x.ivo^ .LBERT R. MAIV LIBRARY AT CORNELL UNIVERS'" B Cornell University 9 Library The original of tliis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924059209738 ON- DIET AND EEGIMEN Etc. ON DIET AND EEGIMEN SICKNESS AND HEALTH ON THE INTERDEPENDENCE AND PREVENTION OF DISEASES AND THE DIMINUTION OF THEIR FATALITY HORACE DOBELL, M.D. JCONSULTING PHYSICIAN TO THE ROYAL HOSPITAL FOR DISEASES OF THE CHEST PHYSICIAN TO THE ROYAL ALBERT ORPHAN ASYLUM, ETC., ETC. SIXTH EDITION REVISED AND ENLARGED. LONDON: H. K. LEWIS, 136 GOWER STREET, W.C. 1875. (1872) Once more i may repeat the thanks, expressed in all the former editions of this work, for the generous assistance i had received , in my scientific calculations from the arithmetical skill of my dear old friend J. J. FAEEANTS, P.E.O.S. LATE PRESIDENT OF THE MICROSCOPICAL SOCIETY; WHOSE GENIAL SPIRIT HAS NOW FOR EVER PASSED BEYOND THE REGIONS OF SCIENCE AND CALCULATION TO "that UNKNOWN, TRACKLESS LAND, FUTURITY; GREAT HERITAGE, WHERE NO MAN KNOWS HIS PART." PREFACE TO THE SIXTH EDITION. In introducing a former edition of this work, I stated that my object and endeavour had been to produce a small book founded upon accurate scientific data — a book from which a doctor might refresh his memory^ and at the same time one which he might safely place in the hands of his patients, to enlighten them on some of those impor- tant points which ought to be understood by the non-pro- fessional and to teach them how vast and intricate is the science and art of " rational medieme." This object and endeavour I have steadily kept in view, in preparing the present edition. To keep it " small," I have cut out all that I thought could be spared ; while to maintain its character as a scientific and practical "re- fresher" to both doctor and patient, I have been obliged somewhat to increase the size of the volume by the follow- ing additions : — In Chapter I. fresh matter is added under the heads " Smoking" and " Afternoon Tea." In Chapter II. I have added a new column to the Ana- lysis Table, giving the Mechanical Equivalents of the British units of heat for each article analysed; also a Table of the weight and cost of various alimentary articles re- VIU PEEIACE. quired to jdeld sufficient force to raise a certain weight to a certain height ; and an epitome^ by a well known writer, of the most recent views with regard to food, heat, and motion. la Chapter III. I have added thirteen pages " On the Wholesomeness and Digestibility of various articles of food," which I hope will be of much use to those who desire to avoid dyspepsia ; and a Table is given shewing the percentage of water in various foods in common use ; and some remarks on different modes of cooking. In Chapter V. I have added to the article "On Getting Thin," some directions for " Getting Pat" ; and I would especially call the attention of parents and of children's doctors to an article on " Fat and Starch in the Nutrition of Children," at p. 112. In Chapter VI. I have added some remarks on " Acid, Gout and Eheumatism from Fermented Liquors." In Chapter VIII. I have added new Eecipes, Direc- tions, and Appliances for the Sick-room, under numbers 4, 11, 12, 15, 18, 19, 20, 21. In Part II., Chapter IX., a Table shewing " the Inter- dependence of Winter Cough with other Diseases" has been introduced; and, finally, the Index has been tho- roughly revised. 84 Harley Street. April, 1875. PREFACE TO FIFTH EDITION. This work was mucli enlarged and nearly re-written in its last edition just two years agOj and it has now been tho- roughly revised. Much new matter has been introduced, and some of the old re-arranged. "With the valuable assistance of my friend Mr. J. L. Johnston, late Principal Inspector of Customs Labora- tories, the Alcohol Table has been completely re- cast, and is now, I believe, as nearly perfect as it is possible to make it. The Articles on Wines and on House-Drainage and the Orphanage Diet Table are quite new ; and other alter- ations will be found, which I hope will make the book more worthy of the favourable reception it has already received. 84 Harley Street. May, 1872. PEEFACE TO FOURTH EDITION. Mt " Manual of Diet and Eegimen" wMcli appeared in 1864 having run through two editions in its first year^ I published a third and revised edition in January, 1865. This has long been out of print, and, as the demand for- the Manual did not decrease, I have- been repeatedly urged to prepare a fourth edition. After many delays, from the interruption of other professional work, I have,, at last, re-written the book, adding much new matter and incorporating several contributions, which I have pub- lished from time to time, on subjects relating to the pre- servation of health. I hope it will be found that I have thus materially increased the usefulness of the work with- out adding inconveniently to its length. My object and endeavour has been to produce a small book founded upon accurate scientific data but essentially practical : a book from which a doctor may refresh his memory, and at the same time one which he may safely place in the hands of his patients, to enlighten them on some of those important points which ought to be understood by th& non-professional, and to teach them how vast and intri- cate is the science and art of rational medicine. Thus, to- XU PEEFACE. make them more intelligent patients^ and in so doing to remove some of tlie doctor's diflBculties in healing them when they are sick, and when they are well to strengthen his hands in the preservation of their health. It gives me great pleasure to be able to renew the thanks I expressed in 1864 to my friend Mr. Parrants, at that time President of the Microscopical Societyj for the valuable assistance I have so frequently received from his remarkable analytical and arithmetical talents. 84 Harley Street. May, 1870. CONTENTS. PEELIMINAliY REMARKS. PAGE The Interdependence of Diseases — Narrow Specialibies and Broad De- partments in the Practice of Medicine — Normal Diet — ^Errors in Diet — ^The Diet of Disease — Food, Eeat^ and Motion — Getting Eat and Getting Thin — Alcohol, its proper place in Diet — Eegimen— The Regulation of Habits — House-Drainage — Importance of Sleep — Proper Hours for Meals — Disinfection — Pseudo-Medical Dogmas, Allopathy, Hydropathy, Homoeopathy, Kinesipathy — Rational Med- icine .1 PART I. Chapter I. RULES FOR PROMOTING AND MAINTAINING VIGOROUS HEALTH IN ADULTS LIVING IN THE CLIMATE OF THE UNITED KINGDOM. Ventilation and Heating — Gaa — House-Drainage — Clothing and Protec- tion from Cold — Sleep — Exercise — Posture^Bathing — Regulation of the Bowels — ^Rest and Change — Smoking — Meals — Proper Hours for Meals — Afternoon Tea 12 Chapter II. FOOD, HEAT, AND MOTION. A foot-pound, a, foot-ton, a British unit of heat— Mechanical-Equivalent of a British unit of heat — Combustion of Carbon, Consumption of Oxygen, Evolution of Heat — Mode in which the Heat evolved from Food is disposed of— Composition of some of the principal articles of of Pood and their Heat-Equivalents and Mechanical-Equivalents — Weight and cost of Food compared with work produced — Uses of Nitrogenous and Non-Nitrogenous Foods. 61 X17 CONTENTS. Chaptee III. NORMAL DIET. PAGE Essentials of a Normal Diet — Mode of constructing Diets — Expensive Diets and Cheap Diets for maintaining health — Tables and Analyses — The Wholesomeness and Digestibility of various articlps of Food — Modes of .OooMng in common use Gl Chapter IV. SOME PRINCIPLES OF DIET IN DISEASE. Principles upon which to arrange the Diet of Disease — Rules for carry- ing out these Principles — Examples of Diets for Consumption, and for Diabetes . , . . . ... 89 Chapter V. FAT. Fat essential to Healthy Nutrition — Importance of distinguishing be- tween Solid and Liquid Fat — On Getting Thin — Bautingism — Ana- lysis of Banting-Diet, shovring its errors and advantages— On Get- ting Pat — Fat and Starch in the Nntcition of Children . . . 105 Chapter VI. FERMENTED , LIQUORS. Administration of Alcohol — Properties of various Wines — Wines in Gen- eral — Spanish Wines — German Wines — Hungarian Wines — Greek Wines — ^Acid, Gout, Rheumatism — Acid and Sugar in Spirituous Liquors — Ardent Spirits and their Peculiarities — Alcohol Table showing the Analysis of Spirituous Liquors 123 Chapter VII. DISINFECTION. Media by which the Catching Diseases are oimmunicatcd — Means for ' preventing Infection and Contagion — Directions for the Sick room and Attendants — Precautions , to be used by Doctors — Mode of cleansing apartments after illness — Proper methods of using Chloride of Lime, Carbolic Acid, and Condy's Fluid . . . .143 CONTENTS. Chapter VIII. SPECIAL EECIPBS, DIRECTIONS, AND APPLIANCES FOE THE SICK-ROOM. PAGE Farinaceous Articles — Beef Tea — Liebig's Extract of Meat — Brand's Meat Jelly and Solid Beef Tea— Darby's Fluid Meat— White of Egg — Whey — Animal Foods Re-cooked — Bread — Special Restorative — Special Nutritive — Cocoa and Egg — Invalid Soup — Combinations of Alimentary Principles in Normal Proportions — Port Wine Jelly — Suet and Milk — Milk with Bum, &o. — Nutritive Enemata — ^Nutri- tive Mixture — Cerealin Tea — ^Poultices and Poulticing by Steam — IiJhalations— Nash's Bronchitis Kettle — Warm Baths — Lights in the Sick-room — ^Nursing Schedule 150 PAET II. ON THE INTBRDBPBNDBNOB AND PREVENTION OF DISEASES AND THE DIMINUTION OP THEIR FATALITY. Ohaptee IX. The Duties of Medical Men — The Interdependence of Diseases shewing the importance of Periodical Examinations 165 Chapter X. ANEMIA . , 186 Chapter XI. FATTY DEGENERATION 192 Chapter XII. ABNORMAL PHYSIOLOGICAL STATES . . ... 201 Appendix. Alcohol — Experiments on the effects of Alcohol on the Human Body — Dust and Disease — Special Action of the Pancreas on Fat and Starch — Importance and Dangers of Rest in Pulmonary Consump- tion — On the Digestibility of Gelatine-yielding Tissues — ^Nutritive Enemata 209 ON DIET, REGIMEN, &c., &c. PRBLIMINAET EBMAEKS. THE INTBEDEPENDENCE OF DISEASES — NARROW SPECIALITIES AND BROAD DEPARTMENTS IN THE PRACTICE OF MEDICINE NORMAL DIET ERRORS IN DIET — THE DIET OE DISEASE EOODj HBATj AND MOTION — GETTING FAT AND GETTING THIN ^ALCOHOL, ITS PROPER ' PLACE IN DIET REGIMEN THE REGULATION OF HABITS HOUSE-DRAINAGE IMPORTANCE OF SLEEP PROPER HOURS FOR MEALS DISINFECTION PSEUDO-MEDICAL DOGMAS, ALLOPATHY, HYDROPATHY, HOMCEOPATHY, KINESIPATHY — RATIONAL MEDICINE. In the practice of Eational Medicine, there are many sub- jects upon which the wise Physician is always glad to find that his patient has some knowledge as well as himself. Among these I know of none more important than the interdependence of Diseases and the principles of Diet and Eegimen. There are few medical questions which so test the" depth and extent of a doctor's acquirements as the interdepen- dence OF DISEASES — by which I mean, the way in which one disease leads to another, substitutes another, aggra- vates, or relieves another ; the way in which disease ap- pearing at one part of the body, depends upon the de- rangement of another part, perhaps distantly separated ; the way in which disease of one kind in an ancestor, leads Z PEELIMINAET EEMAEKS to disease of several different kinds in the descendants ; the way in which one general morbid cause may produce different effects upon different persons^ according to the conditions of health in which they happen to be at the time ; and numberless other similar phenomena. These are matters of the highest importance in the right management and treatment of diseasCj yet they are BO little understood^ that the pains taken by a conscien- tious doctor in their investigation are not appreciated by the majority of persons. Thus it is that patients so often fail to discriminate between the wisdom of the man who will not prescribe for, a part of the body until he has learnt the condition of the whole, and the ad captandum ignor- ance of another man who will prescribe unhesitatingly for a disorder of the whole body without previously ascertain- ing whether it depends upon disease of a part. The chief objection to specialities in medical practice is the danger, that the doctor who treats but one part of the body may lose sight of the interdependence of diseases. This muslj, always be a grave objection to very narrow specialities, but it does not apply to the brbad division of the practice of medicine into Departments — that is to say, such a reasonable application of the principles of the " division of labour" as shall enable each practitioner, not only to completely master the department of Medicine which he selects for special study, but to advance the general knowledge of the profession by his investigations and experience. For example, diseases of the ear are often dependent upon, or are connected with, diseases of other parts of the body; and the doctor who confines his practice to diseases of the ear may be in danger of losing sight of the broad facts of medicine, and in attempting to cure the ear inay damage the body; but by extending his practice to all the ON DIET AND REGIMEN. organs of special sense, wMcli might fairly form a depart- ment of Medicini, be would be obliged to take in a range of observation and thougbt which would enforce a know- ledge of the interdependence of diseases. Again — Diseases of the heart and arteries are intimately connected with those of the lungs and throat ; diseases of the langs with those of the heart, arteries, and windpipe ; diseases of the brain with those of the lungs, heart, and arteries ; and all of these are often inseparably connected, in the relation of cause or effect with affections of the sto- mach, liver, pancreas, kidneys, intestinal glands, etc., etc. Therefore, for a doctor to limit his practice to diseases of the heart, to diseases of the throat, to diseases of the lungs, or to diseases of the windpipe, is to constitute a speciality so narrow that he is in danger of losing sight of the great principles of medicine. If, on the other hand, he selects for special study and practice such a broad department as Diseases of the Chest — that is to say, of all the respiratory and circulatory organs, and the associated processes of digestion and assimilation — he will,,be obliged to take in a range of observation and thought necessi- tating a constant remembrance of the interdependence of diseases, and he will be competent to deal with all classes of disease as well as those peculiar to his own de- partment. I have instanced Diseases of the Chest be- cause it is one of most important " Unes" of practice, and the one with which I am most intimately associated, but the same remarks apply to Obstetrics, to Fevers, to the Diseases of Children, and to other large divisions of medi- cine. Thus departments of medical practice may be wisely selected by different medical men for special study — but narrow specialities are dangerous and objectionable, unless those who confine themselves to them are content to act simply as the assistants of the more general physicians B 2 4 PEELIMINAET EEMAEKS and surgeonSj which is not likely to be the case. (See Part II., ''on the inteedependeitoe and peevention of DISEASES AND THE DIMINUTION OF THEIR PATALITT.") Diet is so little understood that, very often, those are the test off who abstain from all attempts to meddle, with it and are content to follow the dictates of their instinct. This, of course, ought not to be the case, for diet, properly understood, may be made a powerful agent in the restora- tion and maintenance of health ; and errors of diet are at all times capable of becoming serious causes of disease. But, unfortunately, interference with diet, like all good things, is particularly open to abuse, for nothing is easier than to lay down a complicated code of restrictions and rules as to " what to eat, drink, and avoid" and the patient is very apt to think that the skill of the doctor increases with the number and variety of his orders. But those who understand the principles of diet know that the reverse is much nearer to th.e truth, and that learning and skill in dieting a patient, are shown by the wisdom with whict the doctor, instead of meddling with unimpor- tant' details, seizes upon the few essential points on which the vice or virtue of a diet will generally be found to turn. Thus, in a case of diabetes (See Diet for Diabetes, Chapter IV.), the ignorant intermeddler may order fifty restrictions without doing his patient the slightest good; whereas, the doctor who understands the nature of the disease and the principles of diet, will speedily relieve his sufferings by telling him to take whatever he likes, so long as he touches nothing which contains starch or sugar. Thus, again, I have often seen patients suffering from acid dyspepsia who have been ordered and forbidden so many different articles of food that their lives were rendered miserable, without the slightest relief to their complaint, whereas, by forbidding them to take cheese and malt ON DIET AND EEGIMBN. 5 liquor — the chief factors of their malady — and allowing them to eat and drink whatever else they pleased^ their sufferings have been speedily removed and their Hves made enjoyable. It is absolutely necessary that he who ventures to inter- fere with a person's diet should first understand the prin- ciples upon which the food of health is regulated in na- ture; and- nothing assists the intelligent doctor more in getting his orders carried out, than for his patient, as well as himself, to be acquainted with this subject. Ignorance and stupidity are the constant obstacles in the proper regulation of these matters. To elucidate this part of the subject, I have drawn up a brief statement of the " Essen- tials of a normal diet." (See Chapter III.) This is illus- trated by a set of tables, showing the method by which diets may be arranged so that they shall equally well support the human body in a state of normal health and strength, whether they consist of a complicated list of expensive articles, or, of no more than Bread, Cheese, Butter, Cresses and Water. In addition to -this, I have introduced a Chapter "on the wholesomeness and digesti- bility of various articles of food." (Chapter III.) The advances of science have, of late, thrown most im- portant light upon the connection between food and FOECE, a subject of the greatest interest to all, whether medical or not ; for, as we all take food and all desire to be strong, we are unavoidably fascinated by the inquiry what kind of food will give' us the greatest amount of force. I have, therefore, introduced a short Chapter " On Food, Heat and Motion." (Chapter II.) The question of " getting fat or getting thin" whether in health or disease, is one inseparable from the subject of food and force, for we have discovered that heat is but a mode of motion,* and that those elements of food capable * See Prof. Tyndall's Lectures : Heat a Mode of Motion. 6 PEELIMINAET EEMAEKS of liberating the largest amount of heat, may be utihsed as accumulators of fat by economising the motion and heat of the body, and vice versa. In the Chapter " On Food, Heat and Motion" I have introduced a table, shewing the composition of some of the inost impor- tant articles of food, and the amount of heat to be got out of equal quantities of each, and I have also stated the amount of mechanical force equivalent to a given quantity of heat. In order to elucidate the importance of fat, and the subject of getting fat or losing fat by alterations of diet, I have introduced some remarks on " Bantingism," on the means which promote the accumulation of fat, and on the importance of distinguishing between solid and Hquid fat. (See Chapter V.) Prom what I have already said, and from the articles referred to, it must be clear that nothing can take preced- ence of proper food among the means for the preservation of the public health ; and when health is lost, whether by unavoidable disease or by other causes, nothing can be more important than to understand the leading principles which should guide us in altering the food to meet the conditions of disease, and thus to convert diet into a powerful iustrument for the restoration of health. This is a subject which could not be fully discussed in a small work Hke the present, but in Chapter IV., " On some Prin- ciples of Diet in Disease," I have given some rules for the regulation of the food in various diseases, illustrated by Diet Tables for Consumption and Diabetes. The subject of Alcohol, which has of late years occupied so much attention, both in the scientific and in the reli- gious world, and which has been so grievously misrepre- sented and misunderstood, is now placed upon a more reasonable footing, some plain facts having been unques- tionably established by the dispassionate investigations of ON DIET AND BEGIMEN. 7 practical and scientific men. In this country we are particularly indebted to Dr. Anstie and Dr. Parkes for their investigations on this subject. (See Appendix I. and II.) It is now quite certain, as I have long maintainedj that alcohol is food — that is to say, that it is consumed in the body by a process of oxidation similar to that which other kinds of food undergo, that during its combustion force is liberated, and the demand, for other kinds of food dimin- ished. Alcohol, therefore, is able to save the combustion of the elements of tissue formation^ by vicarious oxidation of itself. It is quite certain that ahiohol is one of the most readily oxidisable substances capable of being introduced into the animal organism. In this consists its chief value and its chief danger ; for, on the one hand, it is a,ble to replenish the lamp of life with so little tax upon the digestive func- tions and with so little loss of time, that nothing can take its place when these are the desiderata of most urgent im- port. But, on the other hand, this extraordinary facility for oxidation makes the presence of alcohol in the system a most dangerous impediment to the coinbustion of those less readily oxidisable matters, the full and regular com- bustion of which is absolutely essential to the contiauance of normal health. It is quite certain that alcohol is not an indispensable article of daily food ; a normal diet may be perfectly well constructed without it, and a healthy person, under fa- vourable circumstances, can live without it, just in fact, as the lower animals do. But it is also quite certain that alcohol is a most blessed gift of Providence, when rightly understood and wisely used. It is the endowment of man with those higher attributes which principally distinguish him from the brutes, that constitutes the element in his O PBELIMINAET EEMAEKS nature which has made it necessary to his welfare that Providence should give him this peculiar article of food, in addition to all those placed within the reach of the less intellectual animals. Thus it is a fact, that while man is brutalized by the abuse of alcohol, its proper use is one of his distinctions from the brutes. Alcohol may perhaps be best described as a Medicinal Food. It is essentially a poison, although in its proper use it is- an indispensable element in the. life and happiness of highly civilized society. But it ought always to be regarded as a most treacherous friend. I have drawn up an "alcohol table," (see Chap. VI.), the result of many careful analyses of each article so as to pre- sent a fair average result, from which it can be seen, at a glance, what quantity by measure of each of the ordinary fer- mented liquors represents one ounce by weight of absolute alcohol. The table includes a statement of the proportion of carbon, and of some other matters, contained in fer- mented liquors, besides the alcohol. But it must always be remembered that different kinds of fermented liquors represent many other influences for good or evil, in a dietetic point of view, in addition to those possessed by the alcohol, all of which require consideration in selecting the particular beverage suitable to any given case. I have therefore devoted some pages to a consideration of the general and special properties of fermented liquors. - (See Chapter VI.) It will be observed that I have omitted aloehol from all the Tables of Normal Diet, leaving it to be added in any form and quantity that circumstances may render most advisable. According to my own experience, based upon long and careful observation, an average-sized adult man taking moderate exercise may drink with advantage ON DIET AND EEGIMEN. 9 enough fermented liquors^ eacli 24 hourSj to represent from one to two ounces avoirdupois of absolute alcohol* — provided it be always diluted to the extent of 10 fluid ounces (half-a-pint imperial) of water or some other un- fermented liquor to each ounce avoirdupois of absolute alcoholj " and that it be taken when there is food in the stomach. (See Chapter III.) Regimen, or the regulation of habits, could not be fully discussed without involving physiological and other de- tails which would have far over-run the limits of this book. I have, therefore contented myself with laying down, as concisely as possible, such rules as my own ex- perience, added to that of others, has taught me are most necessary and most suitable to the generality of persons. They must, of course, be modified to suit peculiar consti- tutions, idiosyncrasies, and other circumstances, and to meet the various conditions of disease. In connection with these Eules foe Maintaining Vigorous Health, I have introduced an article " on the Importance of Proper Hours for Meals," also a number of valuable suggestions " on Souse Drainage," for which I am indebted to an experienced architect, (see Chapter I.) On the subject of exercise and training, in addition to the rules I have laid down, I advise everyone to read "A System of Physical Education," by Archibald Maclaren, of the Gymnasium, Oxford, an admirable treatise issued from the Clarendon Press. As a necessary part of a work like the present, having for its object the preservation of health, I have added a chapter (Chapter VII.) on Disinfection, with rules for preventing the spread of the "Catching Diseases." It * It will be seen by tie resume of Dr. Parkes' and Count WoUowioz' re - cent experiments (see appendix) that their results confirm the opinion at which I had long before arrived, by a different process. 10 rEELIMINAET EEMARKS is one of the opprobria of the present day that these diseases are so culpably propagated by the negligence of the heads of families to insist upon precautions, now well known to be capable of preventing contagion and infection. And in Chapter VIII. will be found some special directions for the sick room. In concluding these preliminary remarks I must not lose the opportunity of expressing my opinion upon a matter regarding which there is great misapprehension, and, I regret to say, intentional misrepresentation. I refer to the subject of pseudo-medical-dogmas, such as are in- Yolved in the terms Allopathy, Hydropathy, Homoeopathy, Kihesipathy, &c., and in such expressions as "a stim- ulating system," "& depleting system," "similia simili- bus curantur," " contraria contraribus curantur," and the like. T disclaim t}),em all, and I feel sure that in this state- ment I express the sentiment of the majority of think- ing medical men. It is .utterly unworthy of the professor of a science and art so great as medicine, to " pin him- self" to such narrow dogmas and rules of thought and practice as are indicated by one and all of these expres- sions. The practice of eationai medicine — having for its sub- ject not only that most complex and wonderful fabric the animal organism, but that organism endowed with all those attributes which place man but " a little lower than the angels" — demands that there shall not be any- thing excluded from its service, and that every science and every art shall combine, at its bidding, to assuage the suffering and to save the life of Nature's highest earthly creature. Every honest and intelligent practitioner of rational medicine knows, that there are remedies of unquestionable ON DIET AND TlBGIMEN. 11 potency tlie action of which could never have been dis- covered by any such dogmas as "contraria contraribus curantur" or " similia simihbus curantur." On the other hand, he knows that there are remedies the action of which may appear to be explained by one or other of these principles, but that the more intimately we become acquainted with the occult properties of medicines and the occult physiology of diseases, the more plainly do we see that these apparent explanations of the modus operandi of remedies are absurdly superficial and incorrect. He will not, then, refuse to benefit his patient by the use of the one remedy because he cannot explain its action, or of the other because it appears to act by similarity, or of a third because he thinks it acts by contrariety. Again, he knows that the same disease may assume such different phases, in different constitutions, at different times and in difier- ent places that in one case it may require " stimulation," in another " depletion," that at one period of the same case, "water treatment" may be advisable, at another " gymnastic," at another " mechanical," at another " cU- matic." And he claims these, and all other means bene- ficently placed within our reach which can protect health or benefit the sick, as the legitimate weapons in the armoury of rational medicine. Every theory, every system, every dogma, must give place, at last, before the fact, once unquestionably proved, that such or such a remedy is best for such or such an • occasion. Therefore, in my opinion, all men who " pin their faith" on narrow dogmas, stamp themselves thereby as unfit for the practice of kational medicine. PART I. Chapter I. EULES FOE PEOMOTIIsrG AND MAINTAINING VIGOEOUS HEALTH IN ADULTS LIVING IN THE CLIMATE OE THE UNITED KINGDOM. VENTILATION AND HEATING — GAS HOUSE-DEAINAGB — CLOTHING AND PROTECTION FROM COLD SLEEP EXERCISE POSTURE ' — BATHING — REGULATION OE THE BOWELS — REST AND CHANGE — SMOKING — MEALS — PROPER HOURS FOR MEALS — AFTERNOON TEA. *#* These Rules wiR require to be modified by the medical man to suit special cases. VENTILATION AND HEATING. No sitting or sleeping room sliould be left long with- out a fire^ and every room in which persons live, either by day or by night, should have some opening by which it communicates directly with the outer air ; but this should be so arranged that no draught can fall upon the persons in the room; If several rooms are occupied by turns during the twenty-four hours, the temperature of any one should not differ greatly from that of the rest. No draught should ' blow upon a bed, and during sleep the whole body should have one covering at least of woollen material ; for, while it is very important to keep the air of sleeping rooms fresh, it must be remembered that the body is more susceptible to chills during sleep VENTILATION AND HEATING. 13 than waking, and that changes in the temperature of the outer air are especially apt to occur during the night, and are, therefore, in danger of producing chills before they are observed. (See Sleep). All arrangements for ventilation must be based upon the following facts : — The rate of respiration in an average sized adult man is about 16 times per minute, and each such respiration vitiates about 1 cubic foot of normal atmospheric air ; so that each adult man vitiates 960 cubic feet of air per hour, and consequently will require a supply of fresh air at that rate ; or in round numbers 1000 cubic feet per hour. This supply of fresh air can be provided by observing the following conditions : — A current of air travelling at the rate of 36 linear inches per second is not perceptible as a draught, and at that rate of movement 1 J cubic feet per minute or 75 per hour will be admitted by an aperture of 1 square inch sectional area, communicating directly with the outer air. If, therefore, an apartment is provided with an aper- ture having a ratio of 1 square inch sectional area to each 75 feet of cubic capacity, the whole air of the apartment will be changed onc6 per hour. Supposing, then, that the cubic capacity of an .apart- ment is in the proportion of 1000 feet to each person in it, the requisite supply of fresh air may be obtained, without draught, through an aperture of from 13 to 14 square inches sectional area to each 1000 feet of cubic capacity. But if the cubic capacity of the apartment is only in the proportion of 500 feet for each person in it, the aii- must be changed twice per hour in order to supply the requisite 1000 cubic feet of fresh air for each person. When gas is burnt in cm apartment the following facts must be borne in mind, in addition to the foregoing, for the purposes of ventilation : — 14 HOUSE-DEAINAaB. One cubic foot of ordinary London coal gas produces^ in burning, 2-tliirds of a cubic foot of carbonic acid, about tbe amount produced per hour by the respiration of one adult man, — and as an ordinary fish-tail gas-burner con- sumes about 3 cubic feet of gas per hour, it produces in that time as much carbonic acid as the respiration of three adults. In addition to this there are various highly injur- ious emanations from the burning gas. HOUSE-DRAINAGE. The following valuable practical suggestions from an ex- perienced architect, (Gr. B. Pbitcfett, P.S.A., P.R.I.B.A.,) I give in his own words, as conveyed in a letter to me. Architects have opportunities where other persons have not of observing the action of drains; the evil conse- quences of their misconstruction; of their too frequent proximity . to wells of drinking water through additions and alterations of buildings, or otherwise; of soakage from cesspools; of evaporation of water from so-called " traps," &c. The opportunities referred to must there- fore be my apology for venturing to address you on this subject, and you are quite at liberty to make use of the hints in this paper if they are likely to be of any service to the community. I will commence, then, my observations by the some- what startUng and unpleasant enquiry which should be put to every householder, "Where are your drains and cesspools situated?" This is a question very closely linked with the preservation of life and health as you are HOUSE-DEAINAGE. 15 aware; yetj on this enquiry being made, many tenants at once admit, that they do not know, that they have no idea ; that they have been in the house many years and are only aware, perhaps, of one drain from the scullery- sink which drips into a ditch or pond, or public sewer; that their fathers added a wing to the house, containing a large dining and drawing room, that there is at times a faint smell in these rooms, and the same unaccountable smell when a few friends visit them and when the shutters and curtains are drawn and good fires kept up ; that the ladies are constantly troubled with headache, nausea, and lassitude ; that the children are feverish at times, and death among them is not unknown ! Could these house- holders only see the old brick barrel-drain and the foetid cesspool, with its outlet cut off perhaps, inclosed in this wing, and the rats and insects working their holes in it 'a very little distance below the unventilated floors, they would get out of the house as quickly as their legs could carry them. If premises which have been added to from time to time are pulled down, and especially where a faint smell has been noticed, you may be greatly astonished to find a barrel-drain crossing the house, cut through or broken in before reaching the cesspool or outlet, and a mass of de- composing matter extending a considerable distance under the floors of the rooms, in consequence of the drain being stopped. This occurred without the knowledge of an unfortunate householder who at times perceived a faint smell, but having got used to it disregarded it : hav- ing, however, lost a valuable life in the death of the mother of his young family, and having carried some of his children to her grave, he determined to pull down the rooms and build more airy ones, little thinking what he should discover. It was in this case the want of quality in the air more than of quantity that caused his losses. 16 HOUSE-DEAINAGE. My object in mentioning such cases is to rouse every householder to trace his drains to their outlets, let him see that they are clear and that they have no holes in them, and that they are laid to a good fall. If premises are your own do not mind spending a few pounds. If necessary take out the barrel- drains and put in socket-pipes, truly and well laid on concrete, covered with concrete and jointed in cement, this will keep out rats and vermin and worms, and prevent noxious gases collecting under your floors. If your floors are not ventilated, see if this cannot be done. If you are about to purchase or hire a nice-looking newly-built house, do not for a moment suppose or take for granted that the drains are " all right," for in many new houses the drainage is only run out a little way from the walls and not led anywhere, but left for someone to complete after his family has been struck down, and who upon digging up his flower-beds and destroying the growth of his shrubs and everything else, in pursuit of the drains, finds that they are choked, and full of worms and black stufi", and go nowhere. Whether you occupy an old or a new house and pre- mises, caution is equally necessary. Look at all your surface-gratings, whether in your paths, your stable-yard, your conservatories, porches, lobbies, or wherever they may be, with great suspicion, especially in dry weather. People will sometimes say to themselves when walking about premises, " wherever does that smell come from V little thinking that the water has evaporated from the traps. These surface drains should not be connected with sewer drains at all, but should have a separate service of pipes. See where the rain-water descending pipes run to, look HOUSE-DEAINAGE. .17 well at the joints of these vertical pipes. If you notice discoloration of the paint at the joints^ you may know at once that they are connected with some cesspool or sewer-piping : e.g. a gentleman had low fever among his children, he could not assign any particular cause for it ; one of the rain-water pipeSj however, ran up the walls of his house, within a couple of feet of the nursery windows^ this pipe was painted stone colour, the paint at and above the unstopped joints in this pipe was turned to lead colour. The question as to where the water from that pipe went to was put to him, and answered by ''nobody knows." On examining, it was found (as might have been conjectured) to go into an hermetically sealed cesspool. Every time rain fell and water went into this cesspool, the sewer gas found its way readily through the joints of this pipe, and as the nursery windows were kept open as much as possible after the rooms were warmed by the young life in them, there is very little doubt where the source or origin of the enteric fever was lurking. As rain-water is valuable, have an underground tank to receive it, and an overflow pipe to it, separate from any sewer drain. Let the rain-water pass through a small filter- chamber, filled with shingle and charcoal, before entering the tank : this will take out flakes of soot and particles of leaves and vegetable matter, the water will then keep better. If you wish to know what size to make such a tank ascertain how many square yards of ground your roofs cover. About one hundred and twenty-six gallons of rain-water fall on an average every year upon a square yard of ground : a cubic foot of water is equal to about 6J gallons, you can therefore easily judge what size to make your tank. Touching upon soil pipes and cesspools in private c 1 8 HOUSE- DRAINAGE . houses where -there are no public drains, I would say that too much care cannot be taken to provide for circulation of air in all pipes leading to and from cesspools. Connect these pipes with a 4-iQch tube and carry it up higher than your chimneys on some stout lofty tree, or on some bxuld- ing only a short distance from the house, if possible, and towards the south of the house — as such air generally works towards the sun — and away from the house, if let out south of it. For your water-closets you will find a good D trap about the best check to any pressure of sewer-gas, as it will not be forced through a D trap so easily as through some of the modern shallow traps and syphons ,- but if you happen to have valve-closets, or light traps, a lead pipe can in most cases be put into the leaden bend and carried above the roof; then you will have an essential safeguard, e.g., it will be evident to all that when water goes down a soil-pipe a certain quantity of air must be displaced, this air will rush out into the closet unless am- ple provision is made for its escape elsewhere ; and as the act of a person pulling up a closet handle is first, to stoop, which causes him to emit his breath, and then to raise himself which causes him to inspire, it will be readily noticed that he is sure to take ia his breath at the moment when the water runs down the soil-pipe and the pent-up sewer gas rushes out close to his lungs. Keep the closet seat-flap down, cut holes in the flap to admit of the handle being raised when the flap is closed ; it will, however, be far better to ventilate your soil-pipes and drains. Water- closets should be flushed with a large pail-full of water now and then, because the small quantity of water com- ing in through the supply-pipe into the pan is insufficient for this purpose, especially when the handle is held up a very short time. Jenning's and Underhay's pans are HOUSE-DEAINAGE. 19 better supplied with water than manyj but even with these arrangements no suflScient flush takes pla,ce to well push on the excreta. When these accumulate, ammoniacal and other matters are formed and danger springs up, but there is not the same danger (if any) from fresh sewage. Do not allow slops to be emptied down your water-closets because some may be spilt and get between the seat and the pan, and gradually saturate the wood- work .beneath, causing decay and unwholesome faint smells. Have a pad of dry hair-felt sewn in an oilskin cover placed between the top of the pan and the wooden seat if there is any vacant space there; this will stop draught and the splash referred to. Lime-white with hot lime the floor and inside of the seat-enclosure annually ; this can be readily done by tak- ing ofi" the top or seat. The "effectual ventilation of water-close.ts situated as they often are, is by no means an easy matter. If you open the window, the warm house will quickly receive the smell you intended to go outside, and you will soon per- ceive that the air will not obey your commands. Have a space (however small) between the inner and outer doors of the water-closet; if this space is too confined for a wiudow get external air into it by tubes, this stratum of air will materially assist you, because it tends to balance and check the progress of the air in the water-closet be- yond ; but the better method is to lead a tube from the ceiling of the water-closet into the nearest chimney flue where there is smoke ascending, or where there is suflS- cient warmth to "make it act as you wish ; your water- closet will then soon be cleared of all disagreeables, a valve however, should be balanced in this tube to prevent any sudden down draft. Some provision should be made for disposing of slops c2 20 HOUSE-DEAINAGB. entirely away from the water-closet. People are little aware wliat odd things are put down water-closets. If plumbers told people the queer things they find in water-closet pipes they would not be believed. Water- closets should be strictly guarded^ and domestic servants cautioned against misusing them. The same oversight should be given to traps in sinks and elsewhere; these traps are often lifted off and not put on again, resulting in much- damage to the health of the servants and all the inmates of the house. Let all pipes from sinks, butler's pantries, baths, &c., discharge themselves free to the air before entering sewer drains : this plan can generally be carried out without difficulty or unsightliness. Have all junctions of water-closet pipes with the drains examined now and then, as the stopping often shrinks and the lead decays, especially if the stopping is made of Portland cement. The seating or fixing of the pan on to the soil-pipe should also be examined periodically so as to stop any leakage of sewer gas. All cisterns should be cleaned out once a year, and any deposit removed. If you have a "waste-pipe" in your cistern branched into the soil-pipe, which is too fre- quently the case, look well to it, for unless your drains are sufficiently ventilated, the sewer gas will be forced through the waste-pipe and may be absorbed' by the water in your cistern. If you have a painted lid to your cistern see if any discolouration has taken place ; if you find such to be the case you may be sure that sewer gas has es- caped into your, cistern. If you have drains from your basements and cellars be particularly careful to see that the traps are efficient and kept well suppHed with water ; the great importance of having this seen to is self-evident. Where do you sup- pose the supply of air to your sitting-rooms is frequently HOUSE-DEAINAQE. 21 drawn from ? if they happen to be over rooms or cellars with plastered ceilings, air will percolate from these into your- sitting-rooms. Tou can prove this by blowing a cloud of tobacco-smoke below ; or you may find it out accidentally through something bfeing spilt, such as paraflBn oil for instance. Have your cellars frequently limewhited and the floors cleaned. I will only slightly touch upon wells and drinking- water because it is impossible to exhaust such an impor- tant and interesting subject in a letter, but I do wish to observe, that every householder should know exactly where his well is situated, if he has one. People are little aware how soon drinking water is spoilt by a small leakage of surface-water, or drain- water into it, e.g., an additional drain is thought desirable, an ordinary bricklayer is sent for, who puts it in for you, not knowing that your well is in close proximity to it, or if he knows its situation you are not informed of it; the. conse- quence may be and often is most disastrous. Cases such as this are common through persons hiring houses (on a lease for instance) and who like to see the premises dry quickly after rain ; they do not know and do not trouble themselves to ascertain where their wells are ; but have extra drains put in without thought; their drinking water is spoilt ; the sequel is too certain and the evil often only found out when too late. To eSectually deal with the sewage of large towns so as to remove, and actually to convey away noxious matters from our very midst without the use of the present water system is a great diflSculty, and the prospect of any radi- cal change of the present system in London, for instance, seems an impossibility, on account of the gigantic net- work of sewers already provided and in use. Nevertheless, I will proceed to mention a few grave ob- 22 HOUSE-DRAINAGE. jections with the hope of an amehoration of some of them, by better attention to details in respect to the more effi- cient ventilation of sewers and the prevention of the in- gress of evil-smelling, if not of poisonous, gases into our houses. The worst form of sewer-gas is generally formed and found in the side drains, or branches, which are led up to our houses, and the contents of these are all but stag- nant when the main sewers are filling. Remove, there- fore, where possible, all inlets into the drains leading to the sewers from the interior of your houses. But it may be said that in the majority of cases this cannot be done without destroyir^g the drainage altogether ; the answer is, such cases are, comparatively speaking, few. Take drains from cellars for instance, how seldom they are of real service compared with the great danger of their presence. Cellars can be cleaned down without necessitating a trap and drain into the sewer. Deal with the cleansing of a cellar- floor the same as is done with a boarded floor, by wiping up the water and drying the floor as well as may be. Asphalte is very good for cellar floors, a ad very cleanly. Nasty traps in your cellars and basement, containing in themselves a quantity of stagnant dirty water communi- cating with the sewer, the gas in which can easily be forced into your house, is a grave form of evil. To cure this source of disease, simply dispense with the traps and drains and wipe your floors clean. By some thought and eontrivance it will be found that very many connections with the sewers can be avoided. Waste pipes, again, in cisterns connected with the soil- pipe and sewer should be dispensed with, and means to prevent occasional overflows of water when the badly fitting common ball-taps stick, should be provided for in another direction. Waste-pipes in cisterns connected with HOtrSE-PEAINAGl. 23 sewer drains are out-spoken examples of the stupidity, ■which, with an utter disregard to sanitary laws, persists in such suicidal arrangements. Surely there is great in- consistency in raising alarms about the impurity of Lon- don water, whilst at the same time it is not unfrequently contaminated with a poison through the waste pipes in cisterns which no filter can remove. Where connection with the sewers is actually necessary (as in water-closets) ventilate the soil-pipe by a vertical continuation of it to such a height as circumstances ■will permit. Water-closets uhould not be in the midst of our houses at all, but projected outwards with a lobby or anteroom, as before alluded to ; but it is quite surprising how few junctions with the sewer drains in houses are absolutely necessary. Every internal junction dispensed with is a step in the right direction ; get all connections, where pos- sible, outside your houses, because sewer-gas forced out in- to the open air is soon robbed of its noxious powers, but its escape into the interior of your house is as bad as a murderer entering it. A very sly insidious felon is sewer- gas ! The dry earth system is most excellent and effective, but the cost of bringing dry earth round and removiug that used in populous places would be heavy, and the in- trusion and inconvenience apparently great; time how- ever will show whether this system cannot be developed ■without such drawbacks. Moule's dry-earth system is most in use. Goux's absorbent closet system is equally effective, having been tried and adopted for the North camp at Aldershot, and even in so large a town as Hali- fax. Dry earth commodes, also, for sick chambers are very useful. As compared with the water-closet system, the earth 24 HOUSE-DEAINAGE. closet has several advantages. It is cheaper in its original costj it requires less repair^ it is not injured by frostj it is not liable to damage through hard substances being thrown into it, it greatly diminishes the quantity of water required by each household. My own experience is in favour of the earth system, if carried out under proper authorities. It is deserving of every consideration, but its merits at present are not sufficiently understood by the public to interfere much with the poisoned water system. Formidable sums of money are being spent in draining towns so as to lay on sewer-gas by means of ]pipes to our very bedroom doors. Is this right ? Will not the water system be superseded ? Cleanliness, after all, is the great natural disinfectant ; look well, therefore, to all sources of water-supply, impure water-butts, sinks, and particularly dust-bins; remove frequently all possible sources of nuisance and accumula- tions of impurities ; also, last but not least, get rid of any damp mouldy paper-hangings and the festering paste be- hind them, if you have any such sources of fever on your premises. There is an important lesson to be learnt by all of us. Every householder should make himself acquainted with so much of sanitary science as will enable him to preserve the health of his family. To secure health, sanitary laws must be understood and carried out. A family cut down by preventable sickness cannot be considered a fortunate one, and it is just as necessary to learn something of sani- tary laws to provide against this, as it is to provide the common necessaries of life. CLOTHING. 25 CLOTHING. In winter, the body and limbsj from tlie root of the neck to the toes and elbows, should be covered, next the skin, with some woollen material, such as lamb's wool or flannel. In summer, the material may be lighter, as merino, and need not cover the limbs. The same woollen dress should not be worn both night and day, but should be changed for a woollen sleep- ing vest of the same material as that worn during the day. (See Sleep). Having provided that the skin is so covered that it is protec.ted against sudden changes of temperature, all other clothing should be limited to that which is sufficient to preserve a, comfortable feeling of warmth under the different changes of the season and of the weather. Over-clothing, i.e., such as keeps the body perspiring while at rest or produces perspiration under very shght exertion, should be avoided, especially over-clothing of any one part of the body by which it is kept hotter than the other parts. It is of the greatest importance to keep the feet dry and as warm as the rest of the body. If the weather , is damp, this can only be done by wearing goloshes when out of doors. (See Bathing). A careful analysis, made by me, of a large number of cases of Wintee Cough, Cataebh, Bronchitis, Emphysema, Asthma, showed that fresh colds were the only causes which brought on or aggravated the cough in 72 per cent, of the cases, and_ the most frequent and potent causes of these fresh colds, as stated by the patients themselves, were : — 26 CLOTHING. 1. Sudden changes of temperature in 21 per cent. 2. Pogs and damp air in 19 per cent. •3. Draughts of cold air in 16 per cent. 4. Cold winds in 10 per cent. 5. Getting wet in 14 per cent. 6. Wet feet in 17 per cent. And the same list of causes of fresh colds were found to be the potent provokers of short hreathing. This important list is no less striking for the powers for evil which it is shown to possess, than for the remarkable simplicity of the evil powers them- selves. If, then, these unfortunate sufferers from Winter Cough could have been protected from sudden changes of tem- perature, fogs, mists, cold winds, draughts, wet feet, and wet coats and dresses, 72 per cent, would have kept free from their coughs. It would seem strange if we could not find means of protection against such common-place influences. In truth, there is no deficiency of means of protection against them, and it is because of the very common-place character of these means of protection and of the influences themselves that both are so much neg- lected and under-valued. But 72 per cent, of the cases of Winter Cough which I analysed might probably have been prevented by atten- tion to these common-place things. Let us then give a few minutes to their consideration. 1. Sudden changes of temperature. This is the most diflicult to avoid of any on the Hst. The occupations and amusements of all classes involve such changes, and we cannot stop these occupations and amusements, even were it desirable to do so. The workshop, the counting house, the committee-room, the opera-house, the ball-room, must be warm when the outer air is cold, and changes from one to the other cannot be avoided. But very much can be CLOTHING. 27 done to prevent the body from feeling these changes. The first and most important is the complete envelopment of the body and limbs in wool next the skin, thus inter- posing a bad conductor of heat between the surface of the body and the outer air. It is surprising that, even at the present day, this simple and common-sense protection is neglected by so large a number of persons both of the educated and of the uneducated classes. It is not suffi- cient for the purpose in view that a little body-vest should be worn just big enough to cover the thorax and abdomen, leaving the extremities unprotected. It should be insisted on by medical men that the arms and legs require to be protected from sudden transitions of temperature as well as the trunk. In fashionable life the greatest practical difficulty we have to encounter is the question of exposing the necks and shoulders of ladies in evening dress. It is useless to order body-clothing of w;ool to the throat, and to expect that ladies will give up a fashion which has been followed and thought charming in all countries and all ages. The difficulty is however, to be got over pretty well. Every lady in evening dress should carry with her, as invariably as she does her pocket handkerchief, a Shetland shawl or a mantilla of wool or fur, of a size and shape to cover all those parts not protected by woollen underclothing, and it should only be removed while actually within warm rooms and should be kept at hand to be replaced on passing through passages, or if the rooms become cold, or if sitting in draughts. The main source of protection, then, against sudden changes of temperature to the surface of the body, is to be found in a complete covering of wool next the skin. But besides this, much greater attention, than is common, should be paid to putting on and taking off complete and 28 CLOTHING. efficient over-clothing when going from hot to cold and from cold to hot temperatm-es. This is particularly neg- lected by the working classes and by girls and boys at school. "What I have said with regard to sudden changes of temperature will apply equally to two other causes of fresh colds on our list, viz.^ draughts of cold air^ and cold winds. Both are to be deprived of their sting by proper clothing of the skin and mucous orifices. Gretting wetj and wet feet occupy a very serious place in our list, and there is no doubt that damp and cold applied to the general surface is a most efficient means of producing chill and vital depression, with congestion of the internal organs. It is necessary that cold be com- bined with moisture to produce this effect. Even if all the clothes on the body are wet, no harm will come so long as they are kept warm, and this sug- gests the very great value, to all persons liable to ex- posure to wet, of light waterproof over-alls. They may either be put on to keep the underclothing dry, or, if the underclothing has become wet, either by weather or by perspiration, they may be gut on to prevent too rapid evaporation and consequent reduction of temperature, especially when the person is about to remain still after getting warm with exercise. In this variable climate, therefore, school girls, governesses, shop and factory girls, and all women whose occupations call upon them to brave the weather, ought to carry with them complete water- proof mantles made as light as possible, ' but extending from the neck to the ankles, which can be put on or not as required; and boys and men similarly exposed should carry waterproof over-alls. But if wet and cold to the surface of the body is a fruitful source of catarrh, wet feet — which means wet and CLOTHING. 29 cold feet — is a still more prolific source. There is no external influence which so surely produces congestion of the naso-pulmonary mucous membranOj as wet and cold to the soles of the feet. There is nothing so universally neglected, and yet there is nothing more easy to .avoid. Warm socks, horsehair soles, goloshes, provide efficient protection against wet and cold feet. It does not seem to be half understood that, although a shoe or boot may not be wet through, if the sole is damp it will, by con- duction and evaporation, most effectually carry away the heat from the sole of the foot, and, therefore, ought never to be worn after exercise is over. "We have still one item left on our list — viz., Fogs and Damp air, which were the things most inchned to make the breath short in 24 per cent, of the cases, and the most potent causes of fresh colds in 19 per cent. I have par- ticularly remarked, that although the smoke and other irritating matters constituting fog are unquestionably very injurious, it is the moisture and cold of the fog which are the qualities most potent for mischief to the naso-pulmon- ary tract. There is but one means of depriving a fog or mist of its injurious propetties, and that is a respirator ; and the same may be said of the changes of temperature of which I spoke just now ; a respirator is the only means of protecting the respiratory passages from the effects of transitions of temperature. Although it is quite proper to cover the neck and throat lightly, I am decidedly of opinion that warm wrappers round the neck are objectionable ; they produce conges- tion of the nasal and faucial mucous membrane and thus dispose to the very complants they are supposed to pre- vent. (See the Author's "-Lectures on Winter Gough, Catarrh, Bronchitis, Emphysema, Asthma," dehvered at the Royal Hospital for Diseases of the Chest, 3rd edit. Ghurehill). 30 SLEEP. I am glad to find tlie use of respiratorSj wMch I have so long advocatedj recently demonstrated in one of Professor Tyndall's beautiful lectures. (See appendix III.) SLEEP. During ordinary health, the hours spent in actual sleep should not exceed eight ; and if the sleep is sound, continuous and refreshing, six will be sufficient for many persons. (See Best and Change). It is of great impor- tance, especially with the young and the weak, to main- tain the due proportion between the number of waking and sleeping hours. If, therefore, it is necessary, as in going to places of amusement, , to sit up unusually late, the waking hours, thus spent, should be compensated by a similar number of sleeping hours, tahen in the preceding day; so that over-fatigue may be prevented. For ex- ample, if the usual hour for rising is 8 and for bed 11 and it is proposed to stay up till 3, the hour for rising should be changed to 12 ; or 4 hours rest should be taken at some other time during the day. During sleep, it is equally important to keep the body pleasantly warm, and to avoid keeping it over- heated; and, as serious changes in the weather may happen in the night, and the lowest temperature in the twenty-four hours naturally occurs between 2 o'clock and 6 o'clock a.m., the ventilation and clothing must be pre- pared for these contingencies. (See Ventilation, and Clothing). If sleep is taken after meals, it should not exceed half an hour in duration ; it should be taken sitting back EXEECISE. 31 in an easy chairj with the liead supported behind ; not lying down, and not sitting with the chin resting on the breast ; the feet should be kept warm, and the dress loose round the neck and waist. Every precaution should be taken to secure quiet sleeping-rooms. EXEECISE. During ordinary health, some part of every day ought to be spent out of doors; and in ill-health it is of great importance not to discontinue the observance of this rule without good reason ; for, although in certain states of disease it may be very important to remain, in-doors, it must not be forgotten that proper clothing, goloshes, respira- tors, and unbrellas, may make it not only safe but advan- tageous to go out of doors for exercise, when, without them, it would be very injurious. (See Posture). Out-of-door exercise should be as active as the strength will allow, and should always be continued up to the point of shght — but not over — fatigue. This will be the best measure of the proper amount for both the weak and the strong. Unless the air is pure, and the person strong, exercise before breakfast is more hkely to do harm than good; a tumbler of milk and a biscuit, however, will be a sufficient meal to take before the walk or ride — a more substantial breakfast being taken afterwards. (See Meals). * Especial care is needed not to expose the body to chills when heated by exercise ; and cold drinks should 32 EXERCISE. not be taken at that time, unless the exercise is about to be continued immediately ; and even then the quantity of cold drink taken at once should be very small. (See Meals). In his work " on Physical Education/' already referred tOj Mr. Maclaren makes the following excellent remarks : " Such in brief is Exercise, such the ends which it accomplishes, and such the manner of their accomplish- ment ; viz. the destruction of the tissues, the hastening of the decay and death of every part coming within its in- fluence; but also the speedy removal of all waste, the hastening forward of fresh material for its replacement ; and in doing this it attains three distinct but co-relative results. "1. It increases the size and power of the voluntary muscles employed. "2. It increases the functional capacity of the involun- tary muscles employed. " 3. It promotes the health and strength of the whole body, by increasing respiration and quickening circula- tion." "It is health rather than strength that is the great requirement of modern men at modern occupations ; it is not the power to travel great distances, carry great bur- dens, lift great weights, or overcome great material ob- structions ; it is simply that condition of body and that amount of vital capacity, which will enable each man in his place to pursue his calling, and work on in his working life, with the greatest amount of comfort to himself and usefulness to his fellow men.. .,.*.. Let it not be inferred from this that I consider health and strength as in any manner opposed to each other, on the contrary, they are most intimately allied and are, usually, by the POSTUEE. 33 same means and by the same manner obtained j very closely are tbey connected but they are not the same, and a man may possess either without the other." A most important principle in Exercise, and one which should ever be borne in mind, is, that it should be regu- lated by individual fitness ; for the exercise that scarcely amounts to exertion in one person will be injurious and dangerous to another, and not only is this inequality observable among different individuals, but, the same individual may have parts of his body possessing special power or presenting special weakness. A man may have limbs capable of transporting him at the rate of four miles an hour throughout the day, and for many days in succes- sion, but with heart or lungs all unequal to the effort. Or he may have an organization so frail and a temperament so susceptible to stimulation or excitement, that the one is an abiding danger to the other." When there is no heart or lung disease to interfere, there is no form of gymnastic exercise, so generally e£B- cient as " skipping backwards." POSTUEE. It is of great importance to acquire a habit of drawing the breath deeply and slowly, so as to expand the lungs freely during ordinary breathing. This re- quires that the head and shoulders be thrown well back in walking, sitting, and standing, and that no qlothing be worn tight round the ribs. Those engaged in sedentary or stooping occu'pations should especially attend to this advice.* * See Appendix V. " On the importance and dangers of Eest in Con- sumption." , 34 BATHING. Those whose occupation obliges them to maintain the erect posture for a number of hours each day, should take every opportunity of lying flat down, even if only for a few minutes at a time. They should also bear in mind that standing will not take the place of walking exercise. (See Exercise). All persons whose pursuits require the long continu- ance or frequent assumption of any particular position or movement' of the body or limbs, should take every op- portunity of changing it for an opposite position or move- ment. (See Rest and Change, and Sleep).* BATHING. Warm baths, Turkish baths, vapour baths, shower baths, and cold plunges, should only be used under special medi- cal orders. During ordinary health, the skin of the body and limbs should be smartly rubbed, once in twenty-four hours, first with a rough towel wet with cold water, and then with a dry one till in a glow. The bather should stand on a dry rug while using this " cold friction hatji.i" and it should not last more than one or two minutes,: in- cluding both the wet and the dry rub. Salt may be ad- vantageously added to the water ; and th'e bath may be used either on rising or going to bed, according to the feelings and convenience of each individual. When water cannot be borne cold, it must not be used tepid, but very hot. — The momentary application of very hot water to the * For " Gymnastics" see Mr. Maclaren's " System of Physical Educa- tion," already quoted. For effects of unhealthy posture, see Mr. Heather Bigg'a "Orthopraxy." REGULATION OF THE BOWELS. 85 skin, immediately followed by a brisk friction^ will pro- duce a direct-action glow nearly approaching the re-action glow following the application of cold. If the weather is very cold or the person delicate and chilly^ the upper half of the body should be un- covered and rubbed first, and then a woollen vest should be put on and the lower half uncovered and rubbed. It is well to accustom the feet to being washed in cold water, but it must be done cautiously at first, and they should never be kept in the water more than a few seconds. It is obvious, that there are times when cold bath- ing of all kinds must be temporarily discontinued. REGULATION OF THE BOWELS-. As a general rule, the bowels ought tO' act, at some stated time, once in the twenty-four hours; and it is best to accustom them to act in the morning, after break- fast. If they do not act spontaneously, they should be assisted by some wholesome article of diet which is found to affect them ; or by some harmless aperient medicine, which must be prescribed by a medical man, to suit the particular case ; for the best aperient for one person may be the worst for another. Provided that an aperient medicine is suited to the case, contains no drug injurious to the general health, and is not taken oftener than every second night, there is no harm in taking it at bedtime, whenever the bowels have not acted satisfactorily during the day. d2 36 SMOKING. REST AND CHAKGE. Active life is essential to the health of body and mind ; but both require periods of rest, in addition to the regular hours of sleep. It is much better, therefore, to work vigorously for a time and then to rest, than to keep up a monotonous round of lifeless drudgery. (See Sleep, and Exercise). The "current of the thoughts" is to the mind what posture is to the body ; and both require change to pre- vent weariness and deformity. (See Posture). Eest of body or mind may be obtained either by abstaining from all bodily or mental exercise, or by change of occupation, and as the one gives entire rest and the other only partia.1 rest, it is best to adopt each of these measures at different times. It must be remembered, that as the mind acts by means of the brain, which is a part of the body, it cannot act healthfully while the body is suffering under disease or exhaustion. The " godi^' of the mind is affected by the condition of the brain ; as much as the " gait" of the body is affected by the condition of the limbs. SMOKING. A certain number of persons have a peculiar susceptibil- ity to the poisonous influence of Tobacco, and they should never touch it. But for the majority of adults a moderate amount of smoking does not appear to have any seriously deleterious influence, and in many it acts as a useful anti- dote to brain-worry. SMOKING. 37 A careful and extended examination of the influence of Tobacco on the health of individuals and communities, gave the following results. (Social Science Review, July 11, 1863;. " 1. The effects that result from smoking are due to different agents imbibed by the smoker : viz., carbonic acid, ammonia, nicotine, a volatile empyreumatic sub- stance, and a bitter extract. The more common effects are traceable to the carbonic acid and ammonia ; the rarer and more severe to the nicotine, the empyreumatic sub- stance, and the extract. " 2. The effects produced are very transitory, the poi- sons finding a ready exit from the body. "3. All the evils of smoking are functional in character, and no confirmed smoker can ever be said, so long as he indulges in the habit, to jpe well ; it does not follow, how- ever, that he is becoming the subject of organic and fatal disease because he smokes. " 4. Smoking produces disturbances : — -{a) In the blood, causing undue fluidity, and change in the red corpuscles : (&.) on the stomach, giving rise to debility, nausea, and in extreme cases, sickness : (c) on the heart, producing debility of that organ, and irregular action : {d) on the organs of sense, causing in the extreme degree dilatation of the pupils of the eye, confusion of vision, bright lines, luminous specks, and long retention of images on the retina ; with other and analogous symptoms affecting the ear, viz., inabiHty clearly to define sounds, and the annoy- ance of a sharp ringing sound Uke a whistle or a bell : (e) on the brain, suspending the waste of that organ, and oppressing it if it be duly nourished, but soothing it if it be exhausted : (/) on the nervous filaments and sympathe- tic or organic nerves, leading to deficient power in them, and to over secretion in those surfaces — glands — over 38 .SMOKING. whicli the nerves exert a controlling force : {g) on the mucous membrane of the mouth, causing enlargement and soreness of the tonsils — smoker's sore throat — redness, dryness, and occasional peeling off of the membrane, and either unnatural firmness and contraction, or sponginess of the gums : (h) on the beonchial subiaob of the lungs when that is already irritable, sustaining the irritatioa, and in- creasing the cough. "5. The statements to the effect that tobacco smoke causes specific diseases, such as insanity, epilepsy, St. Vitus' dance, apoplexy, organic disease of the heart, cancer and consumption, have been made without any sufficient evidence or reference to facts; all such statements are devoid of trath, and can never accomplish the object which those who propose them have in view. " 6. As the human body is mqjintained alive and in full vigour by its capacity, within certain well-defined limits, to absorb and apply oxygen ; as the process of oxydation is most active and most required in those periods of life when tlie structures of the body are attaining their full development; and as "tobacco smoke possesses the power of arresting such oxydation, the habit of smoking is most deleterious to the young, causing in them impairment of growth, premature manhood, and physical degradation. . . . ..." Taking it all in all, stripping from the argument the puerilities and exaggerations of those who claim to be the professed antagonists of the practice, it is fair to say, that, in the main, smoking is a luxury which any nation, of natural habits, would be better without. The luxury is not directly fatal to life, but its use conveys to the mind of the man who looks upon it calmly, the unmistakeable idea, of physical degradation. I do not hesitate to say that if a communiby of youths of both sexes, whose pro- genitors were finely formed and powerful, were to be MEALS. 39 trained to the early practice of smoking, arid if marriage were to be confined to the smokers, an apparently new and a physically inferior race of men and women would be bred up. Of course such an experiment is impossible as we live : for many of our fathers do not smoke, and scarcely any of our mothers, and thus, to the credit of our women, chiefly, bo it said, the integrity of the race is fairly preserved: with increasing knowledge we may hope that the same integrity will be further sustained: but still, the fact of what tobacco can do in its extreme action is not the less to be forgotten, for many evils are main- tained because their full and worst efiects are hidden from the sight " If I were equally fair for tobacco as against it, I should be forced to give it a place as one of the least hurtful of luxuries. It is on this ground, in fact, that tobacco holds so firm a position : — that of nearly every luxury it is the least injurious." MEALS. Counting from the time of beginning one meal to that of beginning the next, food should be taken at regular intervals of from four to five hours ; except the interval between dinner and a very slight tea, which may be re- duced to two or three hours. In weakly persons, and vrhen the appetite will allow only a very small meal to be taken at one time, the intervals between all the meals may be reduced to from three to four hours. In illness, the interval must be ordered day by day by the medical man. The chief meal of the day — the full meal— by what- 40 MEALS. ever name it is called, should be taken at whatever hour active occupation, both bodily and mental, can be sus- pended for about two hours; provided always that not less than two hours elapse between the conclusion of the full meal and bedtime. Breakfast should be the second best meal of the day, and should be taken leisurely immediately after rising in the morning. (See Exercise) . The other meals should be taken punctually at the fixed hours, but should be only light refreshments, and small in bulk. No food should be taken in the intervals between the regular meals. As a general rule, pure water may be taken at any time, if indicated by thirst, so that the body is not heated by exercise, and the quantity drunk at once does not ex- ceed a quarter of a pint. (See Exercise). Spirituous liquors should not be taken the first thing in the morning or the last thing at night, without medi- cal orders, they should not be taken when the stomach is empty, and they should not be drunk stronger than in the proportion of one ounce avoirdupois of absolute alco- hol in about ten fluid ounces of liquid. (See Alcohol Table.) One of the principal sources of mischief in the use of alcoholic liquors is the practice of taking them to quench thirst in the place of unfermented drinks. The sense of thirst is a call from the organism for water, not for alcohol. Let the alcohol be taken as food, as medicine, or as a luxury, but not to quench thirst in the place of those un- fermented liquors which are essential to health as diluents and solvents. (See Alcohol Table ; Eemarks on Alcohol in " Preliminary Eemarks ;" Chapter VI.; and Appen- dixl- PEOPEE HOURS FOE MEALS. 41 Alcohol Fasts. — Those who habitually take alcohol daily, should abstain from it entirely for a few days>twice or thrice a year. PROPER HOURS FOR MEALS. Substance of a letter by the Author addressed to employers of labour, and printed for private circulation, 1852. That animal life cannot go on in even passable health and comfort without sufficient food and effectual digestion, is a fact perfectly familiar to all ; yet, unhappily, among those who live an in-door life, effectual digestion is scarcely ever known. They constitute the bulk of that enormous number of persons who suffer from what is popularly known as " indigestion." Now, there can be no question that they are pre-dis- posed to this class of diseases by many circumstances, quite inseparable from their occupations. But that makes it the more desirable to avoid all those causes of disease which are not necessary to their pursuits. 1 am not sipeaking oi &nj particular form of indigestion, but in a general and broad sense, of all those various maladies classed under the popular term. The choice of the hours at which clerks, shopmen, me- chanics, labourers, and other business-servants of both sexes take their meals, depends almost entirely upon the decision of their superiors. If these hours are not well chosen, indigestion, in some form, is the certain consequence sooner or later. And it will be seen from the few plain facts which I shall de- tail, that the notions which have long prevailed as to the proper hours for taking food, and consequently the regu- 42 PROPER HOURS POE MEALS. lafcions of nearly all business establishments, in this re- spectj are inconsistent with the conditions which physio- logy teaches us to be essential to healthy digestion, with the requirements of the various occupations by which servants gain their livelihood, and with the conventional arrangements of society in the present day. I shall hope, by avoiding all technicalities and minute physiological details, and by employing the plainest popu- lar terms, to make my meaning perfectly intelligible to the unprofessional, to whom, in this instance, it is neces- sary to address my remarks ; and I now ask particular attention to the following statement of the conditions ne- cessary to healthy digestion. 1. Pood of appropriate quality and bulk. 2. In the case of a full meal, — rest of body and tran- quility of mind for a short time previous to taking food, and for at least an hour afterwards. In the case of a light meal, — gentle exercise, and moderate mental activity may be allowed with impunity. 3. Effectual mastication, by which the alimentary mat- ter is completely disintegrated and saturated with saliva, and the meal taken slowly. 4. A sufficient interval between any two meals, to allow the first to have been digested and removed from the sto- mach, long enough for the digestive functions to regain their full vigour, before the second is introduced. The period which should intervene will depend upon the rapid- ity of digestion, which may vary according to the quantity eaten, the state of the health, the nature and amount of the previous exercise, the condition of the mind, and many other circumstances. 5. Caution that the stomach is not left empty long enough for the system to become exhausted, and the di- gestive powers thereby weakened. PROPER HOURS rOE MEALS. 43 6. Strict adherence to the same hours for taking food, that the stomach may acquire a habit of preparing for its reception. 7. An interval between the last meal and bedtime, suffi- cient to allow the work of digestion to be concluded be- fore lying down to sleep. Many other conditions might be mentioned, but as the few main points already stated are enough for our present purpose, I shall confine myself to them. The circumstances under which the majority of those persons are placed, whose health we are principally con- sidering, must now be reviewed, in order to compare them with the conditions essential to healthy digestion, and to draw the necessary conclusions as to the proper hours foe MEALS. From the factory artisan up to the banker's or mer- chant's clerk, several important circumstances are com- mon to all. 1. The day is devoted to labour either of the 'body or of the mind, or of both. 2. Business must be continued unremittingly up to the moment of leaving for meals, and resumed immediately on returning from them. 3. The time which can be spared for meals during busi- ness hours, must necessarily be very limited. 4. Some portion of this short time must be occupied in repairing to, and returning from the refreshment place. In many instances, especially in retail trades, the nature of the business renders it impossible to keep to fixed times for those meals taken during working hours. The fact of taking time for meals out of the middle of the day, necessarily makes it later in the evening before the business can be finished ; and this not only to the extent of the time during which work is actually stopped; 44 PROPER HO0RS FOE MEALS. for we all know how much the progress of business is interrupted by the simple acts of discontinuing and recom- mencing it, more especially when books and calculations are concerned. The effects of these combined circum- stances may be viewed daily by visiting the public dining rooms attended by clerks, the lodgings of labourers at their dinner hour, and the offices and factories before and after meal-time — dinner-time more particularly, and din- ner being the principal meal in the day — the full meal — it is of it that I shall chiefly speak. Twelve, one and two o'clock seem to be the national dining hours for the working classes, and sixty minutes the maximum time allowed from business for this chief meal. The hour having arrived, books or tools are hastily laid aside, and the dining place is reached by a sharp walk, which adds to the bodily fatigue of the labourer, and is not long enough or sufficiently leisurely to rest the brain of the accountant. The dinner must be despatched hurriedly, or there will not be time for the artizan to smoke his pipe, or for the clerk to glance at The Times ; or perhaps the reading and eating are carried on at once. Mastication is carelessly performed, the mind is kept occupied, and the stomach rapidly loaded with food before it has had time to make ready for it ; and, in some cases a larger quantity is taken than the stomach has power to dispose of, simply because it is introduced too expedi- tiously for the system to become acquainted, as it were, that the supply of its wants is being effected. The meal finished, and the paper glanced at, or the pipe smoked, the sharp walk must be repeated, now with a full stomach, and business resumed before digestion has had time even to commence : and at this period, when the organic ener- gies ought to be all concentrated about the stomach, they are at once summoned to the brain or to the muscular PEOPEE HOUES FOE MEALS. 45 system. Consequently, the meal remains imperfectly di- gested, or not digested at all, lingers in the stomach beyond its proper time, and is finally expelled in an un- natural condition, unfitted to undergo the important changes necessary before it can be appropriated for healthy nutrition. In all probability the next meal is introduced before the former one has entirely left the stomach, and thus the mischief is increased. Compar- ing the circumstances, here briefly enumerated, with those essential to healthy digestion, laid down before, the antagonism, so evident between them, plainly shows that " Dyspepsia," or difficult digestion, is only the natur- al consequence of so persistent a disregard of the laws of health. I am aware that different businesses do, from their na- ture, present various obstacles in the way of carrying out such sanitary measures as are most desirable, and that one set of rules will not always be practicable in two establishments. Therefore, I should advise that the few principal conditions of healthy digestion before mentioned be carefully borne in mind ; and that in each establish- ment the hours for meals be so selected, that these con- ditions and the calls of business may be arranged in unison with each other. For a considerable period of time, during which my attention has been more particularly directed to this subject, I have made extensive inquiries on points con- nected with it, among employers and their servants, and have also had sufficient opportunities of enforcing the better regulation of meals upon both classes, with effects so decidedly beneficial, that I can with confidence impress the importance of the alterations I propose, and I am convinced of their general practicability. After this experience and a mature consideration of the subject 46 PEOPEK HOUES FOE MEALS. scientifically, I beg leave to call attention to those re- gulationSj which appear to me to afford the nearest ap- proach to the healthy standard that can be practicably arranged to meet the necessary obligations of business establishments in general.* Let me assume that a substantial breakfast has been taken^ soon after rising, and a short space of time allowed to elapse between the meal and the commencement of active business : — (in those cases where the hour for busi- ness is very early, the breakfast should be divided, the fast being broken by a light fluid meal, and a second light meal taken some hours after). But to return to the better plan. Breakfast having been taken, and the day's employment commenced, the arrangements are now under the direction of the employer. From this moment until labour, whether 7nental or bodily, has ceased, no JVLh-meal should be allowed. This is to be considered the first GOLDEN ETTLE. The SECOND is not less important — that some light refection should be taken punctually every four or five hours. By adhering to the first rule, the system will never be charged with the task of active digestion at times when it is amply engaged in other functions ; the digestive organs will not be injured by being called upon to undertake what they cannot properly perform ; while the servant will not suffer from that oppressive languor and inertia, so unavoidable after a full meal, and will be so much the better fitted for his duties. By the second rule the system is maintained in a state of energy; the light refreshment, being easily digested during bodily or mental activity, supports the strength much more than a full but ill-digested and unassimilated meal can possibly do, and leaves the stomach itself unwearied, in a state of * This was written twenty-three years ago and subsequent experience has amply proved the value of the rules laid down. PEOPEK HOURS FOE MEALS. 47 healthy vigour when the hout of relaxation from business arrives. Even in weak persons, a light meal will almost invariably have quitted the stomach in four or at most five hours, and in the strong considerably sooner than this ; at intervals of four or five hours, therefore, according to the strength of the individual and the rapidity of his diges- tion, the stomach will be preparing for fresh work, and will call for it by the return of appetite, which must not on any account be disregarded. And in this place I must again impress ihe serious importance to health, of not NEGLECTING THESE OCCASIONAL EEFEESHMENTS DUEING BUSI- NESS. The day's labour over, the objections to taking a full meal are at an end, provided the second golden rule has been observed ; and the amount of refreshment, necessary to repair the wear and tear of the day's exertions, may now be taken with decided advantage. I must here re- mind both employers and employed, that rest of mind and of body are necessary for a short time before taking a meal. To those who have been mentally occupied with sedentary business, a short leisurely walk will be a very proper prelude to dinner; but to those whose physical powers have been taxed during the day, there should be a short period of perfect rest before commencing the chief meal. It is a habit too common among commercial men to return home, impatient for their dinners, and to com- mence eating immediately, while in a fatigued condition. I have, in many instances, induced such persons to lie down for a quarter of an hour before beginning their meal; and have seen so much benefit arise from this practice, that I can confidently recommend it to all who are actively engaged during the day. When the dinner is finished, one hour at least should be devoted to mental and physical tranquillity — some leisurely amusement being 48 PEOPEE HOUES POE MEALS. f referable to sleep. (See Sleep, Chap. I.) When the meal has not exceeded the bounds of moderation, a sufficient quantity of gastric fluid for the digestion of the whole will generally be secreted within this period of rest ; after which, the same quantity of blood and nervous energy being no longer required by the stomach, some more active employment of the mind or body may be indulged in, and all will go on well. The full meal of the day, then — the dinner — should, under ordinary circumstances, be taken between the hours of five and seven p.m., which will allow time for it to be entirely disposed of before the hour of sleep arrives ; and as the whole night passes without refreshment, a light refection such as our national "tea," is very desirable about three or four hours after dinner. These arrangements will be found perfectly consistent with the essential conditions of healthy digestion; and, with a little contrivance and modification of hours in particular instances, are practi- cable in the majority of large establishments. And here let the friends of " early closing" observe, that by doing away with the injurious, mid-day dinner, there will be so much saving of time in the best part of the day, and con- sequently a better opportunity of concluding business earlier in the evening. It remains for me briefly to point out some of the incon- sistencies of the system now most popular among dyspep- tics and those employed in business. The dinner being taken at one or two o'clock must necessarily be a hurried one ; it is impossible in the middle of business to allow time for rest, before or after the meal, to any serviceable extent : the evil consequences of this, in a large number of instances, have been already referred to. The " tea" being taken between five and seven o'clock, can only be a light meal, for the stomach does not require more so soon AFTERNOON TEA. 49 after dinnerj therefore there is but one alternative, to leave the system without substantial nourishment from two o'clock p.m.j until breakfast next day, or to take another meal just before bed-time : of the two the latter would be the better, if the supper could be limited to a very mode- rate refection; but after waiting from an early dinner until nine or ten o'clock in the evening, a person in health has too good an appetite to be contented with this ; there- fore the stomach is loaded at a time when it cannot empty itself properly before the hour of sleep ; the disadvantages of which are too famiHar to need repeating here. Any one, therefore^ who is anxious to regulate his diet accord- ing to the popular ideas of what is healthy, finds himself in this dilemma. He believes it to be an essential point that he should dine at an early hour. He knows that rest before meals, eating them slowly, and rest after them, are all necessary to proper digestion. He also knows per- fectly well that, in the middle of the day, his business will not allow him either the rest or the leisurely dinner. Supper he is convinced is a most unwholesome meal, yet he knows from sore experience, that to fast from his early " tea" until next morning, leaves him too exhausted to sleep comfortably^ to rise with vigour, or to enjoy break- fast. At length, if he reason at all, it becomes clear to him that to do what he thinks right in one respect, he must do wrong in another — a suflBcient proof that there is error in the whole system. AFTERNOON TEA. Some remark is necessary in reference to the now pre- valent custom, among the upper classes, of dining very lace 50 AFTERNOON TEA. , and taking an afternoon tea. Unless cautiously arranged it is apt to lead to dyspepsia. The rule should be that the tea should precede the dinner by three hours^ and not come sooner after lunch than three hours, assuming the lunch to have' been a good meal ; and if any tea or coffee is taken after dinner it ought to be immediately after, so as to constitute part of the same meal, and to partake in the same process of digestion. It is most injurious to take tea or coffee from one to two hours after dinner or any other full meal. Finally, on going to bed, or about four hours after dinner, a tumbler of water should be drunk to clean .the stomach of the debris of the last meal. This will promote a refreshing sleep and a clean mouth in the morning. Chaftee II. FOOD, HEAT, AND MOTION. A FOOT-PODND, A FOOT-TONj A BEITISH UNIT OP HEAT — MECHAN- ICAL-EQUIVALENT OP A BRITISH UNIT OP HEAT COMBUSTION OP CARBON, CONSUMPTION OP OXTSENj EVOLUTION OP HEAT MODE IN WHICH THE HEAT EVOLVED PEOM POOD IS DISPOSED OP — COMPOSITION OF SOME OP THE PEINCIPAL ARTICLES OP POOD AND THEIR HEAT-EQUIVALENTS AND MECHANICAL EQUIVALENTS "WEIGHT AND COST OP POOD COMPARED WITH WORK PRODUCED — USES OP NITROGENOUS AND NON-NITEO- GENOUS POODS. *»* See Eas'entials of a Normal Diet. Chapter III. The relation between food, heat, and mechanical force has been the subject of some of the most important in- vestigations of late years, and the light which has been thrown upon it is one of the greatest steps in the progress of medical science. But so far as medical art and practice are concerned, very little application has yet been made of this advance in scientific knowledge. This is only what might be expected, considering the occult nature of the subject, and the scarcity of time among the great body of medical practitioners to master and familiarise them- selves with the details of such departments of medical progress. Nevertheless, it is high time that such facts as are at present known, and such applications of them as are at present possible, should be added to the common stock of knowledge possessed by practical medical men ; for it is only in this way that the public can derive benefit from our advances in science. E 2 52 rOODj HEATj AND MOTION. For the purpose^ therefore, of enabling practitioners easily to familiarise themselves with these matters, the following concise statement has been prepared^ : — 1. A Foot-pound is the amount of mechanical force re- quired to raise a pound weight one foot. 2. A British Unit of Heai is the amount of heat required to raise the temperature of one pound of water one degree Fahrenheit. 3. This amount of heat (a British unit) may be convert- ed into mechanical force sufficient to raise a pound weight 772 feet. 4. This amount of heat (a British unit) is generated by a pound weight falling through a space of 772 feet. Hence 772 foot-pounds is called the Mechanical Uquivalent of a British unit of heat. 6. One ton weight is 2,240 lbs.; ^ = 0-34465; therefore, the heat units multiplied by 0'34465, will al- ways give the mechanical equivalent in Foot-tons. 6. The heat of combustion of carbon and hydrogen fully oxidised (to 00^ and H^O) is as follows : — , „ fO evolves 14,5001 I H 62 032 1 ■^^iti^''^ Units of Heat. 7. The total heat of combustion of a compound contain- ing H and is the sum of the quantities of heat which the and H contained in it would produce separately by their combustion. 8. It has been found that the presence of Hydrogen with Oxygen in the proportion to form water does not affect the total heat of combustion. It is only the excess of Hy- drogen that can be made serviceable as a source of avail- able heat. 9. The mean consumption of oxygen by an adult man of average stature (weight 150 lbs.) taking ordinary exer- cise is about 30 ozs. avoirdupois in 24 hours, and the FOODj HEATj AND MOTION. 53 heat evolved by each 1 oz. of oxygen in combining with carbon, hydrogen, etc., is about 340 British units. Hence, 10,000 British units of heat will be evolved every 24 hours by the combination of 30 ozs. of oxygen with carbon, hydrogen, etc.; therefore, the food of an adult man, under ordinary circumstances, should be such as may, in addi- tion to other purposes, evolve at least 10,000 British units of heat. 10. Practical experience in the dieting of large num- bers of men, and other means, have enabled us to establish the fact, that such an average man, as above described, requires, for the maintenance of health, a diet which shall contain about 4 ozs. of plastic materials, 3 ozs. of fat, and 10 ozs. of carbo-hydrates ; and on careful analysis of this diet, we find that it can supply the required 10,000 British units of heat — viz., 2,516 from the plastic, 3,357 from the fat, and 4,150 from the carbo-hydrates ; total, 10,023. 11. The mode in which these 10,000 British units of heat are disposed of, and the purposes' which they serve, may be seen in the following calculation which has been made as nearly correct as possible. 8,000 British units are required as sensible heat, — to raise the temperature of the inspired air to the temperature of the body, to vaporise the pulmonary halitus, and to maintain animal heat. The mechanical equivalent of 2,000 British units (equal to 690 foot-tons) is expended in actual work, more than half of which is employed in internal vital work (the mechanical work of the heart alone is equivalent to 200 foot-tons ; respiratory and other vital movements may be estimated as equivalent to nearly 200 foot-tons more), leaving about 290 foot-tons available for external work, which may be represented by the labour of walking 16 miles; but of course only so much is available for 54 FOODj HEAT, AND MOTION. actual walking, as is not used in tlie other external move- ments of tlie body, which we daily perform. (See Chapter IV.) In the following tafele the conditions laid down in No. 6, 7, 8, of the foregoing paragraphs have been observed in calculating the British units of heat given in the last co- lumn but one, and the mechanical equivalent of the Heat- units given in the last column, has been calculated by the rule stated in paragraph 5. FOODj HEATj AND MOTION. 55 Si's i °S ■g a 03 -+J o u ■" a '2 3 a o P o m P ^ e3 ^ a • J S3 CO Q^ n 3 o S .3 ,=1 ° =" a s w ,^ 5 I ■3 a 'S s » m g O oj Q ;-s i I a "S^ o e B «^ & (D a (D ' — I in to S •SUOJ JO 01 ui luajEAinbg in o in o ui ■^ H po N t-* VO lO ^ H H VD ID >0 M O « CO « ^ ^p OO CTi CT rn b M inoo ro t^ M en t-i o o o o m ro*o o H ro^D H in H b in t^oo r!- ro mtnininoino moo t|-M»£) OlM 01 oio t-^u-ir--. r^ 0^^0 O io O) O^ a\\0 lO ro M m O^ CJIOO ro O inMVOfOM O) O rorow OfOrOWw ro*0 CO O « 00 tN. roco Ino^al^^^NO o\n roini>- ■^^o o co |N. i>, rhoo o ■^ N po t>.io ko roooo inH Moo>o -^ O ON O M OroOroroOOfON Ow ■^O.'^'O _ tN. fo o in c OOOHOOOO ro^O C^ 0> -^00 lO ro rovo t^ ->^ inoo coco ro HwO-^C^OC^MHfOOMcoC^OO'O OOOOOOOOOOOOOOOOO o^io o o int^r^f-moo m q Tj-tN,roio o o otn roco « N VO H CO CT> W rO^O r^rorO'^C4 OiM 00^ OOCI'^h'-t rOtN.M t^W HtOCO H HIO tN.O H HCO ■[■BJauij^ ino o i>.io"^CTic>ioo mio co t^. n w m Qw M "n N M I ^ I O ,000 .ooNOi, otN-i gco .. , > - Ol O -^ COVD CO H O t^ O ' inlioi>-i otn-^i c^co ' o>o intN.oi£joooicooino^HcoinO , ■^o oJOiomOOOH Thco po in M UD O ^O iDOCOC^mOOOOOOOOh I OOO •oi;sBi^i M -^o oco o o*D N w inmO CTiintN.H o 00 o w o in in\o -^oo w tJ- ui m r-- h in OOi-iOpOmOmmOMOwNmOO •siod -npjioAV. 'szQ oooooooooooooooooooo o o o o o ooooooooo pooooooppppppppppppp W M M M M M H H Ji o O. CIS , o o _ -o • g «r 'OcoCO^te __,to iZ (H C_^ " c ™ J- t+H ¥ ^ h5.5P.2 °'a«JgrtSoo.ap O (U J3 56 FOOD, HEAT, AND MOTION. Professor Frankland has determined the weight and cost of Tarious ali- mentary articles that would be required to raise the body-weight of a person of 10 stone or 140 lbs. to a height of 10,000 feet, reckoning in accordance with Helmholtz's calculation, that the animal system is capable of turning one-fifth of the actual energy developed by the oxidation of the food to account as external work. Name of Food. Cod liver oil Beef fat Butter Cocoa nibs Cheshire Cheese . . . Oatmeal . . .... Arrowroot Flour Pe'a-meal Ground rice Isinglass Lump sugar Commercial grape sugar . Hard-boiled eggs . . . Bread Lean ham (boiled) . . . Mackerel Lean beef Lean veal Potatoes Whiting Apples Milk White of egg .... Carrots . .... Cabbage Guinness' Stout (bottled) Bass' Pale ale (bottled) . Weight in lbs. required, o'S53 0-5S5 0-693 0735 1-281 1-287 I-3II i'335 i'34i 1-377 1-505 1-587 2-209 2-345 3-001 3-124 3-532 4-300 5-068 6-369 7-815 8-021 8-745 9-685 12-020 5 1 bottles At price per lb. 16 6 10 6 6 10 21 O 2| 3J 4 o 6 3l 6i 2 6 8 o I 4 i| 5 per qt. 6 I 10 per bottle Cost. £, s. I a. "i 5i oi li iii 3* 3^ 31 4i 5i 01 2 9 H H 6* I 6i 3i SJ 4 "i 3f 4J H °l li 6 " Looked at in the manner above representedj muscular ■work, like heat, in opposition to Liebig's theory, is deriv- able from the oxidation of non-nitrogenous as well as nitrogenous matter, and Professor Frankland^s tables show that "55 lbs. of fatty matter will furnish the same amount of power as is obtainable from TS lbs. of flour, I'b lbs of sugar, 3"5 lbs. of lean beef, and 5 lbs. of pota- rOODj HEAT, AND MOTION. 57 toes. Traube even inverted the proposition of Liebig, and asserted in the most decided manner that the sub- stances by the oxidation of which force is generated in the muscles are not the albuminous constituents of the tissues, but non-nitrogenous principles, viz., either fats or carbo-hydrates. "According to the foregoing table, wherein is men- tioned the cost of the various articles of food required to be consumed to accomplish a given amount of work, it appears, viewing these articles purely in their capacity as force-producing agents by oxidation, that the same amount of work, is obtainable from oatmeal costing S^d. ; flour, 3f (^. j bread, 4f i. ; and beef fat, t)\d. ; as from beef costing 3s. 6^d. ; and isinglass £ 1 2s. Q\d. " Taking all the facts as at present revealed into con- sideration, we appear to be" warranted in adopting the following terms of expression. It is in the first place admitted on all hands that food is the source from which muscular power is derived, and hence th« supply of food should be in proportion to the amount of work that is performed. It was formerly thought that food must be converted into muscular tissue before it could be availa- ble for the performance of work, which involved the origin of work from nitrogenous alimentary matter. The efiect of recent investigation, however, is to show that it is not to an oxidation of muscular tissue that we are to look for the force produced. The muscles appear to stand in the position of instruments for effecting the conversion of the chemical energy evolved by the oxidation of com- bustible matter into working power. Fats and carbo- hydrates can furnish the combustible matter required, and, under ordinary circumstances, probably do largely, if not chiefly, supply it. Nitrogenous matter can do so likewise, but it has to undergo a preparatory metamor- 58 FOOD, HEAT, AND MOTION. ptosis for effecting the separation of nitrogen in a suita- ble form for elimination " As thus considered the non-nitrogenous alimentary- principles appear to possess a higher dietetic value than the nitrogenous, and when regarded solely in relation to capacity for force production, there is no doubt they in reality do so. But there' is a further point to be looked at. The physical development and maintenance of the body- must be likewise taken into account, and for this it is nitrogenous alimentary matter only that can supply -what is needed. Wherever vital operations are going on, there exists nitrogenous matter. It is, indeed, through the instrumentality of nitrogenous matter that the opera- tions of life occur. The tissues which form the instru- ment of living action require to be constructed in the first instance ; and next, to be constantly renovated, to com- pensate for the loss by deterioration which is continually going on. Thus, a demand for nitrogenous alimentary matter is created quite apart from direct contribution to force production ; and, further, not only is nitrogenous matter required for the construction and repair of the tissues, but likewise to form a constituent of the secre- tions, for all secretions which possess active properties owe them to the presence of a nitrogenous principle. Here then is an additional demand for nitrogenous matter, and, it is to be remarked that as increased work leads to ah increased development of the tissues employed and thereby an increased appropriation of nitrogenous matter, so it calls for an increased production of secretions in con- sequence of the larger amount of food that has to be prepared for consumption. In this way, theoretically; without contributing in a direct manner to force produc- tion, the performance of work may be looked upon as necessitating a proportionate supply of nitrogenous ali- mentary matter. POOD, HlATj AND MOTION. 69 ''Practically, it is found that hard work is best per- formed under a liberal supply of nitrogen- containing food. The reason probably is that it leads to a better nourished condition of the muscles and of the body gener- ally. Under the use of animal food, which is character- ised by its richness in nitrogenous matter, the muscles, it is affirmed, are observed to be firmer and richer in solid constituents than under subsistence upon food of a vege- table nature As albuminous food produces firm muscles, so exercise makes them red. To sum up, science intimates that a liberal supply of nitrogenous matter is necessary to produce and maintain muscles in a good condition for work, and the result of experience is to confirm it. " I have been speaking of food considered in relation to the performance of work, but it would be unphilosophical to look at it only in this light. The question should be viewed under a broader aspect ; and the point really for the physiologist to discuss is under what combination of alimentary principles the highest state of development, both mental and physical, is attainable. If regarded as living for the mere performance of work, and looked at economically, man^ it may be said, woidd bear an un- favourable comparison with a machine set in motion by steam. Mechanical work is under no form so costly as under that produced by muscular agency, and particularly by that of man. It has been calculated, it is true, that whilst through the medium of the animal system, one- fifth of the power stored up in the food consumed is realisable as external mechanical work, the amount realisa- ble from fuel is only one-tenth in the case of even the best constructed steam-engine, the remainder being dissipated or lost as heat. Thus far, the animal machine is more economical of its force than the machine of artificial con- 60 FOOD, HEATj AND MOTION. struction; but on the other hand, the fuel (food) con- sumed in the former is very much more costly than that consumed in the latter. Prom this consideration human labour can never compete in economy with steam, and hence, as suggested by Donders, the worse use to make of a man is to employ him exclusively in mechanical work — a proposition which harmonises with the increasing introduction of machinery in our advancing age of civili- zation. Letheby, fOantor Lectures on Food) on the subject of the comparative costliness of food and fuel, says, ' Taking a steam engine of one horse-power (that is a power of raising 33,000 lbs. a foot high per minute) it will require two horses in reality to do the same work for ten hours a day, or twenty-four men ; and the cost would be 10c?. for the steam engine, 8s. Ad. for the two horses, and just £2 sterling for the twenty-four men.' "From what has "preceded we may conclude that, with a supply of nitrogenous matter sufficient for the thorough development and subsequent maintenance of the body in good condition, the best materials for the production of working power, as well as heat, are the non-nitrogenous principles, and that of these the fats* are more effective than the others." " A Treatise on Food," 8fo., by F. W. Pavy, M.D., 1874. * (See Fat, Chapter V.) Chapter III. NOKMAL DIET. ESSENTIALS OP A NOEMAL DIET — MODE OF CONSTEUCTING DIETS EXPENSIVE DIETS AND CHEAP DIETS FOE MAINTAINING HEALTH — TABLES AND ANALYSES — THE WHOLESOMENESS AND DIGESTIBILITY OF VAEIOUS ARTICLES OF FOOD — MODES OF COOKING IN COMMON USE. ESSBXTIAI/S OW A NOEMAL DIET. (See Food, Heat, Motion). A HEALTHY adult man of average stature taking moderate exercise, will require and can consume, daily, from 32 to 40 ounces avoirdupois of dry nutritious food, which should have the following characters : — 1. About a-Jo must be mineral matter. 2. Prom -I to I may be water,* leaving f or not less than ^ or from 15 to 20 ounces of anhydrous solid alimen- tary material. 3. Three or four ounces of plastic matter must be com- bined with three or four times that quantity of heat-giving material. 4. The heat-giving constituents must contain a mixture of fats (hydro-carbons) with saccharine materials (carbo- hydrates), in the proportion of about 1 of the former to 3 of the latter. 6. These heat-giving constituents should supply from 6 * (See table showing the quantities of water in various foocis). 62 NORMAL DIBT. to 10 ounces of carboiij the exact amount required varying with season, exercise, etc. 6. The Articles of Food must be sufficiently varied to meet the requirements of the taste and of the appetite, and their Mechanical and other Conditions must be suited to the digestive powers of the stomach. In addition to these characters, every complete diet must contain some potash-vegetable or fruit; and the total amount of water taken in 24 hours,' including that contained in the dry food, must not be less than 70 ounces avoirdupois. DIET TABLES FOR THE MAINTENANCE OF HEALTH IN ADULTS LIVING IN THE CLIMATE OF THE UNITED KING- DOM. Each diet table contains all the essential elements of nutrition, in forms, quantities and proportions necessary to the maintenance of health. The tables have been made Complete without Alcohol, leaving this to be ordered or not, according to circumstances. But, if fermented liquors are added to any diet table, the quantity of carbon which they contain must be borne in mind. (See Alcohol Table Chapter VI.) It will be observed that the totals of the corresponding columns of the analyses are nearly the same in all the diet tables, showing the important fact that all the essentials of a normal diet may be equally secured in a diet that is simple and cheap and in one that is compli- cated and expensive. In all diets Salt must be used and in those which do not include Potatoes some other Potash-vegetable or Fruit or Cresses or Lime or Lemon juice must be taken. NORMAL DIET TABLES. No. I. 63 Liquid. Dry. Water. Plastic. Fat. Saccha- Carbon. fluid Food for 24 hours. rine. ozs. ozs. ozs. ozs. ozs. ozs. ozs. 6 Meat, Poultry 01 Game (cooked) 3-97 i'3S "53 .... -42 4 Fish . 3-19 ■66 ■03 .... -02 10 Bread . 4'20 i-oo •07 ■ 4'53 I '93 8 Potatoes .5-81 ■14 1-84 -76 2 Rice . •18 •10 -01 1-63 ■73 2i-' Sugar . 2-50 1-05 2i Butter . .... 2-50 1-8=; 5 Milk . 4-34 •25 ■17 -21 -22 i6 Coffee . 1577 -22 -10 i6 Tea . 15-05 .... -05 -02 17 Water. lyoo 54 36 70-41 3"50 3-31 lo-gS 7-01 InPla Stic matter i-8g Totj il 8-99 No. 2. Liquid. Dry. Water. Plastic. Fat. Saccha- Carbon. fluid Food for 24 hours. rine. ozs. ozs. 028. ozs. ozs. ozs. ozs. 8 Meat, Poultry or Game (cooked). 5-29 i-8o -7- -;6 12 Bread . 5-04 I-20 ■08 5-44 2'32 12 Potatoes 8-71 -20 2-76 I-I4 2 Butter .... 2-00 1-48 2 Sugar . 2-00 •84 5 Milk . 4-34 ■25 -18 -21 •23 16 Chocolate 15-20 •07 -32 -38 ■42 16 Tea . 15-95 -05 ■02 16 Water . 1 6 -GO .... .... 53 36 70-53 3-52 3-29 10-84 7^01 In Plasti : matter Tota . - 1^90 8^91 64 NOEMAL DIET TABLES. No. 3. Liquid. fluid ozs. Dry. ozs. Food for 24 hours. Water, ozs. Plastic, ozs. Fat. ozs. Saccha- rine. ozs. 5 20 20 20 18 3 Bread . Cheese Bacon Sugar . Milk . Chocolate . Tea . Water . 7-56 1-28 •76 4'33 ig-co 19-93 20-00 i-8o 1-07 •25 •25 •10 •12 •89 1-88 ■17 •40 8-15 •08 1-50 •21 •50 •07 65 26 72-86 3-47 3'S5 10-51 In Plastic matter Total Carbon. 3-47 •70 1-48 •63 -22 -50 -04 7-04 1-87 8-91 No. 4. Liquid. Dry. Water. Plastic. Fat. Saccha- Ca bon. fluid Food for 24 hours. rine. ozs. ozs. ozs. ozs. ozs. ozs. ozs. 8 16 8 2i Fish . Bread . Potatoes Butter 6-38 6-72 5-81 1-33 1-60. ■14 •06 -II 2-50 7-25 1-84 ■05 3-09 ■76 1-85 10 20 Milk . Cocoa . 6-93 19-10 -40 ■10 -28 •60 •34 -20 •36 -56 25 Ij Sugar . Water . 23-00 .... 1-50 ■63 55 36 69-94 3"57 3'55 II-I3 7-30 In Plastic matter Tota . . 1-93 9-23 NORMAL DIET TABLES. 65 No. 5. Liquid. Dry. Water. Plastic. Fat. Saccha- Carbon. fluid Food for 24 hours. rine. ozs. ozs. ozs. ozs. ozs. ozs. ozs. 16 Bread . 672 i-6o •II 7-25 ' 3'09 3 Peas . •41 ■bs •04 1-40 •6s 4 Bacon . I-I4 •33 2-50 .... i-gS 2 Cheese •73 •61 •51 •05 •40 10 Milk . 6-94 •40 •28 •34 ■S6 20 I Coffee . Sugar . 1971 •28 I -go •13 -42 35 Water BS'oo .... .... .... 63 26 70-65 3"59 3'44 10-32 7'03 In Plastic matter . 1-94 Tota . • 8-97 No. 6. Liquid. Dry. Water. Plastic. Fat. Saccha- Carbon. fluid Food for 24 hours. ozs. ozs. ozs. ozs. ozs. ozs. ozs. 40 Milk . . ■. 34-68 2-00 1-40 1-68 I-8o 4 Rice . -36 -20 -02 3-26 1-46 3 Eggs (two) 2-15 ■43 •32 ■26 2i Sugar . .... 2-50 1-05 I Butter . .... i-oo ■74 9 Bread . 37» -go •06 4-08 1-74 30 Water . 30-00 .... .... 70 19J 70-97 3-5S 2-80 11-52 7-05 In Plastic mattei 1 . 1-92 Tota • 8-97 66 NORMAL DIET TABLES. No. 7. Liquid. Dry. fluid 02s. ozs. 20 3 l^ 20 20 i 25 65 25i Food for 24 hours. Bread . Eggs (two) Butter Milk . Cocoa . Sugar - Water . Water. Plastic. Fat. ozs. ozs. ozs. 8-40 2-0O ■14 •21 ■44 •32 1-50 I7'34 I -00 •70 ig'io ■10 ^60 2S"oo 70-05 3-54 3-26 In Plastic matter Total Saccha- rine. g"06 •84 ■20 •75 10-85 GafBdn. 3-86 -26 I-II -90 •56 •31 7-00 1-9I 8-91 No. 8. Liquid. Dry. Water. Plastic. Fat. Saccha Carbon. fluid Food for 24 hours. nne. ozs. ozs. ozs. ozs. ozs. ozs. ozs. 8 Rice . -72 -40 •03 6-54 2'93 7i Eggs (five) . S-40 I-II •80 -65 7.\ Sugar . '2-50 1-05 l| Butter . I-2S •92 40 Milk . 34-68 2-00 1-40 1-68 i-8o 30 Water . 30-00 70 I9i 70-80 3-51 3-48 10-72 7-35 In Plastic matter Total • . 1-89 • 9-24 NORMAL DIET TABLES. No. g. 67 Ijquid. Dry. Water. Plastic. Fat. Saccha- Carbon. fluid Food for 24 hours. rine. ozs. ozs. ozs. ozs. ozs. ozs. ozs. g Flour . I-I3 1-28 •og 6-28 2-82 H Suet . 1-75 .... 1-38 3 Sugar . .... 3-00 i-26 6 Eggs (four) . 4-32 •88 -64 •52 27 Milk . ... 23-41 1-35 •94 I-I3 I-2I 42 Water 42-00 .... .... 69. 191 70-86 3-51 3-42 10-41 7-19 In Plastic mattei . . 1-89 Tota • • ' 9-08 Nc . 10. Liquid, fluid ozs. Dry. ozs. Food for 24 hours. Water, ozs. Plastic, ozs. Fat. ozs. Saccha- rine, ozs. Carbon, ozs. 22 49 16 1 Oatmeal Milk . Butter Sugar . Water . 2-14 19-07 49-00 2-40 I-IO •93 ■77 175 % •75 4-46 •99 1-30 -32 71 i8i 70-21 3-50 3-45 10-16 7-07 lu Plastic matter . 1-89 Total • 8-96 No. II. Liquid. Dry. fluid ozs. ozs. 25 3i 2 60 60 30i Food for 24 hours. Bread . Cheese Butter . Water . Water, ozs. Plastic, ozs. Fat. ozs. 10-50 i-i8 60.00 Z-5P I -00 •17 ■83 2-00 71-68 3-50 3-00 Saccha- rine. ozs. 11-33 ■08 In Plastic matter Total 4-82 •65 6-95 1-89 8-84 f2 68 NOEMAL DIET TABLES. OEPHANAGB DIET TABLE. The following diet table was arranged, with great re- gard for both economy and health, for a charitable institu- tion, the inmates of which consisted of children averaging about ten years of age, who had all been taken from utterly destitute homes. No. 12. Liquid, fluid OZB. Dry. ozs. Food for 7 days . This standard diet to be provided per head for all the children in the 16 122 12 10 5 4 2 4 i 3 12 7 Meat (cooked) Bread Rice Potatoes Suet Pudding (see recipe. Chap. VIII.) Flour Pudding (see recipe. Chap. VIII.) Cheese Peas (dry) Indian Corn Meal Cocoa (dry^ , Treacle Green Vegetables Dripping or Butter Milk Water (in addition to that contained in dry food.) Asylum and whatever is not taken by those under 10 years of age to be allowed to those over 10. Chemical (approximate) composition Per Day. Water. fluid ozs. Plastic, ozs. Fat. ozs. Saccha- rine. ozs. Carbon, ozs. 80 65 -00 3-37 2-07 10-50 6-05 210 In Plastic matter . . 176 2go I99i Total 7-81 The attention of those who visit the poor is requested to the following paragraph. There is considerable difficulty in selecting diets for the very poor, which combine cheapness and simplicity with the essential chemical composition, in a form which the stomach will tolerate. But the two following will be found to fulfil all these conditions, so far as it is possible to do so without the introduction of meat; and in one of PEOPOETION OF WATIE IN VARIOUS FOODS. 69 them bread is given in the largest quantity consistent with health : — No. 13. _ Allowance for twenty-four hours : Bread, 25 oz. ; cheese, 2 oz. ; butter, suet, or dripping, 2 oz. These yield to analysis: plastic material, 3"1 oz. ; fat, 2'3 oz. ; saccharine material, 11 "4 oz. No. 14. Allowance for twenty- four hours : oatmeal, 16 oz. > milk, J pint; butter, suet, or dripping, 1 oz. These yield to analysis : — plastic material, 3'0 oz. ; fat, 2"3 oz. ; saccharine^ 9'0 oz. To each of these diets must be added limejuice or some land vegetable, salt, and a free supply of pure water. The following table, constructed by Dr. Edward Smith, will shew the proportionate quantities of water which are present in various solid and liquid foods. Percent, of Water. \ Arrowroot . . . . 18 Barley flour . IS Beer and ale 91 Butter-milk 88 Carrots . 83 Cheese . 36 Cream . 66 Dried bacon IS Eels 75 Egg ■ 74 Fat beef 51 Fat mutton S3 Fat pork 39 Green bacon 24 Indian meal 14 Lean beef 72 Lean mutton 72 New milk . 86 Oatmeal • 15 Ox liver . • 74 P Parsnips Pea meal sr Gen t.ofV ITater. 82 15 Potatoes 75 Poultry . Pure butter and fat 74 15 Rice . . Rye meal Salmon . 13 IS 77 Skim cheese . 44 Skim milk 88 Sugar Treacle . 5 23 Tripe . Turnips . Veal Wheaten bread 68 91 63 37 Wheaten flour 15 White fish . 78 White of egg Yolk of egg . 78 : 78 70 WHOLBSOMBNESS AND DIGESTIBILITY OF POOD. THE WHOLBSOMBNESS AND DIGESTIBILITY OP VAEIOUS AETICLES OP POOD. Bebi' and Mdtton. a healthy stomach will generally digest either of these with ease^ but a stronger digestive power as regards meat is required, as a rule, for beef than for mutton. There are exceptions to this, however, and much depends on the quality of the meat, some beef being easier of digestion than some mutton (assuming the cooking to be equally good in both cases). There are also peculiari- ties of stomach with regard to " flavours" which need con- sideration — and it will be found that, whereas the solid inside-meat of either beef or mutton can be digested easily, the stomach is "upset" if the more specially flavoured parts are eaten ; and this will occur sometimes with mut- ton and not with beef, and vice versa. This remark ap- plies to nearly all " flavoury" foods ; it is partly explained by the fact that "flavours" are so often dependent upon volatile and empyreumatic oils, which are apt to regur- gitate. But in the case of meats, when roasted, baked, fried, or grilled, the surface is apt to be over- done, and the action of the heat on the superficial fat produces acrid compounds, consisting of acrolein and fatty acids ; and it is these which disagree although the meat itself may digest and agree. This difficulty does not occur with boiled meats. Another point, and one of great importance, which applies to all solid food, is the way in which it is cut up. It must be taken for granted that, with the best of teeth and the greatest care, portions of solid food will occasionally be swallowed imperfectly masticated, that is, not converted into a pulp ; but when we consider how often teeth are defective and how carelessly ;^eople eat while talking, as a matter of fact, ill-masticated food is swallowed at every meal. Now nearly all the WHOLESOMBNESS A^D DIGESTIBILITY OF F0OD._ 71 difficulty may be avoided by a judicious mode of cut- ting up tlae food while eating. It must be remembered, that the essential point to be obtained, is that the digestive juices in the stomach shall penetrate to the centre of every particle of food and this within a certain time, limited tP; a few hours at the outside. If the food is cut up into dice-like cubes it will often be impossible for the centre to be reached before the stomach has expended its dir gestive force, and thus a number of undigested particles will be leftj either to encumber the stomach whep it ought to be clean and ready to prepare for the ne?:t meal ; or if they have passed out of the stomach, to ca]l upon the second processes of digestion to attempt to do what ought to have been completed in the stomach ; or to irritate the intestines by throwing into them an abnormal quantity of waste. The same thing occur^, though to a less extent, with meats and other foods when their tissue is long-fibred if they are cut in thick slices "the way of the grain." But if the food is thinly sliced "across the grain" every fibre is presented to the ' stomach juices in a thin section with both its ends ex- posed, and it is then quickly and easily saturated by th,e juices of the stomach, favoured by capillary attraction in the direction of the fibres. This is really the great secret in enabling the stomach to deal with solid food — Cut EVEEYTHING ACROSS THE GRAIN AND IN THIN SLICES. It'must be remembered, however, that one object of mas- tication is insalivation, and no cutting up can entirely ta,ke the place of a sufficient masticatipn as far as insalivation is concerned. But this is of less importance with animal than with vegetable foods ; and it so happens that the quickest eaters and worst masticators are those whose saliva is abundant and readily poured out; because a deficiency of saliva necessitates better mastication to render the 72 WHOLESOMENESS AND DIGESTIBILITY OF FOOD. food moist enough to swallow. Advantage may be taken of this fact when people are inclined to swallow their food half masticated by giving it to them dry. In either case, the thin cross-grained slice will be most rapidly saturated with saliva and soonest fit for swallowing. Another point of great importance^ in facilitating the digestion of hard and solid substanceSj is the addition of a proper quantity of water to assist the stomach juices in dissolving them. Very few articles of food are soluble in alcohol and many are rendered less soluble by its pre- sence. It is not sufllcient, therefore, to drink alcohol with meals ; a certain quantity of water must be taken whether alcohol is also taken or not. On the other hand, it is a mistake to deluge the stomach with fluid during digestion, for this dilutes the natural juices to such an extent that they lose their solvent power. Different persons have different requirements in this respect, according to the power of secreting saliva and gastric fluids freely or scan- tily and in a concentrated or diluted state. But, on an average, about half to three quarters of an imperial pint of water is a proper quantity to drink while eating an or- dinary dinner, and this is better sipped during the meal than drunk at a draught either before or after it. Veal and Lamb. Both are the flesh of young animals, which is less nutritive and less invigorating than that of full grown animals, as it contains more gelatine and less fibrine, and, as a rule, it is less easily digested. But Iamb is more wholesome to most stomachs than veal. Eoast- veal especially is far more unwholesome than roast lamb, and often acts almost like a poison to delicate stomachs. This appears to be due in chief part to the quantity of the fat which, when over-heated on the outside of the meat, developes those acrid compounds, acolein and fatty acids, referred to under the head of "Beef and Mutton," and WHOLISOMENESS AND DIGESTIBILITY OF EOOD. 73 these more deeply saturate and impregnate the young meat than the firmer flesh of older animals. Thus it is more difficult to avoid them by the expedient of cutting off the outside of the meat. It is very rare for boiled veal to disagree to the same extent as roast^ and this is partly because boHing does not generate these poisonous com- pounds, and partly because it is more suited to the treat- ment of the abundant gelatinous constituents of young meat. As a rule, roast veal should be avoided by those with delicate stomachs. PoEK, is the flesh of young pig, and what I have said of veal applies in the main to pork, so far as nutritive value is concerned, but as there is more fat in pork than in veal, all the dangers of producing poisonous compounds, by roasting, baking and frying, are proportionately increased. The deepest parts of the lean of roast pork (if cooked through, so as to make sure of killing any parasites that may infest it, and to which pork is especially liable) may be eaten with impunity by most persons ; but unfortu- nately this is not the cut generally liked, the browned out- side being the favourite part, and the most dangerous. The younger the pork the less nutritive it is, but there is less chance of parasites, and in sucking pig this is reduced to a minimum. Now the objections to pork apply in a very much less degree to well-boiled pork. But boiled pork means salted pork, which raises a new difficulty. (See Cooking, &c.) Ham and Bacon. These are the flesh of older animals than pork, and consequently, if digested, they are more nutritious ; but as they are hardened by deep " curing," they are more difficult of digestion in their lean parts, and what I have said under the head of " Beef and Mutton" on the importance of " cutting thin sHces across the grain", applies in its fullest force to these, and to all meats har- 74 WHOLESOMENESS AND DIGESTIBILITY 01 POOD. dened by curing and pickling. The great value of bacon is as a store of fat in a compact and agreeable form, (See Fat), and when toasted in slices, which secures thorough cooking, the fat» seldom disagrees even with delicate stomachs. This is not the case with the toasted lean. Much of the objection to cured meat is removed in the case of tongues in consequence of their peculiar " grain," which enables the digestive juices to penetrate them easily; and many hams and gammons of bacon, which have been well cured, well soaked, and skilfully cooked, and then thinly sliced across the grain, can be well digested by even weak stomachs ; but all these provisions are neces- sary. PouLTET, Game, Wild-fowl and othee Birds. Ex- cept when the flesh is poisoned by what they have eaten, the flesh of all birds, is safe for food. Great differences, how- ever, exist as to digestibility and w]).olesomeness, and these depend mainly upon, three qualities. 1. The amount and quality of fat. 2. The length and size of fibre. 3. The density or closeness of the fibre. Abun- dant > fresh air and exercise diminish fat and improve its quality, and render the fibre shorter and closer; whereas want of air and exercise increase the quantity and deteri- orate the quality of the fat, and produce a loose long- fibred flesh. The fat of all birds is difficult of digestion by weak stomachs, and becomes more apt to disagree iu proportion as it is more oily in quality, and when over-heated readily produces those irritating compounds (acrolein and fatty acids) already spoken of under the head of meats, and as the depth of the lean is not great, a large propor- tion of it becomes saturated with the over-heated surface- fat and participates in its unwholesomeness. This disad- vantage of course increases with the smallness of the bird in proportion to its fat. The consequence of this combina- WHOLESOMENESS AND DIGESTIBILITY OP FOOD. 75 tion of circumstances is that tamed and fattened birds or " poultry" are less nutritious, less easily digested, and more apt to disagree than wild unfattened birds or " game ;" this is illustrated in the case of pheasants, which are rendered much less wholesome in the present day, when they are coddled and fed like tame poultry, than they used to be when they were left in a wild and natural condition, and in the case of barn-door fowls, which are more wholesome than those carefully fattened in yards and cages. In large poultry such as turkey, the deeper lean is almost out of reach of the poisonous influence of the outside over-heated skin and fat, and would be very wholesome, were it not for the bad effects of inordinate over-feeding with want of exercise, which impregnates all the tissues with oil. Water-birds even when wild become more deeply im- pregnated with fat than land birds, and are proportion- ately more apt to disagree. Venison and Haee, rank with game, and the same observations apply to them as to game birds. Eabbit, rather stands alone. The fibre is both long and dense. It is very quickly hardened by careless cook- ing. It requires softening and disintegrating, by gradual stewing commenced at a low temperature, and careful slicing across the grain to make it digestible. It is very apt to disagree from the difficulty of securing these condi- tions, without which it often absolutely resists thorough digestion by weak stomachs. If used for invalids it should be cut up and put in a jar with just enough cold water to cover it, then tied down and placed in a very slow oven till thoroughly cooked, when it may be turned out and eaten with its own gravy. Fish. Msh differ considerably in their digestibility and nutritive value, in consequence of differences in the quantity of fat and the mode in which it is distributed ; 76 WHOLESOMENISS AND DIGESTIBILITY OF FOOD. and in the colour of their blood and the consequent tissue of their flesh. Salmon is a red-blooded fish, and its fat is distributed much as in red-blooded mammalia, and it ap- proaches in nutritive value and digestibility more nearly to meat than to most fish. It is a very wholesome form of food, and when it disagrees it is usually, either, from its being eaten too freely forgetting how nearly it represents an equal weight of meat ; or from neglect in cutting it up in thin slices across the grain, a neglect which is promoted by the readiness with which the fiesh separates into dense flakes convenient for putting into the mouth, and by its being eaten either with a blunt silver knife or with a fork only; or from an inordinate quantity of fat being swallowed, in consequence of the large proportion of fat contained in those parts of the fish usually thought to have the most delicate flavour. If these points are borne in mind, salmon in proper season, may be eaten with advantage by many delicate per- sons who otherwise would be obliged to refrain from it. The followiug fish, like salmon, have their fat distri- buted through the tissues, as in the mammalia : — the herring, pilchard, sprat, mackerel, eel; but they diSer much in the proportion of fat which they contain, and must be selected for dififerent stomachs very much in pro- portion to the power of digesting and assimilating fat. Of these, eels are the richest in fat, containing from 14 to 24 per cent., while mackerel only contains about 7, and salmon and trout from 6 to 6 per cent. Most other fish, as whiting, flounder, brill, turbot, haddock, cod, sole, plaice, are very deficient in fat ; soles, for example, contain only 0"248 per cent., although it is often stored in large quantities in their livers as in the cod. But in addition to this diflerence in the propor- tion of fat contained in different fish, great varieties exist WHOLESOMENESS AND DIGESTIBILITY OE FOOD. 77 in the closeness and toughness of their tissues. In cod, for example^ the flesh is very dense and often tough and " woolly," when it is very difficult of digestion and should not be touched by those with weak stomachs. At all times cod, and other hard, dense-fibred fish, require care- ful cooking, and should be cut up in thin slices across the grain, not eaten in flakes with a fork only. The fat of fish is of an oily quality, (see Solid and Liquid Pats, Chap. V.) and cannot, even when abundant, take the place in nutrition of the soKd fat of meat ; and this and the great deficiency of fat in many fish, make a fish diet unwholesome unless properly admixed with other foods. But, as an adjunct to other forms of animal food in a mixed diet, fish occupies an important place; and the lighter sorts of fish, such as whiting and sole, if judi- ciously cooked, are valuable in the sick room. For this purpose boiling is the safest mode of cooking, but frying may be permitted if the outside is rejected. If boiled fish is thought too insipid, an excellent plan is to finely mince the boiled fish with a little suet, bread crumbs, boiled potato, salt and pepper, make it into cakes, and brown them in the oven. Shell Fish. Lobsters and crayfish consist principally of dense tough muscular tissue, and are extremely diffi- cult of digestion to most stomachs. The difficalty may, however, be greatly diminished by finely mincing the flesh across the grain before eating it. The hard parts of crab are open to the same objections as those of lobster, but there is more non-muscalar material in the crab, which is easier of digestion, though apt to disagree with delicate stomachs from containing certain flavouring pro- perties. Oysters differ greatly from lobsters, crayfish and crabs, being principally gelatinous (See Appendix) and fatty, and when the beard or gill and the hard muscle by 78 WHOLESOMBNBSS AND DIGESTIBILITY OF FOOD. which the fish is attached to the shell are rejected^ they form a digestible and fairly nutritious article of diet which generally agrees well with weak stomachs, especially when eaten raw, and they would be still more wholesome if minced or masticated instead of being swallowed in the usual way. The hard roe of fish is very nutritious, and when pro- perly cooked is usually digested with ease, and forms a very useful relish. The hard roe of a Yarmouth bloater laid open and nicely toasted, will often get down a sKce of toast, or of brown bread and butter, when the appetite is bad; and even when preserved, in the form of caviare and potted cod's roe, may be used in small quantities to induce the stomachs of persons with educated tastes to take other food. Cheese and Ceeam Cheese. "The time required for the digestion of cheese varies with its age and as the fat more or less abounds; and in a fairly good cheese of medium age it is from three and a half to four hours. New cheese and poor cheese require a longer time for digestion, inasmuch as they are masticated with greater difficulty. Old poor cheese also requires a longer time, for it is so hard as to be almost incapable of solution in the gas- tric juices, and if a good cheese he old and greatly decayed it plays the part of an irritant in the stomach which may cause a form of indigestion, and be itself hurried through the stomach into the intestines so rapidly as to almost prevent its digestion. It is probable that the estabUsment of cheese factories in America and in this country, will tend to produce cheese of more uniform quality. There are now nearly 2000 such factories in the United States, and three or four have been opened in England during the last five years. It is necessary for their success that there should be good pasture land and plenty of water in WHOLESOMINESS AND DIGBSTIBILITT OF FOOD. 79 the vicinityj and that the farmers should be able to take their milk to the factory while it is yet fresh and new. The manufacture of cheese by small farmers is not always effected in the most cleanly manner^ neither, with the un- certainty of seasons, is it always lucrative. . . . " Ceeam Cheesb is more digestible than ordinary cheese, both because it is softer and may be readily masticated, and has a less proportion of casein. It is, moreover, pro- bable that the process is effected in from two to three hours." Dr. Edward Smith " On Foods," pp. 125—127. Milk. " There is no milk which is so agreeable and so little disagreeable to the taste as cows^ milk, for it has a fuller flavour than human milk, or that of the mare or ass, whilst it lacks the strong flavour of the milk of the buffalo or goat, and is not so surfeiting as that of the sheep. Some of these peculiarities in other kinds of milk depend upon the quantity of a nutritive material which may be readily determined ; but others, as the flavour of goats' and buffaloes' milk, depend upon an acid which is not so easily measured, and is not nutritious. "The following is the chemical composition of several kinds of milk : — Sp. Grav. 1*000 Water. Solids. Casein and Nitrogenous Compounds. Sugar. Fat. Salts. Goat . . . 33-53 84-49 15-51 3-51 3-69 5-68 0-61 Sheep . . . 40-98 83-23 16-77 6-97 3-94 3-13 0-71 Mare . . . 3374 90-43 9-57 3-33 3-27 2-43 0-52 Ass . . . 34-57 89-00 10-99 3-56 5-05 1-85 0-54 Woman . . 32-67 88-90 10-92 3-92 4-36 2-66 0-13 Cow . . . 33-38 86-40 13-59 5-52 3-80 3-61 0.66 80 WHOLESOMENESS AND DIGESTIBILITY OF FOOD. 'The salts in milk are as follows : — osp> ate of Lime Per cent. • 0-30 Chloride of Potassium Per cent. . 017 J) „ Magnesium „ Iron . o-o6 . 0-007 „ „ Sodium . Free Soda . . 0'03 . 0-04 "As milk is so essential a food for infants, and particu- larly when tke mobher's milk canilot be obtained, it is desirable to prepare a kind wbicb may resemble the latter in composition. Cows' milk differs from human milk chiefly in having a larger proportion of fat and casein, and a less proportion of sugar. If, therefore, a mixture be made of two-thirds of cows' milk and one-third of warm water, to which half an ounce of sugar of milk be added to the pint, we shall obtain a composition very similar to that of the mothers' milk. If sugar of milk be not ob- tainable, it may be substituted by somewhat more than half the quantity of refined cane sugar. Asses' milk differs from human milk chiefly in having more sugar and less fat, so that whilst it is not equal to human milk as a nutrient, it is the best natural substitute for it ; but its use is recommended rather in cases of disease than of health, when it is desirable to modify the composition of the mother's milk. Equal parts of asses' milk and cows' milk approach closely in composition to human milk." — Dr. Edward Smith " On Foods," pp. 315, 316. Vegetables and Peuits.* It has been stated that every complete diet must contain some potash- vegetable or fruit, and the following is a list of such articles of diet. They differ, however, greatly in wholesomeness and nutri- tive value, as will be seen by the analysis table (Chapter II). * Poi those vegetables and fruits which may be allowed in diabetes'. See Diet Table for Diabetes, Chapter IV. WHOLESOMBNESS AND DIGHSTIBILITT OF FOOD. 81 Vegetables. Fruits. Asparagus Apples Broad beans Almonds Brocoli Chestnuts Carrot Cherries Cabbage Currants Celery Dates Cauliflower Figs Cress Grapes | Cucumber Gooseberries Endive Lemons French beans Nuts and Filberts Lettuce Oranges Mustard (green) Pears Mushrooms Pine Apples Onions Plums Parsnip Prunes Peas (green) Raisins Potato ~ Raspberries Radish Strawberries Rhubarb Walnuts Spinach- Turnip .. Tops Watercress The points to be especially borne in mind to promote tbe digestibility of fruitSj are 1 to reject the skins, pips, and stones, and the cellular and woody materials such as form the "core" of apples and pears, and the segments of" oranges and lemons. 2. In all the nut tribe to reduce them to a pulp or to meal before they are swallowed. Thus, chestnuts baked quite to meal are readily di- gested, and nuts beaten to a pulp in a mortar form a highly nutritious and digestible food. Whereas both are exceedingly indigestible in their natural condition. With vegetables, great difference exists between such as may be classed as "green vegetables," containing large quantities of elastic, fibrous, and woody tissue, which are quite indigestible; and the various sorts containing- a 82 WHOLESOMENESS AND DIGESTIBILITY OF FOOD. much starchy miatter, requiring thorough cooking to burst the starch cells and make it digestible (see Chapter VIII.) ; these 'are especially liable to be swallowed in lumps, the outside of which may be soft, but the centre hard and quite impenetrable by the digestive fluids. To prevent this they should be crushed with a fork, a precaution which will enable many delicate persons to digest potatoes, carrots, and the like, who could not otherwise touch them with safety. In addition, however, to the question of actual digesti- bility, both vegetables and fruits may disagree from the essential oils which they contain, and upon which they de- pend in a great measure for their distinctive flavours. This kind of disagreement is of the least serious kind, consisting rather in unpleasant eructations than in the more distressing and dangerous symptoms due to masses of undissolved food. Stomachs have idiosyncrasies in this respect which must rather be individualised than classified. It may be stated, however, that when one species of ^the brassicacise or cabbage tribe is found to disagree, the whole tribe will be also apt to do so, and this more and more in proportion as the essential oil is more abundant. For this reason they agree better when young than old, although this is also due to the smaller proportion of woody fibre and other indigestible tissue which they then contain. After all, cooking, carving, cutting up, mastication, and careful rejection of indigestible parts while eating, will enable persons with weak digestions to vastly enlarge their usual list of permissible articles of diet, both animal and vegetable; and it is to these precautions that I would especially direct their attention, for it is of the highest im- portance to avoid unnecessarily limiting the variety of food allowed to all persons, but especially to those of MODES OF COOKING IN COMMON USE. 83 poor appetites and troublesome digestions. MonotonouSj uninteresting meals, depress the spirits and are subversive of appetite, digestion and nutrition. (See Chapter IV.) Finally, nobody should take meals in solitude. Society, merry talking and laughter, are wonderful aids to appe- tite and digestion, and promote all the functions necessary to healthy nutrition. MODES OF COOKING IN COMMON USE. Boiling, Boasting, Broiling, Baking, Frying, Stewing. Boiling. There is an art in cooking food in such a manner as to avoid, as much as possible, the loss of its nu- tritive principles. " If the object is to extract the goodness of the meat into the surrounding liquid, as in making soups, broths, &c., the article should be minced or cut up finely, and placed in cold water. After soaking for a short time, heat should be applied, and the temperature gradually raised. For broths, no actual boiling is needed — it is desirable, indeed, that it should be avoided, so as not to consolidate and lose the albumen. For soups, however, prolonged boiling is necessary, in order fully to extract the gelatine." If the object is to retain the nutritive properties in the meat, an opposite plan must be adopted, i " The piece of meat should be large, and it should be plunged suddenly into boiling water and the process of boiling briskly main- tained for about five minutes. This coagulates the albu- minous matter upon the surface, and leads to the formation of a more or less impermeable external layer, which pre- cludes the escape of the juices from the substance of the g2 84 MODES OF COOKING IN COMMON USE. meat. After tMs object has been falfilled, instead of boil- ing being continued, a temperature of between 160° and 170° Fah. constitutes what is wanted, and this degree should be maintained, unt^l the process of cooking is com- pleted. Cooked in this way, the central part of the meat remains juicy and tender, and possesses, in the highest degree, the properties of nutritiveness and digestibility. Unless exposed throughout to the temperature named, the albuminous and colouring matters are not properly coagulated, and the meat presents a raw or under- dressed appearance. If exposed to a temperature much above 170°, the muscular substance shrinks and becomes propor- tionately hard and indigestible. The usual fault commit- ted in cooking meat, is keeping the water in which it is being boiled at too high a temperature after the first exposure to brisk ebullition is over." "Fish is rendered firm in proportion to the hardness of the water in which it is boiled. Hence, fish boiled in sea- water or in water to which salt has been added is firmer, and, at the same time, more highly flavoured, than when boiled in soft water, on account of the less solvent action exerted. " Upon the principle of endeavouring to .retain, as far as practicable, the soluble constituents of an article of food, potatoes should be boiled in their skins, and the object aimed at is still further secured by the addition of a little salt to the water. By steaming instead of boiling the result is still more completely attained. " Boiled food is more insipid than food cooked in other ways. From the lower temperature employed, no empy- reumatic products are developed. Being more devoid of flavour, it is less tempting to the palate, but sits more easily on a delicate stomach " Boaniing, should be conducted upon the same principle MODES OF COOKING IN COMMON USE. 85 as boiling. In grdePj as far as possible, to retain the nu- tritive juices, meat should first be subjected to a sharp heat. This leads to the formation of a coagulated layer upon the surface, which subsequently offers an impedi- ment to the escape of the fluid matter within. After a short exposure to a sharp heat, the meat should be re- moved to a greater distance from the fire, so as to allow a lower heat gradually to penetrate to the centre. In this way the albumen and colouring matters are coagulated without the fibrine being corrugated and hardened. . . . " On account of the greater heat employed, roasted meat is more savoury than boiled. The surface also is more or less scorched, and a portion of the fat is melted and drops away under the form of dripping. Some of the Tat like- wise, under a prolonged exposure to a strong heat, under- goes decomposition, attended with a production of fatty acids, and an acrid volatile product known as acrolein, which may cause derangement of a weak stomach. In boiling, the temperature is not sufficient to incur the risk of rendering the fat in a similar way obnoxious." (See " On Wholesomeness and DigestibiHty of various articles ■of food"). "When properly roasted, the meat is juicy enough within to lead to the escape of a quantity of red gravy when the first cut is made into it. "Broiling, produces the same effect as roasting, but the proportion of scorched material is greater, on account of the relatively larger amount of surface exposed. The principle of cooking should be the same, in order to re- tain the central portion juicy. " Baking, renders meat more impregnated with empy- reumatic products, and therefore richer or stronger for the stomach than any other process of cooking. The opera- tion being carried on in a confined space, the volatile fatty 86 MODES OF COOKING IN COMMON USE. acids generated are prevented from escaping, and thus permeate the cooked articles. Meat cooked in this way is ill adapted for consumption where a delicate state of sys- tem exists. " Frying, is also an objectionable process of cooking for persons of weak digestive power. The heat is applied through the medium of boiling fat or oil. The article of food thus becomes more or less penetrated with fatty isi&t- ter, which renders it to a greater extent than would otherwise be the case resistant to the solvent action of the watery digestive liquid secreted by the. stomach. It is apt also to be impregnated with fatty-acid-products arising from the decoinposition of the fat used in the pro- cess. These are badly tolerated by the stomach, and, whether generated in this way or when the food is in the act of undergoing digestion, appear to form the source of the gastric trouble known as heartburn. " Stewing places food in a highly favourable state for di- gestion. The articles to be cooked are just covered with water, and should be exposed to a heat sufficient only to allow of gentle simmering. A considerable portion of the nutritive matter passes into the surrounding liquid, which is consumed as we]l as the solid material. Properly cooked in this way, meat should be rendered sufficiently tender to break down under moderate pressure. If boil- ing be allowed to occur, the meat becomes, instead, tough and hard." "Bashing is the same process, applied to previously cooked instead of fresh meat. "By surrounding the vessel with water in which the article of food is contained, so as to secure that no burning shall occur, meat may be stewed in its own vapour. For example, a chop or other piece of meat taken upon a small scale, may be placed in an ordinary preserve jar, and this< MODES OF COOKING IN COMMON USE. 87 tied ov&r at tke top, and partially immersed" in water con- tained in a saucepan. The water in the saucepan is made to simmer, or gently boil ; and when the proper time has elapsed, the meat is found perfectly soft and tender, and surrounded by a liquor derived from the juice which has escaped during the process. Meat thus prepared is in an exceedingly suitable state for the convalescent and in- valid. ..... " Soups and Broths. The process of preparation is here directed to extracting the goodness from the article em- ployed, the reverse of that in the case of boiling. To ac- complish what is aimed at in the most complete manner the articles should be chopped or broken into fine pieces, and placed in cold water. After being allowed to mace- rate a short time, for the soluble constituents to become dissolved out, it is gradually heated to a point which should vary according to the product required. In the case of broths and beef-tea, which properly contain only the flavouring principle of meat — osmazome — and the solu- ble constituents with finely coagulated albuminous matter all that is required is to produce gentle simmering, and this should be kept up for about half-an-hour. In the case of soups, a prolonged gentle boiling is required in order that the gelatine may be extracted, this being the principle which gives to soup its property of solidifying on cooling.* Bones require boiling a longer time than meat. The chief principle they yield is gelatine, and its extraction is greatly facilitated by the bones being broken into fine fragments previous to being used. " Salting, Pichling, and Smelting, may be alluded to here for the sake of stating that by their hardening action, they give an article difficult digestibility, which cannot * See Appendix VI. " New experiments on Gelatine." 88 MODES OF. COOKING IN COMMON USB. be overcome by cooking." " On Food" &c. By F. W. Pavy, M.D. 1874. Dr. Letheby {"on Food"), gives the following table of the loss of weight, per cent., by cooking. Boiling. Baking. Roasting. Beef generally 20 per cent. 2g per cent. 31 per cent. Mutton generally 20 31 35 Legs of mutton . 20 „ 32 33 Shoulder of mutton 24 32 34 Loins of mutton . 30. .. 33 36 „ Necks of mutton . 25 32 34 Averages of all . 23 per cent. 31 per cent. 34 per cent Chapter IV. SOME PRINCIPLES OF DIET IN DISEASE.* PEINCIPLES UPON WHICH TO AEEANGE THE DIET OF DISEASE — EULES FOE CAEEYING OUT THESE PRINCIPLES EXAMPLES OF DIETS FOR CONSDMPTIONj AND FOE DIABETES. This subject is one upon wMcli it would be very easy to write a large book, but which is very difficult to treat in a short chapter. I must content myself, therefore, with condensing what I have to say into a few statements of opinion, avoiding all attempts at discussion, and if I ap- pear to deliver my views dogmatically it is not because I feel at all inclined to dogmatise, but because I am pressed by the extent of the subject and the narrow limits of our At page 61, 1 have given " the Essentials of a Normal Diet" for health. The question now is, how ought these to be modified in disease ? It will be observed that these " Essentials of a Normal Diet" provide for the mainten- ance of healthy nutrition in a " healthy adult man of aver- age stature taking moderate exercise," and, for simpli- city's sake, it will be the best to make all our remarks apply to this " adult man of average stature" vtider altered circumstances. The first and leading principle of diet in disease is, to provide for the maintenance of healthy nutrition, under the peculiar alterations of circumstances attendant upon disease. In other words, the diet of disease should be as nearly that of health as the altered conditions of the nutri- * Substance of a lecture delivered by the Author at the fioyal Hospital for Diseases of the Chest, 18G5. 90 SOME PRINCIPLES OF DIET IN DISEASE. tive functions, and the altered conditions of the patient's Hfe will allow ; the grand object being to keep up healthy nutrition of the whole organism. The true appreciation of this first principle, in its various bearings, will save us from running into either of those extremes which at different times have disfigured medical practice. We shall not be led to starve our patients upon water-gruel, when they are craving for natural food ; or to stuff them with beef-steaks and porter when every instinct of their nature rebels against it. In fact, it may be taken as a very safe rule, that it is better cautiously to supply a patient with the kind and quantity of food that his stomach calls for, than to deny it to him without an unquestionably good reason for so doing. This may seem very much like letting a patient eat and drink what he pleases. But that is not at all what I in- tend to recommend. All I mean is this, and I wish par- ticularly to impress it, that if we intend to interfere in the subject of diet, we must take care that we thoroughly understand what we are about ; (see p. 6) and in order to do this it is , necessary to keep well up in the following subjects : — 1. The physiology of healthy nutrition. 2. The composition of food, and the essentials of a normal diet. 3. The physiology of disease. If we keep these matters well before the mind, and at the same time keep our wits about us in watching the case under treatment, it is surprising what an immense deal of good may be done by interfering with the diet ; but not otherwise. We start, then with this as our first principle — never to be lost sight of — that healthy nutrition is to be main- tained, if possible, under all circumstances. And we as- SOME PRINCIPLES OF DIET IN DISEASE. 9l sume that to do this in a " healthy adult man of average stature taking moderate exercise/' the essentials of a nor- mal diet must be suppHed. It must be borne in mind, that the proportions and quantities of the different elements of this normal diet are arranged to meet the requirements of the different func- tions of the organism when in a healthy state of activity ; and it therefore follows, that if the activity of any of these functions is altered, the requirements will be altered ; and hence, the second general principle is this : — To alter the quantities and proportions of the elements of a normal diet to correspond with any alterations in the conditions of life. Thus, when a man is overtaken by sickness, and confined to his room or bed, the adult man taking moder- ate exercise becomes an adult man tahing no exercise; and the ingredients of his diet which were proportioned to his moderate exercise must now be proportioned to his no exercise ; and other alterations must be made in like manner, to correspond with other altered circumstances, in addition to any that may be specially required by the aature of his disease.* But I must remind you that, even when a man is con- fined to his bed, and precluded from taking any kind of exercise, he is still necessarily undergoing a considerable amount of muscular exertion, which must be provided for in his diet. For example, so long as life remains, such all-important muscles as those of respiration, and the heart itself, continue to act, and to require that their healthy nutrition shall be provided for by a supply of plastic materials in the food. * See "Food, Heat, and Motion," p. 51. It is there ahown that the mechanical work of the heart, respiration, and other vital functions, require sufficient food daily, to generate 400 foot tons of mechanical force. But the food necessary to generate the 290 foot tons usually required for external work, may be omitted from the diet of one taking no exercise. 92 SOME PRINCIPLES OF DIET IN DISEASE. We come next to the long list of alterations of function which, may be involved in the term " Sickness." And the third principle is — To alter the forms^ quantities^ and proportions of the elements of a normal diet, to meet the altered relations in the activity and condition of organs consequent upon disease. It is evident that, in order to carry out our first principle of maintaining healthy nutri- tion under all circumstances, it may be necessary, under some conditions, to reduce the quantity of every element of diet ; and also, under some circumstances, to alter the proportions of the different elements. This we see demon- strated in some of the lower animals by the phenomena of hybernation. When an animal gives itself up to its winter sleep, every vital function is reduced to its lowest degree of activity ; and the animal is able to maintain healthy nutrition for a long period without taking any food at all ; but as respiration has to be kept up more actively than the rest of the functions, a special store of carbon for this purpose is laid up beforehand in the body. Now, supposing a man to suffer from any state of dis- ease which should place him in the position, as regards his functions, of an animal during hybernation, it is clear that, while his whole diet must be reduced to a very low scale, the heat-giving elements must be supplied in quan- tities out of the normal proportions as compared with the rest ; because no supply of carbon is stored up in prepara- tion for his illness, as it is in the hybernating animal in preparation for its sleep. We see conditions, in many respects similar to these in some stages of fevers, in which absorption, nutrition, and every vital function is at its lowest point consistent with Ufe, respiration being the only one sufficiently active to call for any considerable supply of food. But here, of SOME PRINCIPLES OF DIET IN DISEASE. 93 course, we must not lose sight of an element in the case not present in hybernation — viz., the existence of a poison, which by some means, natural or artificial, has to be eli- minated or destroyed, and which may be keeping some functions in activity, the requirements of which must be met. The precision with which we are able to do this in any given case, will depend upon the correctness of our knowledge of the nature of the poison, and of the organs concerned in the restorative process. Here, no doubt, we are often obliged to act in the dark, and to supply many ingredients which may not be needed, in the hope of furnishing among them that which is required, but which our ignorance prevents us from identifying. And we had far better, whenever our knowledge is at fault, act in this safe manner alid supply much that may be use- less rather than run the risk of withholding that which may be essential to life. But, in the majority of cases, our knowledge will be sufficient for the emergency, if we keep in mind the general principles of action. The fourth principle is this : — To obtain rest for every organ while it is suffering under active disease, by remov- ing from the diet such elements as imcrease its functions. These are conditions which it is not always easy to fulfil without deviating from our first principle. For example — 'in the case of diseased kidney — the healthy nutrition of this organ requires a supply of albuminoid materials, while its function is increased by any surplus of these materials in the organism ; and when its function is in- terrupted by disease, a proportion of albuminoids in the diet, necessary to the healthy nutrition of the organism generally, will be tantamount to an excess as regards the function of the kidney, and the accumulation of retained excretory matters will press injuriously upon the affected organ. In such a case other medical aids than diet must 94 SOME PEIKCIPLES Or DIIT IN DISEASE. he brought to bear ; and wbile the albuminoids in the food are reduced as low as is consistent with healthy nutrition, some auxiliary organs which are not damaged must be stimulated for the time, to save the diseased part from undue pressure upon its functions. A simpler, but still important principle, may be stated as the fifth, viz. :-^In all alterations of diet, to avoid any unnecessary reduction in the number and variety of the forms in which food is allowed to be taken. (See p. 83, '^' Wholesomeness and Digestibility of various articles of food)." This becomes especially necessary to be borne in mind when dieting the dyspeptic, who are often still engaged in the active avocations of business and of society while under medical treatment. To treat such cases by cut- ting off from the daily bill of fare first one article and then another, till the food consists of only two or three permit- ted forms, is to destroy the appetite and the digestive powers by monotony of diet, and to depress the spirits of the patient by a constant series of petty denials. This plan of dieting can only be regarded as the resource of ignorance; because an enlightened view of the case will discover some particular defect in the function of digestion or assimilation which will at once indicate the form or ele- ment of the food which is to be avoided ; and thus it will be only necessary to cut off those articles which specially represent this element, or simply to alter the forms in which they are presented to the stomach. (See p. 4). The sixth principle is also of great importance, viz. : — When it is necessary to remove from the food any of the essentials of a normal diet, to aim at selecting that which will answer the desired end with least danger to the nutri- tion of the vital organs. For example, if it is necessary for any special purpose to diminish the heat-giving ele- ments of the diet, it is safer to remove the carbo-hydrates SOME PEINCIPLES OF DIET IN DISEASE. 95 than the hydro-carbons^ because the latter not only supply carbon for the evolution of force, but are essential to the nutrition of the nervous system, and of the albuminoid tissues generally. (See Pat, Chapter V.) The seventh and last principle which I shall give in this Lecture is of very general application : — When it is de- sired to increase the normal nutrition of a tissue or organ, we must not only supply it freely with the special materi- als requisite for its development, growth, and repair, but at the same time call upon it for the performance of its normal functions — over-fed idleness insures morbid nutri- tion, not healthy life. In the next place I will give you a few Rules which may assist you in carrying out these general principles. Rule 1.— When the power of appropriating any essen- tial ingredient of a normal diet is lost to the organism, the lost function must be substituted by some artificial process, or the ingredient in question must be withdrawn from the diet till the normal function is restored. In obedience to this rule we administer pancreatic emulsions of fat* to patients, who have lost the power of assimila- ting fat without this artificial assistance, while we adopt all practicable means of restoring the normal function.f Rule 2. — Is inseparable from the first, and it is this : — No essential of a normal diet must be withdrawn, without an attempt being made either to supply to the organism in some other way the ingredient of which it is deprived, or to suspend those functions which call for a supply of this ingredient. Thus, to take a simple illustration : — Suppose the power of digesting meat to be lost through a deficient secretion of gastric juice, meat must be with- drawn from the diet till the lost function is restored, or * See Appendix for mode of preparing "Pancreatic emulsion." 1" See Diets for Consumption. 96 SOME PEINCIPLES OF DIET IN DISEASE. else an artificial digestive fluid must be introduced ; or if it is impossible by these means to maintain tbe digestion of meat, the physiological ingredients of meat must be supplied in the form of some albuminoid solution; or, finally, if this cannot be done, then those functions which principally waste the albuminoid tissues of the body must be placed as far as possible in a state of rest, mus- cular action must be suspended untU the function is re- stored. Rule 3. — If an undue waste of any elements of normal nutrition is found to be going on in the organism, and the means remain of appropriating those elements from the food, they must be supplied in the food in quantities as much in excess of those proper to the normal diet of health as will be sufficient to supply the waste, until it is stopped. This also may be illustrated by a very simple example. In Bright's disease of the kidney there is no loss of the power to appropriate the albuminoids from the food, whereas a constant loss of albumen is going on through the kidneys, which must be met by proportionate increase of the albuminoids in the diet. But in following this rule, in this particular case, it will be necessary to observe the j)recautions which I mentioned when speaking of the fourth general principle. Rule 4. — When through any defect in the organism, the elements of a normal diet are lost to nutrition if pre- sented in the usual forms, those forms must be changed ; but care must be taken that in the altered form all the essential elements of a normal diet are supplied in their proper quantities and proportions. Nothing can illustrate this better than the use of milk as a substitute for solid or mixed foods in diarrhoea or sickness. Rule 5. — Has to deal with more complicated difficulties. If such a defect exists in the organism that some of the SOME PRINCIPLES OP DIET IN DISEASE. 97 essentials of a normal diet are misappropriated^ so that the organism is deprived of one or more of the normal elements of nutrition, and at the same time a disease is constituted out of the misappropriated food, then we have a double duty in interfering with the diet. First, the source of the disease must be stopped by withdrawing that part of the diet out of which it is constituted ; and, secondly, the elements of nutrition thus removed must be supplied by some other means or in some other form. Thus, in diabetes, the saccharine and amylaceous ele- ments of the diet are misappropriated ; they do not serve their normal function of supplying carbon for the evolu- tion of heatj and by passing off through the kidneys they constitute an exhausting disease. It is necessary, there- fore, to stop the source of this disease by cutting off the saccharine and amylaceous ingredients of the diet till nor- mal nutrition is restored. But, in the meantime, as car- bon must be obtained by some means, it is taken from the fat stored up in the body, so long as that lasts, and when it is gone from, the albuminoid tissues themselves, till the whole organism is disintegrated ; unless at the same time that we cut off the starch and sugar, we increase the quantity of fat supplied in the food as much in excess of the proportion proper to a normal diet as shall fully sup- ply the demand.* The modern dietetic treatment of diabetes may be taken as a good example of the way in which increased know- ledge of the nature of disease and of the physiology of food enables us to act under what I have called the fifth principle of diet, viz., to avoid any unnecessary reduction in the number and variety of the forms in which food can be taken. In former days the poor parched diabetic was * See Diet fbr Dialietes, p. 104. 98 SOME PRINCIPLES OP DIET IN DISEASE. forbidden to drink water lest he should increase his flow of urine ; now we are able to let him quench his thirst as much as he pleases, so that he takes nothing which con- tains starch or sugar ; and again, by preparing his articles of food in such a manner as to exclude the injurious in- gredients, and by selecting those which are known to con- tain them in the smallest quantities, or not to contain them at all, we are able to present the diabetic with a fairly tempting and varied diet, so that he is able to keep to it for months and years with comparatively little diffi- culty. See p. 4.) 99 DIETS FOE CONSUMPTION. In these Diets for Consumption it is assumed that no fat is assimilated except that artificially pancreatised. In Table I. The required amount of carbon is supplied by an excess of carbo-hydrates. (See p. 95). In Table II. The required amount, of carbon is sup- plied by an excess of albuminoids. (See p. 96). In Table III. The amount of carbon is kept low^ be- cause it is only intended as a temporary diet to be used during periods of rest in a warm room. The arrowroot and some of the fat of the milk are pancreatised by mixture with the "pancreatic emulsion."* (See p. 91). * See Appendix for mode of preparing " Panorentio Emulsion." H 2 100 i ^2 , OOO00OC30OOO « mvo -^ O IT) o^ O -^ ■tJ- Ol t^OO O* IT) H o t^ • • OmOOOO«hO o> Z « o « o « o ro Tt- 1-. • Thvo yo tN, in o , to n t-i dONCOOOOOO H Ti-OO CO Tt- t^ ro p f^ O O O O -0 , , ■!>.« O . u I o .o vo o o o >n o fo . o o o CO o H . o m rn ID O 00 C4 d (4 to .« 5h O u UN 3t3 O (L) j2 ■*-? 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B o o o o s c M Ol ■^ ^ o hi) IT) b lb - Z O (O 1 lO o ID O u o c ID M l-t « E C4 b « z ~e o o o O S S N m tJ- o'S (p CO t^ t^ H- in « b OO vo o VO r^ o t^ J3 M Ol , y CO * • OO rt M o ^ o fO « VI 1 J^ o o 1^ en b H '■* ■i 8 o o 8 M pi en « K rn b ^ ti o - o £• (^ S .2 E E " S 0) t i £ .2 2 ? * 2 j; ^ 5 i 8 § § I ^- ) T3 -a p "■a S i g i .s E -a '^•3 g B § H O DIET FOR DIABETES. Table IV. In this Diet starcli and sugar are reduced to a minimum and fat and albuminoids are given in their place^ some of the fat being introduced in the form of Pancreatic Emulsion to assist in its assimilation. (See p. 97). 104 r/i W H .2 < rt i-H T3 CO O -g « I. J3 f> 01 c I-" fr §£ in H b b 6 o e p * 2 o o ^o lO Oi f^ o in o o M b b b b in H b b o o o o "n O CO u-HO 00 i-i VH O O H lO O O lO Oi t^ t^ w CO in Oi o in o . H lO o ■^ (0 « lo O irno CO m -^lo inoo t^ CO o o m o o o CO mvo N o -^ in N lo t^ "ih M Ol ID O O M in m o b ^ N O in o o yD H u- in rr l-^ M o o o o o o o o o o o O 00 in o O 00 M n ir PO 00 m m ro in O H H M o ro O o o o o 00 ID CO M ID CO . « H CO CO 0,0 " u ho _ . •o-o fi u 0.^"" O O JH J5 UOQO •u ^^ ■- hOT) m 3 o ■ ■ c S^ >- S — c S S T. " H !?„ o (U C n -M C DO u t B ° S 5 Mrt • s S .13 O O a •c rt (U y to o nj • r%^ CO o ^ H ■"S a 3 H o-o 13 •= o p o ^^ 3 - o-Ta cjo «) > ■g4s.s ^ >= B ^ Kl« I- Chapter V. PAT. FAT ESSENTIAL TO HEALTHY NUTEITION — IMPORTANCE OP DIS- TINSmSHING BETWEEN SOLID AND LIQUID PAT — ON GETTING THIN BANTINGISM — ANALYSIS OF BANTING-DIET, SHOWING ITS ERRORS AND ADVANTAGES ON GETTING PAT — PAT AND STARCH IN THE NDTEITION OF CHILDREN. Pat is so essential to tte maintenance of healthy nutri- tion, that the quantity contained in the daily food cannot be reduced much below the proportions given in the " Essentials of a normal diet" and in the normal- diet tables, without great risk of damaging the health. When it is necessary for any special object to reduce the quantity of carbon taken in the aliments, this can more safely be done by diminishing the saccharine and amylaceous matters than the fats. The importance of fat in nutrition should be studiously borne in mind by those who construct diets for the poor, for public institutions, or for the treatment of obesity, diabetes, fatty degeneration, dyspepsia, and the like.* THE IHPOBTANCB OF DISTINGUISHING BETWEEN SOLID AND LIQUID FATS.+ The peculiar isomeric modifications of which stearin and palmitin are susceptible, as shown by Duffy, pointedly * See Chapter IV. "on Diet in Disease." t Substance of an Article by the Author in the "Chemical News, Sept. 4th, 1868." 106 SOLID AND LIQUID FATS. distinguish them from olein, which, so far as at present known, has not this susceptibility ; a distiiiction which is supported by the different behaviour of oleic acid towards chlorine and bromine, from that of stearic or margario acids (Lefort), and by the different action of bile upon stearic acid and upon oleic acid (Marcet). But I think we ought to be prepared to learn, that aolid and liquid fats differ in some important physiological pro- perties, by the first general fact concerning the constitu- tion of all natural fats — viz., that they are mixtures in varying proportions of at least four different bodies, of which the melting points so widely differ — stearin melting at 144° P., palmitin at 114"8° P., margarin (probably a compound of stearin and palmitin) at 116° P., while olein remains fluid at 32° P. That the different degrees of solidity of fats depend upon the proportions in which the solid ingredients are mixed with olein, that olein has a peculiar power of dis- solving the solid ingredients, and that the melting point of the mixture is thereby reduced, appear to me to be facts pointing in the same direction as the foregoing, es- pecially when we remember that the affinity of oleic acid for oxygen is much greater than that of the other fatty acids. The fatty bodies obtained from warm-blooded animals are generally solid at ordinary temperatures, whilst those from fish and from cold-blooded animals are hquid.* And when we consider the high melting points of the solid fats as compared with the temperature of the body in warm- blooded animals, it is evident that the fat in them would be solid at the temperature of their blood, but for the mixture of olein, by which the melting point is reduced. * See Wholesomeness and Digestibility of various articles of Food, Chap- ter III. SOLID AND LIQUID FATS. 107 Therefore the solidity or fluidity of the fat in hving ani- mals is determined by the proportion of olein, which is able to be mixed with the stearin^ palmitin^ and margarin in each individual ; and we are forced to conclude either that it is of no importance whether the fats of the body during life are in a solid or liquid state, or that it is im- portant in what proportion the olein, stearin, etc., shall be combined. It has been already proved by experiments on the fat- tening of cattle, that the soUdity or fluidity of the fat in the body varies with the food — that cattle fattened upon linseed cake, for example, accumulate, in their adipose tis- sue, an oily material of unusual fluidity (Draper), and that the consistence of butter is dependent upon the kind of food given to the animals from which it is produced (Fownesj. The fat in animals is particularly liable to accumulate immediately beneath the cutis, in the omentum, and around the kidneys ; and the fat found in the latter situa- tion, where it is subject to a more uniformly elevated tem- perature than in the integument, is well known to be of a more suety character — that is to say, it contains a smaller proportion of olein, and has a higher melting point. These familiar facts point again to some importance, in the animal economy, attaching to the melting point of the fat and the consequent degree of fluidity in which it should exist during life. With regard to the fat of the integument — the principal deposit of adipose tissue in the body — it appears to me self-evident that the fluidity of this fat must vary with the temperature of the atmosphere in which the animal is placed ; to what extent this is the case, is, in my opinion, a most important subject for enquiry ; and although the 108 GETTING THIN. experiments to determine the question are yet deficientj I hope soon to be able to supply them.* In conclusion^ what I now suggest as a general proposi- tioUj is this : — Thatj in all probability, the stability of the fats of the animal body in resisting too rapid oxidation is dependent upon the degree of solidity which they possess at the temperature of the living animal at any given time ; that alterations in external temperature may afl'ect the solidity of the adipose tissue of the integumentj and, con- sequently, its power of resisting oxidation ; and that, therefore, in all probability, it is of great importance that the food of an animal shall contain a certain proportion of materia] capable of supplying the adipose tissue with solid fat : i.e. fat having a high melting point. ON GETTING THIN. On comparing the following analysis of Mr. Banting's di^t for getting thin with my tables of normal diets it will be seen that it yields less than half the normal quantity of Carbon, leaving the deficiency to be obtained from the fat already stored up in the system, by the consumption of which the obesity is removed. The fault consists in this reduction of Carbon being obtained by diminishing the Hydro-carbons (fats) of the food instead of only cutting off the Carbo-hydrate3 (Sugar and Starch). • Thia statement was first publisbed in 186S, and, up to the present time 1875, the difficulties attendant upon the experiments have baffled those who have attempted to solve the question. GETTING THIN. 109 Mr. Banting's Diet. Approximate ANALYSIS). Liquid. fluid ozs. Dry. ozs. avoird. Food for 24 hours. Water, ozs. Plastic. ozs. Fat. ozs. Saccha- rine. ozs. Carbon, ozs. I6 14 14 2 2 3 Meat, Poultry, Game and Fish Bread . Vegetables (green) Fruit . Tea . Wine (Claret) . 9-25 0-84 179 2-52 i6-oo 13-00 3-13 0-20 0-02 1-25 o-oi .... •90 •15 •40 ■98 ■39 ■07 •15 •02 •70 30 21 43"40 3-37 1-26 i'45 2-31 In Plastic matter • 1-82 Total 4-13 It has happened to me to have to do with a great num- ber of persons who have tried Bantingism, and I do not hesitate to say thatj up to the present time,* Mr. Banting has done a great deal more good than harm. He did not bring forward a single new fact or new idea, but he had the luck, by zealously advertising a striking case of the effects of a plan of treatment long familiar to every medical man who understood physiology, to convince the public of the immense influence on the animal organism of modifications in the quality of food — an influence in the importance of which they did not half believe when urged upon them in the form of medical advice. Mr. Banting candidly told his readers that he was ignorant of the physiology of food, but they did not care for this while determined to try his plan, and hence it is not to be wondered at that while many have been bene- fited many have done themselves harm. But the harm * This was first written in 1864 and I can safely repeat it now : 1876- 110 GETTING THIN. that has been done at present is not very great and is nothing to compare with the harm that will come, if, frightened by some striking case in which Bantingism has nearly cost a man his life, the public rush away from it as blindly as they rushed into it, and establish for a time such a popular prejudice against systems of diet, that a medical man shall not be able to institute those rational and scientific regulations of diet which are often more im- portant than any other means of treatment in the manage- ment of disease The plain and simple facts of the case are these. 1. A certain amount of fat in the system in one of the most essential elements of health. 2. The quantity required by different individuals to maintain health differs. 3. The effects of a deficiency of the quan- tity actually required in any given organism are most disastrous, the tissues of the body and the brain and nerves being at length disintegrated to supply the ele- ments of fat which they contain. 4. When there is a quantity of fat in the body in excess of that necessary to health, it may be lessened with great and needed advantage provided it be done slowly and cautiously — allowing the nutritive functions of the system to accom- modate themselves gradually to the altered condition — and most peremptorily stopping the loss of fat before it has amounted to a deficiency in the quantity necessary to healthy niitrition. Nothing is easier than to malte a fat man thinner by altering his diet, but to do this safely and well is by no means devoid of difficulty, and in a large number of cases requires the greatest caution, considera- tion and judgment on the part of those who rule the modifications in the diet of the patient. But there is no denying that, with such care and judgment, it can in most cases be done safely and advantageously. GETl'INa FAT. 1 1 1 ON GETTING FAT. The measures necessary for getting fat are of course the reverse of those for getting thin. They consist in — 1. An abundant supply of carbo-hydrates and hydro-carbons (fats, starch and sugar) in the food. 2. Means to pro- mote the assimilation of these. 3. Means to prevent waste by oxidation. The artificial fattening of cattle is secured by the adop- tion of similar measures, and affords the most familiar and striking illustration of the subject. In this case, (see Draper's Physiology, p. 251) the first indication is satisfied by the purposed employment of oleaginous and farinaceous articles, as for instance^ linseed cake, or by the selection among ordinary food sub- stances, of those which, like Indian corn, abound in oil. It is to be remarked that the increase of weight of an ani- mal may take place in two ways: first, by adding fat to the deposit in the adipose tissues ; or second, by development of the muscles. It might perhaps be permissible to speak of the former as adipose fattening, the latter as albuminised fattening. According as it has been subjected to one or other of these processes, an animal will be very differently prepared for undergoing severe exercise. A horse fed with Indian corn cannot maintain himself under severe exercise so well as if he had been fed on oats. In the former case his adipose tissues have been developed, in the latter his muscular. The third indication is met by resorting to every expedient which can restrain the action of the respired oxygen. A state of perfect quiescence is therefore to be observed. Muscular movement of every kind increases the activity of respiration. On the contrary, rest dimin- ishes it. If in addition to this state of quiet or rest, sleep 112 FAT AND STAECF likewise be indulged ■ iuj the object is s-till more perfectly attained ; and if a high, temperature be also resorted to, since this checks the oxidation needful for maintaining the system at its due temperature, this further diminishes the waste of fat. Under such circumstances, where everything is done to give a supply of fat, and everything to prevent its con- sumption, it may be caused to accumulate in the tissues to an extraordinary amount. But this very soon inter- feres with the action of the liver. FAT Aim STARCH IN THE NUTRITION OF CHILDREN.* A very interesting article by Dr. Prospero Sonsino, of Pisa, in the September, (1872) number of the " Practi- tioner." " On the Physiological Dyspepsia for Starchy Pood in Infancy," revives an intention, from which I have been diverted by other occupations, of publishing a few words on an allied subject. I propose to speak of the class of cases constituting that wretched form of " atrophy and debility" and " ma- rasmus" in children, in which every part of the body wastes away except the abdomen ; the state described by Dr. Druitt, in the last edition of his " Vade Mecum," in the following few and graphic words : — " Emaciation and voracity ; the belly swelled and hard ; the skin dry and harsh; the eyes red; the tongue strawberry-coloured; the breath foul; the stools clay-coloured and offensive, sometimes costive, sometimes extremely relaxed ; the pa- tient usually dies hectic" (p. 75). * Substance of an article by the Author in the " Practitionee." IN THE NtJTEITION OF CHILDREN. 113 I wish to bring prominently forward the fact that this statBj provided there is no advanced lung- disease, is rapidly cured by Pancreatic Emulsion* given in doses of a teaspoonful every four hours, and regularly persisted in till fat and flesh aire restored. It is, of course, necessary that a proper diet should be insisted on at the same timej but proper diet without the Pancreatic Emulsion will not do. This I have found over and over again in cases where everything judicious in the way of feeding and cod liver oil had been carefully and perseveringly tried without avail, but which, on the addition of the Emulsion to the previous diet, began at once to improve. This fact has been familiar to me for a long time ; and considering how largely Pancreatic Emulsion is now used in the wasting diseases of adults, I am surprised to find that it is not even referred to in the latest works on the diseases of children. Looking through these works and examining their indexes, one is led to the conclusion that their authors are not aware that there is such an organ as the pancreas, or that pancreatic juice has ever been used in any form in the treatment of disease.f Yet scarcely a week now passes but some general practitioner relates to me cases of the successful use in his own prac- tice of Pancreatic Emulsion in the wasting of dehcate chil- dren. Dr. Prospero Sonsino's paper will, I hope, excite more general attention to this important subject. He, how- ever, has laid all the stress of his observations upon the influence of the salivary and pancreatic juices on the digestion of starch. This is unquestionably a point of * (See Appendix IV.) t The word " panoreae" does not occur in the indexes of the last editions of West, Tanner, Vogel, Meigs and Pepper, Eustace Smith, Churchill, on Diseases of Children. I 114 FAT AND STAECH the greatest importance in the case of very young chil- dren brought up by handj as showing the absurdity of attempting to nourish them upon starchy food, not arti- ficially digestedj before the period of life at which the saHva and pancreatic juice attain their functional activity. And even then, as Dr. Sonsino afterwards remarks, " good reasons make us now believe that really it is not proper to feed infants with copious starchy matters, how- ever these may be rendered digestible." The principal results of Dr. Sonsino's investigations are summed up in the two following conclusions, which, however, are not new :^1. "Pancreatic juice in dogs, cats, and rab- bits, in the first week of life — perhaps for some days more — is devoid of any digestive action on starch." 2. " In the early life of man, probably till the beginning of dentition, infants offer a true physiological dyspepsia for starchy aliments, caused by the inactivity of one at least — possibly of all — the humours that concur in the digestion of those aliments" (saliva, gastric juice, pancreatic juice, enteric juice). No doubt, when wasting occurs in these early periods of Ufe, it is very often due to foolish attempts to nourish children upon farinaceous foods, by which dyspepsia and diarrhoea add to the exhaustion of partial assimilative- starvation. But, as a matter of fact, farinaceous food is seldom depended upon without some addition of cow's milk or some assistance from lactation; and we see children suffer from wasting who are fed entirely upon cow's milk or nursed by their mothers, and in such cases the " phy- siological dyspepsia for starchy food" will not account for their decline. Therefore we must not forget, that although normal saliva only acts upon starch, normal pancreatic juice acts also upon fats ; and it is probable that these two functions of the pancreas are sufficiently IN THE NUTEITION OF CHILDREN. 115 independent of each otlier that they may exist separately. This I pointed out in my paper to the Royal Society in 1868, " On the Special Action of the Pancreas on Pat and Starch" (See Appendix IV.) It [is there stated as the results of my experiments^ that " in addition to the in- fluence of the pancreas upon fatj it has the power of converting starch ,into glucose by simple mixture. This property remains to a certain extent after the pancreas has exhausted its property of acting upon fat. The quan- tity of pancreas which before mixture with fat will convert about eight parts of starch into glucose, after saturation with fat will still convert about two parts of starch into glucose." It is possible, therefore, that in different states of depraved health one or other of these properties of the pancreatic juice — that for the digestion of starch, or that for the digestion of fat may be deficient. And thus the depraved nutrition due to such deficiency will not be limited to the period of life anterior to that at which, under normal conditions, the proper functions of the pancreas should be developed. It is evident that when the power of digesting fat fails to be developed at its proper time, the defect must tell with double force upon children already suffering from deficient digestion of starch. The children who become the subjects of the kind of wasting of which I am now treating are especially : (1) those who are suckled by mothers whose milk, though abundant in quantity, is extremely deficient in nutritive properties ; (2) those who are brought up by hand ; and (3) those who, at a later period of childhood, have been subjected to similar chronic defects in diet. Now, it is especially when the mother's milk is poor in fat and lactin that the child becomes " dissatisfied" and " crav- ing," and in the majority of cases it ia this which leads i2 116 PAT AND STARCH to the introduction of farinaceous foodj under the popular nursery belief that it is " satisfying ;" andj as Dr. Sonsino states, if this is given before the power of digesting starch is established^ of course nothing but mischief can result. But organSj like individuals, do not rise to the full performance of their duties unless called upon by the necessity for their activity; and, as I pointed out in 1866 ("On Tuberculosis," p. 40, -second edition), "As the mother is deprived of fat-elements] by lactation, so is the child deprived of them by a persistence in a diet deficient in milk. In the case of the child thus deprived of fat, a double injury is done, first, by cutting ofi" the supply of fat-elements necessary for the protection of the tissues ; and secondly, hy paralysing the function of the ^pancreas by prolonged inactivity." I venture to think that this is a point deserving far more attention than it has yet re- ceived.* It accounts in a great measure for the impossi- bility of restoring these ill-nourished wasted children by any kind of natural diet after they have been allowed to remain in a chronic state of defective nutrition. A child that has been long fed upon diet deficient in fat fails to develope the fat- digesting properties of the pan- creatic secretion, and thus, when proper food is at last presented, cannot make use of it for nutrition. It is probable, therefore, that it is due to this conjunc- tion of circumstances that these wretched eases of fatal infantile wasting occur : the food deficient in fat not only fails to nourish the child, but fails to develop the func- tion of the pancreas for the digestion of fat at a later period of life ; the craving of the child due to the defi- ciency of assimilated fat is met by starchy food, which it has not the power to digest, and which, if digested, can- * See some excellent papers fey Dr. D. S. Brakenridge, "On the influence of a Digestive Habit, &o." Medical Times and Gazette, June, 1868. IN THE NUTRITION OF CHILDREN. 117 not supply the place of fat. Thus it is literally starved from first to last of those elements of nutrition especially essential in early life. We cannot, therefore, be surprised that such cases have proved obstinately fatal, neither is it anything but what one might expect, a priori, that they get rapidly well when Pancreatic Emulsion of fat is added to their diet, for by this means they are enabled to assimi- late both fat and starch. Certainly, of all the satisfactory remedial effects of Pancreatic Emulsion, none equal the almost magical recoveries of some of these miserable wasted children. The cases in which I have seen it administered within the last eight years are too numerous to relate, and I will only briefly mention three of those which first especially excited my attention. 1. A poor woman came to the Eoyal Hospital for Diseases of the Chest with a child presenting the most exaggerated features of emaciation of every part, except the abdomen which was large and hard. She was very excited at having succeeded in gaining admission, and explained in great haste that " all she wanted was some Pancreatic Emulsion, which she had learned could be obtained at the Koyal Hospital." She said the child had been even worse than I saw it, that everybody told her it was a hopeless case, and that she had carried it to her mother's home in the West of England, where it appeared to be slowly dying, when a charitable visitor came in and gave her a bottle of emulsion, saying that he had seen just such a case cured by it. She gave the emulsion, and the child began to improve so wonderfully that she was able to bring it back to London, where it continued to mend till her bottle of emulsion was finished, when it rapidly fell back, and became nearly as bad as ever, before she could find out where to procure more of 118 FAT AND STARCH the remedy. This she had just done^ and hurried off to the Hospital. The child had diarrhoea, but she said she knew that would stop if I gave her emulsion^ as it had done so before. I did as she asked — let her have as much emulsion as she wished, and the child got abso- lutely well. I have seen it this year, a well-grown, plump, hearty little girl. This woman has since had two other children, each of whom has in turn shown signs of marasmus like its elder sister ; in one, when brought to me, the lungs presented small crepitation from end to endj but both of these children were put upon emulsion at an early stage of their wasting, and made easy recoveries. 2. Soon after these cases occurred. Dr. Dingley, of Argyll Square, consulted me about a little patient of his in Soho, who was wasting in the same way ; and as all the usual remedies, both in medicine and diet, including cod oil, had quite failed to arrest the downward progress of the case, we agreed to try the Pancreatic Emulsion. I did not see the case again, but Dr. Dingley has since in- formed me that from the time of commencing the Emul- sion the child began to improve, and steadily progressed till it got perfectly well ; and it remains well to the pre- sent day. Dr. Dingley was so impressed with the success of the remedy in this apparently hopeless case, that he tells me he has since resorted to the same treatment in all similar cases with equally satisfactory results. 3. At the Oxford meeting of the British Medical Association, Dr. Langdon Down told me of a case that had made a great impression upon him, and it is espe- cially important as coming from a man of his large and intimate experience in all that relates to the affections of childhood. The following note from Dr. Down graphi- cally indicates the outline of the case : — IN THE NUTEITION OF CHILDREN. 119 " The patient at Reigate was seen by me in consulta- tion with Mr. Steele^ in the spring of 1867. She was in the most attenuated condition I ever remember seeing. It appeared to be the extreme marasmus of mesenteric disease. The lungs were healthy. The treatment had been most judicious and exhaustive. As something which had not been tried^ I suggested the Pancreatic Emulsion. The improvement was coincident with the altered treat- ment and was very progressive. Five months after I was asked to see her by her father, to test whether I could recognise her. She was playing croquet, and I could hardly believe that the one pointed out to me was our patient, the change was so great. She has ever since had excellent health." These cases, which are well known to many persons besides myself, may appear somewhat " sensational," but they are only samples of numerous others which have oc- curred in my own practice. The fact is, that when these cases a,re properly selected for the treatment, they are all " sensational ;" for the rapidity with which it takes effect, and the completeness of the restoration to health of chil- dren who appeared to be hopelessly dying, is simply start- ling. I have proved over and over again that, whether in children or adults, no amount of milk or cream, however good, will do instead of Pancreatic Emulsion, and I have tried to discover why this should be. Milk, so far as this part of its composition is concerned, is simply an emulsion of fat ; and pancreatic emulsion, as I have shown in the paper to the Royal Society already referred to, is not, as formerly supposed, a chemical combination, but a true emulsion. Why, then, does not milk answer as well ? I believe the explanation to be very simple, and that it turns unon the following points : — 120 FAT AND STAECH 1. The fineness of tlie particles of fat^ and the absence of albuminous envelope. 2. The permanent character of the molecular mixture of fat and water. 3. The proportion of fats having high melting points. (a) In my first paper on Pancreatic Emulsion (" Lan- cet/^ September 10, 1864), I gave the measurements (made by the late Mr. Parrants, President of the Micros- copical Society) of the particles of fat in cod oil and beef fat emulsions, as then prepared for me ; showing that the majority of the particles in the cod-oil emulsion ranged from the 16,000th to the 1,200th of an inch in diameter, and those in the beef-fat emulsion from the 10,000th to the 2,500th of an inch ; and, according to Bowman (" Prac- tical Handbook of Medical Chemistry," p. 174), "The size of the globules in healthy mUk varies from a mere point to about the 2,000th of an inch." Since I pubHshed Mr. Farrants' measurements, pan- creatic emulsion has been made by a much more equal and satisfactory process than at that time, and I have just ex- amined a chance specimen procured from Messrs. Savory and Moore, in which the large majority of the particles of fat range from the 21,600th to the 14,400th of an inch in diameter, the prevailing size being the 18,000th of an inch ; while in a specimen of good new milk (cold), which I have also just examined, the large majority of the parti- cles of fat range from the 7,200th to the 3,600th of an inch in diameter, the smallest being the 10,800th. (6) The permanent character of the Pancreatic Emul- sion is very remarkable, far exceeding that of milk. It " difiers entirely from all other kinds of emulsion of fatty matter, whether chemical or mechanical. All other emul- sions of fat are destroyed by ether, the fat being restored at once to its original condition, The influence exerted IN THE NUTEITION OF CHILDREN. 121. by the pancreas upon fatSj therefore, appears to operate by breaking up the aggregation of the crystals of the fat. It alters the molecular condition of the fat, mingling it with water in such a way, that even ether cannot separate the fat 'from the water. A permanent emulsion is thus formed, ready to mix with a larger quantity of water whenever it may be added." (" Proceedings of the Eoyal Society," already referred to). (c) In the "Chemical News," September 4, 1868, I stated vaj reasons for believing in the importance of fats of high melting points, such as stearine, margarine, and palmatine, over those of low melting points, such as oleine, as elements of food and medicine ; although further ex- periments and investigations are still needed on this inte- resting subject. {See p. 108). Pancreatic Emulsion of > solid fat, consisting principally of stearine, margarine, and palmatine, is therefore quite a different thing from milk, the fat of which is principally oleine. Now, the nearest approach to a pancreatic emulsion is what may be called nascent milk, by which I mean milk just secreted — milk that flows from the mammary gland as it is formed, or, as mothers term it, " as the draught comes in." In this the emulsification is finest and most perfect, but every minute that elapses after the milk is secreted deteriorates this perfection of emulsification, until, as we know, whether retained in the lactiferous ducts or in an artificial vessel, but especially in the latter, and when allowed to cool, the cream separates from the water of the milk, never again to be susceptible of the same emulsifi- cation with water in which it first existed, except under the influence of pancreatic juice. I submit that this is the secret of the superiority of lac- tation, and especially of lactation at the time " the draught 122 FAT AND STARCH. comes in/' over every other kind of infant-feeding, whether in man or in the lower animals. It forms an important distinction between milk- diet, supplied by the natural pro- cess of suckling, and milk-diet administered artificially, and affords some reasonable colour to the old-standing belief in the eflScacy of "new milk warm from the cow" for delicate children, and to the remarkable recoveries re- corded in ancient times of old persons nourished by lacta- tion when everything else had failed. Ohaptee VI. FERMENTED LIQUORS. ADMIN] STEATION OF ALCOHOL PEOPEETIES OF VARIOUS WINES — ^WINES IN GENEEAL SPANISH WINES GBEMAN WINES — ' HUNGARIAN WINES GREEK ^ WINES — ACID, GOUT, RHEUMA- TISM — ACID AND SUGAB IN SPIEIIUOUS LIQUOES — ^ARDENT SPIRITS AND THEIE PECULIARITIES ALCOHOL TABLE SHOW- ING THE ANALYSIS OF SPIEITUOUS LIQUORS. ADMINISTRATION OF ALCOHOL. According to my own experience, tased upon long and careful observation, an average-sized adult man taking moderate exercise may drink with advantage enough fer- mented liquors, each 24 hours, to represent from one to two ounces avoirdupois of absolute alcohol equivalent to from If to 3| ounces of proof spirit* — provided it be always diluted to the extent of 10 fluid ounces (half-a-pint imperial) of water or some other unfermented liquor to each ounce avoirdupois of absolute alcohol, and that it be taken when there is food in the stomach. (See "Prelim- inary Remarks ;" Chapter III.; and Appendix). THE PROPERTIES OP YARIOUS WINES. The subject of wine has of late years become so exten- sive—embracing so many considerations connected with such numerous varieties of wine from different parts of the » See Alooliol Table. 124 PEOPBETIES OF VAEIOTJS WINES. worldj ' — that I have thought it best to give the practical experience of several recognized authorities specially ac- quainted with different departments of the subject. I am glad, therefore, to be able to present the following matter from such reliable sources. The observations on Wines in Oeneral are dictated by my friend Mr. James L. Johnston, late Principal Inspec- tor of Customs Laboratories,, who has, undoubtedly, more correct practical and scientific knowledge of fermented liquors than any other person in this country. For the account of the wines of Spain I am indebted to Mr. F. W. Cosens the celebrated Spanish wine merchant. The description of the Wines of Germany and of the distinctive medicinal properties attributed to them in the districts where they are grown, has been kindly furnished by Mr. M. A. Verkriizen of Fell Street, City, who is well known to have devoted much time to this subject. Mr. Denman, of Piccadilly, the principal introducer of the Wines of Greece, and the author of several works on wine, has favoured me with the concise statement of the medicinal properties attributed to these wines by the nu- merous medical men who have communicated to him their experience. For th.e account of the wines of Hungary I am indebted to Mr. Max : Greger of Mincing Lane, City, who first in- troduced the pure Hungarian wines into this country, and who has so creditably maintained his character both for a scientific and practical knowledge of the wines of his native land, and for the conscientiousness with which he attends to the orders of medical men, when they consider it important that only the purest and most mature wines skall be supplied to their patients. I give the statements of these several authorities near- ly in their own words, and they are responsible for them ; WINES IN 6BN1EAL. 125 butj SO far as it is practicable for one person to do so^ I have endeavoured to test the correctness of their opinions by my own experience. I have only further to add, that there is no department of commerce in which "commercial immorality" is so atrociously and so easily practised as in the wine trade, the most professed connoiseurs being often the most " taken in ;" and, that I know of no protection against the misfortune of drinking half poisonous trash instead of genuine wholesome wine, except that of cautiously select- ing a wine merchant of known honour and probity, and then leaving to him the entire responsibihty of choosing your wines. WINES IN GENEEAL. In the economy of nature, wine has always held a pro- minent position. Corn, and wine, and oil, represent the highest agricultural development of the vegetable world — the corn and oil to nourish and sustain, and the wine to invigorate, refresh, and solace life. — In considering the subject of diet, therefore, whether for health or sickness, so important an element cannot be ignored ; seeing that, while in health it contributes largely to the enjoyment of life, in sickness it is a powerful auxiliary to the Physician, , more particularly under certain morbid conditions affecting both body and mind. In all ages, in wine-producing countries, especially, where it is best known and appreci- ated, wine, rationally used, has been regarded as a valu- able means of promoting health, of prolonging life, and of adding to its enjoyment ; but the penalties which follow the abuse of any of those gifts, provided and intended, by the Creator for the benefit of his creatures, as certainly 126 WINES IN GENEEAL. follow its misuse. This requires no argument to demon- strate, it is within the knowledge of every thinking obser- ver, nor does it furnish any reason for the disuse of wine, for there are few of the most valuable medicaments which are not poisonous if used without discretion. With these prefatory remarks I will proceed to consider briefly the constitution and varieties of wine, its natural and commer- cial alcoholic force, and its hygienic properties. Strictly defined, wine is the fermented juice of the grape. But this theoretical definition is not quite carried out in practice. When perfectly fermented, wine becomes what is technically termed " dry," meaning that the whole of its sugar has been converted into alcohol, within certain limits, however, inasmuch as the production of alcohol, at a certain point arrests the fermentation and further pro- duction of spirit, leaving a margin of unconverted sugar (where that constituent is in excess) to enhance the rich- ness of the wine, as in the instance of the celebrated Sau- terne known as Chateau D'Yquem. For the same reason extraneous spirit added to the fermenting "must" has the efiect of arresting further action, and retaining the unconverted sugar as an element of richness in the liquid. This is the course followed, with recent modifications and exceptions, however, in the manufacture of the Port wine of commerce, and also of the red Tarragona wines of Spain intended to imitate and compete with Port in the English market. Some wines are only partially fermented, in consequence of the over-richness of the " must" through the elimina- tion of a considerable proportion of its watery constituent by natural or artificial means ; as in the instance of the Essenz or Ausbruch wines of Hungary of which the Im- perial Tokay, a wine of wonderful richness, is the highest type. Others again are not fermented at all, but the WINES m GBNEEAL, 127 grape juice is simply inspissated' or concentrated by slow boiling or simmering, as in tbe Tent wine made at Rota in Spain, and used generally for communion purposes in the Anglican Church. Of course under such circumstances this is merely a syrup or conserve of grape juicBj and does not contain a particle of spirit in its natural state ; but as it is customary to add from 20 to 30 per cent, of spirit to it by way of preservative, it is put upon much the same footing as fermented wine, in respect of alcohol. Effervescing or sparkling wines are the last variety. In thern the fermentative action is not only arrested but im- prisoned as it were, to form the- " mousse," as it is called, which is at once their peculiarity and their charm. Dry wines, whether still or sparkling, are preferable to all other kinds from a medical point of view, chiefly on account of their greater freedom from the objectionable unconverted sugar and their more easy digestion, in ad- dition to which their quahty is invariably higher, as being under no disguise. In almost every other respect the grand characteris- tics of wine are common to all, subject to certain modi- fications arising from climate or soil, from the latter of which, especially, some very important hygienic qualities are derived. Colour is a distinction of little importance to the pre- sent question ; it is obtained from the skin of the grape, when the bruised fruit is fermented in place of the ex- pressed juice j red or violet when the black grape is used, from the blue colouring matter of the skins, and brownish- yellow in the case of the white grape, from the apothema, which becomes darker by exposure to the air. But in many cases colour is an artificial production, notably in the case of brown sherries, in which it is owing to an ad- mixture of boiled wine called vino de color ; the normal 128 WINES IN GENERAL. colour of pure sherry, for example, ia a pale greenish or brownish-yellow, deepening with age. For these reasons pale sherries are to be preferred to golden or brown, especially as being purer. The natural strength of wine is, within a limited range, from 18 to 30 per cent, proof spirit* (10"5 to 17"25 alco- hol) which is rarely if ever exceeded. French Claret is a type of the lowest, and the wines of the Pyrenees Orien- tale and Spain generally, of the highest strength. The majority, however, occupy the middle place, and comprise Sauternes, Burgundies red and white, the wines of the Rhine, the Moselle and the Danube, the Italian Peninsula (except Marsala) and the Grecian Archipelago, which are all within 20 and 25 per cent, proof spirit (ITS . to 14'6 alcohol). These wines, as a rule, are brought to market in a nearly pure state, or with such inconsiderable additions of spirit as to be of little consequence. It may be taken for granted that no sparkling or effervescing wines can ever exceed the strength of 24 per cent, proof spirit (13"6 alcohol) ; their real variety, apart from the different sorts of wine employed, consists in the different proportions of sugar added as " liqueur" in the course of manufacture, and which varies from the pure or " brut" wine up to 18 and 20 per cent., the general average in the English market is midway, about 10 per cent., although the demand for the " dry" kinds is greatly on the increase. In prescribing these wines therefore the medical man is dealing with known forces as far as alcohol is concerned ; but it is very different in respect of Port, Sherry, Madeira, and Marsala. The Port wine of commerce is never under 35 per cent, proof spirit (20 alcohol), the average being 38'5 up to 42 * Proof spirit is the ordinary potable spirit of commerce and is equivalent to nearly equal parts of alcohol and water. — (See Alcohol table). WINES IN GENEEAL. 129 proof spirit (22 to 24 alcohol) ; while Sherry, Madeira, and Marsala, although commencing a trifle lower, or at about 3r5 proof spirit (18 alcohol) advance almost if not quite as far. Thus a rich vintage Port wine at 42 per cent., the usual strength of high-class Port wine, must have had 33 per cent, of proof spirit, or J of its bulk of ordinary brandy added to bring it to that condition.* The same may be said of the cheaper red Tarragona wines, lately introduced, which bid fair to supersede the real Port wines in Hospital practice. In its pure state this is a generous wine of considerable natural body and strength, and litely, if its use were encouraged, to be- come a favourite and wholesome beverage with the mil- lion. Although Sherries and other white Spanish wines are largely fortified, in general, for the English market, there are, amongst the drier sorts, Montilla, Amontillado, Man- zanilla, and the lighter kinds termed Vino de pasto, many which would only be injured by being fortified, and are consequently — the higher classes in particular — usually exempt from that debasing operation. Some of these are unequalled for sanitary purposes, especially in dyspeptic cases where the bitter principle (in Amontillado not unhke that of an orange-pip) appears to act as a tor ic. No wine has been so extensively imitated — the usual penalty of admitted excellence — as so-called Sherry; Hamburg especially is facile princeps in manufacturing an article called Elbe Sherry, largely recommended in certain quarters, composed principally of Elbe water and potato- spirit flavoured in an ingenious manner with various ex- tracts and ethers too numerous to mention, bnt which * Three glasses of such wine, therefore, represent more than one glass of ordinary Brandy. K 130 SPANISH WINIS. should 'be shunned as poison under whatever auspices it may present itself. There is scarcely a white wine vended which is not called Sherry and courts consumption under that popular and attractive pseudonym. It would be out of place in a work of this descrip- tion to show the different means by which the natural characteristics of wine are artificially heightenedj when weakj or suppliedj when altogether wanting — such as the elder flower on the Rhine and Moselle, the chamomile in Spain, and the black currant leaf and rasp-berry in Erance to give "bouquet," the elder-berry, blackberry and bil -berry to give colour, in Portugal and Spain. These are harmless, compared with the abominably per- nicious practice of " fortifying" beyond what is necessary for purposes of preservation, where potato or beet- spirit, or some such cheap and nasty production is the agent em- ployed. SPANISH WINES. Of all those wines possessing distinct characteristics, and which impress the palate in a marked degree, none is more prominent, in the opinion of Mr. Cosens, than that one of Spanish growth, known under the generic name of Sherry, and which is so-called from being produced near the town of Jerez de la Frontera in Andalusia, around which cluster the oldest and most famous vineyards. Of late years since railway communication has opened up the interior of Spain to the seaboard, a great impulse has been given to viticulture around Seville, the Montilla district near Cordova, and other outlying localities; the wines bemg light, genuine, and delicate, are in general favour as dinner beverages at moderate prices. SPANISH WINES. 131 The area producing the veritable Jerez has been some- what extended^ since Dr. Gorman^ in 1851, pubhshed his statistical tables of the annual yield which he gave as 52j000 butts for the whole district. There is, probably, little doubt that the famous " Me- thuen treaty," while it secured a temporary monopoly for the wines of Spain and Portugal, induced a much more careful cultivation, and consequently a yield of superior wine ; so mucb so, that since then Sherry has become a household wine as much by force of quahty as by fiscal favouritism. Of course the usual penalty of ex- cellence has to be paid, and Cape and Elbe Sherries have started into notoriety as cheap imitations, damaging the reputation of the pure produce of Jerez, in the estimation at least of the ill-informed. Prom old records still preserved amongst the archives at Jerez, we find that so early as 1268 vineyards are named as existing contiguous to the " Oartuja monastery" on the banks of the Guadalete which fiows past the Portal, or Port of Jerez, a short distance from the town itself. It is also stated that in the year 1483, "no English or Breton ships have arrived this year in consequence of the war with the Biscayens," and in an old print of the time of the sack of Cadiz under Essex, men are seen carrying butts of wine slung by. ropes suspended from their shoul- ders, to a boat on the beach, a vessel apparently of English build, lying at anchor in the Bay, the casks are of precisely the same shape and character as those now in use. There is no doubt that prior to 1483 the wines of Spain were consumed and appreciated in England. In 141& WilUam Horrold was placed in the pillory for counterfeit- ing and vending " olde and feble Spaynishe wyn for good and true Eomeney." K 2 132 SPANISH WINIS. This same counter feiting, for a long period fostered by tlie half duty charged upon Cape wines, has no doubt led many medical men into error as to the exact hygienic effects of Sherry. Judging from continental practice there are many mala- dies for which genuine and generous wine of the Sherry type is the only recognised and approved curative stimu- lant. A large quantity of really superior Sherry finds its way annually into consumption in England, in fact all the costly and rare growths are exported to this country. Domecq, Garvey, Gonzalez, Cosens, and others, devote themselves almost exclusively to the growing, rearing, and exportation of the produce of the oldest and best cul- tivated vineyards of the " termino of Jerez." These wines can be procured in a perfectly genuine state, and in the highest perfection, through the established channels of supply — wine merchants of credit and position. Undoubtedly, good, sound, wholesome, young Sherry may always be procured at a moderate price ; but those who look for high character and rare excellence must bear in mind that great resources are required to enable the shipper to breed fine wine ; much time, skill, and pa- tience, as well as technical aptitude are absolutely neces- sary to secure a favourable result. Pine Sherry must, therefore, always remain more or less costly ; at the same time excellent wine may be procured at a moderate price, while "cheap and wholesome," is only, as a rule, another name for dear because inferior. A teaspoonful of water in a glass of ordinary Sherry, will render it grateful to the delicate digestion of most dyspeptics. The great rage for cheap wines since the introduction of Claret at a low duty, has undoubtedly stimulated the SPANISH WINES. 133 importation from fclie South of Spain of immature wines; such, improperly fermented, carelessly prepared, and of inferior growths have disgusted many consumers; and the medical profession have noted their baneful effects from a hygienic point of view. Ford says in his Handbook, speaking of Manzanilla, "drink it ye dyspeptics," but as there are wines and wines, so are there Manzanillas and Manzanillas, no wine requires more time and skill to grow and rear, or, pro- bably in its immature state, is more injurious to a dehcate stomach. A great deal of controversy has at times arisen as to whether the sprinkling of grapes ■vvfith a very small quan- tity of gypsum is desirable or not ; some assert that the lime in the sack, so feelingly alluded to by Falstaff, arose from this same sprinkling, especially as there is but little doubt that up to the early years of the 18th century, the " Sherris, sack" of history was quite a new wine exported from Spain almost as Must ; hence all the empirical re- cipes given in such books, as the mysteries of Vintners" (1699), &c. With reference to this sprinkling of gypsum practised since the days of Pliny, its sole use is probably to coun- teract the effects of an over-production of albuminous matter dangerous to the wine during the years required to ripen and perfect it. Genius in the management of Sherry has its value, un- doubtedly, but it must be supplemented by training. Condition, time for bottling, refining, all these require long and patient study ; the result being, from skill and good management, bottled sunshine, and, from the con- trary. Daffy's Elixir ! The Red wines of Spain are annually gaining favour, they are ripe at an earlier age than the White and possess 134 GBEMAN WINES. , dietetic and hygienic properties peculiarly their own. At the Claret duty of Is. per gallon instead of 2s. Qd. they would probably become the Eed wines of the million. GERMAN WINES. German Wines when obtained in their native purity contain medicinal and health-promoting qualities of great value. Foremost in medicinal respects^ Mr. Verkruzen says, we should consider the Moselle and Saar Wines ; they are the lightest and contain the smallest proportion of alcohol and Saccharine matter, and are consequently not only the most digestible, but, from the considerable pro- portion of vinous and apple acid they contain, are power- ful promoters of digestion; they act most beneficially upon the secreting and excreting organs and are great purifiers of the blood ; whilst their stimulating power is of the mildest character, though most decidedly perceptible, as in the coldest weather they diffuse throughout the sys- tem a comforting sense of warmth. Dr. Franz Meurer, Royal Prussian Eesident Physician by Government appointment at Zell on Moselle, speaks in the highest terms of the curative and health-promoting quahties of these wines, as the result of his thirty years' practical experience. He recommends them as most valuable in cases of Rheu- matism, Gout, Dropsy, Stone, Gravel, Scorbutic and blood diseases generally. In certain cases those younger and lighter wines which possess a larger proportion of vinous and apple acid are most beneficial; whereas, in other cases, fuller bodied GBEMAN WINES. 135 wines of greater age and possessing a larger degree of alcohol {always natural and not added to the wine) and a less proportion of acidity, of whatever nature it may be, are most beneficial. It is a noteworthy fact that the Moselle and Saar wine,Sj whilst containing more vinous and apple acid than other wines, not only do not sour the stomach like the sweet wines but actually counteract acid- ity of the stomach by promoting its healthy action. In cases where Ports, Sherries, Clarets and Ehine wines produce acidity, the Moselle wines frequently counteract it from the extraordinary lightness of their character and the mild and gentle nature of their appetising power, which gently stimulates without irritating. As daily bever- ages no wines are more suitable. The higher class of these wines are the most recommendable in dyspeptic cases. The principal growths are : — Wiltinger, Zeltinger, Brauneberger, Piesporter, Josephs- hdfer, Griinhauser, Scharzberger and Scharzhofberger, all white wines. These may be described as strongly diuretic and mildly laxative ; the higher class, containing the least amount of acidity, might be considered, perhaps, sedative, as they are wonderfully composing and comforting. The Ehine and Palatinate wines, are of a stronger and more spirituous character than the Moselle and Saar wines, and consequently are more generous, yet amongst these there are many equally light and similarly refresh- ing. Excepting in the case of the lighter sorts, we should recommend greater moderation in the enjoyment of these than of the Moselle wines. Amongst the finest white growths are the following : 136 'GERMAN WINES. Rhbingatjer. Paiatiwate. Maecobeunheb, (light and very Dbidbsheimbe, (fine, full, rather wholesoire, diuretic). sweet wine). Rtjdbsheimbb, (full-bodied stout Forsteb, (soft delicate wine, de- wine, generous). licious bouquet). JoHANNiSBERGBR CABINET, (fine, RupPERTSBERGER, (very finefull- aromatic wine). bodied wine, frequently almost Steinbbrgee Cabiwet, (very fine spicy), grand wine, full-bodied). To say that any , of the wines just named are specially diuretic, laxative, sedative, tonic, &c., would be hardly to represent them correctly, as they all possess these quali- ties more or less according to the quality, vintage, age, A;c., &c., &c. There are twenty or more distinctions of quality to be had in each growth, containing more or less alcohol, saccharine, vinous acid, fixed acid, volatile acid, tannin, &c., &C.J according to the nature of the host of circum- stances which have operated upon the production of the wine from the commencement to the completion of the process, and which diflfer with every season. When invalids require wines for certain cases and ob- jects they ought, after having consulted their medical adviser as to the nature or character of the wine that suits their case, to entrust their order to a wine merchant who understands his business and who is thoroughly conver- sant with the nature of the different wines constituting his stock. As a sedative he will give th'em a fine dry clean old neutral wine, no matter whether a Deidesheimer or Forster ; as a diuretic he will give them a wine containing much vinous and fruit (apple) acid; as a stomachic he will select a wine having a considerable proportion of tannin; and to the low spirited and down-cast he will give a fine wholesome dry and sparkling wine. GERMAN WINES. 137 Amongst the Red Wines of Germany we have several excellent sorts^ suitable especially for convalescents and as family wines. Assmannshauser and especially Oberingel- heimer from tlie Ehine, and the fine Walporzheimer wines from the valley of the Ahr, are fine stomachic wines and great blood enrichers ; in anaemic and other constitutions exhausted by debilityj and also in persons of the phos- phatic diathesis these wines are recommended. Of the Sparkling wines of Germany, a pure Moselle, without muscatel and other artificial flavouring, is the most wholesome, and in cases of weak digestion I should consider such a wine decidedly preferable to Champagne. I have seen wind on the stomach which had almost con- stantly troubled the sufferer for three or four weeks to an alarming degree, entirely and effectually cured (so that during three weeks subsequently no recurrence whatever of the malady was perceived) simply by the use of a bottle of fine sparkling Moselle and ^ lb. dry, hard, short, bis- cuits taken about four hours and a half after luncheon ; the stomach was gently brought into action by the wine and biscuits, the wind was expelled, the whole frame -be- came warm through, and a sense of extreme comfort ensued. By gently acting upon the stomach, and subse- quently upon the bowels, liver, and kidneys, the wine no doubt removed to a great extent the causes which produced the wind and hence the relief experienced for so long. When fatigued, especially in hot weather, there is no better reviver as a glass of half soda water and half still Hock or fine Moselle. HUNGAEIASr WINES. Mr. Max : Greger says, he Can speak with the utmost confidence of the medicinal properties of the different 138 HTJNGABIAN WINES. kinds of Hungarian wines, not only from many years of personal experience in tte districts where they are grown, but from reports that have been forwarded to him, in some hundreds of letters, by medical men who have pre- scribed these wines in their practice. In prescribing Hungarian wines, it must be borne in mind that they are far richer in grape-sugar, and in con- sequent alcohol, than any of the French and German wines, they therefore require a year or two longer to finish fermentation, that is to say to accomplish their maturity. It is, therefore, of the greatest importance to obtain these wines from such sources as may leave no doubt that they are first, genuine, and secondly, matured. Hungarian wines, generally speaking, are full in body, and whilst most other cheap light wines will produce a feeling of coldness, a glass of good Hungarian wine will produce a sensation of warmth all over the body. In anaemia and chlorosis, and in exhaustion from loss of blood, especially by women after childbirth and in chronic nose-bleediag, great benefit is derived from the use of the Hungarian Eed wine, Carlowitz. It is also administered with advantage in bilious disorders, slug- gish action of the liver and hsemorrhagic afiections. Ofner Auslese is prescribed with excellent effect in diarrhoea, and if the case is urgent half an ounce of cinna- mon and an ounce of cane sugar are added to one bottle of wine, which, if well boiled together for half an hour and taken hot at bed time, will produce a very agreeable soothing effect on the bowels. In Hungary, Ofner Aus- lese is the household remedy for diarrhoea, especially during cholera epidemics. Amongst the white wines of Hungary, Somlau should be selected as a substitute for the, so-called, dry sherries of Spain; and CEdenburg and Euster Ausbruch (dry). GREEK WINES. 139 where the tartaric acid contained in all red wines seems objectionable. The Ruster is especially valuable in convalescence from exhausting, diseases, sleeplessness and weak digestion, and in Hungary is considered a valuable sedative in neuralgia; while the (Edenburg finds especial favour with gouty persons, many of whom have been unable to touch any other kind of wine. It has distinctly diuretic properties attributed to it. The different kinds of Hungarian sparkhng wines, are pleasingly exhilarating, leaving but little after depression even when they have been taken to excess. They, there- fore, constitute a satisfactory stimulant where exhilaration rather than alcoholic stimulation is desired. The finest Crown Tokay is an extraordinarily restorative wine, spreading warmth throughout the body to the tips of the toes and fingers, and is therefore of singular value to the old and feeble. It is, however, very rarely found of genuine quality, and when genuine is of great cost. GREEK WINES. The following are the leading properties, in a Dietetic point of view, attributed to the wines of Greece. PKOPEETY. Stimulant and exhilarating. Restorative and supporting. Tonic and restorative. Astringent and blood-making. Refreshing and gently stimulating. » ti jj Tonic and stimulant. Restorative and nutritive. WINE. COLOUR. St. Elie White Thera White Santorin Red Kephesia Red » White Patras White j» Red Como Red ]40 ACID, GOUT, BHEUMATISM. ACID, GOUT, RHEUMATISM, FROM FERMENTED LIQUORS. The question most frequently requiring consideration with regard to the selection of alcoholic beverages, is their tendency to encourage acidity and to promote gout or rheumatism. For practical purposes, these three ques- tions may be merged in the second, viz., their gouty or non-gouty tendency. From long and careful consideration, both theoreti- cally and practically, of the production and composition of fermented liquors and their effects upon digestion and disease, I have come to the conclusion that alco- holic drinks favour the tendency to gout, or actually produce it, in proportion to the quantity they con- tain of saccharine and albuminoid ingredients in which the processes of fermentation and decomposition have commenced but have remained uncompleted. This head will especially include those full-bodied " fruity" wines, in which the course of fermentation has been stopped by added spirit, or in which it is incomplete from want of age; (see p. 126), and malt liquors and cider, in which the process of fermentation is never thoroughly completed by the time they are considered in good condition for drink- ing. The least gouty alcoholic drinks, are those spirits in which no unfermented compounds are present, and those wines in which vinous fermentation has become complete. But unfortunately these wines cannot be borne by acid stomachs, because complete fermentation of wines involves the production of much acid. If they are taken, there- fore, they must be mixed with enough alkaline mineral water to neutralise their excess of acid. It is impoitant to remember that although a fluid may contain much acid, and therefore be unfit for some sto- AEDENT SPIRITS 'AND THEIR PECULIARITIES. 141 machSj it will not generate acid if it is free frona saccharine matter ; whereas a fluid containing saccharine matter will generate acid although it may not contain any. ARDENT SPIRITS AND THEIR PECULIARITIES. Brandy makes people nervous, Gin weakens, Rum and Whiskey produce biliousness, Whiskey is the least objec- tionable. When Whiskey produces biliousness, Rum, which has been made hot and then cooled, may be tried instead. The prominent objection to all ardent spirits, is, that they injure the lining of the digestive canal, and produce diseases of the liver and kidneys. The best means of pre- venting these dangerous effects, is, free dilution with some unfermented liquid. None should be taken neat, and when mixed with water or other fluids they should be well incorporated by pouring many times from one vessel to another; otherwise, the unfermented liquid will be separated from the alcohol in the stomach, and the objects of dilution will be frustrated after all. 142 ALCOHOL TABLE. The weight of Absolute Alcohol (spec, grav 793 at 6o° Fht.) and of solid dissolved, in measured 1 quantities of Spirituous Liquors. *,* This co- SPIRITUOUS LIQUORS. lumn shows the quantity by measure I OZ. avoird. One Imperial Pint contains Per cent * The strength of Ardent Spi- rits is arbitrary, the strengths here given are the commercial average. of each Spi- rituous Li- quor which contains ONE OZ. AVOIRD. of Carbon is con- tained in fluid Extract ozs. Carbon, ozs. Extract. Alcohol Equiva- lent of proof of absolute ozs. avoird. avoird. spirit. Alcohol. Fluid OZ. * . C Proof Spirit . . . 2-26 4-3 — 46 __ 57-15 100 II Whisty 2-6 6-0 •1 4-0 0-6 48-3 84-5 « rt 4 Brandy S^ Rum 2-7 5-0 •2 4-0 1-2 47-1 82-4 2-8 5-3 •2 8-8 1-1 45-0 78-8 ■^ Gin (sweetened) . . 3-2 5-5 ■9 3-6 4-5 39-8 69-6 (■Port 6-9 10-2 11 2-0 5-5 22-0 385 Lisbon (.White) . . 9-0 7-8 3-5 2-6 161 12-0 21-0 Bucellas .... 7-3 11-2 0-9 1-8 4-4 160 28-0 Madeira 6-8 11 07 1-8 3-5 22-0 38-5 Sherry (of commerce) 6-5 lO'O 10 2-0 4-6 20-6 36-0 „ Montilla and ) Amontillado } 6-8 10-1 1-1 20 5-6 18'3 32-0 „ Natural. . . 9-0 7-8 1-5 2-6 5-2 14-5 25-3 Marsala 7-S 117 0-9 17 4-4 19 5 34-0 Eousillon (Masden). 6-3 8-5 17 2'4 8-0 20-6 36-0 Burgundy .... 15-2 23-8 0-4 0-8 1-8 120 21-0 Cbablis (Montrachefc) 19-0 27-0 0'5 07 2-3 12-0 21-0 Claret 16-3 23-4 0-5 0-8 2-5 11-5 20-0 m W Sauterne (Chateau > d'Tquem . . i 90 7-8 3-5 2-6 161 12.0 21-0 £ Hock (Johannisberg) 13-4 20-4 0-5 10 2-5 12-0 21-0 Moselle 16-2 23-3 0'4 0-8 2-0 120 21-0 Champagne and "1 other effervescing > 12-6 11-3 2-3 1-8 11-0 il3-5 23-6 or sparkliugwines 3 ■Hungarian Bed 7 (Carlowitz) ) 141 21-2 0-5 0-9 2'5 14-5 25-8 White I (Somlau) . . ) 19-0 28-3 0-4 07 1-8 12-0 21 '0 ,, Imperial 7 Tokay (essenz) ) 9-0 7-8 3-5 2-6 16-1 10-3 18-0 Constantia (Sed 7 and White) . ) 90 7-8 2-8 2-5 15-0 11'5 20-0 ^Prontignac. . . . 9-0 77 40-0 3'4 0-8 2-4 15-8 10-3 18-0 CiDEl 1 64-0 0-6 37 5-2 9-1 rA le. Burton, Bass, 84s. 12-5 90 3-4 2-2 157 101 17-6 „ 60s. 14-2 130 2-0 1-5 9-6 8-9 36-6 „ Pale „ 60s. 19'0 17-5 1-5 1-1 70 6-6 11-5 CO ,, India (Gardner, ■) X 54s i 23-0 28-0 0-6 07 3-0 5-5 96 o f Sootoh 1 „ Bottled-^ (Edin.)J 19-0 18-1 2-4 1-6 11-4 8-0 14-0 P"' (.Pale . . 25-0 20-6 1-4 ]-0 6-6 5-0 87 H „ "Eightpenny" . 227 22-2 1-1 0-9 5-4 57 9-9 „ Family Is. gallon . 24-9 220 1-2 0-9 57 6-4 9-4 a „ "Fourpenny". . Stout, DubUn, (bottled) 25-4 230 11 0-8 5-3 5-2 91 20-8 167 17 1-2 8-2 6-1 10-6 ,, London . . . 21-5 18-9 1-5 1-1 0-8 6-9 6-9 87 10-3 [p orter, London . . . 85-6 26-6 1-2 6-6 6-4 ^ * 20 Fluid oz. = 1 Imperial pint (measure). 16 oz, avoird. = 1 pound (weight.) Chapter VII. DISINFECTION. MEDIA BY WHICH THE CATCHING DISEASES AEE COMMUNICATED .MEANS FOB PEETENTING INEECTION AND CONTAGION — Dl- EECTIONS EOE THE SICK EOOM AND ATTENDANTS — PEE- CADTIONS TO BE USED BT DOCTOES MODE OE CLEANSING APAETMENTS APTEE ILLNESS — PEOPEE METHODS Of USING CHLOEiDE OP LIME, CAEBOLIC ACID^ AND CONDT's PLUID. Infectious and Contagious (catching) diseases — Scarlet fever, Diptheria, Small-pox, Measles, Typhus, Chicken- pox, Relapsing fever. Puerperal fever. Whooping-cough, Mumps, &c., — are communicated principally by the follow- ing media : — 1. The breath. 2. The secretions and excretions. a. The saliva. 6. The perspiration. c. The urine. d. The evacuations from the bowels. e. The sputa. 3. The skin of the body ; especially the dead peeling skin and the powdered skin which adhere to clothing and are wafted about in the air. 4. The body-clothes. 5. The bed-clothing. 6. Discharges from eruptions, abscesses, wounds, &c. 7. The hair. 8. The walls, floors, and furniture of apartments. It is probable that no infectious or contagious disease would spread if all these media were promptly disinfected. 144 DISINFECTION. The diflBculty lieSj not in disinfecting any one of them when it is specially submitted to uSj for that is easily done, but in keeping up such a rigorous system of disin- fection around the sick person, that none of these media shall escape disinfection ; for common sense tells us that if only one escapes, the protection from infection may be lost. It is evident that the disinfection of the secretions and excretions must be performed as they leave the body, so that the air may not be infected during their passage. For this reason the disinfectants put into spitting pots, urinals and bed pans should be Volatile, like Chlorine and Carbolic Acid, so that an atmosphere of the disinfect- ant may rise from the utensils while they are being used. I, therefore, advise for these purposes Chloride of Lime and water, or Carbolic Acid; and they have the ad- vantage of continuing to give off their disinfecting princi- ples after the contents Of the utensils are thrown down the drains. For most other purposes Condy's fluid will suffice ; it is clean, free from offensive taste or smell and not poisonous. It is not volatile but it disinfects whatever comes in con- tact with it. The air of a room, therefore, may be disin- fected to a great extent by freely dispersing Condy's fluid with a spray producer. Clothes can be disinfected by being soaked in it. The skin can be disinfected by being washed with it. Sponges can be disinfected by being soak- ed in it, but sponges are dangerous spreaders of infection, and it is much better to use pieces of cloth, which can be burnt, and in cleansing wounds to irrigate them with a syringe. Linen and other washing materials can be dis- infected by boiling, but they should be previously put into Condy's fluid or diluted Carbolic Acid directly they are done with and kept in it for about two hours, otherwise they may spread infection before they are boiled. For all DISINFECTION. 145 these purposes Carbolic Acid is most efficient but its smell is objectionable. Whatever is not susceptible of boiling but will bear baking can be disinfected by being submitted to a tem- perature of from 212° to 250° in an oven, and for greater safety a little Carbolic Acid should be put into the oven at the time. 1 . When a catching disease occurs in a house the first thing to be done is — to select a room for the patient as much isolated as possible from the rest of the house ; a room through which no one has to pass and by which there are as few passers as possible ; the top of the house is best as a rule. The room should have a window open- ing directly into the fresh air and an open chimney and fire-placCj and it should be supplied with not less than 1000 cubic feet of fresh air every hour for each occupant whether patient or attendant. (See Chapter I. " Ventila- tion, &c.") Whenever practicable a second room should be set apart, near the patient's room, for the attendants to cook and take meals in and to sleep in when off duty. 2. The second thing to be done is — to remove from the room or rooms selected every thing that cannot be washed, boiled, baked or burnt, and then to hang over the outside of each doorway a curtain kept constantly wet with Condy's fluid. 3. The third thing is: — to decide who is to attend upon the patient. There should always be two persons and no more. They should cover their hair with washing caps, dress in washing clothes, and not associate with the rest of the household or with any other persons. They should each take at least six hours sleep out of the 24. They should each walk out in the fresh air 1 hour per day. They should wash their hands and faces with Condy's fluid 146 DISINFECTION. and water when they leave the patient's room. They should avoid inhaling the breath or exhalations of the patient and they should neither eat nor drink in the sick- room. 4. The fourth thing ia — to place in a corner of the pa- tient's room a large glazed pan containing water and Carbolic Acid or Condy's fluid. Into this pan everything that can be washed or boiled should be put^ directly it is done withj before it leaves the sick-room. The pan should be emptied night and morning or oftener. 5. The patient should be sponged all over with warm water and Calvert's Carbolic Acid Soap twice a day (ex- cept during periods in which it may be thought unadvis- able by the doctor) ; and if the skin is peeling or powdery it should be anointed after the sponging with olive oil containing a little Carbolic Acid (about 10 per cent). 6. Chloride of Lime and "Water or Carbolic Acid should be put into every utensil before it is used by the patient^ and after being used the contents should be immediately thrown down the drain^ together with some fresh Chloride of Lime. 7. The patient's teeth and mouth should be washed with Condy's fluidj or Calvert's Carbolic Acid Soap^ and water several times a day, and when there is any dis- charge from the nose or other passages these should be cleansed in the same way. When the discharges from the body are foetid Savory and Moore's Carbohc Acid vapor- iser should be burnt in the room. 8. It must constantly be borne in mind that no amount or kind of disinfection will take the place of fresh air, and therefore the sick-room must be kept freely venti- lated, carefully avoiding draughts. (See Chapter I.) Gas should not be burnt in a sick-room. 9. The doctor should not communicate with any other DISINFECTION. 147 members of tlie househould after he leaves the sick-room and he should always be provided with a basin of water, Calvert's Carbolic Acid Soap, a nail brush, and a clean towel, with which to wash his hands on leaving. Let it he especially remembered that the mairo points are the prompt disinfection of the infecting media, enumerated in the beginning of this Chapter, and the free circulation of fresh air. After the acute specific disease has run its course, in- fection may last as long as there are any unhealthy dis- charges left by the disease, as long as there is any peeling or powdering of skin, shedding of hair or the like ; and > precautions are needed for disinfecting these means of spreading disease so long as they exist. No doctor who has been in attendance upon Erysipelas, Scarlet fever, Puerperal fever, Typhus, Gangrene, Pyae- mia &c., or 'who has been engaged in a post-mortem exami- nation should enter a lying-in room until he has subjected himself to effectual purification and disinfection ; and it is a safe rule, under all circumstances, for a doctor not to touch a lying-in patient until he has washed his hands with some disinfectant. The difficulties of carrying out this rule are very great in the hurry of practice, but every doctor engaged in Obstetric practice is bound to provide for doing so. And he should nfever go upon his rounds without some disin- fectant with him to mix with the water in which he washes his hands in case of unexpected need. To facilitate this important hygienic precaution, I have ' induced Messrs. Maw, the well-known instrument makers of 11 Aldersgate Street, and Messrs. Calvert the cele- brated manufacturers of Carbolic Acid, to provide a little metal case containing a piece of strong Carbohc Acid Soap, a nail-brush, (for it is useless to wash the hands l2 148 DISINnCTlON. without brushing out the nails) and a little tube of Car bolic Acid, for medical men to carry constantly in their pockets when on their rounds. The whole is no larger than a small snuff-box, and is called " The pocket nism- FECTOE." It ought to be used by nurses and visitors upon the sick, as well as by doctors. When the infectious period of the illness is over and the patient removed from the sick-rooru — everything which has been used or worn by the patient and attendants having been either disinfected or destroyed as already directed — the room must be thoroughly disinfected in the following manner : — 1. The windows and doors being shut, the room must be kept full of Carbolic Acid fumes for 12 hours by means of one of Savory and Moore's Vaporisers — Then the win- dows must be opened for 12 hours before cleaners and workpeople are admitted. 2. The floors, paint, and furniture, must be washed with Water and Chloride of Lime or with Calvert's Carbolic Acid Soap. The ceiling and walls must be Lime-washed, after which the walls may be re-papered if required. While this work is in progress a fire should be kept burning in the grate and the windows open. The following particulars as to the mode and proportions in which to use Chloride of Lime, Oarbolic Acid, and Gondy's fluid, have been Idndly furnished hy Messrs. Savory and Moore, and by Mr. Calvert. For fumigation by Chlorides. — Dissolve one pound of the Chloride of Lime in 4 gallons of Water and, after stirring the mixture well, allow it to settle; pour off the clear liquor and place it in shallow dishes or other con- venient vessels in the rooms and passages of the House. DISINFECTION. 149 For use in chamlier-uteiisils, bed-pans, spittoons, &c., and where a volatile disinfectant is required, a wine-glass- ful of the above solution should be added to a pint of water. Carbolic Acid. — When required for the above purposes, that prepared "for Disinfecting" should be obtained — one ounce of this added to a quart of Water is sufficiently strong to purify drains, water-closets, &c. The mixture should be vigorously stirred or shaken (as Carbolic Acid is not readily miscible with water). Half a pint of this solution put into any utensil used in the sick-room will disinfect the contents, and enable them to be preserved for the inspection of the medical man without any unpleasant effluvia arising. Carbolic Aqjd-oil for anointing patients, should consist of Olive Oil and about 10 per cent, of Carbolic Acid. Condy' s fluid. — For use either with the spray producer tp disinfect rooms, for cleaning sponges or bandages, washing the skin of the patient, the personal use of Nurses or Medical Attendants, dressing wounds, &c., Condy's fluid should be mixed with water in the proportion of a teaspoonful to a pint. Linen and Bed-clothes should be immersed in a solution made by mixing a wineglassful in a pailful of Water ; diluted in this proportion it does not stain the linen. Chaptee VIII. SPECIAL EECIPBS, DIEBCTIONS, AND APPLI- ANCES FOR THE SICK-ROOM. FAEINACEOUS AET-ICLES — BEEF TEA — LIEBIG's EXTRACT OF MEAT — brand's mea'i. jellt and solid beef TEA — dabbt's fluid MEAT — ^WHITE OF EGG — WHEY — ANIMAL FOODS' EE-COOEED BEEAD — SPECIAL EESTOEATIVE SPECIAL NDTEITIYE — COCOA AND EGG — 'INVALID SOUP COMBINATIONS OF ALIMENTAEY PEINCIPLES IN NOEMAL PEOPOETIONS— POET WINE JELLY SUET AND MILK — MILK WITH EUMj ETC. NUTEITIYE ENE- MATA NUTEITIYE MIXTUEE — CBEEALIN TEA — ^POULTICES AND POULTICING BY STEAM — INHALATIONS — NASH's BRONCHITIS KETTLE — WAEM BATHS — LIGHTS IN THE SICE" BOOM NUES- ING SCHEDULE. As tliis does not profess to be a " cookery book" only a few Medical-food Recipes will be here given, witli some directions for the cooking* and appUances of the - sick- room which cannot easily be found elsewhere. — For the ordinary kitchen recipes the reader is referred to the cookery-books of Miss Acton^ and Mrs. Beeton, and to Cre-fydd's "Family Faee," pp. 240 to 249. 1. Farinaceous Aeticles should all be submitted to a temperature of 212° Faht. (boiling water) to make them digestible. 2. Beef Tea should not be boiled, and should not 'be strained through a fine sieve or muslin. It should be made as follows. Take of Rumpsteak, free from fat and minced, 1 lb., cold water 1 pint, a pinch of salt. Put them * See p. S3, On modes of cooking in common us3. SPECIAL RECIPES, ETC. 151 into a jar and tie it down. Place the jar in a saucepan of cold water, raise this water slowly to boiling and, keep it slowly boiling for two hours. Eemove the jar and strain its contents through a very coarse sieve so that all finely powdered sediment may run through. Then pass a piece of bread over the surface to remove any fat that may float upon it. 3. Liebig's Bxteact of Meat and other similar prepara- tions. It is important to bear in mind that these contain very little, if any, nourishment properly so-called ; that is to say, they contain no plastic material, no fat, no saccha- rine matter. Their principal virtues belong to the class of stimulants and blood-tonics. When mixed with water, they are excellent menstrua in which to administer nutri- tive materials, such as eggs, bread, oatmeal, corn-flour, vermicelli ; but without such additions they are quite in- capable of suppoi;ting life for any length of time. Baron Liebig's own writings support this statement. Unless these facts are borne in mind a patient may easily, be starved unintentionally. 4. Beand's Meat Jelly and Brand's Solid Beef Tea are excellent and reliable nutrients, they may be obtained at Little Stanhope Street, or through a Chemist. . 5. Darby's Fluid Meat. This is a new and valuable preparation. It contains all the constituents of lean meat, including fibrine, gelatine, and albumen ; but by the process pursued- these are all brought into a condition in which they are soluble in water and are not any longer coagulable on heating — in which state they have been designated Peptones. This change is effected, as in ordinary digestion, by means of pepsine and hydrochloric acid. The Pepsine employed is very carefully prepared — with- out addition of starch or any extraneous substance. Lean 152 SPECIAL RECIPES, ETC. meat, finely sliced, is digested with the pepsine in water previously acidulated with hydrochloric acid at a tempera- ture of from 96° to 100° Pah. until the whole of the fibrine of the meat has disappeared. The liquor is then filtered — separating small portions of fat, cartilage, or other insoluble matters — and neutralized by means of carbonate of soda ; and, finally, carefully evaporated to the consistence required, namely, that of a soft extract. The resulting extract represents in all its constituents the lean' meat employed, but with the fibrine, albumen, and gelatine changed into their respective peptones or soluble forms. This change is effected solely by the pepsine and hydrochloric acid, or artificial gastric juice, without the evolution or absorption of any gas or the formation of any secondary products. The peptones thus formed, although agreeing exactly in chemical composition and even in many physical pro- perties with the substances from which they are derived, differ from them by a ready solubility in water and even in dilated alcohol. But this process, whatever care may be taken, leaves the Fluid Meat with a strong bitter taste. This bitterness attaches always to meat digested with pepsine ; and tiiis, in the opinion of medical men, would wholly preclude its acceptance and adoption as an article of food. At the same time, it curiously illustrates the identity of the process in the laboratory with digestion in the living stomach. In order to remove this bitter taste, and to obviate the objection to Fluid Meat on that ground, Mr. Darby made many experimental researches, and at length discovered that the purpose is completely and satisfactorily effected by the addition, in a certain part of the process, of a small proportion of fresh pancreas. SPECIAL EECIPES, ETC. 153 The following are methods of using Fluid Meat: — One ounce by weight, or a large table-spoonful, equals the quantity of extract, obtained by boiling, from twenty ounces of meat. Spread between bread and butter, and sprinkled with salt, it makes an agreeable sandwich. Dissolved in water with a little salt and pepper it forms a liquid similar in taste to beef tea. A small dessert-spoonful of the Fluid Meat in half a pint of water, or a tea-spoonful to a large tea-cupful is a good proportion, and this may be increased as desirable. Flavoured with suitable condiments. Fluid Meat may be taken as soup ; and, compared with the amount of solid matter obtained from meat by stewing, it becomes an economical article of diet. For Gravy Soup. — Take a little carrot, turnip, onion, and celery, with a clove, small piece of mace and pepper ; boil gently, strain, and for each half pint of liquor add a table-spoonful of Fluid Meat, with a little salt. For Vermicelli Soup. — Place in a covered jar in the oven a little sliced celery, onion, bruised spices and pep- per, with water ; when the celery and onion are tho- roughly softened, strain, add Fluid Meat, (in the propor- tion of a tablespoonful to half a pint) with salt, a small knob of loaf sugar, and vermicelli previously boiled. Another Soup. — Take two onions, a large carrot and turnip, cut into small slices, and fry them well with a little butter in a clean pan ; when well browned, pour on three pints of boiling water j let stand till cold, skim, strain out the vegetables, add half a pound of girasole root previously boiled in water till soft, and two ounces of the Fluid Meat ; boil for a minute or two ; macaroni or vermicelli, softened by boiling, may be added at plea- sure. 154 SPECIAL RECIPES, ETC. 6. White op Esg differs from tKe yolk principally in containing no fat. On this account it is often better borne by bilious persons. Yolk of Egg contains 29'8 per cent, of fat ; when the stomach can bear it, therefore, it is a more complete nutriment than the white. But white of Egg beaten up in milk answers every purpose. Eggs for the sick should be either raw, or very lightly boiled. 7. Whey may be made either with Warren's sweet Essence of Kennet, or with Treacle, or with sherry, ac- cording to circumstances. a. Eennet Whey — see the directions on the sweet Essence of Eennet bottles. h. Treacle Whey — pour three table-spoonfuls of best Treacle into a pint of new milk while it is boiling ; see that it boils up once after the treacle is added ; set it aside to cool and then strain, c. White Wine Whey is made in the same way as Treacle Whey, three glasses of sherry being used to a pint of milk. Note — When a more nutritious food is desired and suit- able, well beat up the curds with the whey instead of straining ; see that they are not in lumps. 8. All Animal foods are apt to lose digestibility by re- peated cooking, (see p. Bii). 9. Bread should be either toasted or 24 hours old. 10. Special Restorative. I have found the following to be a most efficient restorative food, and the mixture is agreeable to most palates. New milk (cold) 4 parts. Beef tea (cold) 3 parts. Brandy (pale) 1 part. If no other food is taken, about 5 fluid-ounces (a quarter of a pint Imperial) should be given every 2 hours, or half SPECIAL EECIPESj ETC. 155 that quantity every hour. It should be sucked out of a syphon Infants-feeding bottle, not drunk out of a spoon or cup. When desirable this food may be gradually thickened by the addition of boiled corn-flour or other farinaceous articles, and one egg may be well beaten up in each half pint. The flavour may be varied by adding diflerent spices. 11. Special Nuteitivb. Beat up an egg, both white and yolkj quite smooth and free from stringy particles, stir it well into half a pint of hot milk in which enough arrowroot has been boiled to make it about as thick as cream; add a wine-glassful of sherry or a table-spoonful of pale brandy, five grains of pancreatine powder (Savory and Moore's), and some fresh nutmeg; mix all thoroughly by pouring from cup to cup. On this food alone, repeated every four hours, a patient can be well supported for a considerable time. 12. Cocoa and Egg. Beat up an egg, both white and yolk, quite smooth and free from stringy particles, stir it into half a pint of hot milk, and then add a teaspoonful of soluble cocoa, previously liquified with a little of the milk. This forms an excellent breakfast easily taken by those who cannot eat in the early part of the day. 13. Invalid Sofp. The following Invalid soup has proved extremely useful in a large number of cases, and since I first published the recipe in 1864 it has been usually kept nicely prepared by Mr. Donges, Confectioner, Gower Street, W.O. Gravy beef 1 lb., scragg of mutton 1 lb., isinglass 2 oz., vermicelli 3 oz., mushroom ketchup 3 tablespoonfuls, corns of allspice 24, sage a sprig, cold' water 3 quarts ; put the isinglass and the meat cut small into the cold water, gradually boil, skim well, and then add the other ingredients ; simmer four or five hours till reduced to one quart ; strain through a fine hair sieve, and carefully re- 156 SPECIAL RECIPES, EIC. move all fat ; add salt to the taste. This may be taken cold as a jelly, or warm as a soup. Galf s-foot may be used instead of isinglass when procurable; and when allowable a little solution of cayenne pepper should be added ; and the taste may be varied by the addition of a little Worcester, or other wholesome sauce. 14. Combinations or alimentaey principles in nearly EXACT NORMAL PROPORTIONS. (See Chapter III.) a. Flour 4 oz., sugar IJ oz., suet f oz., milk f pint Im- perial, 1 egg. — This will make a good pudding, or it may be given in any other form desired ; with the addition of a little cress and salt and water it forms a complete diet, upon a sufficient quantity of which a person can live healthfully for an indefinite length of time without any other food. h. The same may be said of the following. — Eice 3 oz., sugar I oz., 2 eggs, butter ^ oz., milk f pint (Imperial), water as much as is sufficient to boil the rice in. c. Suet ^ lb., flour 1 lb., water 13 oz. These quantities when boiled yield 2 lbs. of pudding. 15. Port Wine Jelly. Take of port wine 1 pint, isin- glass 1 oz., sugar 1 oz. ; put the isinglass and sugar into J pint of water, warm till all is dissolved, then add the wine, strain through muslin and set to jelly. (An excel- lent way of giving port wiae.) Another form, firm enough to carry in the pocket cut up in cubes, may be made as follows : Take isinglass and gum Arabic of each an ounce, dis- solve in a pint of port wine over a slow fire ; sweeten with fine sugar to the taste, and after straining through a fine sieve, grate in a small nutmeg. Take about a cubic inch when feeling weak or low. 16. Suet and Milk. Put a table-spoonful of shredded beef suet into ^ a pint of fresh milk, warm it sufficiently SPECIAL EECIPESj ETC. 157 to completely melt the suet, then skim it, pour it into a warm glass or cup, and drink it before it cools. If there is any difficulty in digesting the suet add 5 gr. of Pan- creatine powder. (Savory and Moore's). 17. Milk with Edm, Beandt, ob Whiskey. Put one tablespoonful of Eum, Brandy, or Whiskey into half a pint of new milk, and mix well by pouring several times .from one vessel to another. "Bilious" persons should heat the rum before adding it to the milk. 18. NuTEiTiVE Bnemata. When nutriment is given in enemata the quantity should not exceed from 2 to 4 oz., and the temperature should be about 80°. The bowel should be first washed out with half a pint of warm water. — An elastic bottle holding the required quantity is better for nutritive enemata than the ordinary enema syringe. They should be given while the patient is lying on the back with the hips raised on a pillow. The following constitutes a most important means of preserving life when food cannot be given by the stomach. Take of cooked beef or mutton finely grated Jib. Pancreatic Emulsion (Savory and Moore's) 1 oz. Pancreatine powder (Savory and Moore's) 20 grains. Pepsine (Porci) 20 grains. Mix the whole in a warm mortar quickly and add Brandy one table-spoonful and enough warm water to bring the mixture to the consistence of Treacle. Inject from an elastic Enema bottle, as quickly after the mixture is made as possible, and let it be retained. (See Appendix VII.) 19. N0TEITIVB MixruEi. When a patient will take medicine but not food. Liebig's Extract of Meat a tea-spoonful. Loeflund's Liebig's Extract of Malt a tea-spoonful. Tincture of Capsicum one drop. Compound spirit of Horseradish a tea-spoonful. Water 2 table-spoonfuls. Mix well in a mortar. 168 SPECIAL EECIPES, ETC. To be given every 3 or 4 hours. This will often bring back the desire for food. 20. Cbebalin Tea. Cerealin is contained in the white matter adhering to the inner side of the best fresh bran, its digestive power is suspended by a temperature above 1-70° Paht. The tea therefore should be made by infusing fresh bran (taking care to select that which has plenty of the cerealin upon it) in hot water of a temperature below 170°. It may be drunk freely at meals with great advantage where the power of digesting gluten is defective. But should not be taken by those, with over acid stomachs. 21. Poultices. Linseed poultices should be made by filling a muslin bag with crushed linseed, (not linseed meal) then putting it into a basin or dish and pouring boiling water upon it. — When thoroughly soaked it should be squeezed between towels till no water drips from it. The same poultice may be made hot four or five times by pouring fresh boiUng water upon it. Bread poultices should be made of finely crumbled bread treated in the same way as the linseed. Poulticing by steam. A new means oe applying either MOIST OB DET HEAT TO THE SUEFACB OF THE BODY. At a Meeting of the Abernethian Society of St. Bartholo- mew's Hospital, February 10th, 1853, I introduced the use of vulcanized rubber bags, filled with hot water, as a "new means of applying heat, and of maintaining the temperature of warm applications," and the suggestion has been followed to a considerable extent in the use of hot-water bags, as foot-warmers, stomach-warmers, and the like ; but the diflSculty of preventing the water from accumulating in one part of the bag by gravitation, and (when this is prevented by septa and by completely filling the bag) the great weight of the water, have presented hitherto insuperable objections to the general use of large SPECIAL EBCJPES, ITC. ■ 159 hot-water poultices, which in all other respects offer so many advantages. When the part to be poulticed can be placed wpon the hot water bag, it answers perfectly. In the treatment of Bronchitis, Pneumonia, Peritonitis, Phlebitis, and all other inflammatory affections occupying large areas, when it is desired to employ equable warmth for protracted periods, the diflBcnlty of doing so in a satis- factory manner is only too familiar to all practical physi- cians and surgeons. This difficulty I have now removed by an important modification of my original design, viz., the employment of Steam instead of Water, thereby getting rid of all the objections which prevented the complete success of my suggestion in 1853. Messrs. Maw, Son, and Thompson are prepared to sup- ply the apparatus for Poulticing by Steam,* with either dry or moist heat — adapted to any part of the body — at a moderate cost. 22. Fluids soe Inhalations should have a temperature of about 170° Paht. 23. "Nash's Beonchitis Kettle" sold at 253 Oxford Street, is a convenient appliance for impregnating the air of a room with warm moisture either pure or medicated. Pull, directions for use are supplied with the kettle. 24. Waem baths should not exceed a temperature of 98° without medical orders. 25. The lights in a sick-eoom should always be placed behind the patient, not in front. Gas should not be. used at all. (See "Ventilation"). Candles are better than lamps. 26. A WuEsiNG Schedule shojild be used in all Pevers, Inflammations, Sur-gicaL Oases, and other Acute Illnesses. * This apparatus was exhibited at the meeting of the British Medical Association, in Norwich, August, 1874. 160 SPECIAL EECIPESj ETC. Those who have been called upon to bear the responsi- bility of the Nursing in a severe case of Fever, Inflamma- tioUj Surgical OperatioUj or the likej will have a vivid recollection of the difficulties they encountered in carrying out the various Medical Orders upon the punctual attend- ance to which, through anxious days and nights, the patient's life depended. How to 'arrange the hours for Nutriment, for Medicine, for Wine, for Brandy, for dressing wounds, for external applications, for Sleep, &c., &c., without one important item clashing with another, is often a most puzzling ques- tion, requiring the details to be carefully considered and arranged in writing, before it is practicable to work them out. Not unfrequently the orders left by the doctor are mis- understood, or found to be impracticable when they come to be put together and arranged according to time^ — the hours for dressing wounds or taking Medicine clashing with those for Food, the hours for Wine coming upon those for Brandy, or interfering with the necessary sleep, and so forth. When the doctor has gone and, perhaps, as in country houses, cannot possibly be consulted again for many hours, it is difficult to overstate the distress of friends and nurses on discovering that orders, which have been impressed upon them with all the weight of questions of life and death, cannot be implicitly carried out from want of a consistent arrangement of their details. Happily for the sick, and for the doctors, nursing is now passing into the hands of educated Ladies and well trained Nurses, competent to understand and to perform with intelligence that systematic nursing to which the enlightened practical Medicine of the present day at- taches such vital importance. And the introduction of the Clinical Themrometer and similar appliances into the SPECIAL RECIPES, ETC. 161 sick roonij makes it necessary in private houses (where there are no clinical assistants or house-surgeons as in hospitals) to entrust the nurse with the task of keeping -a register of the temperature, the rate of pulse and re- spiration, &C.J at hours when the doctor cannot be in attendance. The doctor who believes in the importance of his own orders will be strict in requiring at each visit an accurate •report of how they have been obeyed. The nurse who intends to obey them faithfully will not be satisfied unless she sees that they are both intelligible and practicable before the doctor leaves the house, and she should wriie ihem down directly he is gone. PAET II. ON THE INTERDEPENDENCE AND PREVENTION OF DISEASES AND THE DIMINUTION OF THEIR FATALITY. "Amid all the dangers that threaten this Metropolis there is a sad certainty more serious than any one of them it is not disease but it is not health. It is a low state of ritality, of physical power, of mental energy, of enjoyment, and even of moral strength." — "The Times," August 4th, 185S. m2 PART II. ON THE INTERDEPENDENCE AND PREVEN- TION OP DISEASES AND THE DIMINUTION OF THEIR FATALITY.* Chaptee IX. THE DUTIES OF MEDICAL MEN THE INTERDEPENDENCE OP DIS- EASES SHEWING THE IMPOETANCB OP PERIODICAL EXAMIN- ATIONS. GrENTLEMENj we are all members of a practical profession. We have taken upon ourselves high and responsible du- tieSj all culminating in action. So long as we choose to assume these duties in a profession^ as yet so far from perfection, we are not justified in spending our time in scientific investigations or speculations, unless they have for their end some practical application for the good of humanity. It is the hope of attaining such an end which has led me on in the design and labour of these Lectures. I proceed at once to lay it before you. In the beginning of the first Lecture I asserted, that we are justified in practising the profession of medicine only in proportion as we believe in the articles of the fol- lowing creed : — 1. That man may be the instrument through whom the * Selections from Lectures "On the Germs and Vestiges of Disease and on the Prevention of the Invasion and Fatality of Disease," delivered by THE AvTHOB to medical practitioners and students at the Boyal Hospital for Diseases of the Chest, in 1861. 166 INTBEDEPENDENCB OF DISEASES invasion and progress of premature destructive changes in the human organism may be prevented or arrested. 2. That man may be the instrument through whom the damaged organism may be more efficiently repaired. 3. That man may be the instrument through whom the sufferings of the human being may be alleviated. In what sense the organism is capable of accomplishing these ends without the instrumentality of man^ I have shown you (in the previous lectures) by numerous argu- ments and examples. I have also shown you the various modes by which it becomes deprived of this capability. The conclusion at which I now arrive is this, that man may be the instrument through whom the capability of accom- plishing these ends may be preserved and restored to the The manner in which man is to exercise this instrumen- tality is the next point for our consideration. , But I think we have almost reduced it to a necessary conclusion. For as we have plainly seen that the organism is competent to take care of itself, provided that it possesses a normal Vital force and is surrounded by normal conditions of life ; and as we have also seen that the great causes of defect in the force are the vestiges of disease and abnormal conditions of life ; and as we have also learnt that the dis- easeSj from which the vestiges result, are invited by de- fects of the force; and that, when thus invited and received into the organism, they are capable of being disposed of without leaving vestiges behind, if the Vital force is free from excessive defect ; that thus these ves- tiges are due to defective force ; and as we have learnt that the earliest invasion of defects in the force — upon which all the long and intricate succession of ills depend as a germ — as we have learnt, I say, that this state of germination exists at a period anterior to the manifesta- AND THE DIMINUTION OF THBIE FATALITY. 167 tion of disease in its ordinary charaoterSj and that it is to be found in the garb of sHght impairments of the general health, the indications of which are more and more eva- sive and occult, the earlier the stage of germination j and, finally, as we have learnt that it is in this occult and evasive stage of germination that the defect is most easily and most efficiently to be remedied ; I think you will agree with me in the practical conclusion at which I have ar- rived. This conclusion is — that the manner in which man is to ■exercise his instrumentality for the prevention of disease, the prevention of the vestiges of disease, and the preven- tion of fatality in disease, is to search out these earliest evasive periods, of defect in the physiological state, and to adopt measures for their remedy. (See p. 206 "Abnormal Physiological States"). This appears to me to be the highest, the most en- nobled duty of the physician, calling for the most abstruse knowledge of the science of life, the deepest experience in disease, the keenest exercise of the perceptive faculties, the calmest, most far-sighted reasoning and the wisest judgment, — a duty as much above the management of acute disease as to rule an empire is above fighting a pitched battle. Now, I am perfectly convinced, from my own observa- ,tion and experience in practice, that patients never think ^f consulting their doctors till these conditions of impaired general health have advanced far enough to have been developed into some form of disease : that thousands and thousands of persons, believing themselves to be in health, are nevertheless undergoing these early, occult, and eva- sive stages of defect in the physiological state; and that •Such persons may be considered to be in health, not only 168 INTERDEPENDENCE OP DISEASES, by themselveSj but by any one accustomed to associate- with them. The only means by which to reach this evil and to ob- tain the good, would be for persons to submit themselves- and their children to systematic periodical examinations. Such examinations ought to include an inquiry into the family history, to learn the hereditary constitution ; into the persona] history, to learn all the previous diseases that have been passed through, and the habits and vicissitudes of life ; into all the conditions of life surrounding the individual; into the condition, of the organs and functions- of the body ; into the state of the secretions and fluids of the body by analyses and microscopical examinations >, and so forth. The examination should be reported in writing ; and, after due consideration, such advice should be given as a careful judgment may dictate, for the future conduct, pursuits, and habits of the patient, with a view to correct- ing any defects or tendency to defects in the organism. Advice should also be given as to the means of removing- any vestiges of disease that have been detected, or if they are not removable, advice as to the best way of overcoming their influence or of averting their increase. To this must be added precautions to be adopted in certain contingen- cies which, according to the judgment of the case, appear- probable. If such a plan as I have here proposed were to be faith- fully and conscientiously carried out by the present and rising generation of well-educated, studious, medical men, immense benefit would be conferred, upon the public. The next question is, then, what would be the efiect upon the profession in a pecuniary and in an ethical sense. With regard to the pecuniary question, it is only necessary to- AND THE DIMINUTION OP THEIR FATALITY. 169' observe that, of course, I do not expect that any man in good practice, whose time is profitably employed, could conduct such an examination and give such advice for the- usual consultation-fee. A special fee would be necessary to enable him to give the necessary time and considera- tion to every case. But this should in no way interfere with the power of the poor to participate in such a system. Every hospital and dispensary should institute a distinct department for the conduct of such examinations, and for giving the ne- cessary advice. Every patient discharged from its wards should be submitted to this department before returning to the duties of life.* I have again and again referred in these Lectures to the- numberless anomalous symptoms, the pains, discomforts, nervous disturbances, etc., etc., which affect persons in abnormal physiological states, and which increase in theii" severity, obviousness, and number, as the states of health become more and more degraded, and the occurrence of some acute disease becomes more imminent. I have pointed out to you that these are the states of health which fill our consulting-rooms and the out-patient de- partments of hospitals and dispensaries. In further confirmation of my statements on this point I may remind you of some apposite observations by Sir Henry Holland on the subject of symptomatic complaints. In his "Medical Botes and Reflections" he says, speaking of gouty blood. — " Irregular actions of the heart, hypochon- driacal depression, as well as the more common symptoms of dyspepsia and disordered secretions, frequently autecede by months the first appearance of gout in the extremities, * For details of the mode of carrying out the Examinations at public Chari- ties, see a paper by the Author read at the Guildhall, June, 1862. " Trcms- actions of the National Association for the 'promotion of Bodal Science." 170 INTERDEPENDENCE OF DISEASES and occasionally give serious alarm even to those who look with medical eyes upon these ambiguous cases." — (p. 246, 3rd edition). ".Modern observation has .led us to recognize some of these relations (of gout with local or constitutional dis- orders) under the names of gouty headache, gouty ophthal- mia, and gouty bronchitis. My own experience would lead me to add many cases of asthma to the number. I have so often seen this disorder prevalent in gouty families, , affecting those who do not undergo the disease in the joints, and ceasing wholly or in part when the gout ap- pears externally, that I cannot doubt the existence of this relation. "The greater tendency to ajpoplexy in this habit is no- ticed by many of the older writers, and confirmed by general experience. " Reference has already been made to hypochondriasis and hysteria ; and it is probable that other disorders of the same class, still less generally viewed under this con- nection, will hereafter be submitted to it. " The relation of gout to the functions and disorders of the liver is another point of much interest in pathology, clearly attested both in the active symptoms of the disease and by those which are common under other forms of the gouty temperament. This, moreover, is one of the points associating it with that group of maladies bearing the vague name of dyspepsia. " The connection of gout with cutaneous affections is an additional topic, yet almost unexamined ; though I cannot ■doubt, from my own observation, that certain of these disorders occur as effects of the habit in question." — {Op. cit., pp. 2&3-54). That enormous quantities of medicine are dispensed in the out-patient departments of hospitals and dispensaries AUD THE DIMINUTION OF THBIE FATALITY. 171 for tte temporary relief of this class of functional derange- ments and local diseases — ^for complaints which might be prevented by the patients themselves if they were pro- perly informed of the causes and premonitory symptoms of their maladies — is a fact which must be perfectly famihar to all my hearers. Such a system of examination and advice as I propose^ if properly carried out, must strike at the root of these evils, and would at the same time reduce the miserable over-crowding of the hospital waiting-rooms, and the enormous expenses incurred for drugs. These are considerations which, however import- ant as elements of social and political economy, are ele- vated far above the rank of financial questions by the fact I have endeavoured to demonstrate in these Lectures, that by these same means, and at the same time, we shall so largely promote the economy of life. I hope, Gentlemen, that you will draw the attention of the treasurers and governors of any hospitals, to which you may belong, to this subject.. It is necessary to the credit and honour of our profession, that improvements in these medical establishments should not come from the pubhc to us, but should originate among ourselves, and be urged by medical men upon the public attention. The foUoyying sketch of a common complaint, and a common story, may illustrate the need for some such sys- tem as I propose. A lad of fifteen is admitted into a hospital watd with a first attack of rheumatic fever. He is treated with skill, and nursed with care, and in two or three weeks he is convalescent, and returns to his home without having received any damage to his heart or other organs. But he has no proper understanding of the na- ' ture of his complaint, of the conditions of Hfe calculated to keep up the morbid influence in his organism ; no clear notions of the diet which he ought or ought not to adopt ; 172 INTERDEPENDENCE OF DISEASES no knowledge of the premonitory symptoms by whicli a fresh attack of rheumatic fever is heralded, or of the pre- cautions necessary when such an attack is feared. He has probably a general idea that his great enemy is cold, and his great friend flannel ; and that is as likely to lead him wrong as right in the measures he adopts. He goes back to his home and his pursuits apparently well. He keeps his skin closely cased in flannel, and his dwelling-rooms warm, but he neglects altogether to pro- vide for efficient excretion by the skin. He chooses a business, either utterly regardless of its fitiless for his con- stitution, or makes as great a mistake by selecting one in which he may be sure of warm — that is to say close — rooms and workshops, by which he is deprived of exercise and oxygen. He drinks beer, eats cheese, and so forth, like other people in his position. After a few months he comes hach as an out-patient at the hospital, with severe acid dyspepsia ; and after consuming the usual amount of drugs for several weeks, gets relief, and goes back to his old habits. A few months more, and he appears again, the subject of a skin disease ; goes again through the con- sumption of drugs, and gets well and goes back to work. By-and-bye he comes again with diarrhoea, and goes through the same process ; at another time with gravel, and gets relief again. At length, a few years perhaps having elapsed and after some months of depressed health,, with palpitations of the heart, gloomy thoughts, irritable temper, and general malaise, he happens to be out on a damp raw day, gets a chill, and applies again at the hos- pital, with a fresh attack of rheumatic fever. This time he suflers from endocarditis, and after some weeks returns again to his home, " discharged cured," but with disease of the valves of his heart. He has been thoroughly well treated, and is very free from rheumatic poison, and hence- AND THE DIMINUTION OF THEIE FATALITY. 173 goes on for a considerable time without much, inconveni- ence J but having no clear ideas of the nature of the dam- age he has received, or of the precautions necessary to pre- vent its increase or the production of secondary diseases dependent upon this damage for their cause^ he gradually becomes the subject of congested lungs and Kver ; of at- tacks of bronchitis to which he was not formerly inclined ; his breathing becomes short, his old dyspeptic troubles, cutaneous affections and gravel, recur again and again, and his capability of following his former occupations gets less and less. If he does not have another attack of rheumatic fever, he comes back to the hospital some future day with chronic bronchitis, or with apoplectic symptoms, or with congested liver, or still later with albuminuria and dropsy. At length he dies, and his death is registered under the head of apoplexy, heart-disease, or dropsy. (See " Tables shewing the Interdependence of Diseases," pp. 177-184). All medical men of experience will admit that this sketch is no exaggeration; that I have, in fact, omitted numerous details of minor diseases and discomforts, that are sure to have existed in the case itself. I have said nothing of the effects upon this man^s children of his continued ill-health, or of the poverty and want of food brought upon his wife and family by the same cause, and acting as fresh causes of disease in them. But I have said enough to make it quite clear, that, in the course of a life prematurely ended, he must have consumed a vast amount of money in the form of drugs, and a vast amount of nervous energy, if not of brains, in the form of medical advice. It is to the first causes, to the " wells and springs" of such a series of calamities as this, that I have directed your attention as fellow medical practitioners and stu- 174 INTERDEPENDENCE Or DISEASES dentSj and to whicli I now beg that yoa will direct tlie attention of the Treasurers and Governors of Hospitals and Dispensaries, of your private patients, and of the public at large. * * ' * * * In my fourth lecture I gave an Etiological analysis of those states of disease assembled under the following six headings in the Eegistrar-General's Eeports of the deaths in London. (Eeport of the deaths in London registered in the 21st week of each of the ten years 1848-57. The Eeport current at the time the notes for these Lectures were made.) 1. TyphuSj typhoid and other forms of continued fever. 2. Apoplexy and Paralysis. 3. Heart diseases and Pericarditis. 4. Eheumatism and Gout. 5. Bronchitis. 6. Atrophy and Debility. I demonstrated that, when we analyse the natural his- tory of any disease, we find that the princvpal factors of Us essential cause, of its predisposing causes and of the causes of its fatality fall under one of the three head- ings: — 1. Conditions of life. 2. Coetaneous diseases. 3. Vestiges of Disease. I showed not only theoretically but from actual obser- vations made by others as well as by myself, how the organism becomes damaged by these Vestiges of Disease — how the vital force becomes defective through these Vestiges, how this defective state of the vital force be- comes the essential cause and the predisposing cause of disease; and how the Vestiges of one disease become the causes of fatality in whole families of other diseases. I endeavoured to prove, by an array of facts, that the vestiges of disease become causes of fataHty in other dis- eases principally in two ways. AND THE DIMINUTION OF THEIE FATALITT. 175' 1. By destroying those modes of matter and that corre- lation of conditions upon which the existence of the vital force in its normal condition depends^ thus producing excessive defect of the vital force. 2. By producing excessive defect in the condition of some part of the organism^ occupying the position, at the time, of an essential instrument in the processes of hfe,^ and thus causing the organism to break down at this it& weakest part. I pointed out that in the large' majority of deaths from disease, the fatality is due, not to the disease itself, but to the vestiges of some pre- existent disease, operating in one or other of the above ways. In illustration of this great fact, I have set forth the course of events, by which the vestiges of disease, passing under the names of anemia and fatty degenebation, be- come the actual causes of a large number of the deaths registered under the following names : — Tabes mesenterica, croup, measles, hydrocephalus, whooping-cough, dentition, convulsions, apoplexy, para- lysis, delirium tremens, intemperance, angina pectoris, diseases of the heart, pneumonia, diarrhoea, mortification, influenza, peritonitis, childbirth, bronchitis, jaundice, liver disease, kidney disease, and some others. As an indication of the insidious way in which the deadly influence is exerted by these states — anemia and FATTY DEGENEEATioN — (which are Only examples of a class), I called attention to the fact that their names do not ap- pear- in the bills of mortality. (See Anaemia, and Patty Degeneration). My present object is to exhibit in a conspicuous man- ner the Inteedbpendence of diseases. (See " Preliminary Eemarks," p. 1). I have, therefore, restricted myself to a statement of the influence exerted by the vestiges of 176 INTEEDEPENDENCE Or DISEASES. eacli of the diseases analysed in the preceding Lectures upon the rest of the same little group, and in order that the different relationships may be seen at a glance I have arranged the facts in a tabular form. In the following tables the first column gives a list of the vestiges of the disease at its head. The second column shows to which of the diseases already analysed each vestige may become the predisposing cause; the third column shows to which of these it may become the essen- tial cause ; and the fourth column shows to which it may become the cause of fatality — the heading under which it will take its place in the Eegistrar's Keports. 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'O o- < < ^ A Ks s jp U <4 » c (2 ^ ^ iS INTERDEPENDENCE OF DISEASES. 185 Having shown the remarkable interdependence wMch ■exists between different diseases — how they act and react upon one another^ I must attempt, in this Lecture, to show to what extent one vestige of disease, or the several vestiges of one disease, may act as essential causes and as causes of death in other diseases. I will first take some Diseases which have no place in the Registrar's report. This will enable us to observe how many of the headings under which deaths are registered in that report owe their existence there to diseases which never figure at all as causes of death. The first example I have chosen is Ancemia, a name that does not appear in the Registrar's Reports. Chaptee X. ANEMIA. A careful examination of the subject teaches us that Ansemia is one of the most frequent vestiges of all severe diseases when they do not terminate in death ; — the pa- tient remains anasmic during convalescenoOj and in a large number of cases continues so long after returning to the duties of life. Again^ we observe that anaemia is contin- ually occurring in connection with the periods of puberty and the cessation of the catamenia, and thatj during the intervening yearSj it is one of the most frequent forms of impaired health connected with derangements of men- struatioUj with lactation, with convalescence from the puerperal state, and during pregnancy. Innumerable other causes may be found for this condi- tion, which is, in fact, the type of most of those miserable states of health referred to by the Times in the memorable article already quoted — " There is a certainty worse than any occasional and precarious plague. We may anticipate it from our own experience — we may see the great fact with our own eyes It is not disease, but it is not health. It is a low state of vitality, of physical power, of mental energy, of enjoyment, and even of moral strength Shocking as it may seem, a plague once in twenty years seems but a light evil to so low a condition of humanity." From a concatenation of circumstances, it so happens that the female portion of the population have to support the principal weight of this dire afliiction. Ansemiated girls, anaemiated brides, an^miated spinsters, anasmiated ANJIMIA. 187" mothers, abound in the consulting room, the out-patient room, the hospital ward, the home; wherever, in fact the physician's duties call him there they are to be found. Yet from the long Hst of diseases named in the mortality tables, this name, anaemia, is absent. Is it, then, a thing to be endured, but not to be feared ? Is it a name for sickness only, and not a cause of death? Quite the reverse, the fact is that, like some individuals of great influence and importance, anemia travels incognito. When we dis- cover its various " noms de guerre," we are startled to find ourselves face to face with the inpersonation of long- dreaded enemies. Tabes mesenteries t, . 18'3 deaths per week Croup . • 6-8 „ Measles . 25-0 ,, Hydrocephalus . 32-5 „ Whooping-cough . 51-1 „ Pneumonia . . 60-3 „ Dentition . . 12-8 „ Diarrhoea . 17-5 „ Convulsions . . . 36-5 „ Bronchitis . . . 64-5 „ Childbh-fch . . 4-3 „ 329-6 These are some of the names under which anemia travels among the sick, and takes its place in the bills of" mortality. The way in which it does so is as stealthy as it is deadly. I will tell you something of how it happens. "Among the children of the poor of London, the most widely-spread of these diseases (tuberculosis, scrofulosis, rickets,) is rickets. It is, however, by no means limited to the poor, or to London, or even to large towns." I quote from one of the most correct medical philosophers of 188 ANJEMIA. modern times. — (Sir W. Jenner^ " Lectures on Eicebts," Medical Times and Gazette, March 17, 1860). " Eickets is essentially and purely a disease of nutrition, not of one part only, but of the whole body. " Eickets causes, primarily or secondarily, more deaths than any other disease of childhood. " The great causes of death in rickets are : — 1. Intensity ■of the general cachexia. 2. Catarrh and bronchitis. 3. Albuminoid infiltration of organs, especially of the lym- phatic glands and spleen (but also of the liver). 4. Laryngismus stridulus. 5. Chronic Hydrocephalus. 6. •Convulsions. 7. Diarrhoea." You see how closely this list of the causes of death in rickets corresponds with the list I have just given of what I have called the " noms de guerre" of anaemia ; and the correspondence is really closer than it appears at first sight. " The connection between rickets and laryngismus stri- dulus," continues Sir William, " is very close I believe the reason of laryngismus stridulus being so con- stantly referred to teething is that the rickety condition retards the development of the teeth, and the medical practitioner refers the laryngismus to that which, like itself, is the consequence of constitutional disease. " If a child pass over the ninth month without teeth, you should carefully inquire into its cause It may be, and this is infinitely the most common cause of late •dentition, that the child is rickety." Many deaths, therefore, registered under the head of DENTITION, may be referred to rickets. " Catarrh and bronchitis," says Sir William, " are un- questionably the most common causes of death in rickets. The softening of the ribs rendering the mechanical power by which inspiration is performed so defective, that the ANEMIA. 1 89' impediment offered to the entrance of the air by the- mucus in the bronchial tubes cannot be overcome ; and collapse of large portions of the lung follows. " This want of inspiratory power, and the consequent accumulation of mucus in the bronchial tubes, affords an explanation of the extraordinary mortality of measles, whooping cough, and bronchitis in rickety subjects." Thus may we refer two more of the headings of the Registrar — ^Measles and whooping cough — to rickets. For similar reasons, and still more from the intensity of the general cachexia and the corresponding defect in the vital force, rickets will be found to be the true cause of fataUty in many of the deaths registered under the name of PNEUMONIA. Then we have the deaths from childeieth 4" 8 per week, and it is very interesting to trace out the influence of rickets in causing these miserable deaths. The mode of its operation is twofold. First, there is the large size of the head in the rickety foetus ; and, secondly, deformities of the pelvis in women who have been rickety in their childhood. On examining into the causes of death in childbirth, as carefully collated by Dr. R. Collins, of the Dublin lying-in hospital, I find that of eighty-one cases of death during parturition, thirty-two were due to rupture- of the uterus, eleven to tedious or difficult labour. If we, then, inquire into the causes of rupture of the uterus and tedious or difficult labour, to which forty-three out of eighty-one deaths were due, we find that narrowing and deformity of the pelvis, and abnormal size of the child's head, stand prominently forward in their importance; and thus we are brought back to rickets as the chief cause of these deaths. But you will perhaps ask, how ansemia is proved to be the cause of the deaths under these different headings, by 190 ANiEMIA. proving that they are due to rickets ? That is, in fact, the important question. The answer is this, that ancemia in the mother produces rickets in the child, and ancemia in the child may lead to ricltets also. This may be as familiar to you all as it is to me ; but I will give you the authority of Sir William Jenner again, who has devoted great attention to this subject : — " The health of the mother has a decided influence in the development of rickets in the offspring Of this much, I am sure — that when the mother is in delicate health, in a state of which ancefnia and general want of 2oower form the prominent features^ without being the subject of disease usually so-called, there the children are often in a very decided degree riclcety, although the father is in robust health, and the hygienic conditions in which the children are placed are most favourable. It is very common for the first two or three children to be free from any signs of rickets, and yet for every subsequent child to be rickety. "Whatever external conditions are favourable to the formation of hydrsemic blood in a child, seem to be favour- able to the development of rickets. "Albuminoid infiltration of the lymphatic glands, spleen, and other organs is by no means an uncommon cause of death in rickets. The two great features, during life, of albuminoid infiltration of these organs in a young child, are emaciation and pallor ; the ancemia is often most remarkable." You will not fail, then, to see at once the intimate connection between rickets and anemia, and between angemia and that list of terrible names in the Registrar's Eeports. I do not wish you to suppose that I attribute all the deaths under those headings to ansemia : that would be a ANEMIA. 19] great mistake. But from an elaborate and careful analy- sis of such deaths, I have found, and you may find, that a very large, a very remarkably large, proportion of them are due to angemia in the individual, or to anaemia in a parent and rickets in the offspring. It is important to bear in mind, that, with the exception of hydrocepha- lus, the diseases I have enumerated from the mortality- tables are extremely common every-day complaints— that they occur and terminate favourably thousands of times every year; that it is only the fated cases that corae into our list, and with which we are now concerned. And what I have endeavoured to show, and what I wish to impress upon you is, that we must look to anaemia as the chief cause of this fatality ; that it is anaemia in the in- dividual or anaemia in a parent that brings these remedia- ble, every-day complaints into the bills of mortality. When, therefore, we see anaemia estabhshing itself, as a vestige of the diseases from which our convalescents have lately suffered, or in any other- way, we must regard it as the grim harbinger of death in a vast family of diseases. The next example I shall give is Fatty degeneration which like the last does not appear in the Eegistrar's Reports. Ohapteb XI. FATTY DEGENERATION. In the present day^ we have all learnt that " something much more than a general tendency to form fat^ or a general excess of fat in the blood is necessary to produce a local fatty degeneration." — (Sir James Paget's Lectures, Vol. I., p. 112). Every year throws new light on the physiology of the process by which this change is brought about ; but of this it is not within the province of these Lectures to treat. I wish^ however, to point out to you that the pathological condition termed fatty degeneration is to be regarded as a vestige of disease — a vestige of perverted assimilation, either local or general, and hence a vestige also of any diseases by which such perverted assimilation is produced. In the third series of Guy's Hospital Reports (Vol. iii. 1857), Dr. Wilks has related a number of in- teresting cases of fatty degeneration, of which the only appreciable and probable causes were haemorrhage, diar- rhoea, miasmata. In these cases the subjects were com- paratively young, the heart was the organ in which the diseased change was most marked, and the body gener- ally was neither fat nor wasted. Fatty degeneration appears to be especially prone to occur in tissues which have passed from a condition of active assimilation to one of comparatively inactive or feeble nutrition, by whatever cause this change may have been brought about. Thus, the muscular tissue is parti- cularly subject to fatty degeneration j it is also peculiar for the vigour of its normal assimilation, and it is when FATTY DEGBNEEATION. 193 this is rendered feeble that degeneration ooeurs. This appears to be the case whether the vigorous assimilation is hindered by arrest of function in the musoleSj as in the case of paralyzed limbSj or by deficient supply of blood, as in disease of the nutrient arteries of a part^ or by a de- praved condition of the blood supplied to the part, as in the case of persons who, after having led active muscular lives, gradually become an^miated by passive hEemor- rhages. I have seen many instances of strong men, ac- customed to vigorous country occupations, who, having become the subjects of bleeding haemorrhoids, by which the blood lost its red globules, and nutrition became en- feebled, suffered from degeneration of their previously strong and vigorous hearts. Many other examples might be adduced of the degeneration of tissues when their assimilation is changed from a vigorous to a feeble state. Thus we find, in watching the course of diseases of the heart, that the heart which has become hypertrophied in opposing some obstruction to the circulation during the active life of the individual, becomes degenerated when, in the further progress of the case, the patient is forced to relinquish active pursuits, and thus ceases to call upon the hypertrophied organ for the full exercise of its muscu- lar power. Thus, also, parts which have .been inflamed are especially liable to degenerate, and fatty degeneration frequently takeu place in organs deprived of their proper functions by disease, as in kidneys spoUt by Bright's disease. Thus, also, the products of inflammation, when they have no further functions to perform, are peculiarly subject to fatty degeneration. Without pressing the subject further, I think we shall all agree that fatty de- generation must be regarded as a vestige of disease, not as a disease in itself, and that in thus regarding it, we 194 JFAITT DEGENERATION. must often look beyond the defect in assimilation to the causes of that defect^ in order to find the disease of which the degeneration is truly a vestige. I must now proceed to show to what a wide extent this vestige of disease acts as a cause of those deaths classed in the Eegistrar's reports under the heads of a variety of dis- "The most interesting examples (of fatty degeneration)/' says Sir James Paget, "are those of primary degeneration of blood-vessels. This has long Ibeen known in the athero- matous disease, as it was called, of the larger arteries, the true nature of which, as a fatty and calcareous degenera- tion of the inner and, consecutively, of the middle arterial coat, was discovered by Mr. Gulliver (see Med. Chir. Tran- sactions, Vol. XXVI.) The descriptions of this complaint by him and by Eokitansky have left nothing unsaid that is yet known ; but the observations are each year becom- ing more numerous and more interesting of similar changes in the minutest blood-vessels. Such changes are especially observable in the minutest cerebral vessels, and their im- portance in relation to apoplexy, of which they seem to be the most frequent precedent, cannot be overstated." — {Ibid., Vol. I., p. 139). Dr. Wilks' experience has taught him that, '" In the majority of cases of sanguineous appolexy, disease of the blood-vessels exists." — [Lectures on Pathological Anatomy, 1859). Dr. Kirkes has shown {Med. Chir. Transactions, Vol. XXXV.) that PABALTSia, consequent upon arrested circula- tion in some portion of brain, is frequently the result of the obstruction of healthy cerebral arteries by masses of fibrine carried into them, after being dislodged from the valves of the left side of the heart, or from some part of the arterial system. FATTY DEGENEEATION. 195 And Dr. Ormerod has pointed out that it is in the ca- •chetic subjects, with feeble circulations, that such masses ^re likely to form in the heart, in the very persons, in fact, who are likely to be the subjects of fatty degeneration of this organ. — {Observations on the Glinical History and Pathology of one form of Fatty Degeneration of the Heart, by B. L. Oemeeod, M.D. Medical Gazette, 1849) . And although Dr. Oi;merod was not prepared at that -time (1849) to consider the occurrence of fibrinous clots in the subjects of fatty degeneration to be more than a frequent coincidence, we do not now doubt that the lan- guid circulation, and the inefficient contractions of the heart in the subjects of fatty degeneration, act, together with other circumstances, in causing these deposits of £brine from the blood. Describing the appearances after death in fatal cases of :DELiEiTJM TREMENS, Dr. Wilks says, " The body, as a rule, presents many degenerative changes, brought about by the intemperate habits. It is this alteration of the viscera, I think, to which death is owing. Delirium tremens is a recoverable afiection until such changes have occurred in the tissues that improvement is no longer possible ; and we then find in the body various morbid changes. These are mostly of the fatty kind, as all alcohoUc drinks tend to this condition." — {Ibid.) In Angina Pectoeis, again. Dr. Wilks, in common with other observers, has found that " the heart is usually fatty, and the coronary arteries ossified." — {Ibid.) " It is impossible," says Dr. Ormerod {Op. cit.), ''to read any collection of cases of angina pectoris without feeling how much further fatty degeneration goes to explain the .symptoms than does any other morbid change usually found on dissection." o 2 196 FATTY DEQENEEATION. Sir James Paget classes the heart and arteries first amoDg the frequent seats of fatty degeneration. — [Op. cit., Vol. I., p. 116). Among the vessels of which the coats have been found degenerated are those of the lungs and placenta ; and pulmonary, or uterine haemorrhages may result from this- state of the vessels. Against the extreme vital depression which accom- panies such diseases as pieitonitiSj inpluenzAj and diae- EHCEA, the salijects of fatty degeneration have no resisting power; they are among the first to succumb; and thus fatty degeneration becomes a cause of death in these and other depressing diseases when they attack adults. Out of 164 deaths from Childbieth in the Dublin Hos- pitalj during the seven years ending November^ 1826, as recorded by Dr. E. Collins, I find thirty-two attributed to rupture of the uterus, and eleven to tedious or difficult labour. Eecent investigations into the causes of rupture of the uterus, show that fatty degeneration of its walls is a most frequent if not a constant coincidence. Fatty degeneration of the uterus, then, is a cause of death in childbirth by producing or disposing to rupture of the organ ; but it has yet another influence on these deaths, for we may be quite sure that a degree of degen- eration must often exist, not sufficient to lead to rupture, but quite sufficient to render the organ incompetent to vigorous muscular contraction, even under the in- fluence of unusual stimuli. And thus it may become the cause of those hopelessly tedious labours which, as we have seen, assist to swell the death-rate in parturi- tion. Thus do we see that among the rational causes of dread that haunt the brain of the accoucheur during a tedious- FATTY DEGENERATION. 197 labour, fatty degeneration of the uterus has a right to stand foremost. In P^ECMONiA, Dr. Wilks say that, in " far the n^ajority -of fatal cases, some pre-existing and more chronic disease is found in some organ of the body." — (Op. cit.J Speaking of the probabilities of death in pneumonia. Dr. Walshe has made the following very wen-considered observation : — " There are certain other circumstances (besides treat- ment) beyond the control of the physician, which exercise a most indubitable influence on the issue (of pneumonia). Among these, the pre-existence of organic disease and the state of health generally of the individual hold an important place. But of all the collateral conditions, age is the most important. While at the two extremities of life, in the new-born infant and in the octogenarian, pneumonia is almost inevitably fatal, the mortality between the ages of six and twelve years scarcely exceeds two-and-a-half per -cent." — (Manual of Diseases of the Ohest, 2nd edition, p. 438). To this I would add, that the octogenarian may be represented at any period of life by the subject of fatty xiegeneration. I need hardly remind you that, in protracted Gheonic Bkonchitis there is no one feature more fearfuUy pro- gnostic of a fatal issue, sooner or later, than the co-ex- istence of fatty-degeneration. In speaking of Senile Gangrene, Sir James Paget says it occurs, " as its name implies, in the old, and often in those who are old in structure, rather than in years ; it affects tissues already degenerate I think that, in .some cases, its beginning may be when the progressive .degeneration of the part has arrived at death. But, if 198 PATTY DE61NEEATI0N. this do not happeiij some iujury or disease, even a triviar one, kills that wliich was already nearly dead, as a severe injury might kill any part, however actively alive." — (Op. cit., Vol. I., p. 461). Under the heads of Livee-diseasb, Jaundice, and Kidney-disease, I may mention some interesting cases examined by Eokitansky. (On Fatal Steatosis — Fatiif Degeneration — of the Liver and Kidneys.) "The cases referred to consisted in steatosis of the liver, accompanied by a high degree of steatosis of the kidneys. Their importance rests upon the possibility of proving them to be parellel to the cases of acute atrophy of the liver, and the analogous renal affection which co- exists with it. " It is evident that in our cases we have not to deal with that steatosis of the liver which occurs so commonly in the course of consuming suppurative processes, but ■with, fatty livers, as they not rarely develope themselves to a high degree, at the side of an abundant formation of fat in the areolar tissue, without the disease being always- attributable to gross feeding. " There exists thus a steatosis of the liver, occurring in individuals inclined to the formation of fat, to which sooner or later a steatosis of the hidney is added, both which diseases attain slowly and imperceptibly so high a degree that, finally, a cessation of the biliary and urinary secretion supervenes, and, after a slight degree of icterus, death , rapidly sets in from anaemia and a hasmorrhagic decomposition of the blood." — (Banking's Abstract, Vol. XXXI., p. 40). I might prolong this subject much further — so widely spread is the influence of this seemingly spontaneous- atrophy, this Vestige of disease. I might give you quota- PATTY DEGINEEATION. 199 tions from reliable authorities to show in how many more diseases than I have yet referred to, the /atoZiii/ is deter- mined by fatty degeneration ; but I should exhaust your patience and overstep our time. I will, therefore, con- clude the list by simply enumerating the causes to which death was attributed in sixty-eight cases analysed by Dr. Quain, in all of which there was fatty degeneration. — (Med.-Chir. Transactions, 1850). List of causes to which death was attributed in sixty- eight cases of fatty degeneration. Rupture of the heart. Cancrum oris. Exhaustion. Gradual decay. Coma. Lethargie. Pleuropneumonia. Haemorrhage into the pericardium. Syncope anginosa. Cerebral haemorrhage. Cardiac apoplexy. Diarrhoea. Syncope. i Gangrene of the intestines. I must briefly remind you, in the words of Sir James Paget, that " Fatty degeneration of the heart often intro- duces unexpected dangers into the ordinary practice of surgery. It is, I believe, not rarely the cause of sudden death after operations. It is one of the conditions in which chloroform should be administered with more than ordinary caution. They who labour under it may be fit for all the ordinary events of a calm and quiet life, but they are unable to resist the storm of sickness, an acci- dent, or an operation." — {Op. cit, Vol. I., p. 129.) To sum up ; we have seen that this vestige of disease, fatty degeneration, may claim as its victims a certain number of deaths out of each of the following headings of the Registrar's report : — 200 FATTY DEGENEEATION. Apoplexy . 26'0 deaths per Paralysis 23-7 }} Delirium tremens and intemperance . 4-5 3} Angina pectoris and other diseases of the heart 31-9 3} Pneumonia . 60-3 }} Diarrhoea 17-5 yj Mortification 4-6 3} Influenza 3-1 33 Peritonitis . 4-4 3> Childbirth . . 4-3 33 Bronchitis . 64-5 33 Jaundice 2-8 3f Liver disease iro 33 Kidney disease . 4-9 33 week. 263'5 deaths per week; out of which fatty degeneration claims so large a share. Chaptee XII. ABNOEMAL PHYSIOLOGICAL STATES. We pass on, Grentlemenj to another and most important branch of our subject. I must now speak more at length of those states of health to which I referred in my second Lecture, when I said that I should impress upon you that " they are inti- mately related to the definitely marked diseases" — those states so puzzling to the young practitioner, because they do not fall under any of the nosological headings which have been his landmarks in the study of disease — those states which, although perhaps familiar in their aspect to most old practitioners, are, nevertheless, most inefficiently treated, or not treated at all, because their interpretation is so little understood, and because their importance is not appreciated ; conditions which are not recognised as disease, hut which certainly are not health, and which I propose to class under the general heading of " Abnormal Physiolo- gical States." I will give you some examples of what I mean. » A family of four children were exposed to the infection ■of measles at the same time, and from the same source ; fill of them were supposed to be ifi health at the time. One had the measles simply and slightly; one had a severe attack of pneumonia combined with it; one indicated a Respiration, amount of air viti- ated by, per hour . Respirator, the only protection from damp, fogs, &c . . Rest and change ■ see Sleep. Rest for diseased organs, to be obtained by removing elements from diet which increase their functions importance and dangers of, in pulmonary consumption . 231 — |- localised, rules for the cau- tions application of, in lung disease .... 234-6 Restorative food . . . ^ . 154 Rheumatic fever, case of, and probable sequelae from want of precautions . . . 171-3 • vestiges of, causes of other diseases . . 177 Rheumatism, vestiges of, the causes of other diseases . 178-9 Rickets, causes of death in 188-9 connection with ansemia 190-1 diseases in which they are primarily or secondarily the cause of death . . 188-91 13 93 INDEX. 247 Soasting, Lints on the best modes of 84 Eokitausky, oases of fatty degen- eration of liver and kidneys . I98 Salivary juices, their influence on the digestion of starch . 113 Salmon, its nutritive value and reasons why sometimes indi- gestible 76 Salting, pickling, and smoking, indigestibility from . . 87 Sohroeder, cotton-wool as a filter 224 Schwann, putrefaction of meat . 223 Sherries, wine known under the generic name of, historical no- tice of their use in England, &a 130-2 extensive fraudulent imitation of ... . 129 • — see also Wines (Spanish) Sickness, see Disease. Sick-room, special recipes, direc- tions, and appliances for 150-61 Sleep 30 importance of maintaining due proportion of . . .30 Smith, Edward, extracts on cheese, milk, &c., from his work " On Foods" . . 78-80 table of the proportionate quantities of water present in various solid and liquid foods . . .69 Smoking, influence of . .36 on the health of individuals and communi- ties 37-9 Sonsino (Prospero) "On the phy- siological dyspepsia from star- chy food in infancy," and in- fluence of the salivary and pancreatic juices on the diges- tion of starch, notice of . 112-14 Soup, invalid . > . . 155 Soups and broths, best processes of preparation of . ._ .87 Specialities, narrow, in medicine 2 Spirits, table of analyses of . 142 ardent, their peculiarities 141 Spirituous liquors, acid and su- . gar in 140 see Alcohol. Starch, on the special action of the pancreas on . . . 224 and fat in the nutrition of children . . . 112-22 Starchy food, physiological dys- pepsia for, in infants . . 114 Steam, see Poulticing by. Steatosis of liver and kidney . 198 Stewing, a favourable process of cooking for weak digestion . 86 Suet and milk .... 15(> Supper, unwholesomeness of a late substantial ■ . .49 Toible of interdependence of win- ter cough with other diseases 184 Tables of the composition of ar- ticles of food . . . .55 of normal diet for adults in the climate of the United Kingdom. . . . 62-8 of alcohol in spirituous liquors 142 of Mr. Banting's diet . 109 • of diets, for consumption, (carbo -hydrate, albuminoid, and fluid) . . . 100-2 of diet for diabetes . 103-4 — ^— of the vestiges and inter- dependence of diseases . 177-83 Tea, afternoon • . . .49 oereaKn .... 158 Teetjiing, retarded, caused by rickets . .' . . .188 Temperature, sudden changes of, as a cause of colds ' . .26 Tendons, experiments illustra- tive of their digestibility . 237 Thin, getting fat or thin . 5, 108 Tobacco, influence of , . . 3l> summary of the influ- ences of, on the health of in- dividuals and communities 37-9 Tongues, objections to cured meats not applicable to . . 74 Tyndall "Lecture on dust and disease" 222 Typhoid, vestiges of, the causes of other diseases ; . . 179 Typhus fever, vestiges of, the causes of other diseases . . 179 Uterus, fatty degeneration of, deaths in childbirth from . 196 Veal, relative nutritive character of, and unwholesomeness 'to delicate stomachs . . . 7^ 248 INDEX. 81 Vegetables) list of, as articles of diet ~ causes of indigesti- bilityj and means of correcting 82 Yenison, its digestibility the same as that of game .' .75 Yentiktion and heating . .12 -^^— facts on which ar- rangements for, are to be based 13 — ^-^ conditions of, for sup- ply of fresh air . . .13 Yerkruzen (M. A.) Notices of German wines .... 134 Walshe, fatality of pneumonia from pre-exi»tent organic dis- ease ' . Water, ixiible of proportionate quantities of, in various foods use of at meals to assist digestion . : . . _ . ' preference of hot to tepid for friction bath ^— — see Baths. drinking, spoiling of by 197 69 72 34 21 leakage of drain-water Water-closets, best mode of trapping, and ventilation of, &c 18-20 Water-proof over-clothing, ne- cessity for . . . ,28 Wet feet, as a cause of colds 28-9 Whey, directions for making . 154 Wilks, remarks on sanguineous apoplexy, delirium tremens, angina pectoris, &c., as con- nected with fatty degenera- tion 194-7 Wines, table of analyses of . 142 properties of various, summary of sources of inform- ation on . . . . 123-5 in general, notices of amount of fermentation and distinctive characters, strength per cent., &c., by James L. Johnston. . . . 125-30 ■^-^— German, notices of by M. A. Yerkruzen .... 134 — — German, valuable quali- ties of, principal growths, &o. 134-7 Greek, properties of, by J. L. Denman .... 139 -^— ^ Hungarian, notices of the different kinds of, by Max Greger .... 137-9 — ^ Spanish, description of, by F. W. Cozens . . 130-4 "Winter Cough" Lectures on, extracts from . . . 25-9 - per centage of causes of fresh colds in . .26 table shewing its interdependence with other diseases 184 WoUowicz (Count) experiments" on the effects of alcohol on the human body . . . 212-21 Woollen material, necessity for, next the skin in winter . 25, 27 Printed by H. K. Lewjs, 136 Gower-st., London, W.C. WORKS BY DR. DOBELL. Illustrated by the Heliotype Process, AFFECTIONS OF THE HEART AND IN ITS NEIGHBOURHOOD. CASES, APHORISMS, AND COMMENTARIES. H. K. Lewis, Gower Street. Juat Published, New and Enlarged Edition (Third), with Coloured Plates, ON WINTER COUGH, CATARRH, BRONCHITIS, EMPHYSEMA, ASTHMA. 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