, namely, the carbohydrates, is, except in the 
 presence of certain clearly denned diseases (glycosuria, diabetes), 
 a suitable and practically harmless nutriment in all circum- 
 stances. 
 
 § 31 Now it will be argued throughout this work that the 
 views of tfie aforementioned minority of the medical pro- 
 fession are correct and that the conclusions deducible from 
 physiologv are applicable in the majority of cases to practice, 
 both hygienic and therapeutic. Hereupon, the following 
 crucial questions arise. If the views of the majority are 
 incorrect (1), how is it that the purely carbonaceous or fuel 
 intake, which must often be excessive from the standpoint of 
 physiological metabolism, is not a frequent primary cause of 
 disease? and (2) how is it — and the fact of this objection may 
 be admitted beforehand — that the purely carbonaceous or fuel 
 intake can be increased — as in the substitution of a vegetarian 
 
 1 Food in Health and Disease, I. B. Yeo, 1897, p. 12. 
 
 35 
 
or modified vegetarian, for an ordinary mixed, diet — under 
 conditions, which theoretically demand a reduction, with, in some 
 cases, absolute benefit? 
 
 § 35. The answer to these questions largely constitutes the 
 purpose of this work. Meanwhile, it may be stated in 
 anticipation (1), that a relatively excessive intake of carbona- 
 ceous material is one of the most fertile of the causes of 
 disease, the diseases so arising being, for the most part, 
 those whose fundamental pathology or meaning has hitherto 
 baffled investigation; and (2) that an increase of the purely 
 carbonaceous or fuel intake does not of necessity involve any 
 increased intrusion of such material into the blood ; often the 
 contrary, indeed, since, as we shall argue, the digestion and 
 absorption of carbonaceous material depends largely upon the 
 nitrogenous or proteid intake (§§ 55 to 60). In short, it will 
 be argued that the views of the aforesaid majority are 
 necessarily incorrect only from the standpoint of metabolism, 
 using this term in its restricted sense ; and that these views 
 frequently become correct when the processes of digestion and 
 absorption are included within the scope of the term. 
 
 § 36. In this chapter, I have endeavored to contrast with 
 each other some of the fundamental laws of nitrogenous and 
 carbonaceous metabolism ; and to show thereby, and from the 
 analogy of the steam engine, that any excess of nitrogenous 
 material in the blood tends to be automatically excreted, but 
 that a carbonaceous excess tends, in some circumstances, to 
 accumulate in the blood. 
 
 36 
 
CHAPTER II 
 
 §§ 37—61 
 
 Carbon income : carbonization of the blood, or the digestion and absorption 
 of carbonaceous material — Oral digestion : conservative influence of 
 oral disease : secondary effects of oral disease — Gastric digestion : 
 conservative influence of gastric dyspepsia : secondary effects of gas- 
 tric dyspepsia — Intestinal digestion and dyspepsia. — Evidence that 
 carbonization of the blood is a vital action and depends on the supply 
 of proteid — Summary. 
 
 §37. It will be convenient to consider next the processes by 
 which the blood is supplied with fuel or carbonaceous material. 
 These comprise the numerous processes whereby the raw 
 carbonaceous material, contained in the proteid, fats and car- 
 bohydrates of the food, is first suitably modified and then 
 transported from the surface of the alimentary mucous mem- 
 brane into the blood — in short, digestion and absorption, 
 processes which we shall often find it convenient to speak of 
 conjointly as 'carbonization.' Digestion occurs in the organs 
 of primary digestion, the mouth, stomach and intestinal canal: 
 absorption occurs to some extent in all three, but mainly in 
 the last. Both processes, though they include various kinds 
 of mechanical and chemical action, are manifestations of vital 
 energy — they are vital functions; and 'since every structure of 
 the body, in which any form of energy is manifested ... is 
 nitrogenous,' the due performance of these functions will de- 
 mand, inter alia, a due supply of proteid in the food. Hence 
 the primary essentials for the due performance of the complex 
 function of carbonization, as carried on in ordinary circum- 
 stances. 1 will concern supply and function : (1) a due supply of 
 carbonaceous material; and (2) a due functional capacity on 
 the part of the organs and tissues concerned, this depending 
 largely upon the supply of proteid. 
 
 § 38. The digestive functions of the mouth are mainly 
 mechanical : the only food-stuffs which are chemically altered 
 
 1 We are not considering here the carbonization of the blood which 
 occurs during starvation : that is an essentially different process and will 
 be referred to later (§§ 187 to 189). 
 
 37 
 
are the starches : these are converted into soluble sugar. 
 Although 'the action of the human saliva. is very energetic, 
 indeed, almost instantaneous' 1 (Bauer), yet the starches will 
 have to be intimately mixed, and remain a certain minimum 
 time in contact, with the saliva. For efficiency of oral diges- 
 tion, therefore, as for efficiency of the whole complex process 
 of carbonization, the primary essentials will concern supply 
 and function. 
 
 1. The amount and character of the food presented. The 
 food should be in such a form that thorough mastication and 
 insalivation is necessary before swallowing is possible : 
 biscuits, rusks, breadcrust, etc., would be ideal forms. 
 
 2. The functional capacity of the organs and fluids of oral 
 digestion. The teeth, mucous membranes and glands will 
 have to be in good order: this will imply due nutrition by a 
 due supply of proteid. The saliva will have to be chemically 
 active : for this, it will have to be alkaline in reaction ; and, 
 since it is a nitrogenous fluid, probably it will be dependent 
 upon the proteid supply for its constant reinforcement. 
 
 It is probable, therefore, that the amount of proteid in the 
 daily diet exercises no inconsiderable influence upon the diges- 
 tion of carbohydrate material in the mouth, and less directly, 
 upon its subsequent absorption. 
 
 § 39. Conservative influence of oral disease. — In the 
 commoner forms of mouth disease, such as dental caries, 
 gingivitis and pyorrhoea alveolaris, mastication is necessarily 
 imperfect and the saliva is not infrequently acid. Hence there 
 will be a failure of salivary digestion, and by so much proba- 
 bly, a failure of subsequent absorption. And, if, as we are 
 arguing in this work, a long series of morbid affections of the 
 general system depend primarily upon hyperpyraemia, then 
 we shall be entitled to regard many of the functional and 
 structural disorders of the oral cavity as at least incidentally 
 conservative in their influence. Conformably, Sir Henry 
 Thompson thinks that most people eat their way to the grave 
 with their teeth ; and many of the older physicians laid great 
 stress upon the condition of the teeth as signs of the 'arthritic 
 diathesis,' a constitutional state which, we shall argue later 
 
 1 Prof. J. Bauer in Ziemssen's Hand-book of General Therapeutics, 
 vol. i. p. 100. 
 
 38 
 
(§§ 858 to 865), is synonymous with hyperpyraemia. Lay- 
 cock, 1 speaking of the characteristic features of this diathesis, 
 refers to 'teeth massive, well-enamelled, regular, even 
 undecayed in advanced life' (J. M. Fothergill). 
 
 The great increase of dental caries and other inflammatory 
 conditions of the mouth during recent years, is beyond dis- 
 pute : as to the cause of such increase there has been much 
 speculation but little agreement. Here, as in other depart- 
 ments of pathology, the dominant prejudice against animal 
 food has been conspicuous: excessive consumption of meat, 
 together with an assumed hereditary tendency to degenera- 
 tion, has been claimed as the essential factor. But recently, 
 there has been a revolt against this teaching: Dr. J. Sim 
 Wallace argues that the modern finely pulverized carbo- 
 hydrate food-stuffs are the directly responsible agents ; and in 
 this he is supported by a report of a 'Decay of Teeth Com- 
 mittee.' The report, 2 referred to, says: — 'Comparing the con- 
 dition of the mouth after a meal of flesh and after some form 
 of carbohydrates, in the one case the mouth is comparatively 
 clean, a few fibres perhaps remaining between the teeth, which 
 may be easily removed : in the other case, the interstices 
 between the teeth and the fissures of the teeth are packed with 
 soft masses of fermentable material, difficult, and in fact 
 impossible, to remove entirely, and thus presenting all the 
 conditions most 'favourable for the production of lactic acid.' 
 
 The following seems a reasonable view of the etiology of 
 dental caries. Carbohydrate retention leading to fermenta- 
 tion and acidity of the secretions and contents of the mouth : 
 erosion of the protecting enamel ; and decay of dentine through 
 bacteria thus admitted to the body of the teeth. And it is 
 more than probable, as ably argued by Harry Campbell, 3 that 
 pyorrhoea alveolaris has a similar origin in soft carbohydrate 
 food. 
 
 Here it will probably be objected that the Hindoos, who 
 are in the main starch eaters, possess as a rule, large, healthy, 
 strong, and exceptionally well-developed teeth. It is apt to be 
 overlooked, however, that, with this race, careful and regular 
 cleansing of the teeth is imposed as a part of their religious 
 
 1 Gout in its Protean Aspects, J. M. Fothergill, 1883, p. 36. 
 
 2 Quoted in the British Medical Journal, August 11, 1900. 
 
 3 'Observations on Mastication,' Lancet, July 25, 1903, pp. 219, 220. 
 
 39 
 
ritual ; and it is easy to see that decay may be prevented by a 
 careful and systematic toilet of the mouth in spite of injurious 
 food-customs. Hindoo vegetarianism, such as it is (for it is 
 by no means exclusive), is in all probability a result of envi- 
 ronment; and it is conceivable that the rigid enjoynment of 
 mouth cleanliness has, in their case, its origin in the remote 
 past in an experience of its dominant necessity under the food 
 conditions of the country. 
 
 § 40. A better index of the influence of food may be 
 obtained from an examination of the teeth of races who take 
 no special care in their preservation. Dr. \Y. A. Alden 1 of 
 Montana, U.S.A., says: — 'I have examined in the last 21 years 
 hundreds of these (Crow) Indians, and have yet to find one 
 with pyorrhoea alveolaris. I have found it in negroes and in 
 the mound builders, but not so in the Crow Indian tribe, as 
 the Crows were almost exclusively flesh eaters, their diet being 
 buffalo, elk, mountain sheep, deer and antelope. I present a 
 model which I have obtained from Iron Bull, Crow Chief, at 
 the age of 70 years.' The illustration of the model, referred 
 to, shows that every tooth in both jaws is present : that they 
 are all perfect in .size and shape; and that no trace of decay is 
 anywhere visible. The aborigines of Australia, excluding the 
 degenerate specimens who live on the confines of the towns, 
 are mainly flesh eaters and are remarkable for the excellence 
 of their teeth ; and the same is true, to a less extent, of the 
 white bushmen of the plains. 
 
 One fact alone seems almost fatal to the view that meat is 
 the cause of the modern increase in dental disease. In 
 Queensland at least, especially in its tropical portion, women 
 suffer more frequently and more severely than men, from 
 dental caries. For some years, I examined systematically the 
 mouths of patients, and I do not hesitate to say that in women 
 disease commences earlier, progresses more rapidly, and 
 attains a higher grade of destruction, than in men. The 
 number of young girls in North Queensland, wearing com- 
 plete sets of artificial teeth, is startling. It is unnecessary to 
 point out that the tendency of the tropics is to spoil the 
 appetite for animal food and to increase the taste for starches, 
 
 1 Items of Interest: A Monthly Magazine of Dental Art, Science and 
 Literature, April, 1900. 
 
 10 
 
sugars and fruits; and that women are notoriously more 
 influenced in this direction than are men. 
 
 § 41. We may then assume that the modern increase of 
 dental and mouth disease is in some way connected with the 
 modern excessive use of soft carbohydrate food-stuffs; and 
 there can be little doubt that, if carbonaceous excess is a 
 common food fault, it is in the main a carbohydrate excess. 
 Shall I then be accused of straining the imaginative privileges 
 I am claiming throughout this work, if I suggest that dental 
 and oral disease, incurred under these conditions, are protests 
 against improper and excessive supply? 
 
 § 42. Secondary effhcts of oral disease. — As in other 
 departments, so here, local disorganization, whether we choose 
 to regard it as conservative or not, leads, ultimately to disor- 
 ganization affecting remoter parts ; and we may trace a series 
 of pathological processes from the starting-point of dental and 
 oral diseases. The influence of imperfect mastication upon 
 gastric digestion and general nutrition will be admitted by all. 
 Recently, William Hunter 1 has called attention in a series of 
 articles to 'oral sepsis as a cause of septic gastritis, toxic 
 neuritis and other septic conditions.' And, in the 'Lancet' for 
 August £2, L903, a case of sapraemia, due to pyorrhoea 
 alveolaris simulating typhoid fever, is described by Dr. J. W. 
 Carr and Mr. E. W. Roughton. 
 
 GASTRIC DIGESTION. 
 
 § 43. The next step in carbonization of the blood is gastric 
 digestion. Here again efficiency will depend upon function 
 and supply. 
 
 1. The functional capacity of the organ, of its glands and 
 of their secretion, will depend, inter alia, upon nutrition by 
 a due supply of proteid food. 
 
 2. The supply of material for gastric digestion concerns 
 mainly proteid, which is the food-stuff mainly digested in the 
 stomach. The amount will be of importance: it is easily 
 conceivable that the functional capacity of the organ may be 
 strained by excess of work, performed even under favourable 
 conditions. The character of the proteid will be of the highest 
 
 1 Med. Reviezc, viii., No. 27, p. 733. 
 
 41 
 
importance: it will have to be soft in consistence and suf- 
 ficiently subdivided. A soft finely divided mince, made from 
 the lean of meat, as free as possible from fat, etc., would be, 
 on theoretical grounds, an ideal food for gastric digestion ; 
 and practically, I know of none more readily digested. Saliva 
 having no action upon proteid, mastication will be less neces- 
 sary than in the case of starch foods ; but it will not be 
 altogether superfluous, since, as pointed out by Harry Camp- 
 bell, 1 mastication acts reflexly upon the stomach and promotes 
 the flow of gastric juice. The conditions under which the 
 proteid is presented to the organ, are of the greatest im- 
 portance: they concern mainly the consistency and state of 
 subdivision of the proteid and the presence, or otherwise, of 
 other food-stuffs in the organ at the same time. Other things 
 being equal, the most perfect gastric digestion will occur when 
 all material, other than proteid, is excluded. 
 
 Arguing from physiology, then, starch should be given in 
 such a form as necessarily to undergo digestion in the mouth ; 
 and proteid should be submitted to the gastric juice 
 unhampered, as far as possible, by the admixture of food- 
 stuffs, which have been undigested in the mouth, and which 
 are indigestible in the stomach. 
 
 § 44. These physiological ideals will not be found to agree 
 with common practice. The proteid of an average meal is 
 presented as a solid, often a very tough solid, requiring toil- 
 some mastication to fit it for a passage through the gullet ; and 
 our practice as regards starch foods, appears to be to hasten 
 by all possible means their passage through the mouth, where 
 they should be in great part at least digested, and to prolong 
 their stay in the stomach, where their digestion is impossible. 
 The every-day dinner of the Englishman must be regarded as 
 highly unphysiological. Meat, insufficiently divided, is 
 swallowed with imperfectly insalivated potatoes. As proteid 
 digestion is commencing, the gastric juice is liable to be 
 suddenly diluted to the point of impotence by a drench of 
 beer or other liquid. Later, a mass of soft undigested — and. 
 as far as the stomach is concerned, indigestible — starch, such 
 as rice, is spread over, and mingled with, the proteid which is 
 still only in the early stages of peptonization. 
 
 1 'Observations on Mastication,' Lancet, July 11. 1 ( .H)3, p. B5. 
 
 [2 
 
We are often advised to restrict the fluid taken during 
 a meal on account of the danger of diluting the gastric juice, 
 but the caution is rarely extended to slop-food in general: yet 
 here it would seem to be even more necessary. The dilution 
 by water is temporary: the fluid excess is rapidly passed on 
 and absorbed, the digestion proceeds as before. But a starchy 
 pulp is retained and hampers digestion, not only by diluting 
 the gastric juice, but by coating the meat fibres and preventing 
 due penetration by the digestive fluid. While thus prolonging 
 proteid digestion, the retention of starch, useless at best, 
 leads to abnormal fermentation, to the production of irritating 
 organic acids, 1 and to the evolvement of quantities of gas — in 
 short, to the phenomena of acid and flatulent dyspepsia. 
 
 § 45. It is an opprobrium of medicine that theory and 
 practice are often in conflict — that medicine is, in other words, 
 an inexact science. The charge can hardly be denied, but I 
 venture to submit that we are too ready to plead guilty and to 
 ignore the instances in which theory and practice can be 
 placed in perfect harmony. This would seem to be true, at 
 least, of gastric dyspepsia ; for I do not hesitate to say that, 
 were we to deduce our practice in this most common disorder 
 from physiological principles (say from Foster's 'Text-book 
 of Physiology'), we should in many even old-standing cases 
 obtain rapid success. In these physiological principles, I 
 would suggest the inclusion of the following: — 1. That good 
 digestion implies quick digestion, and bad digestion, slow 
 digestion. 2. That the commonest cause of slow digestion is 
 the admixture in the stomach of unaltered starch with the 
 proteid that is undergoing, or is about to undergo, solution by 
 the gastric juice. 3. That proteid alone, if mechanically suit- 
 able, is rapidly digested in the stomach. 4. That starch foods 
 should be largely digested in the mouth. 2 
 
 1 Professor J. Bauer says : 'Since the investigations of C. Schmidt there 
 can be no doubt that when lactic, butyric, or acetic acids are found in the 
 stomach, they are always to be viewed as products of the decomposition 
 of the carbohydrates of the food.' 
 
 2 These sentences were written in 1808. Since then I have often been 
 on the point of excising them : the contained truisms seemed too obvious 
 to be other than an impertinence in a work addressed to the medical 
 profession. Yet as late as August, 1903, no less an authority than Harry 
 Campbell finds it necessary to point out that starch foods 'should be given 
 not, as is the custom, as liquid or pap, but in a form compelling vigorous 
 mastication.' — 'Observations on Mastication,' Lancet, August 8, 1003, p. 376. 
 
 43 
 
§ 46. We arc accustomed to lay much stress upon idiosyn- 
 crasy, especially with regard to the digestibility of various 
 articles of diet. There can be no doubt that true idiosyncrasies 
 exist and such should be treated with due deference. But are 
 they anything like as frequent as we are wont to assume? 
 1 very much doubt it. Many alleged idiosyncrasies, on exam- 
 ination and clinical experiment, are apt to resolve themselves 
 into some grossly unphysiological relation between the food 
 and the digestive organs — between supply and function. 
 Patients, nearly always women, inform me almost daily that 
 they are unable to digest meat. This statement, in nearly all 
 cases, amounts to this : that meat, perhaps overcooked or 
 badly cooked, imperfectly masticated and mixed with, or 
 immediately followed by, a quantity of soft carbohydrate, 
 upon which the saliva has had no time to exert any action at 
 all, is followed by flatulence, pain and distension, whereas the 
 omission of the meat from such a meal leads to much less 
 discomfort. This is, of course, easy to understand. But it 
 seems to me that it constitutes evidence of physiological, 
 rather than unphysiological, function on the part of the 
 stomach. And I have yet to find an instance in which a 
 hungry stomach, unaffected with gross organic changes, is 
 unable to digest, without morbid symptoms of any kind, meat 
 in proper amount, properly prepared and properly presented, 
 that is, unmixed with food-stuffs unsuited for gastric digestion. 
 
 § 47. It seems to me that to excessive consumption of 
 starch foods must be ascribed the extreme frequency of 
 dyspeptic conditions. Clifford Allbutt says: — 'There is no 
 superstition more tenacious of life than that which prescribes 
 carbohydrates to all dyspeptics as so "digestible"; and into 
 weak stomachs ready to dilate, is thrown a mass of such a dish 
 as rice pudding — a bulky food, imperfectly insalivated and 
 peculiarly apt to fall into decomposition with the disengage- 
 ment of volumes of carbonic acid.' Harry Campbell 1 also 
 animadverts strongly upon the many serious disadvantages oi 
 tlu- modern tendency towards 'soft and pappy' food-stuffs in 
 the dietary of both children and adults. He says:" — 'In this 
 age of abundant starch and imperfect mastication the stomach 
 
 1 Lancet. July is, 1903. 'Observations on Mastication,' p. 152. 
 ' Brit. Mfd. Journ., April n. L903, p. 855. 
 
 44 
 
and intestines are flooded with undigested starch, this giving 
 rise to many evils.' 
 
 § 48. Shall we not then be justified if we regard the preva- 
 lence of gastric dyspepsia as a protest against the commonest 
 form of carbonaceous excess, namely, excess in soft carbo- 
 hydrates? Such a view amounts to little more than that 
 gastric dyspepsia results in most cases from improper food 
 (supply) and that is not, primarily at least, due to mechanical' 
 or chemical defects on the part of the organ (function). And 
 it is not far removed from the view of Sir Henry Thompson, 
 who says indigestion is mostly not a disease, but an admoni- 
 tion. 1 Tt is the language of the stomach, and is mostly an 
 unknown tongue to those who are addressed.' 
 
 § 49. Conservative influence of gastric dyspepsia. — It 
 will be admitted that the general tendency of dyspepsia is to 
 restrict appetite and to limit absorption ; and if, as I shall argue 
 later, many common affections depend primarily upon hyper- 
 pyraemia, then it will have to be admitted that dyspepsia may 
 play the part of a conservative process. Certain physicians 
 throughout the history of medicine, not to mention a consider- 
 able section of the intelligent public, have held the view that 
 dyspepsia acts as a safeguard against greater evils. Usually, 
 the view is restricted to the case of gout, one of the few 
 remaining strongholds of the humoralists. Fothergill says :' — 
 'In plethoric gout dyspepsia is out of the question. Often, if 
 the patient could only be rendered dyspeptic, it would be the 
 best thing that could happen to him ; for dyspepsia would 
 relieve him from the consequences of too much good living 
 ("I have been a dyspeptic for fifty years," said an old clergy- 
 man. "Thank God for it!" All his brothers had died of 
 gout).' Gout, which I shall argue later, depends upon hyper- 
 pyraemia, is stated by Ewart to be 'commonly acquired with 
 the aid of a sound stomach.' We know that it is chiefly the 
 wealthy classes who suffer from gout. Their food is of good 
 quality: long experience in the art of cooking has led to its 
 preparation in such a way, that immediate peptic discomfort 
 is evaded ; it is calculated, too, to tempt the palate. Conse- 
 
 1 Lancet, November 30, 1901. 
 
 ' Gout in its Protean Aspects, J. M. Fothergill, 1883, p. 111. 
 
 45 
 
quently dyspepsia — at any rate primary dyspepsia, the variety 
 at present under consideration — is rare: excess absorption, 
 common. The stomach is cheated (so to speak) into passing 
 much that it might reject, were it presented in a cruder form. 
 As regards alcohol, it is widely recognized, that the particular 
 variety of intemperance which makes for gout, is not irregular 
 heavy drinking bouts, but the systematic wine bibbing which 
 is customary amongst good livers — exactly that form of drink- 
 ing, indeed, which is unlikely to upset digestion and unlikely 
 to interfere with absorption. And the general tendency of 
 high culinary art is to override and defeat the instinctive 
 avoidance of excess, which is allowed full play under a coarse 
 and monotonous dietary. 
 
 In the case of disorders other than gout, the conservative 
 influence of dyspepsia has been very commonly ignored; and 
 this has led to much confusion in etiology. Most of the dis- 
 orders and diseases to be ascribed later to hyperpyraemia, 
 have, at different times and by various authorities, been 
 ascribed to dyspepsia. I may here refer to asthma, migraine 
 and some forms of skin disease. Some have regarded the 
 dyspepsia, acting reflexly through the nervous system, as the 
 exciting factor of the associated affection : others have 
 regarded the dyspepsia as leading to the formation of deleteri- 
 ous chemical substances (toxins, etc.), which, after absorption, 
 constitute the real underlying factor in the disease ; nor are 
 we called upon to deny the possibility of either of these modes 
 of origin. 
 
 § 50. We may, however, reconsider the whole question 
 from a different point of view. We may take the stand that 
 we have failed to grasp sufficiently the conservative principle 
 of dyspepsia and have come, therefore, to restrict the influence 
 of food in the etiology of disease to its influence in causing 
 dyspepsia: because many disorders are preceded, or accom- 
 panied, by dyspepsia, we have assumed that the dyspepsia is 
 causative. And the frequent observation that many of the 
 disorders in question are associated with no subjective or 
 objective sign of dyspepsia, seems to have led us still farther 
 astray. It has forced us to fall back upon one or other of the 
 only two possibilities which seem to remain, (1) that dyspepsia 
 may be existent, but latent; or (2) that many affections. 
 
 4.6 
 
identical clinically, own, at different times and in different 
 persons, fundamentally different etiologies. 
 
 The prevailing uncertainty as to the relative etiological 
 positions of food, dyspepsia and associated diseases, is voiced 
 in the following passage from the work of a well-known author 
 on dietetics. After referring to the usually prescribed dietetic 
 treatment of certain forms of skin disease, the writer says :* — 
 'In other words these dietetic directions amount to this : if 
 dyspepsia accompanies these disorders, the dyspepsia must be 
 treated by the usual dietetic measures.' From a somewhat 
 similar point of view, another author says of gout," 'the best 
 dietary is in truth that which is most suitable for the dyspep- 
 tic' It may be that this is usually true, but if so, it is true 
 because a simple diet, which precludes excess, is hostile to both 
 gout and dyspepsia : not because gout depends upon dyspepsia. 
 
 In the view we here take, we admit that commonly 
 dyspepsia precedes or accompanies many other diseases, but 
 we explain the association by ascribing the two to a common 
 factor, an excessive carbonaceous intake. We regard the 
 dyspepsia as a protest against the excessive supply and as an 
 attempt on the part of the digestive organs to prevent further 
 intrusion of the excess into the system. The ensuing or 
 accompanying disorder (migraine, asthma, gout, etc.), we 
 regard as an index of the failure of these conservative meas- 
 ures — as events arising in spite, and not in consequence, of 
 the dyspepsia. In short, we admit that the efforts of the 
 organism to deal with adverse conditions are successful only 
 within certain limits. 
 
 § 51. This view will I believe be found to bring into line a 
 greater number of clinical observations than any view hitherto 
 propounded. It will simplify our ideas of etiology; and it 
 will explain a fact, which does not seem often to have been 
 observed but which I am convinced is true, namely, that 
 migraine, asthma, and many similarly induced affections, 
 though possibly less frequent, are, other things being equal, 
 distinctly more severe, if not more intractable, in those who 
 possess more hearty appetites and vigorous digestions, than in 
 poor eaters and dyspeptics. J. Combv, in an article on arthritism 
 
 1 Food in Health and Disease, 1897, p. 511 et seq. 
 
 2 Treatise on Gout, Duckworth, 1S90, p. 366. 
 
 47 
 
in children, enumerates, and ascribes to this assumed diathesic 
 condition, most of the affections which we are ascribing in 
 this work to hyperpyraemia. He says: 1 — 'It has been sug- 
 gested that most of the children suffering from symptoms 
 enumerated are dyspeptic. On the other hand, some of the 
 most typical gouty manifestations in children occur in those 
 who have no dyspeptic symptom.' I am aware that the con- 
 trary has been stated. Graeme M. Hammond 2 says of 
 migraine : — 'All severe cases without exception are chronic 
 dyspeptics.' I can only say that my own experience and that 
 of numerous medical men, whom I have consulted on this 
 point, are directly opposed to this statement ; and I cannot 
 doubt that the total absence of all digestive troubles, in many 
 of the severer cases of the disorders in question, has done 
 much to perpetuate the 'primarily neurosal' fallacy (§ 286). 
 
 § 52. The conservative influence of dyspepsia, when once 
 the idea is entertained, becomes a conspicuous clinical fact : it 
 may be seen in the alternations exhibited between dyspepsia 
 and the affections we are ascribing to hyperpyraemia. Dr. 
 Hawkes tells me of a man of sixty-four who consulted him for 
 dyspepsia. He had suffered from his school days up to the 
 age of fifty-three from 'bilious headaches' recurring once a 
 fortnight or even once a week. About the age of fifty-three 
 he began to suffer severely from carious teeth and pyorrhoea : 
 as a consequence he contracted the habit of bolting his food : 
 this soon resulted in severe dyspepsia which became chronic 
 and has persisted ever since. He volunteered the statement 
 that, since the commencement of dyspeptic symptoms, he has 
 never had a bilious headache. 
 
 Hyde Salter relates cases in which dyspepsia and asthma 
 alternated, the one condition displacing and replacing the 
 other. In one.* a little girl was subject for years to vomiting 
 after every meal : later, the vomiting ceased, and immediately 
 spasmodic asthma appeared: later still, the vomiting reap- 
 peared, and again the asthma ceased. Tn this way they 
 alternated, the vomiting always coming on when the asthma 
 was better.' In another. 4 a girl o\ eighteen, on the death of 
 
 1 Medical Review, May. 1902, p. 873. Synopsis of article in Archives 
 de Medicine des /infants. January and February, 1002. 
 3 Med. Annual. 1002, p. 426. 
 % On Asthma. 1868, pp. 256, 257. *//>.. 
 
 48 
 
a sister, to whom she was much attached, suddenly ceased 
 almost entirely to suffer from long recurrent attacks of spas- 
 modic asthma, but in place of them she became subject 'to 
 attacks of dyspepsia, frequently causing her as much suffering 
 and inconvenience as her previous asthma.' In my own 
 experience, I have met with cases in which recurrent bilious 
 attacks, and even formal migraine, alternated with constant, 
 or frequently recurring, dyspepsia : in one, regular periodic 
 sick headaches of some years' duration remained in complete 
 abeyance for about eight months, during which time severe 
 dyspepsia followed almost every meal. It may be — indeed, it 
 seems most probable — that, in many such cases, the dyspepsia 
 is not primary and directly due to the food, but secondary and 
 dependent, as we shall see later (§§ 77, 78), upon glycogenic 
 distension of the liver; but even so, these cases are still 
 examples of the conservative influence of dyspeptic conditions. 
 
 The view, we have adopted, will have an important bearing 
 on the treatment of the dyspepsia in these cases. Treatment, 
 addressed solely to the suppression of the discomfort attending 
 the gastric disorder, may possibly turn out to be injurious in 
 proportion to its success ; and treatment, which, by means of 
 artificial digestive ferments or other agents, increases the 
 absorption which the gastric revolt is adapted to diminish, 
 will certainly be so. Therapeutic interference will have to be 
 limited strictly to the removal of the common cause. 
 
 § 53. Secondary effects of gastrtc dyspepsia. — Although 
 we may fully subscribe to the view that gastric dyspepsia is 
 often a protest against improper or excessive food and con- 
 servative against the results of excessive absorption (c. g. 
 hyperpyraemia), yet we must admit that long recurrent and 
 unheeded protests, here as elsewhere, tend to local stress and 
 disorganization ; and that such local damage may constitute 
 the starting-point of a series of secondary disorders and dis- 
 eases affecting the system generally. Nor shall we be called 
 upon to modify these views if we find that some of these 
 secondary pathological conditions are more serious or more 
 fatal than those which, we are assuming, the gastric protest is 
 adapted to avert ; for the conservative measures of the organ- 
 ism are not restricted to such as are economical in their 
 operation (§§ 921 to 924). 
 
 49 
 
A few of the pathological conditions, which may take their 
 starting-point from gastric dyspepsia, may here be referred to. 
 Reflex disturbances, such as some forms of headaches: 
 catarrhal conditions of the mucous membrane: gross structural 
 changes, such as glandular and other degenerations, dilatation, 
 possibly ulcer: various forms of malnutrition; and probably 
 some anaemias. We may freely admit the possibility that 
 dyspepsia may lead to the formation of abnormal or toxic 
 compounds which after absorption may exercise deleterious 
 influences upon the economy; but this will not preclude us 
 from ascribing a long list of well-known nervous and other 
 disorders such as migraine, asthma, epilepsy, angina and many 
 more, to hvperpvraemia. 
 
 INTESTINAL DIGESTION AND DYSPEPSIA 
 
 § 54. We know that the process of digestion continues 
 after the contents of the stomach have escaped from the 
 pylorus. The chyme is now brought under the influence of 
 the bile, the pancreatic and intestinal juices, and its various 
 constituents modified still further to fit them for absorption 
 by the blood-vessels and lacteals. In all probability, the 
 digestive processes occurring in the intestinal canal are at 
 least equally important with those occurring higher in the 
 alimentary tract; and it is certain that absorption occurs here 
 to a far greater extent than heretofore. 
 
 Intestinal digestion, however, is much more complicated 
 and much more obscure than digestion in the mouth and 
 stomach ; and the same is naturally true of intestinal dyspepsia. 
 But we may, 1 think, apply to it the same general principles 
 as to primary digestion elsewhere. 
 
 The efficiency of the process will depend upon (1) supply, 
 and (2) function. 1. The supplied material comprises the 
 more or less digested contents of the stomach: the suitability 
 of these for intestinal digestion and absorption will depend 
 largely upon the efficiency of digestion in the oral and gastric 
 cavities, and indirectly therefore upon all the factors which 
 govern these latter, such as proteid supply, etc. 2. The 
 functional capacity of the intestinal canal, concerns its 
 mechanical, chemical and physiological actions: these will 
 depend no doubt upon a multitude of factors, but inter alia, 
 
 00 
 
upon nitrogenous nutrition and therefore, upon a due supply 
 of proteid. 
 
 Consequently, that part of the process of carbonization of 
 the blood, which consists of digestion and absorption in the 
 intestinal canal of carbonaceous material (for it is only the 
 carbonaceous material which now concerns us), will depend in 
 no small degree upon the supply of proteid in the food. We 
 shall expect therefore to be able, in some cases, to increase 
 carbonization by increasing the supply of proteid, in others to 
 decrease carbonization by decreasing the supply of proteid. 
 
 EVIDENCE THAT CARBONIZATION OF THE BLOOD 
 IS A VITAL ACTION AND DEPENDS ON THE 
 SUPPLY OF PROTEID 
 
 § 55. The a priori arguments, advanced in favour of the view 
 that carbonization of the blood is a vital action and is condi- 
 tioned by the supply of proteid in the food, are well supported 
 by experimental and other data. It is well known, as Foster 1 
 points out, that 'when an animal is fed simply on non-nitrog- 
 enous food, death soon takes* place; the food rapidly ceases to 
 be digested, and starvation ensues.' The cessation of diges- 
 tion is not, of course, immediate ; otherwise no meal, from 
 which proteid is excluded, would be of any nutritive value 
 whatever. For a time after the complete withdrawal of pro- 
 teid, the efficiency of the digestive mechanism, solid and fluid, 
 is maintained, doubtless at the expense of the nitrogen of the 
 body derived from previous proteid intake. But the subse- 
 quent failure is rapidly progressive. The above experiment 
 shows that fresh proteid intake is essential to the continued 
 carbonization of the blood ; it does not, how r ever, give any idea 
 of the minimum amount of fresh proteid which is essential. 
 But it is fair to infer that carbonization would increase with 
 the supply of proteid up to a certain point. 
 
 § 50. Under an ordinary mixed diet, the carbonaceous con- 
 tents of the alimentary canal include the carbohydrates, the 
 carbonaceous portion of the proteids and the fats. The former 
 two pass probably by the portal blood-vessels to the liver, 
 where some of the carbohydrates at least are in part 
 temporarily stored as glycogen. Now it is admitted that 'of 2 
 
 1 Text-book of Physiology, 1895, p. 833. 
 
 2 lb., M. Foster, 1895, p. 751. 
 
 51 
 
the three great classes of food-stuffs, the carbohydrates stand 
 out prominently as the substances which, taken as food, lead 
 to an accumulation of glycogen in the liver' (Foster). But 
 'a 1 quantity of carbohydrate mixed with a certain proportion 
 of proteid gives rise to a larger amount of glycogen in the 
 liver than the same quantity of carbohydrate by itself 
 (Foster). And it is reasonable to explain this experimentally 
 demonstrated fact by ascribing to the added proteid some 
 power to assist in the digestion and absorption of the carbo- 
 hydrate. But if this is true, then the carbonization of the 
 blood by carbohydrates will be dependent largely upon the 
 proteid supply. 
 
 § 57. Against this conclusion, it might perhaps be argued 
 that, since many persons consume but a very small amount of 
 proteid, carbohydrate should often appear undigested in the 
 faeces ; and it is asserted that 'in ' health the carbohydrate 
 food that is eaten does not appear in the faeces.' But Herter* 
 points out that 'the fact that there is no soluble carbohydrate 
 material in the faeces does not enable us to infer that it is all 
 absorbed and utilized. Even in health there is always some 
 waste of energy and potential from the fermentation of the 
 carbohydrates' ; and it is natural to believe that a retardation 
 of digestion and absorption, brought about by a reduction of 
 the proteid intake, would be fraught with an exaggeration of 
 such fermentative processes and by a consequent increased loss 
 of energy and potential. Further, the statement that carbo- 
 hydrates do not appear in the faeces is not exclusively true. 
 As Herter says,* 'a frequent peculiarity of patients who are 
 receiving an excess of starchy carbohydrate is that the faeces 
 show the effect of this excess by the presence of undigested 
 starch.' 
 
 § 58. There is ample evidence to show that the digestion 
 and absorption of fats (the carbonization of the blood by fats), 
 depends, in great part, upon the supply of fresh proteid in the 
 food. It will be admitted that the secretion of the bile is largel) 
 dependent on the supply of proteid. '11. Nasse" . . . saw 
 ... a great increase of the secretion of bile, when with fat 
 
 1 lb. p. 751. 'Chemical Pathology, Herter, p. 41. 
 
 % lb. p. 41. *'h. L902, p. 49. 
 
 'Quoted by J. Milner Fothergill, Indigestion and Biliousness, vol. i. 
 p. 170, Lfi 
 
 52 
 
nitrogenous foods were also given. Ritter found that, in a dog 
 fed only on potatoes, or on potatoes and fat only, the amount 
 of bile daily excreted fell very low.' And 'Bidder 1 and 
 Schmidt . . . noticed that, upon an exclusive diet of fat, the 
 secretion of bile at once fell to the level of that in an animal 
 from whom all food was withdrawn.' Less conspicuously, 
 the same occurs in the human subject. Those, who have 
 experimented clinically with various diets, know that, under 
 a diet markedly deficient in proteid, bile is deficient from the 
 motions, which are large, pale and usually dry ; and that, on 
 the other hand, under a diet of nearly pure proteid, as for 
 example the Salisbury diet, bile is in excess in the motions, 
 which are small, dark and usually moist. In the first case, the 
 amplitude of the evacuations may be taken to indicate deficient 
 absorption : in the second, the opposite condition, to indicate 
 the contrary. The excessive bile formation in the second case 
 may explain a fact which I have often observed, namely, that, 
 under a lean meat diet, even in the presence of constipation, 
 the dose of any aperient required to cause purgation is much 
 less than under other dietaries. 
 
 From all this it might be — indeed it often has been — inferred 
 that the bile is manufactured out of the proteid of the food, 
 rather than out of the fats and carbohydrates. But this is no 
 necessary inference. We know that bile formation is a function 
 of the hepatic cells and that these, like all functionally active 
 tissues, are nitrogenous. Hence we have the right to infer that 
 the cessation of bile secretion, which follows withdrawal of 
 proteid, is due. in great part at least, to a failure of function, 
 rather than to a failure of supply; and we may hold this view 
 without denying that the constituents of bile are in part derived 
 from the proteid ingesta. 
 
 But, be that as it may, there is no question that the 
 absorption of fat is largely dependent on the supply of bile to 
 the intestinal canal. Bidder and Schmidt demonstrated this 
 experimentally. 'A ' dog, which in its normal condition 
 absorbed on an average seven grains of fat for every two pounds 
 of its weight, absorbed only three grains, or even as little as 
 one grain, after the bile was prevented entering the intestines 
 
 l Ib. 
 
 ■ Treatise on Diseases of the Liver, George Harley, 1883, p. 87. 
 
 53 
 
in consequence of a ligature being applied to the gall duct.' 
 These observers found also 'that 1 while the chyle in the 
 thoracic duct of a healthy dog contains thirty-two parts of fat 
 per thousand, that in the thoracic duct of a dog with a ligatured 
 gall duct contains only two parts per thousand.' In man, the 
 influence of the bile in promoting the absorption of fats, may 
 be inferred from observations on the faeces. Herter* says :— 
 'Normally the faeces contain a considerable proportion of fat'; 
 but, in cases of jaundice, this proportion tends to increase. 
 
 Hence it is clear that the ingestion of proteid, through 
 dominating bile formation, dominates also in great part the car- 
 bonization of the blood by fats. 
 
 § 59. Finally, what is true of carbonization by carbohydrates 
 and fats, is in all probability true of carbonization by proteids 
 — that is to say, the digestion and absorption of proteids depends 
 upon nitrogenous nutrition and this upon the proteid intake. 
 And what is true of the digestion and absorption, which it 
 effected, directly or indirectly through the action of the saliva, 
 gastric juice and bile, is doubtless true of the digestion and 
 absorption which follows the action of the pancreatic and intes- 
 tinal juices. 
 
 § GO. The actual process of digestion may be in the main 
 chemical; but the manufacture of the chemically active juices 
 is a vital action. Hence digestion, as we have argued, depends 
 primarily upon due nutrition by proteid. Of absorption, the 
 same is true. B. Moore says: 8 — 'It was for many years believed 
 that the absorption of the products of digestion from the 
 alimentary canal was governed by exactly the same physical 
 laws as determine the passage of a solution through an inert 
 membrane, but the accumulation of experimental evidence has 
 rendered such a belief no longer tenable. It is now known 
 that the cells which line the alimentary canal take an active 
 part, not only in absorbing the materials prepared for them by 
 the action of the digestive secretions, but in modifying these 
 products in various ways during the process.' Thus absorption, 
 as well as digestion, depends upon an active or vital capacity 
 of the nitrogenous cells; and it is open for us to regard every 
 
 1 lb. p. i 
 
 * Chemical Pathology, 1902, p. 
 
 • Text-book of Physiology, SchatVr, 1898, vol. i. p. 431, 
 
step in the complex process of carbonization as dependent, more 
 or less directly, upon nitrogenous nutrition and, therefore, upon 
 the supply of proteid in the food. 
 
 SUMMARY. 
 
 § 61. In this chapter, I have attempted to show that the 
 carbonization of the blood — the supplying of the blood with 
 unoxidized carbonaceous material, or fuel — is a complex 
 chemico-vital function of the nitrogenous tissues of the 
 digestive organs, and that it depends, inter alia, upon a due 
 supply of proteid in the food : that some functional disorders, 
 for example, dyspepsia, and even some structural diseases, for 
 example, dental caries, may sometimes be regarded as conserva- 
 tive against hyperpyraemia, inasmuch as they tend to restrict 
 the carbonization of the blood : that many general diseases do 
 not, as so often assumed, depend upon dyspepsia, but own 
 with it a common factor in an excess of carbonaceous food; 
 and that some functional disorders and structural diseases, 
 though immediately conservative, often form the starting-points 
 of secondary pathological processes. 
 
 L.ofC. 
 
 DO 
 
'v 
 
 FED 13 1905^ 
 
 V 
 
 ,\ 
 
 LBJ'_ *0j 
 
 )\ w ni ^ 1 
 

 
 
 
 • s s 
 
 
 / 
 
 
 
 
 
 ^ c 
 
 . 
 
 
 < 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
y. W 
 
 !- : /^ /V y"V 
 
 c ' 
 
 
 .V 
 
 
 
 % 
 
 
 
 
 A V \D * o . * * A <\. 
 
 
 o 
 
 
 ■ 
 
 ® : ■■ ■■ Ilii fc 
 
 APR. 74 
 
 ^^"^ N. MANCHESTER, 
 INDIANA 
 
ism 
 
 • 
 
 Sfc 
 
 
 
 — 
 
 "JW HBMWhi ■■■■!■ jbl 86 
 
 BlHHilB 
 
 JmBBHHP 
 
 jBHBHBB 
 
 SSll 
 
 hbbhbhH_ 
 
 VBHH 
 
 mi 
 
 » 
 
 i 
 
 an 
 
 
 m 
 
 mwum 
 
 mmmm 
 
 InHHT 
 
 t m BMHS i 
 
 m 
 
 ; 
 
 m 
 
 noma