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FORTY YEARS 
 
 IN THE 
 
 MEDICAL PROFESSION 
 
FORTY YEARS 
 
 IN THE 
 
 MEDICAL PROFESSION 
 
 1858-1898 
 
 BY 
 
 JOHN JANVIER BLACK, M.D. 
 
 MEMBER OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA; MEMBER OF THE 
 DELAWARE STATE MEDICAL SOCIETY, ETC. 
 
 'yf ?nan is as old as his arteries'' 
 
 PHILADELPHIA 
 
 J. B. LIPPINCOTT COxMPANY 
 
 1900 
 
Copyright, 1900, 
 
 BY 
 
 John Janvier Black. 
 
 d-A^'^W^ ^^U6v*w^^> 
 
 PRINTED BY J. 8. LIPPINCOTT COMPANY, PHILADELPHIA, U.S.A. 
 
PREFACE 
 
 I HAVE given forty years of faithful and conscientious 
 work to an exacting and laborious profession, and here are 
 the notings of some of the results. I trust they may enable 
 my readers now and again to while away a leisure hour. 
 Call them what you will; call them, if you choose, the mere 
 flotsam and jetsam which have rolled in upon the waves of 
 the sea of my personal experience, and which have been cor- 
 ralled by the breakers and strewn, figuratively, upon the 
 shore, in the following pages. 
 
 JOHN JANVIER BLACK. 
 
 New Castle, Delaware, December, 1899. 
 
CONTENTS 
 
 CHAPTER I. 
 
 PACE 
 
 Voyage to San Francisco — The Isthmus of Panama — The Western 
 Coast of Mexico — Arrival at San Francisco — United States 
 Marine Hospital, San Francisco — Diseases among the Sailors — 
 The First Japanese Embassy to the United States — R. H. Dana, 
 Jr. — San Francisco in the Early Days — The Medical Profession 
 — Duels — The Climate — San Francisco in 1894 — John China- 
 man 13 
 
 CHAPTER II. 
 
 University of Pennsylvania, Medical Department, i860 — The Build- 
 ings and Conveniences for Faculty and Students — The Faculty — 
 The Lectures — The Quiz Classes and Students — University Char- 
 acters — Outside Teaching — The Course 32 
 
 CHAPTER III. 
 
 The Jefferson Medical College, Philadelphia — The Faculty — Joseph 
 Pancoast and James Syme — S. D. Gross — The Tone of the Pro- 
 fession in Philadelphia — Clinics — Hip-Joint Cases — Clinical Lec- 
 turers in Philadelphia — The Atlees and other Great Men — Pro- 
 fessional Methods — Trained Nurses — The Philadelphia Hospital, 
 Blockley, in the Early Sixties — Typhus Fever 48 
 
 CHAPTER IV. 
 
 Started for Liverpool in a Sail-Ship — Tornado — Narrow Escape and 
 Return to New York — Better Success by Steamer — Paris in 1866 
 — The Hospitals — The Doctors — Velpeau, Jobert de Lamballe, 
 Nelaton, Ricord, Sichel, Charcot, Trousseau, Liebreich, Pasteur, 
 J. Marion Sims — Napoleon III. and why he failed — Tone of the 
 Profession in Paris — London — Sir William Ferguson. Sir Thomas 
 Watson, Sir James Paget, and Others — Edinburgh — Simpson and 
 Syme — Ether and Chloroform — Berlin — Von Langenbeck — Fre- 
 richs — Vienna — Clinical Schools and Lectures — Billroth, Skoda, 
 Oppolzer, Tiirk. and Others 67 
 
 7 
 
CONTENTS 
 CHAPTER V. 
 
 PAGE 
 
 Returned from Europe and Settled in New Castle, Delaware — Its 
 Peculiar Freedom from Certain Diseases — The Medical Profes- 
 sion in Delaware — Country Doctors — A. Conan Doyle — Ian Mac- 
 laren — Bacteriology Forty Years Ago — Pathogenic and Other 
 Germs — Toxines — Immunitj' — Inflammation — Operations Forty 
 Years Ago and their Results — Asepsis — Antisepsis — Origin of 
 Life — Sir Joseph Lister — Obstetrics and Antisepsis — Hospital 
 Gangrene — A Strange Coincidence — Surgery away from the 
 Centres — Disinfection — Necessity of — Gonorrhoea — Bladder Trou- 
 bles — Syphilis — Eye Troubles — Gynaecology — Proctor Knott — Ap- 
 pendicitis — Radical Cure of Hernia — Intubation and Trache- 
 otomy — Fractures and Dislocations — Instruments — Rontgen Rays 87 
 
 CHAPTER VI. 
 
 Post-Mortems, etc., Forty Years Ago — Treatment of Pneumonia Then 
 and Now — Heart-Troubles — Digitalis, etc. — Auscultation and Per- 
 cussion — Vivisection — Improvements in Pharmacy — Dangers in 
 Drugs — Sugar-Coated and Compressed Literature — The Blood — 
 The Trolley — The Bicycle — Preventive Medicine — Diagnosis — 
 Wall Diseases — Nitrification — Malthusian Theory — Diphtheria — 
 Croup — Sir Morrell Mackenzie — Tetanus — Immunity as to the 
 Sting of the Honey-Bee 126 
 
 CHAPTER VI L 
 
 Nervous Diseases Forty Years Ago — Somnambulism — Hypnotism — 
 Motor Disorders — Lunacy — Delirium Tremens — Epilepsy — 
 Chorea — Diseases of the Cord and its Membranes — Tetanus — 
 Hydrophobia — Hysteria — Neurasthenia — Dr. D. D. Richardson's 
 Views on the Treatment and the Care of the Insane — The Feeble- 
 Minded — Notes by Dr. Martin W. Barr — The Deaf and Dumb — 
 
 Colonel William Boiling John Brainwood — Thomas Hopkins 
 
 Gallaudet — Edward Miner Gallaudet — Hon. Amos Kendall — Dr. 
 Crouter — Peet — Rogers — Gillett — Noyes — Fay — Manual Method 
 and Speech — Swedish Movements — The Bath — Electricity — The 
 Masseur and the Masseuse — Hypnotic Suggestion — The Danger- 
 ous Classes — The Degenerates — How shall the Problem be solved? 173 
 
 CHAPTER VII L 
 
 Ptomaines — Definition of, etc. — Composition of, etc. — Vegetable Al- 
 kaloids — Changed Food Supply — Canning, etc. — Poisonous Gases 
 in the System — The Different Ptomaines — A Growing Evil — 
 Fatigue and Ptomaine Poisoning — Chronic Ptomaine Poisoning 
 
 8 
 
CONTENTS 
 
 I'AOK 
 
 — Ice-Crcam and Crcam-PufF Poisoning — Personal Experience 
 in Ptomaine Poisoning — Auto-intoxication in Disease — The Re- 
 flexes from Ptomaine Poisoning and Auto-intoxication — Patho- 
 genic Poisons — The Death Struggle and Auto-intoxication . . . i88 
 
 CHAPTER IX. 
 
 Diet now on a Scientific Basis — Study the Individual — Idiosyncrasies 
 —Teach Diet in the Schools— Diet in Youth and Old Age— Carls- 
 bad and its Doctors — Diet and the Poor — Division of Foods — 
 Animal and Vegetable Foods — Tissue-Builders and Force-Pro- 
 ducers — Uses of Food — Oxidation and Health — Water — Rations 
 for Individuals — Children and Protcids — Atwater and Woods 
 on Composition of Foods — All about Eggs — Fish compared with 
 Beef, etc. — White Potatoes, Spinach, Asparagus, etc. — Lead Poi- 
 soning — Coffee and Tea — Chocolate and Cocoa — Dietary Studies 
 among the Plain People — The Germans and German Thrift — 
 Study of a Family as to its Diet, Cost of, etc. — Diets for Cor- 
 pulency and Leanness — Systems of Diet — Banting and Others — 
 Different Kinds of Breads — Toast, etc. — Kissingen and Vichy 
 Remedy for Fatness — Food consumed per Person per Year in 
 Different Countries — Time required for the Digestion of Various 
 Foods — Sterilizing and Pasteurizing Milk — Infant-Feeding — Ar- 
 tificial Infant Foods— Diet for the Old— Ward McAllister— In- 
 fantile Scurvy — Concerning Milk — Tests for Milk — Regulating 
 the Milk Trade— Graded Milk I97 
 
 CHAPTER X. 
 
 Origin of Alcohol, Whiskey, Brandy, Port Wine, Sherry, Champagne, 
 Burgundy, Claret, Rhine Wine, Porter, Ale, Beer — Per Cent, of 
 Alcohol in Each — Effect of Alcohol on the System — Effect of 
 Alcohol on Bodily Temperature — Alcohol as Food — System con- 
 sumes more in Disease than in Health — Strength of Wines — 
 Colors of Wines — National Drinks — Methods of artificially aging 
 Whiskey, etc. — Rum, Gin, Cordials, Malt Liquors — IMethod of 
 making, etc. — Malt Extracts — Wines — Grapes, Varieties of. etc. 
 — The Wine-Taster — Peculiarities of Wines — Sherry, Madeira, 
 Port — Ward McAllister — Burgundy, Sauternes. Hock, Johannis- 
 berg — Champagne " a Drink for the Gods," as well as an Inven- 
 tion of the Devil — Vin Brut, Vin Sec, Vin Tres Sec, Sparkling 
 Moselle — German and Italian Wines — American Wines — Cali- 
 fornia Wines — Care in prescribing Alcoholics — Value of Fruit 
 and Nuts as Articles of Diet — Value of Fruit as Food from an 
 Economic Stand-Point — The Lesion in Rheumatism — Is Fruit 
 Healthy Diet? — The Divisions of Fruits — Special Fruit Cures — 
 The Ripening of Fruit — The Most Digestible .Fruits — Fruit 
 
 9 
 
CONTENTS 
 
 PAGE 
 
 Syrups and Fruit Juices — Canned or Tinned Fruits and Vege- 
 tables — Fruits in Colonial Times — Fruit in Florida, California, 
 and Australia — Medicinal Properties of Fruits and Nuts — Why 
 Leaves change Color — The Apple — Varieties of Apples — Varieties 
 of Peaches — Varieties of Pears — Grapes — Apricots — The Plum — 
 East India Fruits — The Mangosteen — The Durian, Pine-Apple, 
 Banana, Plantain, Orange, Shaddock, Olives, Lemons, Mulberry, 
 Melons — Partridge-Berry and Salicylic Acid — The Haw-Berry — 
 Gooseberries, Currants, Cranberries, Cherries, the Quince, Black- 
 berries, Raspberries, Strawberries — Decay of Fruit — Mushrooms, 
 Morels, and Truffles — Nuts — Chestnuts, Peanuts, Almonds, Fil- 
 berts, Pecans, Shellbark or Shagbark, Brazil Nuts, Chilean Nuts, 
 Betel Nut, Pistachio Nut, Kola Nut, Guarana, Butternut, Wal- 
 nuts — Eucalyptus Globulus 269 
 
 CHAPTER XL 
 
 George B. Wood and S. D. Gross on Tubercle — Koch's Discovery of 
 the Bacillus Tuberculosis — Present Definition of Tubercle — 
 Physical Attributes of Tubercle — Tubercle Bacillus in Man and 
 the Lower Animals — Pulmonary Tuberculosis in Man — The 
 Physician and Tuberculosis — Early Diagnosis Important — The 
 Bacillus and Diagnosis — Case of Chronic Interstitial Pneumonia 
 and Tuberculocidin — Tuberculins and their Therapeutic Principles 
 and Uses — Toxines and Antitoxins — Koch's Tuberculins A, O, 
 and R — Maragliano's Serum — Virchow's Objections to Koch's 
 Tuberculin A — Mulford's Serum — The Economics of Tuberculin 
 — Tuberculous Cattle in Europe and America — Necessity for 
 Action — Prevention and Treatment of Tuberculosis — Surgical 
 Tuberculosis — Treatment of Haemoptysis — Murphy's Method of 
 treating Pulmonary Tuberculosis — Secondary Infection — Cures 
 — What Factors hold Tuberculosis Latent — Climate and Environ- 
 ment — Pulmonary Hemorrhage and Altitude — The Indians as an 
 Object-Lesson — Relieving Crowded Centres — Sanitaria and Sana- 
 toria and Treatment — Common Colds — Consumption in Hotels — 
 Solitary Life Best — Altitude — The Heart and Altitude — Diabetics 
 and Altitude — The Climate of the United States East and West — 
 Sanatoria and Climate in Europe — Serum Treatment in the Adi- 
 rondacks — Inhalations as Remedies 377 
 
 CHAPTER XII. 
 
 Rheumatism an Infectious Disease — The Bacillus of Rheumatism — 
 Thyroid Extract in Rheumatism — Uric Acid in Rheumatism — 
 Nuclein — The White Blood-Corpuscles — Diagnosis — Treatment 
 — Rheumatic Gout — Multiple Arthritis Deformans — Gout — Ar- 
 teriosclerosis — Metabolism — Anabolism — Katabolism — Theories 
 
 10 
 
CONTENTS 
 
 I'AGK 
 
 of Gout — Origin of Uric Acid — Causes of Gout — Gout of the 
 Intestines — Treatment of Gout — Water — Lithia — Diet in Gout 
 — Intermitting Heart — Alcohol in Gout — Cider Cure for Gout — 
 Vegetables in Gout — Contracted Kidney — Medicines in Gout — 
 Piperazine and Pichi in Gout — Thyroid Extract causing Gout 
 — Menstrual Gout — Carlsbad — An American Carlsbad — Diabetes 
 Mellitus — Glucose — Starches — Dextrose — Glycogenic Matter — 
 Tuberculosis and Diabetes — Pancreatic Lesions — Carl von Noor- 
 den — The Liver and Glycogen — Fat — Hyperglyca^mia — Causes of 
 Diabetes Mellitus — Mayer's Theory — McCaskay's Suggestions- 
 Relationship between Diabetes and Obesity and Gout and Dia- 
 betes — Gluten — Diagnosis — Tests for Sugar — Pregnancy and Dia- 
 betes Mellitus — Alcohol — Recoveries — Diabetes and Gouty Kidney 
 — How to watch a Diabetic — Diabetic Coma — Diabetics Vulner- 
 able — Diabetics and Tuberculosis — Thyroid Treatment — Progno- 
 sis — Diet and Treatment — Jambul and Piperazine — Substitutes 
 for Cane Sugar — Wines and Spirits — Waters — Fruits — Nuts — 
 Allowable Articles of Diet — Terrapin — Rest Treatment — Gluten 
 Flours and other Diabetic Flours and Foods — Analysis of Maca- 
 roni, Flours, etc. — The Soja Bean — Aleuronat Flour — Adultera- 
 tions 418 
 
 II 
 
FORTY YEARS 
 
 MEDICAL PROFESSION 
 
 ¥¥ 
 
 CHAPTER I. 
 
 Voyage to San Francisco — The Isthmus of Panama — The Western 
 Coast of Mexico — Arrival at San Francisco— United States Marine 
 Hospital, San Francisco — Diseases among the Sailors — The First 
 Japanese Embassy to the United States — R. H. Dana, Jr. — San Fran- 
 cisco in the Early Days — The Medical Profession — Duels — The 
 Climate — San Francisco in 1894 — John Chinaman. 
 
 The unexpected frequently shapes a man's destiny. In 
 my case this was not so, for my paternal grandfather and 
 my father were both well-known practitioners of medicine 
 in Delaware. For this reason it was decreed by my family 
 that I, willing or unwilling, should also become a physician. 
 
 I take the date of my entry into the profession as June 5, 
 1858, on which day I sailed for San Francisco, California, 
 on the steamer Moses Taylor, from New York. The ship 
 was a side-wheel, wooden vessel, with two walking-beam 
 engines, of fair speed, but a notorious roller, and very un- 
 comfortable in a rough sea. She was of about two thousand 
 tons burthen, and as she carried nine hundred passengers, 
 besides her crew, it is evident how overcrowded and uncom- 
 fortable we must have been, especially so as during a part of 
 the voyage we were exposed to the intense heat of the 
 tropics. The voyage w^as uneventful as far as Aspinwall. 
 
 13 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 There we were landed and were held until the ship could be 
 unloaded and the passengers transferred across the Isthmus 
 of Panama. At this time yellow fever was raging in Aspin- 
 wall, but none of our people became infected. At Panama 
 we were embarked upon a larger steamer, the John L. Ste- 
 phens, for San Francisco, stopping at Acapulco and Man- 
 zanillo, Mexico. We received additional passengers at 
 Panama, making our number on the Stephens fifteen hun- 
 dred in addition to her crew. The heat in the tropics was 
 very severe, ice on the ship was twenty-five cents a pound, 
 yellow fever was raging in Acapulco, and, worse than all, 
 small-pox broke out among the passengers on our ship. 
 After a time we arrived safely at San Francisco, and I only 
 speak of these matters as apropos to my induction into the 
 profession. My paternal cousin. Dr. Richard Tybout Max- 
 well, who had studied medicine with my father, graduated 
 at the University of Pennsylvania, and entered the United 
 States navy as assistant surgeon, had remained in the navy 
 a number of years, and like many other army and navy 
 officers, had resigned as full surgeon and entered upon pri- 
 vate practice in San Francisco. Dr. Maxwell took me as 
 his private student and established me as dresser in the 
 United States Marine Hospital, San Francisco, of which 
 he was surgeon in charge. I was just fresh from Princeton 
 College, and to me the change was both abrupt and novel, 
 as may well appear. 
 
 In those days the marine hospital service was not organ- 
 ized, and had no such masterly corps of surgeons and scien- 
 tific men, with a Wyman at their head, as exists to-day. 
 The surgeons in charge were generally local practitioners, 
 appointed by the Secretary of the Treasury, and did not 
 reside in the institution. At the San Francisco Hospital, a 
 fine large building, at the time one of the few fine ones in 
 the city, had just been finished by the government with a 
 capacity of about three hundred beds. This building is now 
 used as a sailors' home, and has been so much shaken by 
 earthquakes as scarcely to appear safe as an abode for human 
 
 14 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 beings. The government lias now establisherl a new hospital 
 in a new building, out on the Presidio reservation, near the 
 ocean, where the sick and unfortunate sailors have all the 
 advantages of the well-regulated marine hospital service of 
 the present day. 
 
 To go back to the old hospital : The organization was 
 composed of the surgeon in charge, Richard Tybout Max- 
 well ; assistant surgeon, John Young Lind ; steward, Mere- 
 dith A. Sullivan ; apothecary, Frank T. Maynard ; orderly, 
 William Lindop; student of medicine, John Janvier Black; 
 together with a corps of nurses and cooks such as could be 
 held together, taken generally from convalescent patients, 
 and held as long as possible, the almost daily gold excite- 
 ment alluring all adventurers to the new fields, and those 
 who escaped these sirens generally, sooner or later, fell vic- 
 tims to the sailor's love of rum and its attendant excite- 
 ment, and in their maudlin state were shanghaied aboard 
 some departing vessel, and only recognized their helpless 
 state when they awakened from their debauch and found 
 themselves far out on blue water, bound most likely on a six 
 months' voyage. 
 
 A case recurs to me here worth relating as showing in 
 glaring colors the ups and downs of a sailor's life. One 
 morning an English sailor, a magnificent specimen of the 
 physical man, was brought in suffering from a gunshot 
 wound of the right shoulder. James Whitford, I well re- 
 member, was his name. He had been employed as a runner 
 of a sailors' boarding-house, kept by a man by the name of 
 Sheridan. Whitford stated that Sheridan had shipped the 
 men on the English clipper Beau Monde for a long voyage. 
 To carry out the thrifty designs of such men in San Fran- 
 cisco in those days, he had commissioned WHiitford to go 
 the next night and kidnap the same men from the Beau 
 Monde he had shipped in the morning, with the intention 
 of getting another advance from some other confiding cap- 
 tain, and so on ad infinituin. 
 
 The officers of the Beau Monde were looking for just 
 
 15 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 such trouble, and as Whitford's head appeared above the 
 rail the first officer shot him in the right shoulder, as before 
 stated, and down he dropped into the bay, but was rescued 
 by his companions and brought to the hospital. 
 
 Whitford's case went on, and was a most interesting one 
 surgically, one that probably would not happen now in the 
 days of antiseptic methods. Sepsis supervened. Among 
 other troubles, I remember, an abscess of the liver developed, 
 which opened through the diaphragm into the lung, and the 
 pus, tinged with the bile, all came by expectoration through 
 the mouth. A large abscess developed at the right hip, the 
 head of the femur was dislocated and absorbed, and the head 
 of the bone made a new socket on the dorsum of the ilium. 
 After probably a year the man recovered, with a shortened 
 limb, a physical wreck. I never saw in any human being 
 such an exhibition of brute courage and strength as this man 
 possessed, and his vindictive nature was proved by the sequel. 
 
 After he left the hospital he went back to Sheridan's 
 sailors' boarding-house as bouncer and bar-keeper. Not long 
 after he had taken his new position he deliberately shot the 
 proprietor dead, saying, as he shot, it was his sweet revenge 
 for the ruin Sheridan had brought on him in the Beau Monde 
 affair. After a trial in the courts, Whitford was judicially 
 executed by hanging, and I have always regretted I was not 
 at hand to hold a post-mortem over the remains. I have 
 often thought that many a fair romance has been builded on 
 a series of circumstances less weird than those surrounding 
 the life of this unfortunate sailor. Man-of-war discipline 
 was maintained in the hospital, which, under the conditions, 
 was not difficult; sailors are accustomed to obey, and give 
 little trouble usually. Now and then a sea lawyer bobs up 
 among them ; throttle him, and the rest is easy. The govern- 
 ment provided amply for their wants in all respects, and 
 gave them more comforts and a better home than they ever 
 obtained elsewhere. Although at the present time they are 
 much better protected from sharpers the world over than 
 they were in the days I am writing of, they are at best an 
 
 i6 
 
FORTY YEARS IN TITE MEDICAL PROFESSION 
 
 unfortunate class of peo])lc, never having 1)ut one lianrl with 
 which to help themselves, the other going to the owner, as 
 they express it. The ends of their short lives generally find 
 them struggling with the angry billows, and, whether on sea 
 or on land, little it matters to them. The clinical material 
 in this hospital was plenty, diverse, and interesting. The 
 material was collected, as it were, from the world over. The 
 venereal wards were especially ])rolific in acute and chronic 
 cases. Secondary and tertiary syphilis and strictures of the 
 urethra were very common. It is in this class of diseases 
 that poor sailors suffer so horribly. They ship often through 
 ignorance, but generally nolens volens, utterly regardless of 
 their condition, and they either die at sea after terrible suffer- 
 ing or are landed at the end of the voyage, hopeless wrecks 
 and cruel sufferers. Skin diseases, both specific and non- 
 specific, were common, and the clinical material in parasitic 
 diseases was especially abundant and interesting. Jiggers, 
 the tropical penetrating fleas, the guinea- worms {Filaria me- 
 dinensis), and the dififerent tape-worms were very common. 
 Scurvy was a frequent disease among those admitted. It 
 was common at that day on our own merchant ships, out on 
 long voyages, and also on the French and German ships. 
 Few if any cases came from the English ships. All sailors 
 arriving in those days from long voyages were in probably 
 a slightly scorbutic condition, but not out of health suffi- 
 ciently to apply for relief in a hospital. It would be better if 
 all sailors were taken in charge by some friendly hand at the 
 end of long voyages, for if not, they usually go on a debauch 
 and reship, and are in no wise built up after the long priva- 
 tions of the previous voyage. This is one great reason of 
 their broken health and short lives as a class. 
 
 I never saw scurvy among the officers of the ships. This 
 showed the cause in a great measure. All the men got, as a 
 rule, was salt meat and hardtack, now and then a little duff, 
 and morning and evening some weak cheap tea with molas- 
 ses. Six months of such diet is enough to sicken any man. 
 Add to this a dreary voyage, quarters often cold and never 
 2 17 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 dry, never a cheery word from any one, nor a morsel of food 
 but what is almost distasteful, from frequent repetition of 
 the same stuff, and you have all-sufficient causes for scurvy. 
 The symptoms then were the same as now, — the spongy and 
 bleeding gums, the loose teeth, the iron hardness of the 
 muscles, especially the calves of the legs, the petechial hem- 
 orrhages, the foul breath, and the great and general weak- 
 ness of the individual. The tendency to hemorrhage was 
 frequent and persistent, and the blood dark and thin. Of 
 course, at that day no thought was given to it as now as a 
 disease of infection and possibly of microbic origin. The 
 circulation in the sailors' cases was weak and the heart often 
 irregular. We found the first great remedy to be recum- 
 bent rest. I once saw a fine physical specimen of a man 
 brought in with others of a crew infected with scurvy. He 
 got up to walk across the ward, and fell dead. Post-mortem 
 showed no lesion of organs to account for death. Exhaus- 
 tion was the cause. Had he been kept on his back for a few 
 days, he would in all probability have recovered. This case 
 has ever after been a lesson to me to conserve the strength 
 of a weak patient, the need of watchful care to those ex- 
 tremely ill. Fresh vegetables, oranges, lemons, and the like, 
 giving their salts as citrates and such in the digestive tract, 
 fresh meats, and the salts of potash direct in the shape of 
 potash bitartrate were the usual remedies used, with the best 
 success. 
 
 We had patients from every clime, and here was a 
 good place to study racial characteristics. An interest- 
 ing group was that from the Japanese Embassy, which 
 came over after old Commodore Perry had opened up 
 the ports of Japan to the outside world. They came to 
 San Francisco on their way to Washington in the old side- 
 wheel frigate Powhatan, under the care of distinguished 
 officers of our own government. Many of the servants 
 were ill after their arrival in San Francisco with acute 
 pulmonary troubles. All these fell to us in the hospital, 
 and we appropriated a large ward to their use. We could 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 not do much with them at that day. They were just 
 coming out of their seckision of centuries, and were very 
 suspicious of outsiders, and particularly of doctors and medi- 
 cines. Several died, and were buried by their own peculiar 
 ceremonies. The cadavers were continually guarded until 
 burial, and never a coffin was lowered into the grave until 
 the lid had been lifted as a last precaution. The redoubtable 
 Japanese Tommy was with this commission, a bright, rest- 
 less little mortal, and a frequent visitor to the hospital ; but 
 no time to be sick had Tommy. Those with us were in- 
 veterate gamblers, great smokers, and, as they grew to better 
 health, quite jovial, yet always suspicious, reserved, and sly. 
 Of course they gambled. They were all men of one sword. 
 They gambled among each other, not with our men. At last 
 one or two of the Japs had about won everything all the 
 others of the party possessed. Then their cunning came in. 
 They sold nearly everything they had, even their swords, to 
 the hospital employees. When their resources from this 
 manoeuvre were gone they had come to their wits' end. 
 They came to the hospital authorities to interfere to have 
 their property returned, for if they went back to Japan sword- 
 less, each swordless man must then and there commit liari- 
 kari. The ruse was successful, but had the embassy remained 
 I have no doubt the same process would have been gone over 
 again ad iniinitum. These people brought their own food, 
 and ate none of ours. They lived on rice, tea, and what 
 looked like a persimmon pickled in brine, and eaten with 
 their rice. In a medical way we learned little of them or 
 from them. To-day what advances these people show" ! 
 
 I remember another very interesting visitor to the hos- 
 pital, — Richard Henry Dana, Jr.. author of " Two Years Be- 
 fore the Mast," that greatest of sea-tales, and for the writing 
 of which every man who has been a sailor or who has had 
 to do with sailors should doff his hat at the mention of Dana's 
 name. That book started the crusade which has done so 
 much to right the sailor's wrongs and to ameliorate his for- 
 mer deplorable condition. Dana was on his way around the 
 
 19 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 world, and this was his first visit to the Pacific coast since he 
 left, at the end of his memorable voyage of " two years before 
 the mast." He made a rigid inspection of the hospital and all 
 that pertained to it. He knew how to inspect : he went to 
 the nooks and the corners, to the beds, the clothing, the drain- 
 age, the food supply, the tables, the dishes, especially the 
 cups, the spoons, before and after they had been washed. 
 The grounds received his careful attention ; in fact, the whole 
 plant and its contents, patients and all, were thoroughly 
 looked over. He was a pleasant, genial gentleman. I had a 
 pleasant time with him on several occasions, and said good-by 
 for the last time as he passed over the rail of the clipper ship 
 Mastiff, en route for China, on his way around the world. 
 The Mastiff was loaded with Chinamen, living and dead, on 
 their way back to the Flowery Kingdom. In their proverbial 
 recklessness with fire, they fired the ship three days out from 
 San Francisco. All had to take to the boats. In a day or 
 two they were rescued by an English ship bound for China, 
 and were there landed safely at the end of her voyage, or 
 rather at Honolulu, where she stopped en route. This was 
 great good luck, as in those days seldom a ship sighted an- 
 other on that voyage. 
 
 The first major operation in surgery I saw was an ampu- 
 tation at the hip- joint upon a poor fellow brought in for 
 crushed limb, caused by an accident in a steamboat's engine. 
 The limb was fearfully mangled, and the femoral vessels 
 being exposed made their ligation easy, as a preliminary to 
 the disarticulation. I was given the responsible position of 
 holding the limb, and thus my initiation as a saw-bone was 
 a formidable one. Dr. Maxwell did the operation very dex- 
 terously, making, rather from necessity, lateral flaps of skin 
 and muscle. The poor fellow died in a few hours, of exhaus- 
 tion. I remember it was discussed at the time whether or 
 not the operation was proper under the circumstances. The 
 man rallied sufficiently and lived long enough to compel 
 action, and the operation was decided to be justifiable. I 
 have since been placed in a similar position, and operated 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 with like result, but believe 1 was justified. There have been 
 few recoveries fnjni primary ani[)utations at the hip for ac- 
 cident or gunshot wouiul, but a surgeon may be called upon 
 to give the patient the glimmering chance even in such des- 
 perate emergencies. 
 
 In those days San Francisco was a new mushrofjm West- 
 ern town, cut off almost entirely from the outside world, the 
 mails only coming twice each month by the Pacific Mail 
 steamers via Panama. The town then was mostly built 
 along the Bay of San Francisco on made ground ; the streets 
 were either sand ways or planked with wood, with a popula- 
 tion of less than forty thousand souls. 
 
 There were many refined and cultivated people living there, 
 quite a number of United States army and navy people, 
 among them young men who afterwards became famous, — 
 Halleck, McPherson, Ogden, Sawtelle, Mackall, Keys, Mur- 
 ray, Alden, and others. There were also many refined 
 English, French, Germans, old native Californians, and 
 Mexicans. The tone of the medical profession was not 
 highly elevated. There were bickerings and jealousies 
 among the members, composed as it was of men of nearly 
 all nations and gathered from all parts of the world. The 
 business was profitable to those in full practice, but living 
 expenses were great. The fees were from three to five dol- 
 lars each visit, with surgical and other special services in 
 proportion. Among the more prominent men were R. T. 
 Maxwell, H. H. Toland, Thomas Bennett, F. A. Holman, 
 Benjamin Coit, John Hastings, E. S. Cooper, L. C. Lane, 
 R. Beverly Cole, Charles Bertody, H. M. Gray, Augustus J. 
 Bowie, Isaac Rowell, J. M. McNulty, Robert K. Nuttall, 
 William Hammond, and A. B. Stout. 
 
 I give these names here as a contribution to the history 
 of the profession in a town now become the metropolis of 
 the Pacific coast, and really one of the medical centres of 
 the Western world. Maxwell was a retired, or rather a re- 
 signed, naval surgeon, who took up civil practice in San 
 Francisco in 1854. He was an able man, a good all-round 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 medical man. He was a fine operator, and especially excelled 
 in gehito-iirinary surgery. In obstetrics he had a deservedly 
 large practice. He had decided artistic talent, painted well 
 in oil, and was a fine musician and linguist. He died in 1883. 
 Toland had a very large practice, was quite a surgeon, and 
 made a large fortune. He founded the Toland Medical Col- 
 lege in San Francisco, now connected with the University 
 of California, and died some years ago. Thomas Bennett 
 was an Englishman, a man of fine presence, well educated, 
 and a good all-round doctor. He is deceased several years. 
 F. A. Holman was a fine man and a very good surgeon. 
 Coit and Hastings were general practitioners, the latter the 
 author of a " Dissector's Manual." E. S. Cooper was a re- 
 markable man, of decided talent, and very ambitious. He 
 was very aggressive, and started out as a surgeon exclusively. 
 In 1858 he founded the first medical school on the Pacific 
 coast, the Cooper Medical College. From this beginning has 
 grown, greatly owing to the munificence of Dr. L. C. Lane, 
 Dr. Cooper's relative, the present Cooper Medical College 
 and Lane Hospital. Dr. Lane is a very prominent surgeon, 
 and has been such for many years on the Pacific coast, as 
 the successor of Dr. Cooper, who died comparatively a young 
 man many years ago. Dr. Cole is still prominent, particularly 
 as a gynaecologist. Bertody, Gray, Bowie, and Rowell have 
 passed away. Rowell, I think, was Professor of Chemistry 
 in the Cooper school in the early days. He was Broderick's 
 surgeon in the famous duel between him and Judge Terry, 
 when Broderick received his death wound. I remember, the 
 ball struck him in the upper part of the chest, embedded itself 
 in the soft parts, and was extracted the second day. Sepsis, 
 with its usual train of symptoms, followed, and in a few days 
 Broderick passed away. 
 
 Duels were common there in those days, but this one, 
 owing to the prominence of the parties, — one a United States 
 Senator and the other a judge of the State Supreme Court, — 
 created much comment, the cause being disagreement on na- 
 tional politics. 
 
FORTY YEARS IN THE MEDICAL PROEESSION 
 
 McNulty was a very fine man, who is still living in South- 
 ern California. Nuttall is long since deceased. Hammond 
 was an old army surgeon, a man of decided talent, had a fine 
 practice, and I think is still living, retired, out of the city. 
 Stout is, or was recently, living, a very old man. He was a 
 very able man, and one of the best surgeons (mi the coast. 
 
 In the early days San Francisco was a healthy town, and 
 surgical cases did well, owing to the cool and dry climate, 
 sandy nature of the soil, natural drainage, and salt water sur- 
 roundings. Paludal malaria was almost unknown, and 
 zymotic diseases were quite rare. Pulmonary troubles and 
 catarrhal troubles generally were common, and renal disease 
 was very prevalent, this being due to the climatic conditions; 
 the average temperature being about 60° F., the skin did 
 little work, and threw the onus on the kidneys. Free living 
 of the people was an additional factor as to renal troubles. 
 Gunshot wounds were frequent, but machinery accidents rare, 
 as there was so little manufacturing done in the city. Of the 
 forty thousand people, ten per cent, were probably Chinese. 
 Towards the ocean there was little beyond Vallejo Street, 
 and in the opposite direction South Park was the built-up 
 limit. To the west there was little beyond Taylor Street, 
 and the docks were confined between Vallejo and Harrison 
 Streets. The churches and schools and other public buildings, 
 compared with those of to-day, were crude, but served their 
 purpose well, and were a happy leaven in the seething caul- 
 dron of wickedness at that day rampant. The climate then 
 is the climate of to-day : for the strong and vigorous, per- 
 fection; where to merely breathe and exist is perfect bliss; 
 where it is never hot ; where it is never cold ; where the 
 woman never puts away her seal-skin nor the man his top 
 coat; where, if it is too hot in the sun it is too cool in the 
 shade ; where it is pleasanter in winter than it is in summer ; 
 where for six months in the year a windmill is as sure a 
 source of power as a steam-engine; where it is apt to rain 
 any day at any minute for six months in the year, and during 
 the other six months no cloud mars the horizon ; where the 
 
 23 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 north wind holds sway and the sea fog moistens the verdure 
 ahnost nightly, a potent aid to the irrigation constantly 
 needed by all growing plants and forest growth. 
 
 After an absence of thirty-four years I visited San Fran- 
 cisco for the second time, in the spring of 1894. Instead of 
 the discomforts of a sea voyage in an overcrowded ship 
 through the tropics, I crossed the continent in a Pullman car, 
 surrounded by all the luxuries of modern travel. Surprised 
 and enchanted at the growth of the country from the Atlantic 
 seaboard on through the West, we entered California in the 
 Sierra Nevadas, my last recollection of which was racing a 
 storm for shelter more than thirty years before. On through 
 forty miles of snow-sheds, we cross the great mountains, 
 and in two hours or little more from the time we could jump 
 into snow-banks over our heads we could alight from the 
 cars and pick oranges from the trees. Passing down the 
 beautiful Sacramento Valley, through the lovely town where 
 the palm and the olive grow side by side in the open air, on 
 to Oakland, crossing at Benicia in the largest ferry-boat in 
 the world, we come face to face with the modern metropolis 
 of the Pacific. When I had last been in Oakland, it was a 
 mere hamlet ; I found it now a beautiful and prosperous city 
 of one hundred thousand people. Crossing on another mag- 
 nificent ferry-boat, I landed at Market Street, San Francisco. 
 What a change from the passiveness of years before ! Here 
 are extensive buildings for the railroads and ferries, and the 
 rendezvous of probably the first and best system of cable 
 roads in the world. It is wonderful how they move up and 
 down the very steep hills ; some of them a horse can scarcely 
 crawl up, and until one becomes accustomed to it there is 
 great soreness of the muscles of the abdomen and back caused 
 by holding on and exercising muscles not accustomed to 
 action in such a degree as holding on in the cable car causes. 
 A course of massage for vigorous exercise of these muscles 
 as a preliminary to San Francisco cable-car riding would be 
 a proper proceeding. Two cars generally run together, — a 
 motor car, open, and a trailer car, closed. The open car is 
 
 24 
 
FORTY YEARS IN THE MI':i)ICAL PROFESSION 
 
 enticing, but the newcomer should sit in the sun when prac- 
 ticable, and protect the throat, or very annoying colds are 
 sure to follow. There is no better way to get a view of the 
 city than by going over the hills by the numerous cable lines. 
 These lines are already, in a measure, being competed with by 
 electric lines. Some say the hills generally are too abrupt 
 for electric roads. I doubt it. The possibilities of electricity 
 have been by no means reached as a source of motive power 
 in such matters. 
 
 There are now in the city probably three hundred and fifty 
 thousand people, — ten per cent, still Chinese. There are over 
 one hundred and twenty-five miles of paved streets, fifty 
 banks or more, eighty public schools, over three hundred 
 churches, twenty-four parks, about twenty theatres, and 
 thirty hospitals. The annual rain-fall is about twenty-five 
 inches. The mean temperature is about 56. 5 "^ F. ; average 
 maximum temperature, 62.4° ; minimum temperature, 50.7^ ; 
 highest temperature on record, 100° ; lowest, 29° ; clear or 
 partly cloudy days each year, 283 ; cloudy days, 82 ; number 
 of days on which rain falls each year, average, 70. These 
 statistics show an average of twenty years, and are interest- 
 ing in a medical point of view. 
 
 The hotels are among the very finest in the world, and 
 living in them is comparatively cheap. The Palace Hotel — 
 if it has a rival in the world, it is the Waldorf-Astoria, in 
 New York — is a grand monument to the enterprise of Ral- 
 ston and Sharon. Its location, the intersection of Market 
 and Montgomery Streets, is the liveliest place in the city, and 
 the din and confusion there cause one to imagine himself in 
 the very busiest centres of New York or London. House- 
 rents are not high and the necessaries of life are not dear, a 
 contrast to years ago, when I have paid fifty cents for two 
 apples. I believe one can to-day live cheaper and live well in 
 San Francisco than in any other large town in the country. 
 Servants' wages alone are high. At the best hotels you can 
 live on the American plan at a very low rate. Those who know 
 how to live well, I think, prefer the European plan, and have 
 
 25 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 a few choice dishes, well cooked and well served. You may 
 get a thoroughly good breakfast table d'hote for fifty cents 
 and dinner for one dollar. The Palace serves a good table 
 d'hote dinner with wine for one dollar and twenty-five cents. 
 At the restaurants one may imagine himself in Paris. One 
 may breakfast a la fourchette for almost any sum up to one 
 dollar and twenty-five cents, all with wine. The fifty-cent 
 dinner at the French restaurants is really a good one of its 
 kind, with a red or white native ordinary wine. You will get 
 a soup, a fish, an entree, a joint, with vegetables, a salad, a 
 sweet, cheese, coffee and cognac, service and attendance by 
 Frenchmen ; and it is good. 
 
 Of the better California wines, if you want them, you can 
 get a half-bottle of Zinfandel, Riesling, Mont Rouge, or Sau- 
 terne for fifty cents, a good red or white Burgundy for sev- 
 enty-five cents, and native champagne for seventy-five cents. 
 I doubt if true fermented champagne, strange as it may 
 appear, is yet made in California. The foreign wines sell for 
 about the same prices as they do the world over, and the 
 Californian is much given to them, to the exclusion of the 
 native wines. Notwithstanding this, with experience in the 
 fining and refining of the soil, California is bound to become 
 a great wine country. Beer still flourishes there to a greater 
 extent than one would suppose in a wine-producing country. 
 It is the drink of the masses. Wine may be aristocratic. I 
 know of no better reason. This wine business in California 
 is of great interest to the medical profession, and I have no 
 hesitation in recommending medical men to look them up in 
 all relations as to their medical use. 
 
 My excuse here for saying so much about San Francisco 
 and California is that it is properly a subject for physicians 
 to study. So many of our patients ask our advice as to travel 
 for health and recreation, and we cannot know too much of 
 just such matters as I am writing about and propose to write 
 about in this work to give them intelligent advice and intelli- 
 gent help. The markets are fine; the meats are good; the 
 game, fish, fruits, and vegetables are not excelled anywhere, 
 
 26 
 
FORTY YICARS IN Till': MEDICAL PROFESSION 
 
 except that the flavor of all our Eastern fruits and vegetables 
 is superior to that west of the Allegheny Mountains, 1 think. 
 The oysters are a revelation. I pass by the little copi)ery 
 native oysters, which sell for forty cents ])er hundred, while 
 the Eastern oysters sell for about the same price per dozen. 
 They are not successfully propagated in the California waters, 
 but are brought as small ones from the East, transplanted to 
 good beds, and are soon better than, or certainly not inferior 
 to, the best Chesapeake and Delaware oysters. Here we see 
 the good work of the United States Fish Commission. In 
 early days no shad, striped bass, nor catfish were to be seen in 
 California. Now the very finest shad can be gotten every 
 month in the year at reasonable prices. So the striped bass, 
 the catfish, and the carp. The only criticism I heard on the 
 Fish Commission was that they had introduced carp. The 
 fishermen called it a hog, and accused it of destroying the 
 spawn of other more valuable food fish. This may be a libel 
 on the carp, but in my opinion no man need wish to eat it 
 when he can get suckers. 
 
 To-day San Francisco keeps up her well-earned reputation 
 for hospitality. Some of the private residences are among 
 the finest in the world, and are the scenes of lavish entertain- 
 ment. Strange as it may appear, a great many of the finest 
 houses are built of wood, the California red wood ; indeed, 
 the great majority of them. There are probably three rea- 
 sons for this, — expense, healthfulness of the wooden struc- 
 ture, and fear of the effect of earthquakes on the more massive 
 buildings. The San Franciscan will not acknowledge that 
 the latter reason holds true now, but the other two reasons 
 probably do. The dwelling section of San Francisco is a 
 wooden town. 
 
 The fire limits for wooden structures are being curtailed 
 every year, yet very slowly. The red wood is not inflamma- 
 ble, it burns very slowly, and fire in it is easily subdued, yet, 
 with the high winds and dry weather, the fire department 
 must be very efificient to serve the people as well as it does in 
 keeping down destructive conflagrations. It is a grand or- 
 
 27 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 ganization, and owns a half-million of real estate, many steam 
 fire-engines, cisterns for water where necessary, with many 
 horses and men. Seeing it in service, one notes the perfect 
 discipline of men and horses, and absence of hurry and 
 bluster too often seen in such service, and one learns to con- 
 fide in it sincerely when it comes out triumphantly from a 
 roaring fire fanned by a howling gale in a district crowded 
 by frame buildings where rain has not fallen for months. 
 
 Golden Gate Park is the pride of the city, and great reason 
 have the people to be proud of it. It is a great therapeutic 
 factor, doubtless. One thousand acres have already been im- 
 proved, reclaimed from the sand hills, where nothing grew at 
 first but the scrub oaks, and where the sand grass and lupine 
 were planted. It proved better ground than it looked. It 
 was only necessary to haul a little earth and a little long 
 manure and use plenty of water in this alkaline soil, and 
 plant; nature did the rest. The soil looks sterile, if not 
 sterilized, and probably adding soil in small quantity starts 
 up nitrification. 
 
 All nature expands as though struck by the magician's 
 wand. Here the herbage and the arborage and the flora are 
 superb. No description can do them justice. It is a paradise 
 for the weary, the invalid, the horticulturist, and the botanist. 
 The eucalyptus tree {Eucalyptus globulus), by its rapid 
 growth, has aided the authorities much in rapidly developing 
 the park, but I am quite sure as the other trees grow they will 
 have to remove a great many of them, for by its power of 
 absorbing and evaporating moisture you see the baneful effect 
 of the eucalyptus on all surrounding grass and foliage. To 
 some its balsamic odor is agreeable, and it is undoubtedly 
 health-giving, and I trust as many as possible may be spared. 
 The children's playground and houses are monuments of fore- 
 thought and of Mr. Sharon's generosity. They have their 
 nursery, their ponies, their donkeys, all free as air, and there 
 are no signs of " Keep off the Grass." The park is never 
 closed ; policemen patrol it day and night. The conserva- 
 tories are well constructed and the contents admirably classi- 
 
 28 
 
FORTY YEARS IN THE MEDICAE PROFESSION 
 
 fied, with the finest colleclicjii of hej^onias in the world. The 
 museum of natural history has a fine collection, and is well 
 worth a visit, and must prove a great educator. The monu- 
 ments to Hallcck, Rev. Thomas Star King, and Key serve as 
 a beginning, and doubtless many more will appear in time. 
 The aviary is a remarkable exhibition, and only possible in 
 such a climate. It is of wire netting, 300 by 150 by 32 feet. 
 It contains one hundred and fifty species of birds, two thou- 
 sand of them. It is most interesting, and a great educator for 
 all. There is a large wind shelter on Strawberry Hill within 
 the park, where those who drive may stop for the grand view 
 it affords, with shelter from the driving northwesters, so 
 common to the summer -months. The music-stand, the suspen- 
 sion bridge, the deer glen, the buffalo pasture, and Roman 
 bridge all go to complete one of the grandest public pleasure- 
 grounds of the world. Sutro Heights and the Cliff House 
 are resorts much frequented, and although not yet strictly 
 public, they afford additional opportunity for recreation and 
 amusement. 
 
 The Presidio, the old Spanish military post, contains over 
 fifteen hundred acres, and is the present government military 
 post. It is situated in the northwest suburbs, and slopes to 
 the harbor, and is an additional grand breathing space for 
 the people. It overlooks the bay and the other government 
 military posts. Fort Point, Point San Jose, with Alcatraz 
 and Angel Islands. The Presidio has fine grounds well laid 
 out, with shade and ornamental trees and flowers. It is one 
 of the most desirable of all our army posts for officers and 
 men. 
 
 The cemeteries, when compared with those of early days, 
 show well the strides the city has made, and are situated near 
 and around Lone Mountain, which is surmounted by a cross 
 visible from all points. I think this cross was a gift from the 
 late George W. Childs, of Philadelphia. Here are Laurel 
 Hill, Calvary, the Masonic Cemetery, the Odd Fellows' Ceme- 
 tery, and the Chinese Cemetery. In those lovely spots are 
 the remains of many of those who made San Francisco and 
 
 29 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 California what they are, and the mausoleum architecture 
 displayed is worthy of the grandeur of ancient Rome. Here 
 repose the remains of Latham, banker, senator, and governor ; 
 of Larkin, pioneer among pioneers ; of Maxwell, Toland, and 
 Cooper, eminent in medicine ; McAllister, father and son, 
 learned in the law ; Hearst, capitalist and senator ; Broder- 
 ick, pioneer and senator; Babcock, the merchant; Folsom, 
 the soldier; Sharon and Flood, each of whom had gathered 
 riches beyond the dreams of avarice. The remains of these 
 and other great men have been gathered here on the borders 
 of these lovely avenues, and under the shade of the laurel and 
 the oak may their dust forever mingle with the soil of the 
 State they loved so much and served so well ! 
 
 Coming cityward from the park, we pass, on Jackson and 
 Pacific Streets, the beautiful Pacific Heights, the coming 
 part of the town for residences ; where the air is pure, loaded 
 with salt and ozone from the ocean ; where the view is lovely, 
 embracing mountain and sea and landscape combined. Here 
 are costly residences now, the kitchens and workrooms on 
 the main avenue, while the dining-rooms, libraries, and other 
 desirable apartments are in the rear, where, from the rapid 
 descent of the land, the view is unobscured. Down on the 
 water front we see the wharves and docks and the great im- 
 provements resulting from the bulkheading, over which the 
 bitter fight was made many years ago. The torredo has been 
 conquered ; he will not cross a crack in his work, and the 
 built-up pile made by starting with a small four by four and 
 building up with one-inch stuff, and coating with various 
 compositions, has sounded his death knell. 
 
 There is only one thing galling to the American as he looks 
 over the scene, — the general absence of the old clipper ships 
 of the early days and the display of foreign flags on most of 
 the great ships now in the docks and at anchor. The Chinese 
 quarter of the present, growing from the nucleus of years 
 ago, has extended, and taken in parts of the city where 
 formerly were desirable places of residence, particularly on 
 Stockton Street beyond Washington Street. Much of Sac- 
 
 30 
 
FORTY YEARS IN THE MKDICAL PROFESSION 
 
 ramento, Dii Pont, Pacific, Jacksf)n, and Washington Streets 
 is now Chinatown. In a step we go from Christendom to 
 Heathendom, practically from a typical American town to 
 the middle of the Flowery Kingdom. John walks in the 
 middle o^ the street for the same reason he wears his cue, he- 
 cause he did so at home. He eats smoked ducks hecause he 
 did so at home ; for the same reason he gambles and smokes 
 opium. If he is free from any of our own vices and many 
 more, we fail to see it; if he has any virtue unknown to the 
 average Chinaman at home, it is not apparent. He is here, 
 in fact, a heathen among heathen, and, like the leopard, can 
 never change his spots. The Argonauts, the Forty-Niners, 
 keep up the old society, have built a fine hall, and have an 
 abundant capital to insure the endurance of the organization, 
 which extends from father to son, and doubtless the sons will 
 be found ever ready and willing to uphold the honor and dig- 
 nity of the land so thoroughly guarded by their forefathers. 
 Many of the newspapers of the early times still hold sway, 
 reinforced by many others, both able and influential. The 
 Bulletin, a creation from the brain of the martyred King, 
 fertilized by his blood lost in the days of lawlessness and 
 passion, still sheds a brilliant lustre from its pages. The Call 
 yet lives, having grown from a pigmy to a giant. The Ex- 
 aminer and the Chronicle, creations of later days, join the 
 others in upholding the honor and the dignity of the Golden 
 City, whose growth no one can estimate who knew it in its 
 infant days, and whose future we can only imagine, consid- 
 ering its past. We can measure its coming greatness by no 
 human scale, but can only conceive of a mighty town like 
 Atlantis risen from the sea; a creation of the magician's 
 wand, a realization of an Aladdin's tale. 
 
 31 
 
CHAPTER II. 
 
 University of Pennsylvania, Medical Department, i860 — The Buildings 
 and Conveniences for Faculty and Students— The Faculty — The 
 Lectures — The Quiz Classes and Students — University Characters — 
 Outside Teaching — The Course. 
 
 In October, i860, I matriculated in the Medical Depart- 
 ment of the University of Pennsylvania. At that time the 
 buildings were situated on Ninth Street just above Chestnut, 
 where the present United States Post-Office now stands. 
 There were two buildings. The one nearest Chestnut Street 
 was occupied by the Medical Department, and a short dis- 
 tance from it, towards Market Street, was a similar building, 
 occupied by the Department of Arts. A high iron railing 
 enclosed the whole along Ninth Street, and there was no gen- 
 eral outlet to the rear of the buildings. The basement was oc- 
 cupied by the rooms for the Dispensary, Clinics, store-rooms, 
 vat-rooms for cadavers, etc. There were three general lec- 
 ture-rooms, one used by the Professors of Practice, Materia 
 Medica, and Physiology, one entirely by the Professor of 
 Chemistry, and the other by the Professors of Surgery, Ob- 
 stetrics, and Anatomy. There were private rooms for the 
 professors adjoining the lecture-rooms, with a small ward 
 for surgical cases. The upper floor of all was occupied by the 
 dissecting-room, next to Ninth Street, and the opposite room 
 was devoted to the classes in bandaging and practical sur- 
 gery. As to comforts for either students, or even the pro- 
 fessors and their assistants, in the way of bath-rooms, toilet- 
 rooms, or general wash-rooms, there were none worthy of the 
 name. Yet they were in general keeping with such as were 
 furnished students in the better schools and universities of 
 the day. The lecture-rooms were badly lighted by day and 
 by night, and the ventilation was worse. Princeton College 
 
 32 
 
FORTY YEARS IN 'illE MEDICAL PROFESSION 
 
 was no better in the way of such comforts. At that time there 
 was not a decent water-closet connected with the college, and 
 not a bath-room in the whole collection oi college buildings 
 in Princeton. More, there was no way in which a student 
 could get a drop of hot water except by heating it on the 
 stove in his own room, and in the North College, just com- 
 pleted, that was not possible, as it was heated by hot air, with 
 no thought of a bath-room attachment. 
 
 What would college men think nowadays, if they had to 
 do their bathing in individual bath-tubs in their own rooms, 
 as we did who were college men forty years ago? In this, as 
 in other such matters, we behold the evolution of a civiliza- 
 tion, and almost shudder at our very recent release from 
 what may appear now as a near approach to almost savage 
 existence. At the University the benches were hard and un- 
 inviting, and the rooms were, as a rule, crowded. Every 
 one took matters as they came, and good-humoredly, and as 
 the country was just on the eve of the great convulsion of 
 the Civil War, causing great unrest in all matters of govern- 
 ment and finance, no one had as yet dreamed of the great 
 strides and advancements in store in the comparatively near 
 future for the grand old University and her medical school. 
 The head of the faculty at this time, next to Professor Jack- 
 son, both in age and years of service, was Dr. Hugh L. Hodge. 
 He was nearly blind, and excited the sympathy of every one 
 in his lectures in his efforts to make clear his demonstration. 
 Hodge, like all the members of his family, was a great man 
 and undoubtedly one of the foremost obstetricians of his day 
 in any country. Dr. John H. Packard generally assisted him 
 at his lectures, and was in every way more than friend to the 
 old gentleman. In those days gynaecology had made little ad- 
 vancement as a distinct branch of surgery, and an obstetrician 
 rarely took up a knife for anything; and should a case for 
 Caesarean section present itself in his practice, he called in 
 the general surgeon for the work. Indeed, not to have done 
 so would have been looked upon rather as a breach of pro- 
 fessional etiquette. Dr. Hodge had a great reputation as a 
 3 33 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 gynaecologist as gynaecology was understood in those days. 
 He referred most of the evils of the female organization to 
 irritable uterus, and was very successful in the treatment of 
 displacements of that organ with the pessary bearing his name 
 to-day and still so well known to the profession. 
 
 I remember some years since to have been called in by a 
 very aged lady to consult concerning some irritation involving 
 the vagina and adjacent parts. Upon examination I found 
 a mass of granulations, and embedded in it some hard metal- 
 lic-like substance. I questioned the patient, of course, to try 
 to find out the cause of the trouble. She told me Dr. Hodge 
 had treated her for some time more than twenty years before, 
 and she thought he had introduced some instrument. The 
 case was then plain, and I removed the encrusted instrument 
 by cutting it into segments, and her trouble soon subsided. 
 
 While on the subject of pessaries, one case comes to my 
 mind showing the quick resourcefulness of that great sur- 
 geon, the late Richard J. Levis. A professional friend came 
 to Levis in great trouble, saying he had introduced a glass 
 globe as a pessary, and the globe had from some cause been 
 broken into bits ; and how to get it out without mangling his 
 patient he did not know. Levis took in the situation at once, 
 procured some plaster and water, filled the vagina with the 
 mixture of proper consistence, allowed sufficient time for the 
 setting, then removed the cast, glass and all, without doing 
 any injury whatever to the grateful patient. 
 
 The walls of the vagina are very prone to throw out gran- 
 ulations and bury within them any substance which may by 
 its presence offend them. Here is a case illustrating this point 
 and of practical application : Some years since I applied a 
 Goddard pessary to a woman for a complete procidentia uteri, 
 and made her entirely comfortable, as these instruments often 
 do. Unexpectedly I did not see her for some years, when she 
 applied to me to examine the condition of her trouble. Of 
 course these instruments should be removed and thoroughly 
 cleansed, and if necessary renewed at shorter or longer inter- 
 vals. In this case I found the external bars in position, but 
 
 34 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 the cup and part of the stem buried in g-ranulatif>ns, which 
 held the uterus in perfect position. My first thouglit was to 
 cut away the offencHng growth and release the instrument, 
 but on second thought I cut away the stems and then took 
 away about two-thirds of the ring, leaving the other third in 
 the mass, holding the uterus to the vaginal wall. Here was a 
 perfect correction of her trouble. I examined the case, at 
 long intervals, several times. The corrected condition re- 
 mained perfect until she died. 
 
 To return to Professor Hodge. He published a work on 
 diseases of women, according to his views of the matter, and 
 a colossal and standard work on obstetrics. In this labor he 
 was greatly assisted by his son, the late eminent surgeon and 
 cultivated gentleman, H. Lenox Hodge, and, as he himself 
 has said, without the help of his son, on account of his own 
 lack of eyesight, the book would never have been written. 
 
 William Pepper, Sr., father of the late distinguished Pro- 
 fessor William Pepper, Jr., was Professor of the Practice of 
 Medicine, having recently been elected to the chair made 
 vacant by the resignation of Dr. George B. Wood. Dr. 
 Pepper was a compactly built, rather small man. He was 
 quick in his movements and very sprightly and earnest as a 
 lecturer. He was a clear thinker, and his lectures were models 
 of their kind, for in those days the course only lasted about 
 five months, and to condense the immense amount of m'atter 
 to be gone over successfully in that short time required both 
 skill and ability. Dr. Pepper had a great aversion to the 
 use of tobacco, and very properly attributed many ailments 
 and exaggerations of ailments to its abuse. In summing up 
 the causes of the disease he happened to be lecturing upon, we 
 always looked for, as he cast his eyes over the class with a 
 
 knowing nod, " And, gentlemen, the use of tobacco " 
 
 While Dr. Pepper was a most interesting and successful lec- 
 turer, it was in his clinic he excelled. He was a masterly 
 diagnostician, and it was a real treat to hear and see him go 
 through a case before the class. He had a thoroughly edu- 
 cated ear and a wonderful sense of touch, each trained by 
 
 35 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 faithful study and practice under Louis. He labored under 
 great disadvantages, from failing health, almost from the 
 time he connected himself with the University. He made a 
 brave and manly fight to the end, and when he died the Uni- 
 versity lost a devoted teacher and the profession in America 
 one of the ablest of the many very bright men who at that 
 period adorned it. William Pepper, Jr., who has recently 
 died prematurely, was a worthy son of a worthy sire. As a 
 young man in hospital life in Philadelphia I knew him well, 
 as I did his brother George, another bright man, who died 
 just on the threshold of a brilliant career as an obstetrician. 
 William Pepper, Jr., was a man of fair physique, pleasing 
 address, and polished manners. He had naturally a wonder- 
 ful gift of language and facility of expression, in both of 
 which he expanded as he grew in years and practice. No 
 doubt he had exceptional opportunities in his chosen profes- 
 sion at the start, but no man ever took greater advantages of 
 his opportunities or used them more successfully. Not only 
 was he successful beyond measure in all that pertained to his 
 life as a physician and as Professor of Medicine in the Uni- 
 versity of Pennsylvania, but he did wonderful work in build- 
 ing up and developing all of the great schools connected with 
 the University, and the grandeur of his work in this direction 
 is well worthy of a lasting remembrance. Indeed, the great 
 institution of to-day may, with no slight to other men, be 
 said to be at once his work, his monument, and almost his 
 tomb, for doubtless he died of old age at fifty-five, from over- 
 work and over-zeal, both as a physician and as a citizen of 
 Philadelphia, the city of his birth, the town he loved so well 
 and did so much to honor and adorn. 
 
 The venerable Samuel Jackson was the Professor of Physi- 
 ology and Institutes of Medicine. Jackson was a remarkable 
 man, and probably might be called the medical philosopher 
 of his day among the medical men of America. He was a 
 lovely old gentleman, short and stout, and at this time un- 
 able to walk without assistance. I cannot say much for his 
 didactic course on physiology, for his lack of arrangement 
 
 36 
 
FORTY YEARS IN Tin<: MICDICAF. I'Rf^I'KSSIOiN 
 
 and common method rendered it ini])ossil)le tf) a])Sorl) me- 
 thodic knowledge from his non-metho(hc methods. Many 
 of his lectures were rare treats, and the mf)st interesting were 
 when he started on some subject entirely germruie to his 
 course, and then accidentally branched out on some intercur- 
 rent fact that came up by accident. He was fond of bringing 
 up facts, clinical facts, from his large experience in practice, 
 and often charmed his listeners, through the whole hour de- 
 voted to his lecture, by a dissertation on the philosophy of 
 dreams, or the localization of cerebral functions, or some 
 equally interesting subject. The old gentleman was fortu- 
 nately easy in his examinations for degrees. I remember the 
 subject of my own thesis. The first question he asked was, 
 what was the subject of my essay? After I had told him he 
 launched forth and gave a most exhaustive and able discourse 
 on the subject, making me feel, I remember at the time, that 
 I had known very little before. This took some time; then 
 he asked me one or two trifling questions, said, in a very 
 complimentary way, he should like very much to read what I 
 had written, that he did not feel very w^ell that morning, and 
 politely said good-by. 
 
 Dr. Francis Gurney Smith succeeded Dr. Jackson in the 
 chair of Physiology. He was a rather large, fine-looking 
 man, of fine manners and address, and a captivating lecturer, 
 one of the very best among the faculty. The course then 
 was a very simple one, — about three didactic lectures a week, 
 with absolutely no laboratory or experimental work on the 
 part of either teacher or student. Dr. Smith usually wound 
 up his course each winter with a special lecture on "Life and 
 Death." It was beautifully written and well delivered, and 
 did much to leave a good impression of his abilities among 
 the students. Dr. Smith died a comparatively young man, 
 in the midst of his work and well-earned fame. The diasrno- 
 sis of his last illness had a pathetic sadness about it. and 
 shows well the protean forms of renal disease, and how re- 
 lentlessly and stealthily it often creeps upon us. He had not 
 deemed himself much out of health, and had taken for some 
 
 37 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 reason a specimen of his own urine to compare with a known 
 diseased specimen, to exhibit before some students. He had 
 shown albumin as he had expected to find it in the diseased 
 specimen, both by Heher's test and by heat. When he went 
 to show the different reaction in his own heaUhy urine, he 
 was horrified to find the albumin appearing there. The reali- 
 zation appeared to crush him, and ever after until his decease 
 he appeared far from well. 
 
 Robert E. Rogers was Professor of Chemistry. He was a 
 fine lecturer, but probably not so brilliant a man as his 
 brother, who had preceded him in the same chair. He had 
 a good apparatus at the University, and was, as a rule, very 
 successful in his experiments before the class. He was the 
 Dean of the Faculty, and thus saw much of the students, and 
 was always personally popular with them. Several years 
 after this Dr. Rogers, who was much given to experimenta- 
 tion with mechanical matters, lost his arm in a washing- or 
 wringing-machine in the West Philadelphia Military Hos- 
 pital. This was a fearful blow to him, which, together with 
 domestic affliction, greatly marred his later life. For reasons 
 best known to himself, he left the University and accepted 
 the proffered Professorship of Chemistry in the Jefferson 
 school, which position he filled satisfactorily for a number of 
 years before his death. 
 
 Henry H. Smith, a tall, commanding, very handsome man, 
 was Professor of Surgery. Dr. Smith had been a private 
 pupil of the late Professor William E. Horner, the great 
 anatomist of his day, and afterwards married his daughter. 
 He was a good operator, but there was neither the brilliancy 
 nor the blood in the surgical amphitheatre of the University 
 of that day, such as one saw in the Jefferson arena during 
 the palmy days of Pancoast and Gross. Dr. Smith was a 
 careful and good teacher, and in his clinics one saw practice 
 as it comes to us every day, and from which, after all, the 
 pupil absorbs his very best lessons. 
 
 Joseph Carson was the Professor of Materia Medica and 
 Pharmacy. He was a lovable, pleasant gentleman, and well 
 
 38 
 
FORTY YEARS IN THE MEDICAL I'ROEESSION 
 
 grounded for the work in his special branch. To many stu- 
 dents materia medica was a dry subject; this was much owing 
 to insufficiency in their preliminary training in clicmistry and 
 botany. Dr. Carson had prepared a syllabus of the subject, 
 or rather a synopsis, which was a help to his students. He 
 was fond of a joke, but, strange to say, he could never suc- 
 cessfully get off one; he wanted to laugh himself, and laughed 
 too soon. The joke nearly always stuck in his throat, and 
 left him disconcerted and embarrassed. One of his choicest 
 was his mercury joke, — hydrargyri chloridum mite and hy- 
 drargyri chloridum corrosivum, " but, gentlemen, I assure 
 you there is a mite difference between the two substances." 
 
 Joseph Leidy was Professor of Anatomy. Leidy was a 
 famous man. In all that pertains to nature, whoever was 
 second, Leidy was surely first. His reputation was world- 
 wide, and when he died the whole world lost one of her 
 brightest and greatest men. Probably in no place of all places 
 of honor he held, did he appear to less advantage than as a 
 didactic lecturer to students on anatomy. Anyhow, the di- 
 dactic lecture has had its day. At the present time it is no 
 way to teach medicine, and is fast losing ground, as it should, 
 and soon I trust we shall hear it no more in the halls of medi- 
 cal science. As a student I learned much more in the quiz 
 than I ever learned from didactic teaching. It has been ever 
 so, and will be ever so. Let us empty the cerebral blood- 
 vessels of didactic instruction ; let us eliminate its toxines and 
 come to rational proper methods of teaching. There was 
 little spice in his talk, and he invariably impressed me as one 
 who was lecturing as a means by which to live, and not as 
 one who lived to lecture. He was no surgeon, and applied 
 anatomy had no place in his teachings, yet the acknowledged 
 greatness of the man inspired his listeners, for whatever word 
 Joseph Leidy uttered in a scientific atmosphere could but in- 
 spire his hearers. He generally told of his experience in prac- 
 tice, and limited it to one case. He had opened an office soon 
 after graduating, when a w^oman came in with her child with 
 a grain of corn in its ear. " Well, gentlemen," he would ask, 
 
 39 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 " did I hurry ? Was there an anatomical reason for hurry ? 
 No; remember, gentlemen, the corn could not get into the 
 child's brain, as the mother feared, but I feared it might drop 
 out without my assistance before I got my dollar." Here 
 was applied anatomy for you, anyhow, but Leidy never gave 
 us much more. This mere sketch does little justice to so 
 remarkable a man. Dr. William Hunt's memoir of Leidy is 
 full and most interesting, and should be read by all who can 
 admire the genius and brilliancy of this unassuming, quiet, 
 modest gentleman, who died when the world needed more 
 than ever his great talents and indefatigable industry. 
 
 William Hunt was Demonstrator of Anatomy. No better 
 man ever lived than William Hunt. Bright, genial, pains- 
 taking, and industrious, he made a good demonstrator of 
 anatomy and successfully filled the position for a number of 
 years. He was a good practical anatomist, and his lectures 
 on surgical anatomy were among the best delivered in Phila- 
 delphia in his day. He was made surgeon at the Pennsylva- 
 nia Hospital in the early part of his career, and held the place 
 up to the time of his death. The vast material available at 
 this hospital was a great opportunity for any man in surgery, 
 and Hunt made good use of it. He was conservative and 
 non-aggressive, but he had wonderfully good judgment, and 
 probably no one was better ecjuipped than Hunt for passing 
 upon the propriety or non-propriety of an operation. His 
 nature was most kindly, and he was always ready with a joke 
 or a good story applicable to the environment. Among his 
 stories, two of the best were McMullen's nose and the stone 
 case. As I remember the stone case, when he was first made 
 surgeon at the Pennsylvania Hospital he found a little boy 
 had been admitted to his ward who had stone in the bladder. 
 This was a great find, as stone cases were considered in those 
 days among the most desirable for a show clinic. Hunt had 
 arranged to operate on the coming Saturday. About the time 
 the patient was ready for the ether previous to being taken 
 into the amphitheatre, the father appeared and asked for an 
 interview with the surgeon. " Now, doctor, you are a young- 
 
 40 
 
FORTY YEARS IN 'IMfK MI':I)IC:AL PROF-ICSSION 
 
 looking- man. Did you ever in your life do an operation of 
 this kind?" Hunt said he was completely taken aback, but 
 soon recovered himself and promptly answered, " No; but 1 
 consider myself entirely f|ualified to do the operation, and 
 promise to do all in my power to help your boy." The father 
 answered, " Well, doctor, I think I will take him to an older 
 man." And then and there he made preparation to remove 
 the lad from the institution, and did so. Hunt went before 
 the class and unreservedly told the whole story as it had hap- 
 pened, adding-, in his droll manner, " Gentlemen, I would not 
 tell a lie, no, not even for a stone case." Personally I was 
 greatly attached to Dr. Hunt; he was one of my preceptors 
 and a good and kind friend in my early life ; and it is a mel- 
 ancholy pleasure to me to drop a tear upon his tomb and place 
 a fragrant flower upon his grave. 
 
 D. Hayes Agnew succeeded Dr. Hunt as Demonstrator of 
 Anatomy at the University. Every one knows who Dr. 
 Agnew was, — one of the grandest of men and one of the 
 greatest of surgeons. As a practical anatomist he had no 
 superior, and as a teacher of anatomy he was wonderfully apt 
 and successful. Being botli anatomist and surgeon, he made 
 his lectures inviting on vvdiat students have generally consid- 
 ered dry matter, by bringing in regional and applied anatomy, 
 and his school in the rickety old building on what is now 
 Ludlow Street, back of where the old University stood, is 
 well remembered by many men still living who were fortunate 
 enough to get the benefit of his teachings. Agnew took a 
 great interest in young men, and was as kind and afifable to 
 the tyro as to the veteran in the profession, and he carried 
 this kindly manner and affability into his professional life as 
 a consultant, and greatly to these kindly traits, strengthened, 
 of course, by his surpassing ability as a surgeon, did he owe 
 the fact of his enormous consultation practice, extending to a 
 majority of such cases, perhaps, happening at the height of 
 his busy life, in the States of Pennsylvania, New Jersey, and 
 Delaware. No thought or look ever escaped him which could 
 be construed as an effort to deteriorate a professional brother 
 
 41 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 in a case with him. He always left his co-consultant with the 
 feeling- that he was his equal, and every man who had him 
 once wanted him again. All great surgeons do not act as 
 Agnew did, either towards students or towards those who call 
 them in as advisers, and such men sooner or later suffer both 
 in lack of clients and admirers. Agnew was a constant and 
 unceasing worker, from the time he came from his vocation 
 as a country practitioner, all through the days of his obscu- 
 rity in his dingy dissecting garrets in the city, up to almost 
 the very hour of his death. His literary work will long re- 
 main a monument to his memory, both in his great volumes 
 on surgery and in his other books and monographs. He took 
 little recreation, and was little versed in the ways and frivoli- 
 ties of the world. He was in religion a zealous Presbyterian, 
 and in the church he found his amusement and relaxation 
 from his weary toil, rather than in social pleasures. I doubt 
 if he even went to the theatre, possibly had never even seen a 
 circus. He, indeed, knew nothing but work. Thousands got 
 the benefit of his self-denial, and when he died the world lost 
 one of its grandest, greatest, and best of men. 
 
 There were several quiz classes at the University during 
 the later days of its Ninth Street existence which did good 
 work for the students, and were particularly of advantage, 
 for a majority rushed through in the two years' course then 
 allowable rather than take the three years' term. Many men 
 doubtless made their final examinations successful only by 
 aid of the quiz, and, besides, the quiz masters were nearer the 
 students than the professors, and gave them a feeling of con- 
 fidence, a feeling that they had some friend to turn to in their 
 hour of trial. Morris, Boiling, and Darby had a large quiz 
 in rooms at Ninth and Chestnut Streets, which afterwards 
 became Morris, Boiling, and Hodge, and later. Boiling, Hutch- 
 inson, and Hodge. Levick, Hunt, and Penrose had a large 
 and most successful quiz down Jayne Street below Ninth, 
 opposite the entrance to the Medical Department, and back 
 of Baity Sower's well-known saloon. The late Dr. Bishop, a 
 genial good man, and the late eminent Joseph Janvier Wood- 
 
 42 
 
FORTY YEARS IN 'rillC MIODJCAL I'J<()J' ICSSION 
 
 ward, who did such good work in the mcchcal history of the 
 late Civil War, had also a large (jiiiz class. The present emi- 
 nent University ])rofessors, Tyson and Wood, with the late 
 Professor Pepper, had a very successful class, and another 
 was Black, Boardman, and Woods. 
 
 Janitor Price was a genial man, who took charge of the 
 matriculating hooks and gave advice to the students from a 
 distance in the little office to the right of the general entrance, 
 and was afterwards succeeded hy William Salvador, who was 
 promoted from the charge of the surgical ward connected 
 with the surgical clinic. Salvador is still connected with the 
 University. 
 
 Old John Brown, good old John Brown, was a kindly old 
 man in charge of the rooms and belongings of the Professor 
 of Surgery, and janitor of the bandaging-room. The noto- 
 riety attaching to John was the long time he had been con- 
 nected with the University Medical School. At that time, 
 1863, he had been there, I think, about fifty years, having 
 served Professors Smith, Gibson, and probably far into the 
 time of Physick. 
 
 Of all the minor characters about the University, Nash, 
 the janitor of the dissecting-rooms, was probably the most 
 unique and the longest to be remembered. Imagine a very 
 tall, lanky man, with arms too long for his body, with a halt 
 in his gait which compelled him to drag his limb, giving him 
 a compound gait, a gait between that of a Jackey just ashore 
 from a long cruise, and constantly hitching up his trousers, 
 and that of a man learning to walk with an artificial limb 
 above the knee. Nash had all these movements in his walk : 
 he jerked up behind, described an outward semicircle, and 
 then planted his foot with a flop at each step. He was pock- 
 marked, had a small, restless gray eye, a voice with a squeak 
 and a wheeze which appeared to come from his boots. He 
 had an intimate acquaintance with all the dealers in subjects 
 within many miles of Philadelphia, was well up in preparing 
 them for dissection, always abused the hospital doctors as 
 being the cause, through their post-mortems, of the non-suc- 
 
 43 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 eess of his arterial injections, — and, as a rule, these never 
 were successful with him, — got up skeletons for sale to the 
 students, mixing his cuneiforms and pisiforms in a way. as 
 Hunt once said, sure to cause trouble when the great reckon- 
 ing to all men should come, was fond of rum, cursed like an 
 army corporal, swore by Dr. Leidy, and looked like the devil, 
 as imagined by man. Peace to his ashes. 
 
 There was another character about the University at that 
 time, a student from North Carolina or one of the Southern 
 States, who to me is rather a memory than a reality, and 
 whose name I have forgotten. He was a true wit and a wily, 
 mischievous wag, up to all kinds of pranks, and, withal, a 
 good student and a jolly good fellow. He left his name em- 
 balmed in the University as the author of the Turpentine song. 
 Through the works and suggestions of that eminent profes- 
 sor, George B. Wood, the oil of turpentine was looked upon 
 as a sovereign remedy in many ailments of mankind, and the 
 luckless being in those days with typhoid fever who escaped 
 a turpentine julep every few hours might be looked upon as a 
 freak in nature. I wish I had a copy of the song. I don't 
 know that it is in existence. It referred to some unfortunate 
 imaginary girl in a paroxysm of hysteria. All I remember is 
 the refrain, — 
 
 " Turpentine, Turpentine, 
 We poured cold water down her spine; 
 We gave her oil of turpentine; 
 Turpentine, Turpentine." 
 
 With emphasis and high inflection on the " tine" in the last 
 line. 
 
 The little lecture-room on Ludlow Street back of St. Ste- 
 phen's Church was a favorite lecture-room for many men 
 who had been, and are now, prominent in medicine in Phila- 
 delphia. Dr. R. A. F, Penrose, Emeritus Professor of Ob- 
 stetrics and Diseases of Women and Children in the Uni- 
 versity, delivered his well-attended and popular courses of 
 lectures there as an adjunct course to the regular University 
 course. These lectures continued each winter until Dr. Pen- 
 
 44 
 
FORTY YEARS IN TIIIC MEDICAL PROFESSION 
 
 rose was elected to succeed Dr. Hodge. Penrose was doubt- 
 less the best teacher of his day of the art of obstetrics. None 
 who ever heard him will ever forget his (Ad friend Mrs. 
 O'Flaherty and the lifelike demonstrations he gave with her 
 as subject. Mrs. O'Flaherty under Penrose's faithful care 
 and assistance probably had more children than any other 
 woman who ever lived, and every conceivable operation that 
 could be performed upon a lying-in woman did Mrs. O'Fla- 
 herty undergo time and again. She served her day and gen- 
 eration well, and many of her sex owe her a debt of gratitude 
 for the help she gave in the education of many of the great 
 obstetricians of the present time. The obstetrical hat was 
 another inseparable part of the equipment of Penrose's school. 
 Now and again an advanced student was given a case to at- 
 tend in the poor district. On these occasions the wearing of 
 the obstetrical hat was compulsory, for no woman would 
 respect any doctor in those days under such conditions wdio 
 did not wear a high hat. Dr. Penrose still lives, retired, en- 
 joying a well-earned rest, respected and admired by the thou- 
 sands he has served so well both as teacher and physician. 
 
 In the same little lecture-room Dr. S. Weir Mitchell now^ 
 and again gave a lecture on some subject, generally connected 
 with physiology in an experimental way, and it is only neces- 
 sary to say that Mitchell gave a lecture, to say that it was 
 bright, educating, and entertaining. At that time he was 
 carrying on his great work on snake-poisons, and these mat- 
 ters were the subjects of some of his lectures. Fortunately 
 for the world, this brilliant man still lives, physician, novelist, 
 and poet, his work ever enduring, his talents ever increasing. 
 May he continue to live many years, and pass the evening of 
 his life as becomes the accomplished and cultivated gentleman 
 that he is. Before leaving the University it may be well to 
 take a survey of the course of lectures delivered there, and 
 the work done by the students previous to applying for their 
 degree, and compare it somewhat with the work now done in 
 the same institution by men before they take their degree. I 
 think this will show the great changes that have taken place 
 
 45 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 in medical education and the great advantages men of the 
 present day have over those of forty years ago. Compare 
 these changes with the advances in practice, and they only 
 show that one has necessarily kept pace with the other. Com- 
 pare the changes and advances in both medical education and 
 medical practice with the changes and advances in all matters 
 pertaining to human change and human progress, and it only 
 shows the great advancement of all things towards a higher 
 civilization, — the evolution of man towards the perfect type. 
 The completion of a two years' course allowed a student to 
 present himself for graduation, and very few were they who 
 did not accept the opportunity, it having been taken for 
 granted that they had been studying medicine in all for three 
 years. 
 
 The following may be taken as a typical day of routine at 
 the school: Nine o'clock a.m., quiz class; ten a.m., lecture 
 by the professor of chemistry; eleven a.m., lecture by the 
 professor of anatomy; twelve m., lecture by the professor of 
 practice; one p.m., lecture by the professor of surgery; three 
 P.M., lecture by the professor of materia medica; four p.m., 
 lecture by the professor of obstetrics; seven p.m., lecture by 
 the demonstrator of anatoni)^; eight to ten p.m., dissecting 
 or practical surgery. There were also dispensary clinics held 
 several hours each week in the University Dispensary De- 
 partment which students were invited to attend. Wednes- 
 days and Saturdays were clinic days at the University and at 
 the hospitals, — ten a.m. to twelve m. at the hospitals, and 
 from twelve m. to two p.m. at the University, one hour each 
 of medicine and surgery, respectively. These duties, together 
 with a few outside lectures on anatomy and obstetrics, com- 
 prised the whole course, and well it did, for the students were 
 pressed almost beyond endurance if they worked and were 
 conscientious. The fault was with the system, the cramming 
 system, and the course too short even for that. There was 
 no practical work in chemistry, none in histology; pathology 
 was taken little thought of, and I don't remember even once 
 looking through a microscope as a part of my course at the 
 
 46 
 
FORTY YEARS IN T[IIL MEDICAL PROFESSION 
 
 University; all of this iKjtwithstanding the work then re- 
 cently (lone by Virchow in pathological anatomy and the whis- 
 perings of the cell doctrine, the onmis cellula e cellula oi this 
 wonderful man. 
 
 Turn to the course of studies for the degree of Medicine 
 to-day and see the change. It is apparent at once what makes 
 this change possible, — the compulsory course of four years, 
 and this is scarcely sufficient. The classes are divided into 
 sections, and the mere didactic lectures in the general course 
 are fast becoming the least essential part of the curriculum. 
 The dissecting and practical surgery classes are carried on 
 about as in the olden times. The dissecting done by students 
 even at this day is sufficient to give them a practical insight 
 into the rudiments of the work only. To become a good 
 practical anatomist, a man must pass many midnight hours 
 over the cadaver after he has passed from the halls of his 
 alma mater. 
 
 To-day the student takes up in their order, with a fair 
 amount of time devoted to each, and with special instructors, 
 practical chemistry, practical biology, general pathology, nor- 
 mal histology, practical pharmacy, practical physiology, 
 demonstrations in morbid anatomy, autopsies, bedside teach- 
 ing, with practical work in dermatology, obstetrics, and such 
 like work. A man coming out who has faithfully followed 
 his work and taken proper advantage of such a course should 
 at least be in condition to commence to learn to be a doctor. 
 
 47 
 
CHAPTER III. 
 
 The Jefferson Medical College, Philadelphia — The Faculty — Joseph Pan- 
 coast and James Syme — S. D. Gross — The Tone of the Profession in 
 Philadelphia — Clinics — Hip-Joint Cases — Clinical Lecturers in Phila- 
 delphia — The Atlees and other Great Men — Professional Methods — 
 Trained Nurses — The Philadelphia Hospital, Blockley, in the Early 
 Sixties — Typhus Fever. 
 
 Four decades ago the Jefferson Medical College in Phila- 
 delphia had a larger class than the University, and a faculty 
 not surpassed in ability by any in the country. Such great 
 men as Charles D. Meigs, Franklin Bache, John K. Mitchell, 
 Robley Dunglison, Thomas D. Mutter, and others had about 
 closed their long services to the institution, and had been suc- 
 ceeded by Samuel D. Gross, Ellerslie Wallace, J. Aitken 
 Meigs, and S. Henry Dickson. The two great and shining 
 stars of this faculty were Joseph Pancoast and Samuel D. 
 Gross. The former, professor of anatomy, and the latter of 
 surgery. Pancoast was a thorough practical anatomist, his 
 knowledge gained from hard unceasing practical work. As 
 a practical surgeon he was undoubtedly one of the greatest 
 that ever lived. At that day he had an enormous and lucra- 
 tive practice, and did most of the consultation work in the 
 States of Pennsylvania, New Jersey, and Delaware, just as 
 Agnew did at a later day. Pancoast was a large, thick-set 
 man, with a good deal of manner, a kindly manner, which at 
 times appeared forced. His hand, that organ which did so 
 much for him and for humanity, was large, heavy, and thick, 
 with immense blunt fingers; any other than a hand you 
 would look upon as facile and dexterous almost beyond belief. 
 The facility with which he cut for stone was a revelation. He 
 was fond of the bilateral operation in proper cases, and he 
 was unapproachable in this method. He could do a robust 
 
FORTY YEARS IN THE MEI>ICAL PROFESSION 
 
 Operation, as a hip-joint, and pass with j^raccful case t(j a case 
 of cataract and remove tiie lens witli all the skill and confi- 
 dence of a Bowman. It was in practical work as a surgeon 
 that Pancoast excelled. It was wonderful how he could use 
 those great blunt fingers. They appeared to take on any shape 
 he chose to give them ; they could turn and twist and reach 
 anywhere. He had a telescopic eye, the artistic touch of a 
 Levis, the precision and confidence of an Agnew, with all the 
 grace and rapidity of a Morton. He had all these gifts and 
 even more. He did little on the literary side of the profes- 
 sion. He was an impressive-looking man, and had a very 
 impressive manner in clinic. His audience was always en 
 rapport with the man, and his patients looked upon him as 
 next to divine. Should I be asked to name the two greatest 
 operating surgeons of that day, I think, without deteriorating 
 others, I should name Joseph Pancoast, of Philadelphia, and 
 James Syme, of Edinburgh. Should I be asked to name the 
 one greatest, I should name Joseph Pancoast, of Philadelphia. 
 The mention of Pancoast's name naturally brings up the 
 name of his great colleague Gross. Samuel David Gross was 
 the Professor of Surgery, and was an emperor among men. 
 He would have been a great man in any calling, and nothing 
 I can say here can add to his fame, for I doubt if any name 
 in the profession has had more written about it in laudation 
 than the name of Samuel D. Gross. I knew him well, was his 
 resident at Blockley, have seen him under many conditions 
 and under many circumstances, and under all these conditions 
 and under all these circumstances he was the same great man. 
 Gross's methods were in advance of the methods of the day 
 in many matters. Before an amputation he always made us 
 raise the limb and drain the superficial veins by rubbing, and 
 then would apply a bandage, much the method used by Es- 
 march at a later day, and onl}' lacking the elastic bandage, 
 the ordinary tourniquet taking the place of Esmarch's elastic 
 one. I think he paid more attention to cleanliness in his dress- 
 ings than most of the surgeons at that time, and insisted on a 
 nearer aseptic condition than others, far as it was removed 
 4 49 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 from the asepsis demanded to-day. He also paid more atten- 
 tion to drainage of wounds than did most of his colleagues. 
 As a diagnostician he was very correct, and his vast store of 
 experience served him well in this direction. As a writer and 
 author he was one of the greatest the profession has ever pro- 
 duced, and his great work on general surgery will ever stand 
 as a monument to his memory. In personal appearance Gross 
 was an imposing-looking man, and from pictures handed 
 down to us I should imagine there was a strong resemblance 
 in him to the great John Hunter, his great admiration, and 
 whose biographer he was. In pathology Gross was far ahead 
 of most of his contemporaries. All were fearfully lacking 
 as compared with our modern workers, but Gross was a 
 leader, a close student of pathology, as well as a writer and 
 teacher. 
 
 Robley Dunglison was a remarkable man and filled the 
 chair of Physiology with ability. As an author he is well 
 known, and in his great work, Dunglison's Medical Diction- 
 ary, has left a legacy to the profession which makes it greatly 
 his debtor. J. Aitken Meigs, his successor, long since de- 
 ceased, was a painstaking man, and had a world-wide reputa- 
 tion for his special work. 
 
 Dr. Ellerslie Wallace served acceptably in the chair of 
 Obstetrics, and often in his lectures gave vivid pictures of the 
 accidents that may come to us in obstetric practice. 
 
 John Barclay Biddle, about 1865, was made Professor of 
 Materia Medica and Therapeutics, served the school success- 
 fully for a number of years, and was noted as an author of 
 text-books of much merit. 
 
 I have always been an admirer of the high tone of the pro- 
 fession of medicine in Philadelphia. I have travelled a good 
 deal over the world, I have observed the profession critically 
 in many places, and in no country, in no city, in no town, 
 have I ever found more true gentlemanly courtesy between 
 doctors, more true genuine ability in the ranks of the profes- 
 sion, or a higher tone in all matters germane to the great 
 calling we have the honor to follow. 
 
 so 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 The great hospital clinics of the decade between i860 and 
 1870 were held at the Pennsylvania Hospital, at the i'hila- 
 delphia Hospital, Blockley, and at the University and Jeffer- 
 son schools. At the University Henry H. Smith held the 
 surgical clinic, and William Pepper, Sr., the medical clinic. 
 At the Jefferson, Gross and Pancoast held the surgical clinic, 
 of course, and Dickson the medical. At the Pennsylvania 
 Hospital there were many bright men and good teachers. 
 There were Pancoast, George W. Norris, William Hunt, 
 Thomas G. Morton, and Agnew as surgeons; W. W. Ger- 
 hard, J. Forsyth Meigs, Da Costa, Levick, and others in 
 medicine. At Blockley there were Samuel D. Gross, Agnew, 
 Levis, Maury, Lodge, Kenderdine, and others in surgery; 
 Da Costa, Tutt, Zeigler, and others in medicine ; and R. A. F, 
 Penrose and Duer in o1)stetrics. 
 
 The great operations for show clinics of that day were 
 stone in the bladder, the tying of the larger blood-vessels, 
 amputation at the hip- joint, and tumors. I remember well 
 three amputations at the hip-joint by the three great sur- 
 geons, Joseph Pancoast, Samuel D. Gross, and D. Hayes 
 Agnew. Pancoast's was the first case, that of a middle-aged 
 woman for a sarcomatous growth of the thigh. It took 
 place in the amphitheatre of the Jefferson clinic. There was 
 a large audience present of physicians and students, and S. 
 D. Gross assisted at the operation. The whole scene was 
 dramatic. Both Gross and Pancoast had something to say. 
 Pancoast's address was quite pathetic: he spoke of the poor 
 woman, the gravity of the operation and its uncertain ending 
 for the patient, said she had seen her clergyman, had had the 
 last rites of her church, and trusted herself to her surgeon 
 and to her God. After the ether had been administered, 
 which was done after the preliminary examination and ex- 
 planation of the case had been gone through with, the abdomi- 
 nal tourniquet was applied by Pancoast himself. He spoke 
 of its uses, and said, " Gentlemen, there zvill be no hemor- 
 rhage." He then took his place, with nothing but a large 
 scalpel in his hand. Gross stood by him, and Maury had 
 
 51 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 charge of the limb. " Now, gentlemen, are we all ready? 
 Maury, you are a good fellow. I depend on you; when I 
 say lift, you lift; when I say lower, you lower; when I say 
 right, move the limb to the right; and left, move to the left." 
 He commenced by making first an anterior skin-flap, then a 
 similar posterior one, then a circular of the muscles, com- 
 pleting the operation by dislodging the head of the femur, 
 without once stopping or laying down the knife. There was 
 no bleeding, and the securing of the vessels and the dressings 
 completed the brilliant operation. The patient made a good 
 and rapid recovery. 
 
 Not long after Pancoast's operation. Gross had a similar 
 one in the same amphitheatre. This case was a man with a 
 sarcoma of the thigh of rapid growth. It was near the open- 
 ing of the session, and was made a grand occasion to give 
 eclat to the school. Pancoast was there, grand and imposing. 
 He said, " Gentlemen, Professor Gross is the hero of this 
 occasion, but while he is arranging his preliminaries I will 
 do a little operation to put in the time." He then removed a 
 tumor from the parotid region in a man, and did it gracefully, 
 rapidly, and successfully. Then came Gross's turn. His case 
 was that of a man of middle age, with good antecedents. 
 Pancoast was near, and his regular assistant, Maury. Gross 
 ordered the limb raised at right angles with the body. Then 
 he massaged the limb to drain it of its blood, then had it 
 bandaged as high as possible, not to interfere with his work. 
 He then, with Pancoast's assistance, applied the abdominal 
 tourniquet. He next took up a large scalpel and made, first, 
 an anterior skin-flap, then a posterior one; next he dropped 
 the scalpel and took up a catling of medium size, made short 
 anterior and posterior flaps of the muscles, and completed 
 the operation by disarticulating the head of the bone with the 
 same knife. There was no hemorrhage. These two cases 
 show the great success of the abdominal tourniquet, with no 
 after ill effect. The vessels were soon tied off, the flaps 
 stitched, with the additional support of a long needle, proba- 
 bly five inches long, run through, then across several inches, 
 
 52 
 
FORTY YEARS IN TITE MEDICAL PROFESSION 
 
 and through again. The (h-cssings and bandages completed 
 the operation, most beautifully and thoroughly done, 
 
 I saw something of the after-treatment of this case with 
 Maury. There were no soiled towels or dressings lying 
 around, I assure you, when the old gentleman was expected. 
 The man made a good recovery. 
 
 The next case was Agnew's, at the clinic of the Pennsyl- 
 vania Hospital. I think Pancoast was in Europe then, but 
 Gross and many of the other surgeons of the city were on 
 hand. This case was an elderly man who had been to some 
 extent a drinker. His vessels were somewhat hardened, 
 which made the case a little unpromising. It also was a case 
 of sarcoma, and was no doubt an operable one. The day 
 before, Agnew had laid out the line of his incisions for the 
 flaps by tracing them with a dampened stick of silver nitrate 
 on the skin. He had the limb raised at right angles to the 
 body and massaged, to empty the vessels, and applied a band- 
 age. This was particularly well here, for there were some 
 varicose veins below the knee. Next he applied the abdomi- 
 nal tourniquet, as was done in the other cases. When e\-ery- 
 thing was ready, he took a large scalpel in his hand. Agnew 
 was ambidextrous, and it made no difference to him which 
 he used. He made his skin-flaps anteriorly and posteriorly, 
 following the lines already laid out. These finished, he 
 opened the sheath of the femoral vessels and tied both artery 
 and vein ; then with a catling he completed the operation by 
 making short anterior and posterior ilaps of the muscles, and 
 lastly disarticulated the bone. There was no hemorrhage. 
 The operation was completed by tying off the vessels remain- 
 ing, stitching the flaps, and applying the dressings. The man 
 did well until about the tenth day, when he died of secondary 
 hemorrhage, a result not altogether unlocked for, and from 
 no fault of the operator either during the operation or during 
 the after-treatment. The operation was beautifully done, 
 exhibiting that care and attention to detail for which Agnew 
 was always noted. Two out of three cases successful was a 
 wonderful record in those days before asepsis and antisepsis 
 
 53 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 were thought of. They were, of course, secondary cases, — 
 that is to say, not cases requiring amputation for primary 
 injury. Such cases are very different, and most of them have 
 died from shock during or soon after the operation. There 
 is one thought comes to me before I dismiss Agnew's case: 
 Did opening up the sheath of the femoral vessels and tying the 
 vessels before completing the operation tend towards pro- 
 ducing the secondary hemorrhage? Had the man's blood- 
 vessels been sound, he probably would have recovered, but I 
 believe it better to control the hemorrhage by other means 
 than by preliminary ligation. 
 
 I had one primary case with my friend, the late Dr. George 
 Troup Maxwell, of Florida, — a little boy, from a railroad 
 crush. He rallied enough and lived long enough to demand 
 action, but died shortly after the successful operation. I have 
 no statistics at hand, but I think there was one case survived 
 out of a great many in the Crimean War. In the late war of 
 the Rebellion, during the first part of it, a number died after 
 or during the operation. So much was said at the time about 
 these operations that I think an order was issued forbidding 
 them on the field, at least. Dr. Edward Shippen, late of Phil- 
 adelphia, later on in the war did one primary operation at the 
 hip, and the man recovered, notwithstanding he was banged 
 around in an army ambulance for hours, if not for days, im- 
 mediately succeeding the operation. To-day, thirty and more 
 years since the time we have been speaking of, with all the 
 improvements in instruments, in technique, with our knowl- 
 edge of asepsis and antisepsis, and other advantages, amputa- 
 tions at the hip in secondary cases should be, and are, cases 
 in which we may, in a majority of instances, look forward to 
 success, and in primary cases the chances ought to be de- 
 cidedly more hopeful and operation in more of these cases 
 justifiable, provided always, the loss of blood has not been too 
 great and shock has sufficiently subsided. Wyeth's method 
 is now the accepted method in this greatest of operations, and 
 with the control of hemorrhage, and the rigid practice of 
 asepsis, the mortality must materially decrease. 
 
 54 
 
FORTY YEARS IN THE M1<:DICAL PROFESSION 
 
 Alfred Stille succeeded Dr. Pepper as Professor of Prac- 
 tice at the University. He is a most accomplished and schol- 
 arly man, and for many years delivered a finished and able 
 course of lectures, both didactic and clinical. He still lives, 
 enjoying a well-earned ease in his old age, greatly respected 
 both as a citizen and as a physician. 
 
 Among the clinical lecturers of distinction in Philadelphia 
 at this time was W. W. Gerhard. In diagnosis of diseases 
 of the chest he probably excelled any man in America, and 
 as an author was well known for his writings on this special 
 subject. He was very irritable during his clinical talks, and 
 treated his class much as any old dominie might have treated 
 his boys in school-rooms of the olden time. Edward Peace 
 was surgeon to the Pennsylvania Hospital, and did some skil- 
 ful work, among other cases being one of ligation of the sub- 
 clavian within the scaleni. Being a man of means, he retired 
 at an early age from active work. The brilliant John Rhea 
 Barton retired early under the same conditions, which early 
 giving up of professional work caused Gross to speak of him 
 as one of the ablest and most brilliant of surgeons, yet at the 
 same time one of the worst. 
 
 Paul Beck Goddard did little teaching in his later days, but 
 he was one of the ablest and most scholarly of all the members 
 of the profession in the country. It was said at one time of 
 Goddard, that he could fill, with honor to himself and with 
 special benefit to the class, any one or all of the seven profes- 
 sorships which then comprised the course of our medical 
 schools. That is to say, he could fill the chairs of Anatomy, 
 Surgery, Practice of Medicine, Obstetrics, Physiology, Chem- 
 istry, and Materia Medica, and, I may add, be Demonstrator 
 of Anatomy too. 
 
 Addinell Hewson was surgeon at the Pennsylvania Hos- 
 pital, was a good clinical teacher, and an accomplished sur- 
 geon and gentleman. George W. Norris was a surgeon of 
 great attainments, was the great authority on fractures of his 
 day, and lectured regTilarly at the hospital. The Pennsylva- 
 nia Hospital had an immense amount of clinical material in 
 
 55 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 fractures, and it was a treat to have Norris take up this sub- 
 ject for a cHnic. 
 
 I have ah"eady spoken of WilHam Hunt. His friend and 
 companion Thomas G. Morton still lives, having served as 
 surgeon of this hospital for more than thirty years. A won- 
 derful service in years, and what an experience to a man ! 
 what a mine to work ! Morton has not failed to work it. He 
 is to-day one of the great surgeons of the world, whose bril- 
 liancy, rapidity, and dash are excelled by none. Oh, for a 
 record of such a life work ! such a record as Ian Maclaren or 
 a Conan Doyle would write, — the joys, the sorrows, the 
 struggles for life, the triumphs and the disappointments, the 
 sunlight, the gloom, the pathos, the joy, coming and going, 
 day and night! We all get weary of the heavy work, the 
 heavy scientific literature of the profession. To come home 
 weary, possibly irritated, possibly grieved, to sit down to 
 such a character as Doctor MacLure, is positive rest for 
 mind and body wearied by unceasing toil; and what a rest 
 would it be to peruse at such times a record of over thirty- 
 four years of a surgeon's experience in a great hospital, told 
 by some gifted man ! 
 
 John Forsyth Meigs was a regular lecturer at the Penn- 
 sylvania, a son of the great obstetrician Charles D. Meigs. 
 John Meigs, as he was always spoken of, was a very busy 
 man; in fact, much of the time overworked, from his im- 
 mense family practice. He was a great authority on chil- 
 dren's diseases, as his well-known work on that subject attests. 
 Ellwood Wilson was his friend and frequent consultant in 
 private practice, with an enormous obstetric practice, and was 
 a man of great skill, had abundant success, and, like Meigs, 
 worked nearly to the day he died. 
 
 William H. Pancoast was a bright, pleasant man, a son of 
 the great surgeon, who at times lectured acceptably and after- 
 wards succeeded to his father's chair of Anatomy in the Jef- 
 ferson school ; afterwards resigning this chair and going to 
 the Medico-Chirurgical College, where he was actively em- 
 ployed until he died. 
 
 56 
 
FORTY YEARS IN Till': MICDICAL PROFKSSION 
 
 Edward Uartshornc and I Icnry Hartshorne were promi- 
 nent in the profession in IMiiladcl])hia at this time, the one a 
 surgeon and the other a well-known lecturer and author. ]). 
 Francis Condie was also known favorahly in diseases f)f chil- 
 dren, on which suhject he wrote a very elahorate work and 
 edited Sir Thomas Watson's " Practice of Physic." 
 
 Among the greatest of the great names in surgery of the 
 early period of forty years ago is that of Washington L. 
 Atlee, a worthy follower of his great prototype, Ephraim 
 McDowell. Atlee was one of the great pioneers in ovari- 
 otomy when he was struggling to give the operation a sub- 
 stantial basis on which to stand as a justifiable proceeding. 
 I have heard the operation denounced from the amphitheatre 
 of one of the great medical schools as next to murder, and 
 the man who performed the operation as little less than mur- 
 derer and little more than fiend. Atlee continued on in his 
 heroic struggle, exhibiting all the attributes of a great and 
 fearless man, working to the very day of his death. His 
 death was pathetic, but worthy of the great man he was. He 
 knew he had malignant disease of the stomach, and when 
 scarcely able to support himself he left his home, went to the 
 house of a patient at a distance, and returning to his home 
 exhausted, he died. 
 
 '■ Like one who wraps the drapery of his couch about him 
 And lies down to pleasant dreams." 
 
 Equally eminent in surgery and gynsecology was his dis- 
 tinguished brother, John Light Atlee, of Lancaster. One 
 cannot mention the name of either of these two great men 
 without thinking of the other. The Atlees were a family of 
 doctors, and they have all been distinguished men. Walter 
 Franklin Atlee, of Philadelphia, child of Lancaster's great 
 son, still lives, a worthy successor of his father and uncle. 
 As a general surgeon he has been eminently successful, and 
 as a gyn?scologist. in the days wdien it required all the force, 
 all the strength, and all the powers of a man to be a g}'njecolo- 
 gist, he was the peer of any of them. Until time shall be no 
 
 57 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 more, no woman should pass the grave of an Atlee and fail 
 to drop a tear upon his tomb. 
 
 Forty years ago in Philadelphia there were few specialists. 
 In the eye, Dr. Isaac Hays and Dr. Littell did little or no 
 other work. They were both very eminent men of their day, 
 and Dr. Hays was a very scholarly man and cultivated gen- 
 tleman, and edited until his death, the, at that day, great 
 American medical journal, the American Journal of the Medi- 
 cal Sciences, or, as it was always better known, " Hays's 
 Journal." All the general surgeons like Pancoast, Gross, 
 Agnew, Morton, Hunt, Levis, and others, did eye-work. 
 Ezra Dyer came to Philadelphia, fresh from Von Grafe's 
 clinic in Berlin, and soon established a large practice. He 
 was followed by George Strawbridge, a most accomplished 
 oculist and eye surgeon, still doing good work. Dr. Charles 
 H. Burnett left the Philadelphia schools, went to Europe, and 
 returned to Philadelphia, where he has since worked success- 
 fully, and is to-day one of the world's great authorities on the 
 human ear. 
 
 In medicine, few of the contemporaries of the elder Pepper 
 and Stille survive. Da Costa is probably the nestor, a great 
 didactic and clinical teacher, a most accurate diagnostician 
 of world-wide fame. May he live many years to enlighten 
 the profession he has served so well and done so much to 
 adorn. James Tyson, the Professor of Clinical Medicine at 
 the University of Pennsylvania, is a wonderfully active man 
 in the profession, both as teacher and practitioner, and so is 
 Horatio C. Wood, the Professor of Materia Medica. All of 
 these men have done great and creditable literary work, and 
 upon their shoulders in Philadelphia, together with D. F, 
 Woods, Woodbury, I. Minis Hays, Henry, Stengle, Taylor, 
 Hare, Starr, Cleeman, Ingham, Daland, Anders, Chapman, 
 Gittings, Wistar, James C. Wilson, Arthur V. Meigs, and 
 Musser, distinguished authors and teachers, Wallace, Stryker, 
 Hickman, Cadwalader, Cheston, and others equally well 
 known, have fallen the mantles of Chapman, Mitchell, the 
 Peppers, and other renowned men. These mantles they will 
 
 58 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 worthily wear until the cycle revolves again, and others, now 
 unknown, shall fill their places; and so the cycle will revolve 
 until time shall be no more. 
 
 John Ashhurst and J. William White now stand, by reason 
 of age and ability, with Morton and Keen and Brinton at the 
 head of the list of surgeons. Ashhurst and White are pro- 
 fessors of surgery at the University, and Keen and Brinton at 
 the Jefferson school, and each maintains the ancient prestige 
 of these two great colleges. There are mafiy bright and able 
 surgeons, younger men, in the city, most prominent among 
 whom are Henry R. Wharton, teacher and author; Allis, 
 Packard, Mears, Roberts, Simes, Martin, S. Ashhurst, Hearn, 
 Deaver, T. S. K. Morton, Porter, Barton, La Place, Willard, 
 Dulles, Harte, Le Conte, and McClellan, distinguished author 
 and teacher. 
 
 Among gynaecologists are Baldy, author, teacher, finished 
 diagnostician, and operator ; C. B. Penrose, at the head of his 
 specialty at the University; Girvin, Duer, Price, Montgom- 
 ery, Shoemaker, Hirst, Professor of Obstetrics at the Univer- 
 sity; Davis, of the Jefferson school; Noble, Baer, Woods, 
 Kruser, Ashton, and others well known. 
 
 On the eye, ear, and throat are Harlan, Norris, Oliver, 
 Gould, a most accomplished man; de Schweinitz, Cohen, 
 Randall, Stout, Risley, McClure, and many, many more. Not 
 long ago you could count the eye men on the fingers of one 
 hand ; now they are very numerous, and still increasing, and 
 so is the good they are doing, for in eye troubles great ad- 
 vances have been and are being made. Philadelphia lost two 
 of her brightest and brainiest men when Osier and Kelly 
 went to Baltimore, where they are now doing great work, and 
 with Halsted, Welch, and others are rapidly establishing at 
 Johns Hopkins one of the great medical centres of the world. 
 
 In forty years the knowledge of the pathology^ of and 
 treatment of diseases of the skin in America has made great 
 progress. It was only taught casually in the schools until 
 recent times, and little attention was given to cases, even in 
 clinics; in fact, I don't think teacher or pupil knew much 
 
 59 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 about them. During and after the war of the RebelHon skin 
 troubles increased greatly in America, and are now, as we 
 all know, quite common. Dr. L. A. Duhring took up the 
 subject as a specialty early in his professional life, and now 
 has a world-wide reputation. Dr. Arthur Van Harlingen 
 and Dr. John V. Shoemaker are known experts in this spe- 
 cialty, whilst Dr. Henry W. Stelwagon is particularly well 
 known as both author and teacher. In nervous diseases there 
 are Mitchell, father and son, Sinkler, Mills, Chapin, Dercum, 
 Martin W. Barr, Horatio Wood, J. Madison Taylor, and 
 others. It was at first not my intention to speak of the living 
 in these articles, but among so many distinguished names it is 
 impossible to forbear mentioning a few. 
 
 In the decade between i860 and 1870 the hospitals in Phila- 
 delphia were sufficient for the needs of the people, and were 
 well conducted. The Pennsylvania was the great surgical 
 institution, and probably had the best medical wards. Block- 
 ley was a great obstetrical and venereal school, besides having 
 a profusion of general practice. The Episcopal was a fine 
 hospital, and so was St. Joseph's. Wills Eye Hospital was 
 devoted especially to diseases of the eye. During the war the 
 government established a number of large hospitals in Phila- 
 delphia for sick and wounded soldiers, and they did great and 
 good work. These were the West Philadelphia, the South 
 Street, Nicetown, Fifth and Buttonwood, Broad and Cherry, 
 Turner's Lane, Chestnut Hill, and the United States Army 
 Officers' Hospital, at Camac's Woods, now Eleventh and 
 Berks Streets. Everybody took an interest in these organiza- 
 tions, and among the surgeons in charge the names of Camac, 
 Hopkinson, Le Conte, S. W. Gross, and John Neill, one of 
 Philadelphia's most noted anatomists and surgeons, are well 
 remembered. William Camac, M.D., did a great work in this 
 service. He, at his own expense, converted the old family 
 homestead at Camac's Woods into a delightful home and hos- 
 pital for sick and wounded officers, and through the many 
 dark days of the war worked and watched, relieving the suf- 
 fering of the many unfortunates there committed to his care. 
 
 60 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 In October, 1864, 1 was elected one of the resident physi- 
 cians of the Philadelphia Hospital, Blockley. 1 had been in 
 the medical corps of the United States army since 1862, and 
 was glad to avail myself of the great resources of Blockley 
 for clinical experience. This hospital was the refuge for the 
 indigent sick and indigents generally of Philadelphia City and 
 County. There were about three thousand patients within 
 the walls, six hundred being on the insane side, an entirely 
 separate department. The institution was governed by the 
 Board of Guardians of the Poor, and had a complete organiza- 
 tion, which was more or less political, but at that time was 
 composed of very good men and free from the scandals that 
 had some time previously clustered around it. The practice 
 there was interesting, and I soon learned one fact, — that the 
 habitues of almshouses and prisons, as a rule, being accus- 
 tomed to over-stimulation in all of its phases, withstand 
 knock-out doses with great impunity, and the dosage com- 
 mon among these classes is no safe criterion for dosage in 
 private practice. The under employees were taken from the 
 inmates, as a rule, and whilst many of them were good ser- 
 vants, they were, as a class, moral imbeciles, and I doubt if 
 the employment of such in such institutions is economical 
 either to the municipality or to the State. Now, since the in- 
 troduction of the trained nurse into the profession, a wonder- 
 ful change for the better has come to such places as Blockley, 
 and one who was there in the olden time, and seeing the order, 
 attention to detail, and perfect discipline of the corps of well- 
 bred, well-trained women ministering to the unfortunate sick 
 there to-day, cannot help but note the contrast and applaud 
 the modern methods and modern ideas. 
 
 The clinical material of every class of disease available at 
 Blockley was enormous. There were the old men's wards, 
 the old women's wards, the children's asylum w'ith its wards 
 for the sick, the men's and women's medical wards, the male 
 and female surgical wards, the male and female venereal 
 wards, the obstetrical wards, and the Department for the 
 Insane. There were generally two visiting surgeons on duty, 
 
 61 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 one taking the surgical and the other the venereal wards. 
 One medical man was generally on duty at a time, and con- 
 tinued for three months ; and so in the obstetrical wards. Dr. 
 S. W. Butler had charge of the Insane Department, with Dr. 
 Sparks as assistant. The services of these gentlemen were 
 continuous. Outside of the Department for the Insane there 
 were eight resident physicians, so arranged that four new 
 men came on in the spring and four in the autumn. In the 
 venereal wards I served as resident to Professor Gross. He 
 took great interest in this branch of the profession, and was a 
 dualist subject to conditions, as syphilographers were divided 
 in those days. His distinguished colleague in the hospital, 
 Agnew, was a unicist, but I thought at the time was weaken- 
 ing a little in his belief. Dr. Gross was a strict disciplinarian 
 in his wards and clinics, was rather fond of a joke at the 
 expense of his patients, and when the old gentleman com- 
 menced to whistle in a whisper and kick an unoffending towel 
 across the ward, somebody might expect to hear from him in 
 an emphatic way. He was always most dignified and cour- 
 teous in his clinics, a gentleman of the old school par excel- 
 lence, and was fond of making his residents assume respon- 
 sibilities, as for example, when about to amputate a leg, he 
 would often give the tournicjuet a toss to one side and call 
 upon one of us to hold the femoral artery with the thumb. At 
 such times he did rapid work, but if some rebellious vessel 
 caused delay in its ligation the luckless resident at the femoral 
 had his own troubles, I assure you. As a recompense and 
 compliment, after the operation had been successfully brought 
 to a close, the old gentleman, drawing himself to his full 
 height, would turn to the class and say, " Gentlemen, with 
 competent and intelligent assistants, a surgeon can do almost 
 anything." In the surgical wards I served with Agnew. Oh, 
 Agnew was a lovely man ! No wonder students admired him 
 and so many of them came to him for advice in their profes- 
 sional work. I have seen him under all conditions, — in his 
 work in the dissecting-room, at his home, in his hospital work, 
 in his clinic. I never saw him ruffled or excited, I never saw 
 
 62 
 
FORTY YI<:AK.S IN Till': MI'.hlCAL PROFESSION 
 
 him rude to the most menial of those about him, and T never 
 saw him cross with a patient/ He was very attentive to his 
 wards and to his hospital duties, and of course his work was 
 done as few but he could do it. He was kind and considerate 
 to his residents, and took pains to teach them and give them 
 a chance. He has more than once said to me, when cases 
 involving considerable were in the wards, " Now, you take 
 this case; you can do it, and doing it will help you at some 
 later day in your work." 
 
 I went through the obstetrical wards with Dr. R. A. F. 
 Penrose as chief. Penrose was thoroughly up in his spe- 
 cialty, and this was before the days of his professorship at 
 the University. He was most considerate and kind to his 
 residents, and took great pains to teach them. I know I was 
 under great personal obligations to him, and when I left his 
 wards I had done over and over again many of the important 
 operations, such as application of the forceps, etc., which 
 served me well when thrown on my own resources in after 
 life. Edward L. Duer, the accomplished accoucheur and 
 gynzecologist of Philadelphia, was one of the visiting obstetri- 
 cians, and so was Frank F. Maury, but he resigned and took 
 the first vacancy in the surgical wards. Maury was a bright 
 man of delicate physique, was assistant to Professor Gross 
 for a long time, and could do anything in operative surgery 
 he had ever seen Gross do. He obtained a good practice in 
 general surgery, but was particularly well known as a special- 
 ist in venereal diseases. His health failed, and he died a com- 
 paratively young man. 
 
 Richard J. Levis had the surgical wards during the sum- 
 mer term, and therefore had no class for clinics. He was a 
 mastery in surgery, and was a master mechanic, and his lec- 
 ture on Surgical Emergencies should be read by every one. 
 If Levis was caught in an emergency without an instrument 
 he could do more than any man I ever knew to supply the 
 defect then and there. As an operator he covered all the 
 domain of surgery, from a hip- joint case to the most delicate 
 operation on the eye. He did little literary work, and the 
 
 63 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 result of his labors was mostly buried with him when he 
 died. 
 
 Da Costa had charge of the medical wards, and gave his 
 clinics twice a week. He brought to bear in his work at 
 Blockley the same great ability he has always exercised, and 
 did great work for both students and patients. Dr. Alfred 
 Stille was also a visiting physician, and was scrupulously 
 careful and exact in his work. Dr. Ziegler had the medical 
 wards in summer, and of course held no clinic. Dr. Charles 
 Pendleton Tutt, a most industrious and painstaking physician, 
 was another of the visiting physicians. He had ward classes 
 of students in the spring, and whilst devoting himself assidu- 
 ously to this work took typhus fever, from the contagion in 
 his own wards. I remember sadly his terrible illness. Dr. 
 Francis Gurney Smith was his physician, and the present 
 Professor Tyson, of the University, Dr. D. F. Woods, and 
 myself took care of him. He died at his home in Philadelphia, 
 opposite the United States Mint, near Broad and Chestnut 
 Streets. I mention this case here to show the changes that 
 have taken place since that time, 1865, I think it was. Here 
 was a case of that most loathsome and contagious disease, 
 typhus fever, in the very midst of the best part of the city. 
 There was no restriction as to those coming and going from 
 the house. We who were in attendance even did not take 
 any, or, if any, very few of the precautions we would take 
 to-day. The funeral was not private, any one going who was 
 inclined. I do not remember that any one took the fever from 
 this case. This exemption was surely due to the kindness of 
 an overruling Providence rather than to any human agency. 
 
 Now, as to typhus fever, this plague of Athens. In the 
 winter of 1864-65 we had a serious epidemic of it inside the 
 walls of Blockley. In those days, in those old out-wards, the 
 homes of the indigent, it was like poverty, " always with us," 
 and likely to break out whenever the host was available. 
 When I think of how we treated such cases, as to environ- 
 ment, etc., I wonder we did not all die. Indeed, I wonder we 
 were not all executed by judicial hanging, for I reckon we 
 
 ' ■ 64 
 
FORTY YEAKS IN THE MI-.DICAL PROFESSION 
 
 should have been hanged anyh^nv, hut the g(jod old hymn very 
 truly says, — 
 
 " God works in a mysterious way, 
 His wonders to perform." 
 
 In those days we thouglit a sick man sliould l)e kept well 
 housed and warm, no difference what the trouble. Many and 
 many a time 1, have gone personally into the alcoves (jr dens 
 in the out-wards, which the old paupers loved to think of as 
 their own home, and dragged (jut the inmates, covered with 
 the typhus rash, with a temperature high enough to almost 
 burn one ; and then the sickening, mousy odor ! They were 
 sent at once to the general medical wards and treated there ; 
 think of it ! Dr. William H. Ford, my dear friend, who since 
 that time has done sd much noble, able, and disinterested 
 work, which work only stopped the day death overtook him, 
 was one of the resident physicians. As President of the 
 Board of Health of Philadelphia for many years, by his un- 
 ceasing care and vigilance he has made all such diseases as 
 typhus fever impossible of spreading in epidemic form in the 
 great city, and this work has all been done within a few years. 
 During this epidemic in Blockley I remember one of the great 
 surgeons amputating a colored woman's arm above the elbow. 
 I had care of the after-treatment. On the third day she de- 
 veloped typhus fever; she was kept in her bed in the ward, 
 treated there, and died there. She was taken to the dead- 
 room after death. I posted her, using only ordinary precau- 
 tions. The only extraordinary precaution we used was that 
 no subject dead of a contagious disease went to the anatomi- 
 cal rooms of the medical schools. The fever went on through 
 the winter; none of the physicians took it until Dr. Tutt in 
 the spring, but many patients and a number of nurses suc- 
 cumbed. After the warm weather came and the buildings 
 . were opened up, and the gentle breezes and heavy gales of 
 spring went through the wards, the typhus contagion (we 
 are not sure to-day of its exact nature, although it is probably 
 zymotic) went out at the windows, and this is how the great 
 epidemic of 1864-65 left Blocklev. Let it return now, we 
 5 ^ 65 " 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 have all grown in knowledge and prudence, and we Avould 
 welcome it as the unpatriotic old Whig, Tom Corwin, wished 
 the Mexicans to welcome our troops going to Mexico in the 
 war of 1847, — " We would welcome it with bloody hands to 
 hospitable graves." 
 
 Among the resident physicians was John S. Parry, an 
 original thinker and one of the brightest of men. He has 
 left the profession a classic in his work on " Extra-Uterine 
 Pregnancy," good authority to-day, twenty-two years after 
 his early death, which took place in Florida in 1876, of con- 
 sumption. Among the other residents were Dr. William H. 
 Wallace, now a prominent practitioner in Philadelphia ; Wil- 
 liam H. Helm, now of Sing Sing, New York; William 
 McClure, the well-known oculist; C. E. Smith, of St. Paul; 
 R. Stansbury Sutton, the well-known gynaecologist of Alle- 
 gheny City; Dr. H. W. McCoy, of Indiana; Dr. Robert 
 Miller, of Kentucky; and Dr. Sparks, of Philadelphia. At 
 that day the organization of the hospital, as far as using the 
 vast amount of clinical material at hand was concerned, was 
 very incomplete ; the residents were kept busy, but the pathol- 
 ogy was not worked up in any way approaching completeness, 
 and it was sad to see the waste of so much grand material 
 which could have been made so useful. Even in those days, 
 in advancing the science of medicine and in educating those 
 in the profession, both old and young, this lack of organiza- 
 tion for work was apparent in the profession in general in 
 Philadelphia. It was rare that a proper interest could be 
 gotten up in the general meetings of the College of Physi- 
 cians or of the Pathological Society; even if a lecture by 
 some bright man should be announced on some interesting 
 subject, those interested quaked with fear lest no appreciative 
 audience might be present to encourage the lecturer. Pro- 
 fessor Gross was one of the most regular attendants and 
 workers at these meetings, especially at the Pathological So- 
 ciety. He was greatly interested in pathology, had written 
 on it, and more than any teacher of his day impressed its im- 
 portance upon his hearers. 
 
 66 
 
CHAPTER IV. 
 
 Started for Liverpool in a Sail-Ship — Tornado — Narrow Escape and 
 Return to New York — Better Success by Steamer — Paris in 1866 — 
 The Hospitals — The Doctors — Velpeau, Jobert de Lamballc, Nelaton, 
 Ricord, Sichcl, Charcot, Trousseau, Liebreich, Pasteur, J. Marion 
 Sims — Napoleon III. and why he failed — Tone of the Profession in 
 Paris — London — Sir William Ferguson, Sir Thomas Watson, Sir 
 James Paget, and Others — Edinburgh — Simpson and Syme — Ether 
 and Chloroform — Berlin — Von Langenbeck — Frerichs — Vienna — 
 Clinical Schools and Lectures — Billroth, Skoda, Oppolzer, Tiirk, and 
 Others. 
 
 In 1866, not being in robust health, having been engaged 
 in private practice in Philadelphia, I went to Europe for the 
 dual purpose of recuperating and studying some of the for- 
 eign methods then in vogue in medicine. 
 
 I determined to try a voyage longer than the usual steamer 
 run of a few days, so took the American clipper ship Emerald 
 Isle, Captain Eves. I remember embarking at the Battery 
 and being rowed by one of the harbor boatmen in a small boat 
 to the ship, anchored away down towards the Narrows, in the 
 upper bay. There was an easterly storm blowing then, which 
 increased hourly, and held us at our anchor unable to proceed 
 for a week. We had all sorts of adventures, being fouled by 
 other vessels carried from their moorings. At last the wind 
 backed around to the west, and on a Sunday morning the 
 captain came down in a tug, and we were soon under way. I 
 remember the third mate, a rattling little Irishman, made the 
 remark that we were going to sea under a bad omen, — the 
 wind had gone around the wrong way, had backed around, 
 and would soon come back to the storm quarter again and 
 give us hell, as he expressed it, in a way more emphatic than 
 elegant. Mr. Kelly was right, the storm did return, and we 
 had a week of terrible blows and hurricanes, at the height of 
 which our ship sprung a leak, was thrown on her beam ends, 
 leaked badly, with four and a half feet of water in her hold, 
 
 (>7 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 all her pumps choked with grain from the cargo, and nearly 
 every sail blown from the bolt-ropes. A sad plight to be in, 
 surely. It was not my first experience at sea, but it was my 
 worst experience. 
 
 Nowhere can a man feel more utterly hopeless and dejected 
 than under such conditions, waiting every moment for his 
 ship to sink under him. Even here the doctor comes in, as he 
 so often does in forlorn hopes. The steward was an old 
 packet rat, a middle-aged man, who had been to sea all his 
 life. During the height of the gale he was very, very sea- 
 sick, and, to use a sailor's expression, had thrown up every- 
 thing but his boots, cursing and swearing at a terrible rate all 
 the time. In the midst of one of his worst paroxysms I heard 
 the captain call out to him, " Steward, let up there! we are 
 in rough times ; you don't know where you may be this time 
 to-morrow. I will send the doctor to you." I heard him yell 
 back, " Captain, I don't care a d — n ! D — n the storm ! d — n 
 the ship ! d — n the doctor ! I ain't afeared to die. I don't 
 want to live." This shows the horrors of sea-sickness, and 
 that there are times in one's life when even doctors are 
 scorned. 
 
 After several days the gale abated, and the pumps were 
 cleared, enabling us to keep down the water. I will never for- 
 get the lovely morning when the sun came out, giving us 
 summer temperature, with only a gentle tropical breeze. The 
 ship lay there with scarcely a sail intact, listed very far to 
 starboard, and every one utterly exhausted. The captain 
 talked the matter over with me and the first officer, and we 
 agreed that every man possible should have six hours sleep. 
 The first officer remarked, rather cheerfully, that if the wind 
 came out " norwest" we would never get back to New York, 
 and the ship could never go to the other side in her present 
 condition. The captain said we were two hundred and forty 
 miles from Sandy Hook, and he would endeavor to get her 
 back there as soon as possible. After a rest to the crew, every 
 one was put to shifting the bags of corn between decks to the 
 port side, which had the effect of easing the ship up a little 
 
 68 
 
FORTY YEARS IN THK MEDICAL PROFESSION 
 
 towards an even keel. yVfter some new sails had l^een bent, 
 we started back, took a pilot next day, and soon a tug appeared 
 and took ns to about the same anchorage in New York liay 
 we had left a week before. I returned the life-preserver Cap- 
 tain Eves had kindly strapped on me, and with a light heart 
 said good-by to him and his crew. 
 
 As his ship would pro1)al)ly be delayed a month before 
 sailing, I secured passage in the Arago, Captain fiadsden, a 
 first-class wooden side-wheel steamship. I had a lovely voy- 
 age, meeting several old friends, there being only eighty first- 
 class passengers and none others. The ocean during the 
 whole trip of fourteen days to Havre (you modern traveller, 
 think of fourteen days to Europe!) was as calm as a river, 
 and at no time on the voyage was there an hour we would not 
 have been safe in a batteau alongside the ship. This proved 
 the old sailor's advice correct, — wdien you are ready to go to 
 sea, go; don't wait for weather; you can never tell what is 
 coming. 
 
 We got our first glimpse of England in Falmouth harbor, 
 where we arrived early in the morning, and crossing the 
 channel, passing close by the celebrated Eddystone Light- 
 House, we arrived at Havre in due time, and entering the 
 locks were hoisted up into that wonderful artificial basin, the 
 harbor of Havre, large enough to hold five hundred ships the 
 size of the Arago. Through Normandy, with a short visit to 
 Rouen, inspecting the great Cathedral and the scene of the 
 burning of Joan d'Arc, we Avere soon in gay and lovely Paris. 
 After looking around for a few days, paying visits to friends 
 and delivering letters, I soon took up the object of my visit 
 and began to look up matters pertaining to medicine. 
 
 These were the days of the second empire, and Louis Na- 
 poleon was at the very acme of his power. All this had its 
 effect upon medicine, and only those in favor of the ruling 
 power could expect positions of emolument and distinction. 
 
 The most striking character I met in Paris, and the one 
 who impressed me most among medical men was Velpeau. — 
 Alfred Armand Louis JMarie \^elpeau. I suppose one reason 
 
 69 
 
FORTY YEARS IN THE MEDICAL' PROFESSION 
 
 of this was that in my day students probably heard most fre- 
 quently the name of Velpeau, of all foreign doctors, for he 
 was great and eminent in two great specialties, surgery and 
 obstetrics; in fact, he was a great all-round man in the pro- 
 fession. He was of obscure origin ; in other words, entirely a 
 self-made man. I first saw him in the wards of La Charite, 
 busy, going around among the beds early in the morning, 
 with a number of students with him. He was rather a tall, 
 spare man as I remember him, in ordinary dress, the top of 
 his head adorned with a green velvet skull-cap, which he 
 always wore during his hospital work. He had a note-book 
 and pencil in his hand, in which he took copious notes as he 
 proceeded on his rounds. The old gentleman was generally 
 good-natured, often joking, yet a strict disciplinarian. He 
 was at this time seventy-one years of age. When he was 
 thirty-five he was surgeon at Pitie, and worked until he died, 
 August 4, 1867. 
 
 Jobert de Lamballe was another interesting character and 
 great surgeon, with an especial reputation in plastic opera- 
 tions. He was a very rapid operator. It is said of him that 
 when everything was ready for a shoulder- joint operation in 
 his clinic, he would pick up a knife, count, with deliberation, 
 un, deux, trois, and the disarticulation was accomplished in 
 three movements of the knife. He was an irritable old fellow, 
 always ready for a fight, as were most of the Paris doctors, 
 and it was not uncommon for one great surgeon, when lec- 
 turing before a class, to speak of some other great surgeon as 
 " the Httle butcher around the corner." I saw little of Jobert 
 de Lamballe, as he had about given up work, and died in a 
 year or two after this time. 
 
 Auguste Nelaton was probably the most popular surgeon 
 as a practitioner at this period in Paris. He was an elegant- 
 looking man and a most accomplished gentleman. A Pari- 
 sian by birth, he was a pupil of the great Dupuytren. He 
 wrote little, but was for a long time Professor of Clinical 
 Surgery. Later he was made a senator of France, and was a 
 member of the Academy. All of these honors were showered 
 
 70 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 upon him out of the gratitude of Napoleon III., whose friend 
 and surgeon he was. Nelaton was a very a1)le and cajjable 
 genito-urinary surgeon, and a man oi great mechanical inge- 
 nuity and resources, as his celebrated Garibaldi porcelain- 
 pointed probe attests. Speaking of the friendship of Napo- 
 leon III. for Nelaton brings up a matter in which these great 
 men were actors, and which I have always believed was a 
 great factor in the downfall of the unhappy emperor, and had 
 very great possible effect on the modern history of Europe. 
 The matter I speak of came to me very directly from profes- 
 sional sources. Napoleon III. had suffered for a long time 
 from organic stricture of the urethra and its attendant trou- 
 bles. Nelaton was his surgeon, and when he was about fifty- 
 five years of age Nelaton was compelled, after having done 
 many minor operations, to make a very complete and radical 
 operation and form practically a new urethra. Any one 
 familiar with such operations, and with the conditions before 
 and after such operations, knows too well the sufferings at- 
 tendant upon such an existence. Probably for ten years pre- 
 vious to his downfall Napoleon III. was a terrible sufferer, 
 and doubtless could give little thought to the details of states- 
 manship or government. Those around him became corrupt, 
 the whole administration of the government became cor- 
 rupted, and when he, with the puny will and sickly judgment 
 of one w^eighed down with all the cruel sufferings such as he 
 sustained, led poor France into the Franco-Prussian War, 
 then, and not until then, did the truth dawn upon him of the 
 absolute hollow rottenness of his government and, as a natu- 
 ral result to all this, the thorough inefificiency of his army. 
 The sorrowful surrender at Sedan marked the downfall of 
 this unfortunate man, and his death at Chiselhurst, England, 
 in January, 1873, whilst undergoing the operation of crush- 
 ing for stone in the bladder, under the direction of, and by the 
 skilful hands of, Sir Henry Thompson, only confirms the 
 view I have here given of his case, and shows that his horri- 
 ble vesical suft'erings pursued him, beaten, humiliated, and 
 exhausted, to the very brink of his grave. Nelaton died in 
 
 71 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Paris, in September, 1873, only a few months after his great 
 benefactor. 
 
 Malgaigne, one of the greatest of French surgeons, died 
 about this time. He is best remembered to-day as the intro- 
 ducer of Malgaigne's hooks for holding together the divided 
 fragments in fracture of the patella, an instrument which has 
 not met with great favor by the profession, but in the present 
 days of antisepsis is less dangerous than formerly. 
 
 Civiale was a great authority also in Paris at this date, 
 1866. He worked persistently and intelligently, opposed by 
 Velpeau, Nelaton, and other great surgeons, on his hobby 
 of crushing stone in the bladder, instead of cutting for it. 
 He perfected his lithotrites and other instruments, and has his 
 justification to-day; and were he alive he would see his oper- 
 ation an unqualified success, without limitation as to years or 
 sex, and, with the improvements of Bigelow, the American 
 surgeon, and others, see still greater triumphs in the imme- 
 diate evacuation of the debris. 
 
 Cloquet was a well-known surgeon, and perhaps the best 
 anatomist of his day in Paris. 
 
 Philippe Ricord was the great authority on venereal dis- 
 eases, and although born in Baltimore, Maryland, was a true 
 Parisian. He served at the Hopital du Midi and was won- 
 derfully active, a great experimenter, not sparing even him- 
 self. He was now well on to seventy years of age, still active, 
 with an enormous clientele, as the great authority of his day 
 on his specialty. 
 
 On the eye, Liebreich was the man I saw most of, and 
 probably had the greatest reputation at the time, although I 
 think Sichel, whom I never saw to know, had been for years 
 the great oculist of the city. I saw Liebreich operate a good 
 deal, and he was very expert. He appeared to seek and do a 
 great number of operations for strabismus, and always su- 
 tured the conjunctiva with very fine silk. I thought the 
 after-effects were bad, and I imagine he did not keep it up. 
 With aseptic precautions sutures might do better. Liebreich 
 was a tall, spare man. of very dark complexion and very black 
 
 72 
 
FORTY YRARS IN TUK MKDfCAL PROFESSION 
 
 hair; he lor)l<e(l Hke a Spaniard. He probably came from 
 over the Rhine, or very near it. He was not a Frenchman, 
 and I think was compelled to leave Paris in a hurry when the 
 Franco-German War came on. 1 think- he went to London, 
 but I am not sure. 
 
 As every one knows, Paris is full of lio.spitals, and presents 
 the greatest advantages for clinical study. As I remember 
 them, La Charite and the Llotel Dieu were the great and in- 
 teresting ones. They were internally very old and ram- 
 shackle in their appearance. They were kept scrupulously 
 clean, but there appeared to be plenty of harbor for rats, mice, 
 roaches, and other vermin. Their organization was superb 
 for that day, and their great advantages were not allowed to 
 go to waste, whether clinical, pathological, or histological. I 
 remember Fournier and Logier as great hospital workers, and 
 they rarely visited the institutions without spending some 
 time in the dead-house. 
 
 Trousseau died in 1867, and to the day of his death was the 
 great physician of Paris of his time. He made a great spe- 
 cialty of diphtheria, and worked up tracheotomy as no other 
 man had done before him. He was a tremendous worker, 
 was Professor of Therapeutics, and worked up paracentesis 
 thoracis in chronic pleuritic efifusion, besides all troubles con- 
 nected with the windpipe. Claude Bernard was the great 
 physiologist of this time, and was an indefatigable and origi- 
 nal worker and experimenter; indeed, no man approached 
 him in his special lines. He died in 1878, when experimental 
 physiology lost her great and shining light. Dr. Campbell 
 was the great obstetrician of Paris, and Dr. Beylard. who 
 came from Philadelphia, was the favorite physician of the 
 American colony, and was a great and good friend to me 
 during my residence in the city. 
 
 One of the most interesting times Paris has ever seen in 
 her medical history was upon the advent of the great sur- 
 geon, J. Marion Sims, within her borders in 1861. No man 
 doubts to-day that Sims was a great man: no man doubts 
 that he was one of the great men of the world : and no man, 
 
 73 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 if he be true to himself, doubts that Sims was one of the chief 
 founders of the art of gynaecology, and almost personally and 
 absolutely the founder of plastic gynaecological operations. I 
 doubt if the tone of the profession in Paris was ever good. 
 The whole business always has been constantly riddled with 
 professional jealousies and hopelessly divided into cliques of 
 the most ultra and inharmonious natures. 
 
 The causes of this state of affairs are easily to be seen when 
 one makes a study of the conditions. The divisions into 
 cliques is the first cause, and these cliques are intensely 
 jealous of each other, and let pass no occasion to abuse each 
 other, even in the public lecture-halls. Next, the individuals 
 abuse each other, and they carry these personal quarrels with 
 them in their daily rounds, and retail them to their patients, 
 and thus the patients, becoming imbued with the scandals, 
 retail them to their friends; hence society in Paris is full of 
 the medical scandals of the day. They gloat over them, and 
 of course the scandals gather as they go, and it is a common 
 thing to hear details of Dr. So-and-so's great and successful 
 operation, and of Dr. Somebody-else's lamentable failure 
 under like conditions. When Sims entered Paris the tongues 
 began to wag. His fame had preceded him, especially as to 
 his success in vesico-vaginal fistula. There were cases in 
 Paris, in fact, all over France, where Nelaton had pronounced 
 cure impossible, where Velpeau had seconded Nelaton in a 
 like opinion, and, more than that, where Jobert de Lamballe, 
 the great plastic surgeon of the French, had failed inglo- 
 riously. Sims took up these cases, and in the presence of the 
 great lights, Velpeau, Nelaton, and others, operated on them 
 and cured them. It was a great triumph for Sims, a great 
 set-back for the boasted priority of French surgery. Although 
 they had to recognize Sims and his great successes, they con- 
 tinued to belittle him and abuse him. 
 
 I remember one night attending a large private dinner of 
 gentlemen, composed chiefly of those who were permanent 
 residents of Paris, belonging to the so-called American col- 
 ony. As is usual on such occasions, the rows among the 
 
 74 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 French doctors came in as part of tlie conversation. Sims 
 came up among others. Tlie guests appeared to be mostly in 
 favor of the Parisians; few said anything in favor of Sims, 
 but now and again one would quote something Velpeau had 
 said slighting him, or something Nelaton had said. I remem- 
 ber one man particularly, who said that a few days before he 
 had casually met Ricord coming out of a hotel, that Ricord 
 had stopped him, asking, " And do you know our friend the 
 new American Dr. Seems? Who is this Dr. Seems, any- 
 how?" The only real friend and defender Sims appeared to 
 have among the local guests was one gentleman who defended 
 him lustily, and Mr. Pepper, who sat next to me, told me that 
 some time before Dr. Sims had performed an ovariotomy on 
 his wife, to which operation she had succumbed, and, he 
 added, he loved her dearly, too. 
 
 In those days Paris was a superb place of residence for a 
 foreigner, so clean, so thoroughly policed, and very inexpen- 
 sive. You could live as a prince and be thoroughly comforta- 
 ble, and be equally as comfortable, only less luxurious, on a 
 few francs a day. So long as I remained there I never saw 
 any trouble, such as brawls or street rows, and the only really 
 drunken man I ever met was the man who undertook to drive 
 me to the station on my final leave-taking for London. I sent 
 for a cab, and when it came I got in with my luggage, not 
 noticing the driver more than to tell him where to go. Soon 
 I found myself in a trench on the Boulevard. Fortunately, I 
 was on top, the driver and horse under me. In a few mo- 
 ments I was quietly lifted out, and soon after me the driver, 
 helplessly drunk, as I saw, the cab and horse being reserved 
 for a proper lifting apparatus, which soon arrived. No crowd 
 was permitted to gather; there was no noise, no confusion. 
 In a few moments an of^cer gently tapped me on the arm, 
 pointed me to a fresh cab, where I found my luggage all safe, 
 and was soon on my way to the station again. Thus I cele- 
 brated my departure from enchanting Paris, and with fond 
 anticipations of my visit to merry England, I was soon on my 
 way to the channel. 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 At this time in England, 1866, London was supposed to 
 have the best physicians in all Europe, and to Paris was given 
 the pre-eminence for surgeons. When we come to review the 
 list of surgeons in England and Scotland and Ireland, such a 
 review does not appear to strengthen this claim : Sir William 
 Ferguson, of London, was the peer of any man of his day, 
 and in some of his special plastic operations was probably un- 
 equalled; Sir James Paget, the great authority on surgical 
 pathology; Bowman, undoubtedly the most skilful operator 
 on the eye of his time ; Annandale, Heath, Hewitt, all great 
 surgeons; and last, but not least, Mr. Lister, then of Edin- 
 burgh, afterwards Sir Joseph Lister, and now Lord Lister, of 
 London, the great apostle of antisepsis, whose wife did so 
 much to help him in his work, a daughter of the great James 
 Syme, and who lately died, leaving her famous husband bereft 
 and inconsolable; Toynbee and Wilde, the great aurists of 
 their day; Syme, the wizard of Edinburgh; Sir James Y. 
 Simpson, his great antagonist, unapproached in his day as 
 an obstetrician, gynsecologist, and surgical specialist, and in- 
 ventor, too ; Lizars ; Matthews Duncan, student of Simpson ; 
 Sir Spencer Wells, and other noted names by the dozen, show 
 the English people to have been no laggards at that day in 
 the world's race for surgical honors. 
 
 Sir Thomas Watson, the nestor of the London physicians, 
 honored by royalty and plebeian alike, lived almost a full cen- 
 tury, and gave to the profession a monumental work in his 
 " Practice of Physic," which for lucidity of thought, beauty 
 of expression, and as a specimen of finished literary style and 
 pure Anglo-Saxon English, has been rarely approached and 
 surely never excelled by any work in medical literature. 
 Coming after Watson, the names of Jenner, Gull, Garrod, 
 Todd, Thomas King Chambers, Fothergill, Clark, and scores 
 of others attest her claim as a centre of medicine and medical 
 science. At this date, the names of Tyndall, in England, and 
 Pasteur, in France, were comparatively little known, and 
 Koch was probably a child in kilts. Since that time these 
 men have grown to be giants, and the great Pasteur has 
 
 76 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 passed away to join the silent majority. Whilst Tyndal! is 
 great, whilst Koch is great, J.ouis Pasteur was the greatest, 
 to my mind, among all scientists of his class who has yet lived. 
 Think of what this man has done and what a pioneer he was ! 
 No one had blazed the way for Pasteur in his great experi- 
 ments, and no one has approached him in the good done to 
 mankind, for, even without Pasteur's work, I doubt if to-day 
 we would have been advanced to the point we are in anti- 
 sepsis and asepsis. No wonder France is proud of Pasteur, 
 and has done great honor to his memory. He saved her in- 
 dustries and almost her very existence in his combat with and 
 investigations into the silkworm disease. He found the moth 
 with the concentric rings to be the cause of the trouble ; de- 
 stroy these moths, destroy their eggs, said Pasteur, and the 
 silk industry was saved to France. He did equal service in 
 his investigations into the fermentation of wines, destroying 
 the germs by high temperature. So with the anthrax pest, 
 so with the diseases of the vines, did he wrestle and conquer. 
 But above all these, oh, that great boon to those unfortunates 
 who have suffered from the bite of the rabid animal ! Oh, 
 the pangs, the horrors, the terrible forebodings these poor 
 unfortunate people suffered before this work of Pasteur with 
 the virus of rabies! His methods, his careful \vorkings, his 
 results, almost approach inspiration. At this work, after 
 these results, even there are scoffers, those who say there is 
 no such disease as hydrophobia in a human being. Away 
 with such ! I have seen it ; I have seen it in man approach- 
 ing old age; in man in the vigor and strength of youth; 
 yes, I have seen it in a little child, who never gave a thought 
 to his condition after the first pain of the bite subsided, and 
 who never even knew he had a nerve or felt a nervous twang 
 in his short life. Yes, there is such a disease as hydrophobia; 
 it has been proved bacteriologically from the human being to 
 the lower animal, and that ends the discussion. 
 
 The utility of Pasteur's treatment is now generally ac- 
 knowledged ; even the Germans acknowledge it, and have 
 established centres for carrying it out. Hydrophobia is the 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 disease in man communicated to him by a rabid animal. 
 Rabies is the same disease in the lower animal, or supposed to 
 be. Both are infectious, although the micro-organisms of 
 neither have as yet been isolated. In the treatment of hydro- 
 phobia Pasteur has stepped in advance of the bacteriologist, 
 for in the other diseases treated with the products of the 
 biologic activity of their germ causation, the micro-organism 
 has been separated and identified before the therapeutic agent 
 has been separated and used. Pasteur's treatment of hydro- 
 phobia is just the opposite. I have little doubt but that the 
 micro-organism of rabies will soon be found, and establish 
 the Pasteur treatment of hydrophobia rationally and accepta- 
 bly to the most exacting of scientists. 
 
 A most interesting matter in connection with hydrophobia 
 is the so-called rabies mephitica, hydrophobia from the bite 
 of the common skunk, the mephitis mephitica, a very com- 
 mon little animal which generally makes its presence known. 
 Its habitat is from Hudson's Bay to Mexico. The more 
 southern ones have more white coloring and are smaller than 
 the northern ones. I suppose it is also known in Europe, as 
 the French call it I'enfant du diable, or the devil's own. The 
 fluid having the skunk odor is in no way connected with the 
 urine, as is generally supposed, but is secreted by two glands, 
 one each side of the anus, called anal glands. Voluntary 
 muscles control the fluid secreted by a number of smaller 
 glands around the reservoir for holding the fluid. The tail 
 has nothing to do with the squirting or dashing" of the fluid. 
 The fluid is for defence and offence. This is the so-called 
 mephitic battery, and when it opens on you, look out ! Until 
 the fluid of this battery is all discharged he rarely, if ever, 
 bites, and this fact will be found of importance farther on. 
 The fluid contained by the gland is not of large amount, and 
 the animal is harmless in this respect until more is secreted, 
 which takes some time. The animal can squirt the fluid from 
 six to eight feet when he discharges his battery. The fluid is 
 phosphorescent at night, and at a distance when discharged 
 looks like a puff of white smoke or a puff of steam in daytime. 
 
 78 
 
FORTY YICAKS IN THE MEDICAL J'KOFESSION 
 
 If too freely inhaled by man, it causes nausea and cramps. Tn 
 minute doses it is said to be antispasmodic. 
 
 These matters are all thoroughly treated of by the late Dr. 
 Elliott Crues, U. S. A., in his work on the " Fur-Rearing- Ani- 
 mals of North America," and 1 beg to acknowledge my in- 
 debtedness to this work, and to the articles by the Rev. Horace 
 C. Hovey and Dr. John G. Janeway, U. S. A., published in Dr. 
 Crues's book. Mr. Hovey claims that rabies from skunk-bite 
 is a different species of rabies from rabies canina and other 
 forms of rabies. He proposes the name Rabies Mephitica. 
 He claims that rabies mephitica is caused by a special virus 
 generated by skunks ; that possibly there may be a causative 
 connection between the inactivity of the anal glands and the 
 generation of a malignant virus in the glands of the mouth. 
 As I take it, he believes the skunk-bite is always followed by 
 rabies mephitica; that the skunk only bites when his me- 
 phitic battery is exhausted, and his bite then always produces 
 hydrophobia. Old hunters in the Rockies, he says, all believe 
 the bite of the skunk is always fatal, producing hydrophobia. 
 I would suppose the mephitic battery of the skunk with hy- 
 drophobia would always be empty, from the convulsive nature 
 of the disease. The muscles controlling the battery are vol- 
 untary in health, but with rabies would be affected by either 
 clonic or tonic spasm. 
 
 Hovey claims the spasms of rabies canina are tonic, and of 
 rabies mephitica are clonic; that morphia acts in rabies me- 
 phitica, and does not act in very large doses in rabies canina. 
 Hovey asks, " Do skunks take and give rabies, or are they 
 among the animals that spontaneously generate a poison in 
 the glands of the mouth and communicate it by salivarv inoc- 
 ulation?" 
 
 Surgeon M. M. Spearer, U. S. A., gives an account of four 
 cases of skunk-bite. He thinks there is a marked difference 
 between the symptoms and those of hydrophobia. The four 
 cases were all fatal. He says the skunk virus is as peculiar to 
 it as that of the rattlesnake is to it, and is not an occasional 
 outbreak of disease like the sestus veneris of the wolf, or the 
 
 79 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 rabies canina. The instinct of the dog shows this. He is as 
 cautious A\hen attacking skunks as when he attacks venomous 
 snakes, and is seldom bitten. Hovey says the skunk is of the 
 North American mustehdcC, and if this is true the mustehdse, 
 as well as the felidse and canidse, can communicate rabies, or 
 a new disease communicated by the mustelidse has been dis- 
 covered, which generically resembles rabies canina, whilst dif- 
 fering from it specifically. Hovey thinks we might go so far 
 as to seek a solution of the whole dread mystery of hydropho- 
 bia in the theory that this awful malady originates with the 
 allied genera of mephitis (skunks), putorius (minks), and 
 mustela (weasels), being from them transferred to the cat 
 and the dog and other families of animals. Harvey suggests 
 that the defensive fluid of the skunk might be found to be the 
 natural antidote to the salivary virus. Well, as to this, na- 
 ture, we know, generates her poisons, why not her antidotes ? 
 These suggestions of Hovey's were made twenty-five years 
 ago, and since that time Pasteur has taught us enough, at 
 least, to make all victims of the bites of rabid animals hope- 
 ful, when before all were given over to despair and almost 
 hopeless horror. Surgeon John G. Janeway in his article 
 does not agree with Hovey in the main, but does agree in 
 part. He does not believe, with Hovey, that mephitic inocu- 
 lation is sure death. He has known men and dogs frequently 
 bitten, and they did not go mad. I may add here, men and 
 dogs are frequently bitten by mad dogs and cats, and yet do 
 not go mad. The reason is, they, although bitten, were not 
 inoculated, owing to some circumstance, as clothing or some- 
 thing of that kind absorbing the virus before the fang of the 
 biting animal has entered the flesh. It is said the skunk most 
 frequently bites man on the face, hand, ear, or other exposed 
 parts, and Janeway admits that the bite of the skunk oftener 
 than any other animal produces hydrophobia, and gives this 
 as a reason. Janeway says the rabid skunk at once exhausts 
 his battery, and has little or no odor, then they bite, as Hovey 
 says. 
 
 In hydrophobia the virus affects the eighth pair of cranial 
 
 80 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 nerves and their l)ranclics, especially the rjcsopbaj^cal l)ranch, 
 the result being the well-known difficulty in swallowing-. 
 The motor nerve of the larynx is also affected, causing sigh- 
 ing, catching of the breath, and difficulty in expelling the 
 frothy mucus accumulated in the throat. Hovey and Jane- 
 way agree that these troubles are more serious in rabies 
 canina than in rabies mephitica, that the periods of incubation 
 of the two are al)out the same, and that man has never been 
 known to inoculate man. All authorities and all experience, 
 I believe, agree on this point. Janeway concludes by de- 
 claring that rabies or hydrophobia produced by the skunk is 
 the same rabies or hydrophobia produced by the dog or cat 
 or similar animals. My own experience agrees with that of 
 Janeway, that dogs and men bitten by skunks do not always 
 die from the bite, either of hydrophobia, rabies, or other trou- 
 ble of the kind ; but I am free to confess there is something 
 peculiar and interesting in this study of the bite of the skunk 
 and its effects. These oddities, or apparent oddities, in na- 
 ture are interesting and most alluring, and all these peculiari- 
 ties connected with the mustelidae in contradistinction to the 
 same matters connected with the felidse and canidse are 
 worthy of the closest study and most watchful scrutiny. God 
 bless the memory of Louis Pasteur ! 
 
 Probably the most unique character in the profession in 
 the British Isles, if not in all Europe, at this date was Sir 
 James Young Simpson, of Edinburgh, a Scotchman by birth. 
 He was a person w4th a leonine head, yet was one of the 
 gentlest of men. He and Syme were always squabbling, 
 but Syme was the more aggressive, and was very intolerant 
 as to Simpson, whom he considered a mere obstetrician, and 
 not entitled to any opinion of his own on any matter pertain- 
 ing to surgery, and more than once made the public state- 
 ment that nothing of importance or of good in surgery could 
 ever emanate from the brain of an obstetrician. Simpson was 
 a most wonderful man, as gynaecologist, obstetrician, sur- 
 geon, and scientist, and, above all, as the discoverer of the 
 anaesthetic properties of chloroform and the introducer of 
 6 8i 
 
■ FORTY YEARS IN THE MEDICAL PROFESSION 
 
 anaesthesia into obstetrical practice, and as one of the intro- 
 ducers and perfecters of acupressure, at one time much used 
 for securing blood-vessels, but now generally barred by the 
 introduction of aseptic methods with animal ligatures. In 
 regard to the use of anaesthesia in labor, he had quite a con- 
 troversy with the late Professor Charles D. Meigs, of Phila- 
 delphia, who opposed it bitterly, claiming that labor was a 
 physiological process, and we had no right to dull its pangs 
 by artificial methods. Simpson held to his views, and to-day 
 such methods are in general use. 
 
 I am fully persuaded, so far as my own experience goes, 
 that whilst the use of anaesthetics in labor, when properly 
 guarded, is perfectly safe as to general conditions, and causes 
 woman to remember her great trial only as a pleasant dream, 
 yet at the same time it frequently interferes with prompt ute- 
 rine contractions, and renders the patient more liable to post- 
 partum hemorrhage. 
 
 When I first entered the profession in the United States 
 Marine Hospital in San Francisco I saw nothing but chlo- 
 roform used as an anaesthetic. In the clinics of the Uni- 
 versity of Pennsylvania, during the service of Professor 
 Henry H. Smith, a mixture of chloroform and ether was 
 used, and sometimes the A. C. E. mixture. Agnew pre- 
 ferred ether, and Gross was very partial to chloroform, and 
 if using ether and there was any delay, he would gener- 
 ally order us to pour on a little chloroform to reinforce the 
 ether. I have never seen a death from or during anaesthe- 
 sia. The nearest fatal case I ever saw was from ether, in 
 a gunshot wound case in the United States army during 
 the Civil War. As Agnew said, there are a certain num- 
 ber of cases who die under ether, and one of these cases 
 may come to any one of us at any time, and we cannot 
 help it. The consensus of opinion among surgeons now is to 
 use ether, because it has been shown that fewer deaths on an 
 average occur from its use than from chloroform. As ether 
 rather tends to increase blood-pressure when used as an anaes- 
 thetic, and chloroform tends to lower it, it possibly makes 
 
 82 
 
FORTY YEARS IN THE MEDICAT. PROFESSION 
 
 chloroform the safer remedy in ol)stetrical cases, especially 
 where there are convulsions, and because pain is a vasomotor 
 stimulant. In such cases as contracted kidney, accompanied 
 by hypertrophy of the left ventricle of the heart, where we 
 often have such excessive blood-pressure, also in chronic 
 bronchial troubles, as in old short-neck wheezers, as we may 
 call them, chloroform may be safer. Children have, as a 
 rule, high blood-pressure, and as chloroform is dangerous, 
 as a rule, by paralyzing the vasomotor system, therefore we 
 may generally give it to children with great safety. These 
 are our present lights on the subject. However, science and 
 scientific experimenters never stand still. There is one thing 
 always to remember about chloroform, it is more obnoxious 
 to the kidneys, as a rule, than ether, and has a well-marked 
 devitalizing effect on all nerve-tissue of whatever grade. 
 Again, remember, after anaesthesia, especially prolonged an- 
 aesthesia, and especially in neurotic women, we often have a 
 train of bad symptoms following, that may take months of 
 careful treatment to rectify, and it is well always to watch 
 for and remember such symptoms in all cases after surgical 
 operations. 
 
 There are two proper ways to give an anaesthetic : either 
 use an Allis inhaler, or merely pour the fluid on several folds 
 of gauze; this method cannot be excelled. 
 
 Again, remember, after the use of ether and chloroform 
 particularly, we may have pneumonia, heart troubles, and 
 other circulatory irregularities come on. These cases occur 
 most frequently after pelvic operations and after operations 
 on the tongue and parts adjacent thereto. During my profes- 
 sional life I have seen a few of these cases. They may 
 amount to lobar pneumonia or to broncho-pneumonia, and 
 either may be slight or grave. Examine your patient care- 
 fully if after anaesthesia he presents any circulatory trouble. 
 Before operations on the parts connected with the mouth too 
 much care cannot be taken to render the mouth, nose, and 
 all near parts as near as possible absolutely aseptic, and keep 
 them so, for secondary infection mav readilv occur, and we 
 
 83 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 may have the micrococcus lanceolatus and the streptococcus 
 present at once. It is important in all cases to have the towels, 
 inhalers, or whatever may be used in anaesthesia thoroughly 
 aseptic. There is another condition sometimes coming on 
 after anaesthesia, especially after operations on nervous 
 women. It may come at once or be deferred for some hours, 
 or even days. The patient suddenly becomes greatly de- 
 pressed, with great oppression of the breathing, with all the 
 symptoms of heart-failure. There are no signs of pneumo- 
 nia or other inflammatory troubles, only inability to get a 
 satisfactory breath, which requires prompt attention in the 
 way of heart and other stimulants. The trouble is undoubt- 
 edly of neurotic origin, and may be mistaken for pulmonary 
 embolism, which, of course, might possibly occur under such 
 conditions. The same troubles in a lesser degree sometimes 
 come on during or after alcoholic intoxication. 
 
 At the suggestion of Dr. Norcross, of Philadelphia, oxygen 
 has lately been administered with chloroform with reported 
 good effect. Dr. Thomas S. K. Morton has lately experi- 
 mented largely with the simultaneous administration of ether 
 and oxygen, by an ingenious apparatus. Also the petroleum 
 ether mixture of Schleich is just coming into notice, and may 
 prove a boon to suffering humanity, but its containing chlo- 
 roform has so far been an objection. Simpson, Morton, 
 Wells, and Jackson are dead, but the great work they did in 
 life lives and grows after them. 
 
 During my visit to Europe I travelled generally through 
 Germany, and remained long enough, particularly in Berlin, 
 to get a good insight into medical matters and the medical 
 schools. Germany was then brimful of glory and brimful of 
 sorrow, for she had just emerged from a successful war, 
 which terminated in their great victory at Sadowa, or K6- 
 niggratz, as the battle is most frequently called, over the 
 Austrians. Soldiers were everywhere, and I remember well 
 the grand appearance they made on review and during their 
 drills, and with what contempt they treated those not in 
 accord with them, as when in Hanover the elegant palace and 
 
 84 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 grounds of the poor blind King William were utterly given 
 over to the soldiers, with the grand apartments of the first 
 floor given to the cavalry horses as stables. 
 
 The great surgeon of Prussia at that day was Bernhard 
 von Langenbeck, then in his prime at fifty-six years of age. 
 He was not an imposing-looking man; he had rather a weak 
 face, a sort of so-called jimber-jaw face, but lie was a great 
 man, and lacked neither great courage nor great learning. 
 He was the greatest surgical pathologist of Europe, and was 
 the successor of the great Dieffenbach, in the University of 
 Berlin. He had been doing great work in the war, great mili- 
 tary surgeon that he was, and he looked almost worn out 
 with his labors. Von Grafe, the oculist, was the idol of Ber- 
 lin in all circles, and in his short life probably did more than 
 any man who had lived up to that time to advance everything 
 pertaining to eye troubles, not least of which, by any means, 
 were his researches as to the nature and treatment of glau- 
 coma. Frerichs was one of the leading physicians connected 
 with the Berlin schools, and is now, years after his death, well 
 remembered for his exhaustive treatise on the liver and its 
 diseases. Berlin was full of able doctors, but they had hardly 
 got well into line in their work, everything having been dis- 
 organized by the war. 
 
 Vienna was the great medical centre of Europe at this time 
 outside of London and Paris, and was undoubtedly the IMecca 
 for a great majority of students coming from countries for- 
 eign to Europe. As a clinical school it had no equal then, and 
 has surely no equal to-day, material of all kinds being plenty, 
 both living and dead. I believe there are phlegmatic Germans 
 in Vienna who will hire out to a doctor and allow him to cut 
 ofif their legs for experimental purposes, provided they be paid 
 well for their suffering. Among the great surgeons in Vienna 
 at this date were Schuh, Dumreicher. and Pitha. Among 
 the obstetricians were Professor Karl Braun. celebrated the 
 world over. Professor Spaeth, and Professor Chiari, both 
 great masters and teachers. Among the oculists were Arlt, 
 Jaeger, and Stellwag. Among the physicians was Skoda, 
 
 8s 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 without doubt the greatest diagnostician of his day, but I 
 never looked with much favor upon his treatment, for really 
 I do not believe Skoda gave much thought to treatment and 
 had little faith in the efficacy of remedies. He was an enthu- 
 siast in diagnosis, but not practical in therapeutics. Oppolzer 
 and Tiirk were great all-round physicians, and gave great 
 celebrity to the Vienna schools, especially the former. 
 
 I cannot close this brief reference to the Vienna medical 
 men without mentioning the most celebrated pathological 
 anatomist of his day, Karl Rokitansky. He was rector of the 
 University of Vienna, was worshipped by the faculty of 
 Vienna, and was justly honored by scientists the world over. 
 
 My visit to Germany ended, I commenced my homeward 
 journey, and left Europe with all its wonders in science, in 
 arts, and in culture, thankful for what I had seen and more 
 than thankful for what I had learned. More than that, I left 
 it more than ever satisfied with my own country, with my 
 own people, and that my lot had been cast as a citizen of the 
 United States of America. 
 
 86 
 
CHAPTER V. 
 
 Returned from Europe and Settled in New Castle, Delaware — Its Pecu- 
 liar Freedom from Certain Diseases — The Medical Profession in 
 Delaware — Country Doctors — A. Conan Doyle — Ian Maclaren — 
 Bacteriology Forty Years Ago — Pathogenic and Other Germs — 
 Toxines — Immunity — Inflammation — Operations Forty Years Ago 
 and their Results — Asepsis — Antisepsis — Origin of Life — Sir Joseph 
 Lister — Obstetrics and Antisepsis — Hospital Gangrene — A Strange 
 Coincidence — Surgery away from the Centres — Disinfection — Neces- 
 sity of — Gonorrhoea — Bladder Troubles — Syphilis — Eye Troubles — 
 Gynaecology — Proctor Knott — Appendicitis — Radical Cure of Hernia 
 • — Intubation and Tracheotomy — Fractures and Dislocations — Instru- 
 ments — Rontgen Rays. 
 
 After having returned from Europe, for reasons personal 
 to myself, and which I have no cause to regret, I settled in 
 the little city of New Castle, Delaware, a town of about five 
 thousand inhabitants. I only speak of this because I have 
 found a very peculiar condition existing here, in the territory 
 covered by this town, as to its condition of healthfulness. 
 The situation is on the Delaware River about thirty miles 
 below Philadelphia, and is on a point or peninsula jutting out 
 into the river, with a fall towards the river sufficient for 
 natural drainage. The rise and fall of the tide twice in 
 twenty-four hours is about six feet, and the tidal rate is about 
 four miles per hour. Whilst the town originally was built 
 on a slight bluff, above and below the town are lowlands, 
 protected by substantial banks and drained by tidal sluices. 
 These sluices and banks have always been well cared for, and 
 have given good clean meadow-land. The point I wish to 
 note is this, — and I note it from observation of over thirty 
 years and from statistics gathered from my records of daily 
 practice, which I have scrupulously kept, — the very rare oc- 
 currence, comparatively, on this little point of land on which 
 the little city of New Castle is situated, of infectious, conta- 
 gious, zymotic, or microbic diseases. For over thirty years. 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 with very little let-up, I have been a very busy man in the 
 practice of medicine. In that time I have done probably as 
 much work as a man should do, and among my patients in 
 this town (I omit all cases in my consultation work at home 
 or abroad) I have not averaged five cases each year of croup- 
 ous pneumonia. I mean by croupous pneumonia the infec- 
 tious inflammatory disease, where the diplococcus pneumoniae 
 is probably present, coming on with the chill, the bounding 
 pulse, the flushed cheek, high temperature, the crepitant rale, 
 the bloody sputa, the rapid breathing, and so on, as the case 
 proceeds. I have never seen epidemic croupous pneumonia 
 here. Epidemic croupous pneumonia I look upon as a con- 
 tagious disease, and the mortality is generally high. Non- 
 specific broncho-pneumonia and capillary bronchitis, espe- 
 cially among the young, and which are possibly non-microbic 
 and non-contagious, are probably as common here as in other 
 places near b3^ Now for the apparent reason. The peninsula 
 on which New Castle is situated juts out into the river, with 
 lowlands above and below it. The banks are all thoroughly 
 washed twice each twenty-four hours by the tides of the Dela- 
 ware River, and by this rise and fall of the tides a system of 
 capillary drainage is produced, which acts on the whole town 
 site, stagnation is prevented, and the hosts for the developing 
 of the obnoxious microbes are in a large degree wanting. 
 Other zymotic diseases are rare here, and have been rare, 
 taking thirty years past. Even malarial fevers have never 
 abounded except during the time when the blanket of malaria 
 was over the whole country some years ago, when even the 
 hills of New England were not exempt. I have never seen 
 scarlet fever seriously epidemic here, except upon one occa- 
 sion in over thirty years, and a serious epidemic of diphtheria 
 has prevailed only once, and that when in October, 1878, the 
 great tidal wave swept the shores of the Delaware and carried 
 away the river-banks above and below the town. These re- 
 mained down until the following June, when they were re- 
 stored. Then the dead fish and decaying matter in general 
 furnished a most convenient host for the plants, and diphthe- 
 
FORTY YIlARS IN THE MEDICAL PROFESSION 
 
 ria came upon us in vigorous form. This cxcmiJtion from 
 zymotic disease extends only a short (hstance in the country, 
 below, above, and back of the tow^n, and as we travel west and 
 southwest, and pass the water-shed of the Delaware and ap- 
 proach the Chesapeake, we find, especially, croupous pneu- 
 monia, frequently epidemic and often fatal. 
 
 Among- professions in Delaware the medical profession has 
 always held a high position, and its members have always 
 been prominent in all matters pertaining to good citizenship. 
 The Delaware State Medical Society was founded in 1788, 
 and to this day its organization has been held intact, and its 
 place among like societies in the United States has always 
 been recognized as among the foremost and most zealous. 
 In times gone by the names of many men of prominence have 
 been enrolled in the medical profession, and their descendants 
 to-day are prominent in all parts of the country. Among 
 some of those prominent as practitioners in Delaware in early 
 times, I may mention the names of Tilton, Sykes, Naudain, 
 Clayton, McCalmont, McLane, Lofland, Morris, Vaughn. 
 Couper, Thompson, S. H. Black, Askew, Mitchell, Merritt. 
 Porter, Bush, C. H. Black, Saulsbury, Jump, Hamilton, 
 Whiteley, Kane, Colesberry, Barr, Lowber, and Clark. Most 
 of these men were what we are accustomed to call country 
 practitioners. By country practitioners I mean men prac- 
 tising away from and not within easy reach of the medical 
 centres. This applied in their day more than it does now, for 
 communication is so perfect and rapid in nearly all parts of 
 the country that it is possible for nearly all to keep readily in 
 touch with all centres of trade and business. I know and 
 have known many of these so-called country doctors, and 
 among them are many strong and vigorous men in both mind 
 and body. They are always factors in their neighborhood. 
 Being strong men, they often drift away from pure profes- 
 sional work, and become too much routine practitioners. This 
 is often not their own fault, for, being available men, they 
 are often drafted into politics and into political places by their 
 fellow-citizens, and thus in many cases the public, whilst 
 
 89 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 gaining a good official, loses a competent and faithful physi- 
 cian. It would be much better if physicians working in iso- 
 lated locations would take up some by-study which would 
 help them in their profession, such as botany, comparative 
 anatomy, scientific farming, or horticulture, which combine 
 so much of nature study, rather than drift off into politics, or 
 into the mere routine work of pill-giving and empirical drug- 
 ging- 
 
 I know well a great many country doctors, and I know 
 many of them to be good all-round men, fair general practi- 
 tioners of medicine, good diagnosticians, some very good 
 obstetricians, and some very good every-day surgeons; I 
 know men who have done general amputating; I know men 
 who have done all of the operations in obstetrics, including 
 Caesarean section; and I know of ovariotomy having been 
 done by the country doctor, and successfully, too. These 
 men, like our city friends, have their own troubles ; they have 
 their professional jealousies, their little tilts with one another, 
 their troubles with and from the neighborhood gossips and 
 from ungrateful patients, but they as a class are equal to all 
 emergencies, and can hold their own with the best of God's 
 creatures. 
 
 A little story of A. Conan Doyle's holds up to nature most 
 admirably the feelings and the engendered jealousies and 
 rivalries often seen when anything comes between the head 
 doctor of a small town and the full sway he has been accus- 
 tomed to hold for a long time before. I cannot recall the 
 name of the story, but it is true to nature and abounds in 
 skilful knowledge of human nature. A new doctor comes to 
 town and puts out a sign. We will call him Dr. A. Smith. 
 The old doctor of the place is a man of really great merit, 
 and is somewhat worried over the outset of the new one. He 
 waits for the new one to call, and the new one waits for the 
 old one to call. They do not meet, but the old doctor soon 
 finds out the new doctor is a woman. She proves to be a 
 woman of talent and especially well prepared from hospital 
 experience to do general surgery and eye work, and soon 
 
 90 
 
FORTY YEARS TN T1[E MEDICAL PROFESSION 
 
 makes a local reputation from some fortunate cases, 'i'he old 
 doctor has still never met her, but feels that he is losinpj his 
 pre-eminence to the new woman. The fj]Ji)ortunity comes for 
 the new woman, who is really a fine character. The old doc- 
 tor meets with a runaway accident and serious injury, is car- 
 ried into a near-by house, and the first doctor found and 
 called in is Dr. A. Smith. Of course the first meeting is 
 somewhat embarrassing, but Dr. A. Smith goes to work and 
 at once shows to our old friend she is no novice, but a really 
 skilful and accomplished surgeon. Well, Doyle elaborates 
 the story very artfully. The case goes through very favora- 
 bly, the doctor recovers, and the two become inseparable com- 
 panions. Every one reading the story at this point makes up 
 his mind they will marry. Doyle brings it out differently. 
 Dr. A. Smith soon leaves the small town, goes to a large city, 
 and becomes a great specialist. Every physician should read 
 this little story, and see how " one touch of nature makes the 
 whole world kin." 
 
 Ian Maclaren says he has often been asked the question, 
 Was there ever any doctor so self-forgetful, and so utterly 
 Christian, as William MacLure, the hero of his " Doctor of 
 the Old School"? To which he replied, as he said, on his 
 conscience, not one man, but many, in Scotland and in the 
 South Country. Should I be asked the same question, I 
 should answer, on my conscience, yes. I have known more 
 than one William MacLure in the medical profession. No 
 set of worthy men ever had a greater compliment paid them 
 than had the country doctors when Ian Maclaren took one 
 of them as the hero of his lovely and pathetic story of " A 
 Doctor of the Old School." 
 
 That medicine to-day is a progressive science and not the 
 empiricism of the olden times is shown very plainly when we 
 review the course of surgery in the last forty years. Even 
 during this short time surgery has advanced from a mere 
 empirical art to true scientific methods. The surgeon is no 
 longer a mere mechanic, but must be truly a scientific man in 
 all that the name implies. The great advances have been all 
 
 91 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 along the line, in diagnosis, in manual procedure, in technique, 
 in his armamentarium, and, above all, in the magnificent re- 
 sults of the cases treated. 
 
 Forty years ago, bacteriology played little or no part in 
 surgical diagnosis. We knew little of the saprophytic or of 
 the pathogenic bacteria. We knew little of the habitat of 
 germs, or of the parasitic nature of many of the pathogenic 
 germs, or that some could live in both dead and living animal 
 matter and some in dead tissue alone. We knew little of the 
 nature of germs, of their life history and of their require- 
 ments for existence. We knew little or nothing of the tem- 
 perature required for their growth and development, or of the 
 effect of sunshine on their prosperity, all very practical points. 
 Now we know much about them. We knew nothing of how 
 bacteria were propagated, nor that the spores were much 
 more difficult to destroy than the parent, another important 
 point in practice. Every living thing generates its own poi- 
 son, and, it follows, so do bacteria. The growth of the 
 colony is limited by the poison it generates, and hence we 
 have toxines. Some of these toxines are fermentative, or 
 ptomaines so called, which are cadaveric alkaloids and very 
 poisonous to animal life, as most of us in the course of a life- 
 time know from bitter experience. Ice-cream poison cases, 
 cream-puff poison cases, fish poison cases, are the most promi- 
 nent. Others of these toxines are called toxalbumins, and are 
 more or less synonymous with the ptomaines as to results. 
 Bacteriology has advanced to such a point as to have become 
 a great life-study and work within itself, and the different 
 germs can be grown like potatoes, and their life history can 
 be studied with absolute exactness and detail from laboratory 
 cultures, and again by inoculation into the lower animal life; 
 and Koch's law requires this culture growth and reproduction 
 of the original through inoculation into the lower animal. 
 
 By this study of the life history of germs we find how they 
 infest the body, how they enter, whether by skin or mucous 
 membrane, or otherwise, or by the mouth only, as the comma 
 bacillus of cholera. We have also learned how they are elimi- 
 
 92 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 nated or excreted from the body, and also the symptoms they 
 produce, and the resistance the animal body fjffers to them, 
 being the difference between health and disease, for none of 
 us know how many thousands of millions are bustling about 
 us and lurking in our throats and other parts of our bodies, 
 the fortunate escaping all ill effects, the unfortunate succumb- 
 ing to many of the ills " flesh is heir to." After all, we are 
 all exposed; it all depends upon the soil the germs light on; 
 those that fall on, to them, good soil carry misery and death 
 in their train, whilst those that fall on stony ground perish, 
 and individual life goes on with unconcern ; immune, we say, 
 the subject is. 
 
 Now, this question of immunity is a burning question, and 
 the production of artificial immunity is in the direction of the 
 great strides being made to-day in bacteriology, and sufficient 
 has been done in diphtheria, not mentioning hydrophobia, an- 
 thrax, tetanus, and other diseases, to have already written one 
 of the most brilliant pages in the history of medicine. Here 
 again practically every living thing generates its own poison, 
 for the great Pasteur took the opposite course to antitoxins 
 when he recommended the starting of a deadly epidemic by 
 inoculation of a few individual specimens with a toxine or 
 disease to rid Australia of her rabbit pest. The great advance 
 made in bacteriology was in the staining of the germs to be 
 examined, and has made possible the great advances made in 
 examining by the microscope many of the pathogenic germs. 
 Take, as an example, Ziehl's solution for coloring tubercle 
 bacilli, following the usual technique. The bacilli that most 
 concern the surgeon are those mostly concerned in suppura- 
 tion of some kind, — the staphylococci, comprising pyogenes 
 aureus and pyogenes albus ; the streptococci, the gonococcus, 
 the bacillus coli communis, or the bacterium coli commune. 
 The bacillus pyocyaneus is found in the greenish pus — the 
 pus we see, or rather formerly saw, for \ve aim not to have 
 pus now about wounds — coming from wounds profusely 
 when granulations are just commencing, causing renewed 
 vitalit}^ in the condition, creamy, laudable pus. The Klebs- 
 
 93 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Loeffler bacillus, the germ of diphtheria, also concerns the 
 surgeon. The bacillus tuberculosis is a most important germ 
 which the surgeon now has to know of and deal with, which 
 only a few years ago he did not dream of as a cause of the 
 troubles he was endeavoring to relieve. Especially is this 
 the case in bone surgery. Also the germs of anthrax, hydro- 
 phobia, glanders, tetanus, and others concern him. 
 
 Forty years ago, in any medical school, upon the advent of 
 a new professor, his standing in the profession and his ability 
 to fill the position was generally measured by his views on 
 inflammation. Even at this day there was little solid knowl- 
 edge, but it was usually looked upon as a fire to be quenched, 
 as it were, by water ; for water, and little of it, was about the 
 diet presented under the antiphlogistic system, and this was 
 freely purged away, although it was about this time that Dr. 
 Tod began his advocacy of opposition to the extreme antiphlo- 
 gistic school, urged on, perhaps, by the well-known views and 
 practice of Robert Graves, the great Dublin physician; and 
 probably both were in a measure followers of Cullen, who 
 was among the first to discountenance the abuse of venesec- 
 tion. 
 
 In looking over an old book on surgery published nearly 
 fifty years ago, I read, " The operator must bear in mind the 
 great principles of all sound practice, — viz., the treatment of 
 inflammation. Is the wound to heal by first intention or by 
 granulation? Is the object of the operation to be attained by 
 exciting inflammation, or will its development destroy the 
 result? Is the action to proceed simply to the effusion of 
 lymph, or to suppuration?" One man is quoted as always 
 purging his patients during the after-treatment of capital 
 operation to prevent inflammation. Many years ago Pro- 
 fessor S. D. Gross wrote to me in regard to a case that had 
 not gone on well, using at the end of his letter these words : 
 " God knows surgery is not a sinecure, but a most corroding, 
 soul-disturbing profession." Were he alive to-day, with the 
 use of modern methods, his case would have gone on well, 
 and he would not have needed to pen such pessimistic senti- 
 
 94 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 ments; althoug-h, in the main, they still hf)l(l true, for surgery 
 doubtless is, with all the help given it by modern methods 
 and modern ideas, " not a sinecure, but a most corroding, 
 soul-disturbing profession." 
 
 Thirty-five years ago Gross's idea of inilammation was that 
 in considering it, it was necessary, first, to consider the nature 
 of the capillaries in which the morbid action is mainly carried ; 
 secondly, the character of the blood which is so singularly 
 changed in inflammation ; thirdly, the part played by the 
 nervous system ; and fourthly, the condition of the tissues at 
 the seat of disease. This definition conveys the advanced 
 ideas of that time, and really throws no light on the subject; 
 and to show this is why I refer to it. He speaks of changes 
 wrought in the blood, etc., its color, arrangement of globules, 
 bufify coat, etc., the white and red corpuscles stopping the 
 capillaries and producing stagnation, and so on to the prod- 
 ucts of inflammation. He also thought the nerves played an 
 important part in inflammation. There was no hint yet in 
 those days of zymosis, although the germ theory of disease 
 had been talked about. He did not think inflammation was 
 necessarily attended by suppuration, as Miller, the Edinburgh 
 surgeon, did. Gross thought inflammation, as a rule, should 
 be treated by the lancet, low diet, mercury, blisters, and all 
 the antiphlogistic remedies ; yet he said there was a period in 
 almost every attack of severe disease when the patient would 
 need brandy, wine, quinine, and nutritious food. 
 
 I have quoted Gross at length as one of the great authori- 
 ties of the time I refer to, in order to contrast his ideas with 
 those of to-day, where what we know of inflammation is not 
 mere guesswork and empiricism, but approaches the exact 
 results of scientific work. The surgeon to-day, as of old, 
 recognizes inflammation by pain, redness, swelling, heat, and 
 impaired function; and by the results of microscopical ex- 
 amination he gets definite information as to its cause, etc. 
 It may be said that he recognizes bacteria, or rather, more 
 broadly, microbes, as the cause of all inflammation, be the 
 original cause what it may, whether accident, disease, or 
 
 95 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 injury. There may be exceptions here, as in such a disease 
 as gout, but in this day of wonderful discovery we are not 
 even sure of that. Here, then, is absokite tangible evidence 
 as to the cause of inflammation, the great bugbear of forty 
 years ago, when all definitions were mere guesswork, for 
 the reason that scarcely anything was known of the true 
 cause of the condition. Oh, how the great men of that day 
 floundered in the mire of ignorance ! Yet the new professor 
 just called to his chair was usually gauged as to his ability 
 by his lecture on inflammation. The improvements in micro- 
 scopes and their collaterals, together with the improved meth- 
 ods and technique, have done everything for the surgeon, and 
 when we come to add to this the practical application of 
 knowledge thus attained by such men as Pasteur, Cohnheim, 
 Senn, Park, Tyndall, and Lister, we commence to see the why 
 and the wherefore of the great march of surgery, from the 
 ranks of an empirical art to the broader domain of a great 
 science. 
 
 When I was a hospital resident the surgeon came in from 
 the street, took off his gloves, probably his coat, then his 
 shirt-cuffs, rolled up his sleeves, and was ready for work. If 
 he washed his hands as a preliminary, it was for his own 
 comfort, not from any thought of saving his patient from any 
 contamination ; nor did he give a thought to what case he had 
 come from, as to whether or not he might carry trouble to 
 the operatee. The assistants came from any ward they hap- 
 pened at the time to be in, and prepared themselves about as 
 the chief had done before them, and took about the same pre- 
 cautions, and these precautions aimed chiefly at their own 
 convenience. In the well-appointed hospital utensils were of 
 course kept scrupulously clean and neat, but there was no 
 attempt at sterilization or thought of germs. The instru- 
 ments were spread on a tray, fresh from their receptacles, 
 looking clean, from the washing and wiping after their last 
 use. The dressings were simple, — lint, bandages, and proba- 
 bly a jar of cerate, and adhesive plaster. If the case was a 
 ward case, the parts to be involved in the operation were gen- 
 
 96 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 erally shaved and washed the (hiy hefore. If the case was a 
 recent accident just in, and sliock had passed off, the patient 
 was at once taken to the operating-room, placed on the table, 
 and etherized, and then and there his clothing, at least the 
 part involved, was removed, the parts were shaved and washed 
 with soap and warm water, and he was ready for the sur- 
 geon. 
 
 The operation completed, the dressing was simple. For an 
 amputation of the leg below the knee, for instance, sutures, 
 adhesive straps, a Maltese cross of sheet lint, covered with 
 simple cerate over the stump, and retained by a simple roller 
 of cotton cloth. Drainage was seldom or never used. This 
 was usually removed within the first forty-eight hours, and 
 the case treated as occasion required to the end. Suppuration 
 was always very free ; pus cavities often formed ; erysipelas, 
 secondary hemorrhage, or gangrene might come at any time, 
 depending much on the condition of the patient or of his en- 
 vironment. 
 
 In the Philadelphia hospitals, especially in the Pennsylva- 
 nia Hospital, the great accident hospital of that day, erysipe- 
 las, with all its attendant surgical horrors, was common in the 
 winter months, especially in the months of February and 
 March. The cause of this is apparent : the house closed 
 against inclement weather confined the germs and checked 
 them from floating out on the air currents, as they did when 
 doors and windows were open. Now this has all been changed 
 by methods so simple and so perfect as to make us stand 
 amazed that no one had ever perfected it before. I say per- 
 fected, for many before the days of Lister appeared to have 
 inklings of the germ theory of disease and of their ill effects 
 in wounds of all kinds, whether surgical or accidental. For 
 asepsis and antisepsis, the credit of their development and the 
 first rules of application is universally accorded to Sir Joseph 
 Lister, now Lord Lister, and no great title was ever better 
 earned or more worthily bestowed. Other great scientific 
 experimenters are almost equally worthy, among them the 
 great Pasteur, Tyndall, Schwam, Koch, Theodor Billroth, 
 7 97 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 and others, all uncrowned kings among men, worthy, living 
 or dead, of the homage of all mankind. 
 
 Up to within recent years we were all at sea in regard to 
 the origin of life, of the ultimate element, and the scientific 
 man, the theologian, the materialist, the Deist, and the infidel 
 all had their theories, and some men thought to be among 
 the ablest among those living, had full faith in spontaneous 
 generation. This theory at last was completely nullified by 
 the grand work, especially of Pasteur and Tyndall, and that 
 within thirty years. As to the origin of life, according to 
 Virchow, science can only recognize one cause, previous life. 
 " Omnis cellula e cellula," " Omne vivum ex vivo," are his 
 declarations. Spontaneous generation has no claims for him. 
 Creation does not satisfy him. His idea of the origin of life 
 is life itself; beyond this he cannot lift the veil. Without 
 saying so, whatever is beyond he leaves to the discussions of 
 theology and theologians. 
 
 The recognition of the germ theory of disease, of the lower 
 orders of life as the cause of disease, of the parasitic nature 
 of all fermentative or zymotic diseases really brought about 
 the recognition of antisepsis in surgery, and the recognition 
 of antisepsis brought about the recognition of the necessity 
 for the aseptic condition — of asepsis. Lister's first practical 
 work was in the nature of antisepsis. He taught the necessity 
 of having everything made clean about operator, assistants, 
 the patient, the instruments, the dressings, and the environ- 
 ment, and, in addition, he impregnated the atmosphere, the 
 operator, the patient, the assistants, and everything concerned 
 with germicidal sprays. I will never forget my first experi- 
 ence. It was at the Pennsylvania Hospital. Dr. Thomas G. 
 Morton, with Agnew and Hunt, was making an ovariotomy. 
 The steam-atomizer was started early in the preparations with 
 a carbolic acid solution, and when all was finished I do not 
 know that I could say who had been in most danger, patient, 
 operator, or lookers-on. It was a most unpleasant experience 
 in every way, but the patient developed no septic symptoms, 
 nor did anybody suffer more than temporary inconvenience. 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 As time passed on it was soon found that all these formali- 
 ties were not necessary, that it was not air contact, bnt mate- 
 rial contact with wounds that was most to be dreaded; in 
 other words, render everything — operator, patient, assistants, 
 dressings, brushes, and the general environment — aseptic be- 
 fore doing the operation. Instead of germicidal poisons for 
 instruments, dressings, etc., we rely on steam, boiling water, 
 and formaldehyde solutions, and for patient, operator, and 
 assistants, scrubbing, scrubbing, scrubbing, with water, soap, 
 ether, and formaldehyde solutions, until all living parts to 
 come in contact with living parts are thoroughly and abso- 
 lutely aseptic. I have amputated a thigh, using only two 
 per cent, formaldehyde solution, and had best results and 
 no pus. There are some glaring defects yet that I am sure 
 we must remedy before we get perfect asepsis. It has been 
 found that in coughing and sneezing over an agar plate, 
 and then examining after a proper interval, colonies of bac- 
 teria were developed. Here is a source of infection from the 
 surgeon or assistants. To remedy this all must wear gauze 
 masks, and the coming surgeon zvill zvcar them. The coming 
 surgeon will also wear gloves of some kind, of a kind that will 
 least blunt his sense of touch. These will be especially neces- 
 sary in military surgery and where asepsis cannot be rigidly 
 practised. Think of the changes wrought by these methods. 
 They can only be appreciated by those who had experience 
 in large hospitals or in military life, or in obstetrical practice 
 previous to twenty-five years ago. 
 
 Before asepsis had been so thoroughly impressed on obste- 
 tricians puerperal fever often raged in communities for 
 months, and the mortality often became fearful. In large 
 cities like Philadelphia and New York it was very often epi- 
 demic, and sporadic cases were always occurring, and made 
 the life of the obstetrician one of dread and horror, and the 
 safety of all lying-in women was in great jeopardy. Whilst 
 many medical men recognized its contagiousness, and de- 
 clined other cases whilst attending it, others denied its conta- 
 giousness and, we now well know, spread it far and wide as 
 
 99 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 they passed from case to case. To-day traumatic erysipe- 
 las, if there is another kind, is comparatively unknown, and 
 the results in compound fractures are simply miraculous, 
 and operations never dreamed of thirty years ago are now 
 performed with impunity and great success. Antiseptics 
 have also invaded the domain of the skin specialist, but 
 it is in military surgery where asepsis and antisepsis are 
 bound to show their great efficiency, in the prevention of 
 much cruel suffering and in the saving of thousands of 
 lives. Those of us who had experience in our late Civil 
 War, and those who saw the slaughter wrought by gan- 
 grene, secondary hemorrhage, and allied horrors, now en- 
 tirely preventable by antiseptic methods, surely can appreciate 
 the great work done by Lister and his followers, and can 
 never cease to thank God for giving such instrumentalities to 
 man for the alleviating of human suffering and the lessening 
 of human anguish. The great distress in war in those days 
 was not at the front in the excitement of battle, nor during 
 the excitement of the primary operations on the field during 
 and after the battles. The horrors came generally a few days 
 afterwards, in the rear, when sloughing, gangrene, and sec- 
 ondary hemorrhage became rife and made life a burden not 
 only to the poor patients, but to the surgeons and all those 
 engaged in helping them. 
 
 The remedies used for gangrene and its allied troubles were 
 numerous, and were limited in number only by the names in 
 the pharmacopoeia. Bromine was the great remedy. The 
 dead parts were cut away and the bromine applied with a 
 glass rod to the sound tissue, which it destroyed by oxidation, 
 and thus had germicidal action. Proper aseptic precautions 
 were not thoroughly taken, and little headway, as a rule, was 
 made against the disease, and reamputations, of course, were 
 generally followed by gangrene in the new stump. I used 
 Monsel's salt, the powdered subsulphate of iron, very freely, 
 and thought I got better results than from bromine. 
 
 When I think of these cases of hospital gangrene, second- 
 ary hemorrhage, and the like, the most affecting scene I ever 
 
 lOO 
 
FORTY YEARS IN THE MEDICAL PROEI-ISSION 
 
 witnessed always comes up l)efore me, and there is a very 
 strange coincidence connected witli it. A young officer, an 
 only son, a thoroughly fine and noble fellow from one of the 
 New England regiments, was fatally wounded in the spine 
 during one of the engagements in Grant's Wilderness cam- 
 paign. He was brought to the rear, and I had charge of him 
 in one of the hos]:>itals. I became interested in him. As he 
 lingered on, his mother and sister, very nice people, came 
 from their home to see him and do what they could to help 
 him. He lasted only a short time, in great suffering. On a 
 beautiful, warm, moonlight evening he was rapidly sinking, 
 his distressed mother and sister hovering over him, when 
 suddenly, without any collusion, a near-by band slowly and 
 softly struck up the dirge very familiar in those days, which 
 runs about as follows : 
 
 " Soon with angels I'll be inarching. 
 With bright laurels on my brow ; 
 I have for my country fallen, 
 Who will care for mother now ?" 
 
 Just as the last notes died away, — " Who will care for 
 mother now?" — his soul passed to the great beyond, and his 
 terrible sufferings ceased forever. Of all the sad and pathetic 
 scenes I have witnessed, this was the saddest and most pa- 
 thetic. Such is war, which now again after many years is 
 coming towards us with rapid strides, and again just such sad 
 and pathetic scenes may be witnessed in the land. There is 
 one consolation, sufifering will be much less among the sick 
 and wounded, there will be little or no gangrene and second- 
 ary hemorrhage, and every soldier will be, or should be, pro- 
 vided with dressings with which to bind up his own or his 
 comrade's wounds temporarily, until the surgeon shall get 
 him and bring to bear his skill, aided by modern methods and 
 modern ideas. Thus the great world moves on. 
 
 Since the introduction of antisepsis and asepsis the pre- 
 paring the environment of the patient has become equally as 
 important as preparing the body of the patient. This is easy 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 to accomplish in the well-constructed modern hospital, where 
 everything- has been made to conform to this end. In a pri- 
 vate house this is much more difficult, often impossible, and 
 even when attempted the whole scheme may be spoiled by 
 some thoughtless member of the family invading the apart- 
 ment with untidy dress, or fresh from some deadly infection. 
 For this reason I do not hesitate to advise patients who are to 
 undergo operations of almost any kind to seek a well-regu- 
 lated hospital, where they may obtain the best surgical advice 
 and take quarters suited to their purse, either in the wards or 
 in private apartments, where they may obtain comforts equal 
 to our best hotels, and where at a moment's notice good sur- 
 gical service may be present for any emergency. 
 
 I have done a good deal of surgery during my professional 
 career, but in practice away from the centres it is hard and 
 exacting work. Since the advent of the trained nurse it has 
 improved somewhat, but when a man does a capital operation 
 he is apt to be disturbed at any moment and very often, day 
 or night, during the first day or two, for if even a drop of 
 blood appears on the dressing the doctor is summoned at once, 
 and to a man weary already from overwork this anxiety be- 
 comes almost unbearable. Under all circumstances, I believe 
 it better for the patient and for the doctor to send all but 
 emergency surgical cases to a well-regulated hospital. Hos- 
 pital work is an absolute necessity for a successful surgical 
 career. This is the very opposite to the advice I should have 
 given thirty years ago. Then the average hospital was a 
 pest-house to be avoided in all cases where operative inter- 
 ference was required. So much for the evolution of science 
 in germ destruction. 
 
 Disinfection is now carried on to include the whole town 
 under the supervision of boards of health, and the technique 
 is applied to houses and their surroundings, to the sick-room, 
 utensils, receptacles for sputa especially, and for the alvine 
 evacuations. Indeed, the disinfecting organization should 
 doubtless always follow the doctor. Under modern methods 
 and care the vile spitting habit is being much curtailed, for, 
 
 102 
 
FORTY YEARS TN TFTE MEDICAL PROFESSION 
 
 besides its filthiness, it is a j,n-c<it factor doubtless in spreading 
 disease. Tbe whole tendency t(j disinfect is spreading, but 
 not any too rapidly. All places of resort should be regularly 
 made as nearly aseptic as possible; so shoukl all public con- 
 veyances, especially the sleeping-apartments of cars and boats, 
 churches, hotels, schools, especially water-closets and such 
 apartments, for undoubtedly the most loathsome diseases may 
 be induced by contact in such places. School-books and library 
 books should be regularly disinfected, and there is no doubt 
 in the world that more care should be exercised by barbers as 
 to absolute cleanliness, and all their tools should be sterilized 
 each time before use. All such rules apply with equal force 
 to dentists, and, of course, to physicians too, whether caring 
 for man or beast. There is one thing that should be carefully 
 avoided, — never use a catheter, speculum, or instrument of 
 any kind in a cavity lined by mucous membrane without first 
 thoroughly sterilizing it. This is readily done by boiling 
 glass and metal instruments, and if made of rubber, soak 
 them from ten to fifteen minutes in one to one thousand 
 bichloride solution or in a two per cent, formaldehyde so- 
 lution and then thoroughly wash with water that has been 
 boiled at least twenty minutes. The surgeon's hands also, of 
 course, should be sterilized, as should the lubricant used, and 
 also the organs of the patient and their surroundings. These 
 rules should apply to both males and females. There is a 
 formalin sterilizer for instruments and all dressings now on 
 the market which is simple, cheap, and effective. The forma- 
 Hn is put up in solid tablets, and a simple lamp furnishes the 
 heat. You will thus avoid cystitis and other horrors in your 
 patients. Physicians should protest to patients against many 
 of the habits characteristic of human beings, such as rubbing 
 the eyes with the unprotected fingers, for no man knows when 
 he touches a door-knob, for instance, but that some one before 
 him may have left the gonococcus or some vile germ as a 
 parting legacy to closing the door, and a gonorrhoeal oph- 
 thalmia may follow to an innocent victim. The possibility of 
 such accidents by some such means should be instilled into 
 
 103 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 all, and many a sorry victim may be saved from all the hor- 
 rors of syphilitic and other infections. The hands of every 
 man, woman, and child should be sterilized daily. Cleanli- 
 ness should be taught to all and practised by all. " Cleanli- 
 ness is next to godliness," and self-preservation, the first law 
 of nature, is the coming great factor in the carrying out of 
 this proverb. The scales are falling from the eyes of man ; 
 science is pointing the way; he begins to see that, living in 
 filth, he, like all living beings, generates his own poison, and 
 that the philosophy of rational existence is wash, wash, wash, 
 scrub, scrub, scrub. Instilling such methods into his patients, 
 the physician becomes what he should be, a public teacher, 
 and thus becomes more and more than he even now is, a public 
 benefactor. 
 
 As I look forward to the coming branch of the profession 
 which shall bestow on mankind its greatest benefits, to that 
 branch which shall shed its most brilliant lustre upon the 
 world at large, I see always looming up before me, before all 
 others, the one great light, — the forerunners of which are 
 antisepsis, asepsis, general technique, and absolute cleanliness, 
 — the coming grand practical work, preventive medicine. As 
 to antisepsis and asepsis in obstetrics, they are of great im- 
 portance, or rather, I will say, absolute care and cleanliness 
 on the part of physician, patient, nurse, and all the help 
 around the woman and the entire inorganic environment 
 should be scrupulously clean, and kept scrupulously clean, 
 during the labor, and the whole lying-in, not forgetting the 
 child, both for its own sake and for the mother's. If we have 
 sufficient warning of the case, the apartment should be pre- 
 pared as for a surgical operation, and all articles to be used 
 during labor should be kept in this room, first having been 
 sterilized by heat, wet or dry. When labor begins the patient 
 should be absolutely cleansed and dressed by the nurse, having 
 first cleansed herself, and no other unprepared person should 
 approach the patient during her labor. When the doctor ar- 
 rives he should wash up thoroughly, and doubtless should 
 wear a clean sterilized linen overall gown and rubber gloves, 
 
 104 
 
FORTY YI-ARS IN TJl)-: MEDICAL I'ROFKSSION 
 
 and own an incubator to be absolutely en regie. If the case 
 goes normally, the doctor and nurse need no assistance. 
 Cleanliness is the rule to the end. 1 f operations are necessary, 
 they must be done absolutely under antiseptic ])recautions. 
 In cathetcrizaticju especially, be careful t(j be cleanly. The 
 nurse may use one good vaginal douche of corrosive chloride 
 of mercury one to five thousand, to be followed at once by 
 one of water at the first cleaning up, and after that, if any are 
 used, use only sterilized water. Be sure the syringe is asep- 
 tic, or you do more harm than good. I prefer acetanilide or 
 boric acid to iodoform for use, if necessary, on both mother 
 and child. Solution of formaldehyde will probably be the 
 antiseptic most used in these cases in the future. During my 
 professional career I have delivered a great many w^omen, and 
 performed about all of the obstetrical operations, from Caesa- 
 rean section down, and I think, in fact I know, I can more 
 than count on the fingers of my two hands all of the septic 
 cases I have had. Absolute care as to cleanliness and careful 
 technique has been my rule. 
 
 What I have said before applies to cases where we can 
 elect just what we are to do, and do it secundum arteni. 
 What about the other cases? — the cases where you are called 
 just on the eve of the birth of the child, or, may be. find the 
 child born on your arrival ; the woman in unclean apart- 
 ments, with unclean surroundings of every kind, including 
 the granny and officious neighbors just run in, the woman 
 herself unclean? Well, just do the best you can. Do all you 
 can to clean yourself and make others clean around you. 
 There is a proverb that '* God takes care of little children and 
 drunken men." We may add to this, the average lying-in 
 w^oman. Do as you may, you cannot get aseptic conditions 
 in the average private house, in the average private lying-in 
 patient, in the average attendants on these cases. All you 
 can do is to do the very best you are able, and trust in the 
 Lord; and I must say the Lord is very kind to these poor 
 sufferers. One thing favors patients in general obstetrical 
 practice, especially when away from the medical centres : the 
 
 105 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 normal ^'agi^a will take care of a few of the average germs, 
 whether pathogenic or benign, and physicians away from 
 centres are much less liable to carry contagion than those 
 constantly exposed in the crowded districts. Always remem- 
 ber one thing: if exposed to a septic case, especially if you 
 have handled a case, particularly an abdominal or a pelvic 
 case, where sepsis has been well established, wash as you 
 may, use germicides as you may, you cannot make your hands 
 aseptic in less than forty-eight hours, and you run the risk 
 of taking the life of any surgical or obstetrical case you ap- 
 proach within that time. Under aseptic methods the public 
 hospital is now just as good and desirable for surgical cases 
 as the same hospital was undesirable and unfit twenty-five 
 years ago. To-day the public lying-in hospital, instead of 
 being a charnel-house, is above all other places the safest and 
 most desirable place for the confinement and treatment of par- 
 turient women. Indeed, it is the only possible way to give 
 them aseptic accouchement with absolute aseptic surround- 
 ings and conditions. In my judgment it would be well now 
 if every community had its lying-in resort, to which any 
 woman could fiee as a safe refuge in her great trials. I have 
 little doubt that the coming woman will have such refuge and 
 generally avail herself of it, with men and women as special- 
 ists in obstetrics, which will insure more perfect aseptic condi- 
 tions than the general practitioner can give. 
 
 In abortion or miscarriage, any time before the viability of 
 the foetus, antiseptic precautions are of great importance, and 
 I think much of the blame given to the use of the intra- 
 uterine curette is because we are not sufficiently careful of 
 antisepsis in its use. If you find you cannot check the prema- 
 ture expulsion of the ovum, say before the fourth month, do 
 not hesitate to use an antiseptic tampon, made of any material, 
 — iodoform gauze, bichloride gauze, or of house rags even, — 
 soaked with bichloride one to four thousand. Often we have 
 to take the best material we can find. Use a boric acid douche, 
 and pack in the tampon well ; give ergot and quinine, and in 
 from twenty-four to thirty-six hours you should find the 
 
 io6 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 ovum unruptured in the vagina, with no necessity of entering 
 the uterus either with the finger or instrument. Give a hot 
 vaginal boric acid douche if you choose, also intra-uterine, at 
 once, and nature and good care will do the rest. It is the 
 ruptured ovum that gives the tnnihlc. This must be gotten 
 rid of promptly, if possible, especially if there be the least 
 odor, and here the curette comes in. The patient should be 
 thoroughly washed externally, and physician and nurse 
 should also thoroughly wash up antiseptically. .Use the hol- 
 low curette invented by the great Vienna obstetrician, Carl 
 Braun; they come in sets of three, — one spoon, one sharp, 
 and one dull, with a common handle to screw on. Attach 
 your curette to a fountain syringe containing your fluid, and 
 then you can irrigate as you curette. Curette a uterus with- 
 out these precautions, and you run great risk of infecting 
 your patients. Be rough, tear the lining membrane of the 
 uterus, and thus infection may enter. Be rough, and you 
 even may go through the organ. 
 
 There is another trouble which will bear watching, — viz., 
 laceration of the cervix during labor, either by the foetus, by 
 instruments, or by the hand of the obstetrician. Here we 
 may have free and even fatal hemorrhage. Of course, the 
 surgical way is to draw out the uterus, which, with the proper 
 instruments, can easily be done in its relaxed condition, and 
 suture and tie the vessel or vessels if necessary, which will 
 not often be necessary. When in a position where you cannot 
 do this, and this often may happen, pack the laceration with 
 lint or absorbent cotton, or any porous material, soaked in 
 liquid subsulphate of iron, and the case must be a very serious 
 one, indeed, if the hemorrhage does not stop at once. The 
 iron itself is an antiseptic, and a good one. Injections of hot 
 water may be tried, and will often be found to succeed. Bear 
 in mind this injunction: whenever you have hemorrhage 
 from the genital tract in a woman, watch it. Alwa}'s find out 
 the cause and the point where from. There are many causes, 
 as we all know, of such hemorrhage. If it happen to be of 
 malignant origin, delay is fatal. Glandular involvement 
 
 10- 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 comes on, and your patient is lost. An early diagnosis gives 
 the surgeon his opportunity and the patient her one and only 
 chance. This \ve are learning every day. 
 
 In malignant disease, where possible, operate early, operate 
 radically, avoid hemorrhage, and hence avoid shock. On this 
 line S. W. Gross and Halsted have been pioneers among us. 
 This rule applies to the little crack on the lip which does not 
 heal. Do not let the glands near it enlarge before you get 
 rid of it. This rule applies to rodent ulcer and to lympho- or 
 other sarcomas. Then do not wait for them to spread by the 
 blood-vessels before you get rid of them. 
 
 Genito-urinary surgery, like general surgery, has greatly 
 benefited by modern methods and modern ideas. First, as 
 to gonorrhoea in the male. Forty years ago we knew little 
 or nothing of its pathology. Now we know it is caused by a 
 specific micro-organism, the gonococcus of Neisser. I wish 
 I could say as much for the treatment. Forty years ago we 
 thought ourselves fortunate if our patients were free in six 
 weeks ; to-day we are satisfied if we can dismiss them well in 
 about the same time. It might be supposed, knowing the 
 cause, and that cause a microbe confined to a small and easily 
 approachable space, all we had to do would be to apply a ger- 
 micide and that would end it. Not so. It is a question 
 whether germicides are ever efficient applied to microbes on 
 mucous membrane; whether to be successful they must not 
 reach beyond. There are some new silver salts coming up 
 now for which great claims are made, but upon what scien- 
 tific grounds I do not as yet know. In my experience the 
 average case of gonorrhoea does just as well, and very many 
 of them much better, especially as to unfortunate sequelae, 
 when treated by rest, at least as much as we can get the pa- 
 tient to take, a very restricted diet, as near to sterilized milk 
 as we can get, urethral irrigations of sterilized water, with 
 absolute general cleanliness, the wearing of a suspensory 
 truss and a protecting bag for the penis, with a little absorbent 
 cotton in the end, dampened with a little of a one or two per 
 cent, formaldehyde solution. 
 
 io8 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Until we can assure ourselves of a successful application 
 to destroy the micro-organisms, I am almost sure the fore- 
 going is the safest and best treatment for the average case of 
 gonorrhcea in the male. Always be sure to warn your patient 
 of the danger of infecting his own or other persons' eyes by 
 reckless use of hands, towels, etc., and in treating gleets al- 
 ways combine dilatation of the urethra with your treatment. 
 As to the silver salts, I would prefer protargol. For simple 
 clap, first stage, with the gonococci present, inject three to five 
 times in twenty-four hours, preferably warm, a penis syringe- 
 ful of one per cent, solution, holding it several minutes. This, 
 like all injections, at first causes smarting and increases the 
 discharge. After four days the gonococci should diminish 
 and also the discharge; then use the injection twice only in 
 twenty-four hours, and when gonococci have disappeared use 
 simple astringent injections. If this happy result is main- 
 tained in a number of cases, in more than my experience yet 
 justifies, it would go to place protargol as a germicide to the 
 gonococcus. For posterior urethritis, irrigate with a quarter 
 of one per cent, solution of protargol, preceding it by a boric 
 acid irrigation, with salol by the mouth. For the deep ure- 
 thritis which causes so much sufifering, apply locally a few 
 drops of nitrate of silver solution, one to one thousand. 
 
 In the female about the same rules will apply. AVe know 
 now that here the urethra is most often involved, and that the 
 walls of the vagina are sometimes, but not at all in very many 
 cases. The best treatment is by irrigations of urethra and 
 vagina and uterus when possible, distending the vagina to its 
 utmost limit so the fluid may come in contact with all parts, 
 and by the use of suppositories of cocoa-butter, etc. There 
 is one serious trouble following gonorrhoea in the female 
 which has come to the front in the evolution of bacteriology 
 and gynaecology, — viz., gonorrhoeal salpingitis, which may 
 be acute or chronic: so always look out for it. for many a 
 poor virtuous woman suflfers from it. as a result of connubial 
 infection, for no one knows the limit of life of the gonococcus 
 of Neisser, and man may carry it as long as he has the least 
 
 109 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 remnant of a gieety discharge. As a rule, I think its life 
 limited, and colonies like the colonies of micro-organisms 
 generally, generate their own poison and die. Toxines de- 
 veloped in the urine of the individual may destroy them and 
 be one way of cure, but from the nature of the case, these 
 gleet cases are exceptions, and these exceptipns are the sad 
 cases. 
 
 In epididymitis, orchitis, and other sequelae of gonorrhoea 
 there has been little change to note in the treatment. You 
 may still take your choice, from strapping, puncture, suspen- 
 sion, rest, and a diet as near sterilized milk as possible. In 
 the treatment of strictures of the male urethra antiseptic sur- 
 gery has helped much, as septic troubles now must rarely fol- 
 low treatment of such by operation. Thirty years ago the 
 treatment by divulsion was common, and Holt's instrument 
 was in the hands of most genito-urinary surgeons. This 
 method has deservedly fallen into disuse, and dilatation, in- 
 ternal urethrotomy, external urethrotomy with and without a 
 guide, and resection of the stricture and suture of the urethra 
 are now most in vogue. 
 
 Operations for exstrophy of the bladder now have a better 
 chance since the introduction of antisepsis, but at best are not, 
 as a rule, satisfactory. Surgeons do not hesitate to attack 
 any part now, and great advances have been made in the 
 treatment of all bladder troubles, and particularly of troubles 
 involving the prostate, and by the able work of White and 
 others castration and division of the vas deferens, and 
 even more radical operations on the prostate itself, promise 
 some relief to sufferers from such afflictions. The relief for 
 stone in the bladder has somewhat changed. Thirty years 
 ago, the lateral operation was almost universally used, the 
 bilateral rarely, the median operation being sometimes used 
 for small stones. Then, greatly through the work of Sir 
 Henry Thompson and Civiale, lithotrity became much used; 
 and after this, by aid of Dr. Bigelow, of Boston, litholapaxy, 
 or removing the stone by aspiration after crushing, became 
 most frequently used. Now the old operation of suprapubic 
 
 no 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 lithotomy has been revived, and is often and very successfully 
 done. Much credit is due to Dr. Charles Winslow Dulles, of 
 Philadelphia, for work done in reviving this very easy and 
 rational way of relieving so serious a trouble. The chief 
 danger to be feared after this operation is a fistulous opening, 
 which may decline to heal, and thus give great trouble. 
 
 In syphilis there have been many changes during forty 
 years, but whether it is of microbic origin or ncjt is not yet 
 known. We no longer hear of unicists and dualists. We 
 know now that chancre is the initial lesion of syphilis, and 
 that the chancroid or soft chancre is not a syphilitic lesion, 
 and is never followed by syphilitic infection. We know Ricord 
 was right when he said chancre was not auto-inoculable as 
 chancre, and that chancroid is auto-inoculable. We know 
 that bubo following chancre is hard, and that following chan- 
 croid often suppurates. We know now that we may have a 
 mixed initial lesion, being a chancre and chancroid coming 
 on the same spot. I am uncertain about this, but it may let 
 many a man out on diagnosis, at any rate; and when doubt- 
 ful, treat it as a chancre anyhow. Forty years ago ever}- 
 effort was made to eradicate the chancre as soon as it ap- 
 peared, strong caustics being used; and excision was prac- 
 tised at Blockley, and is even now in vogue. It was formerly 
 thought this getting rid of the initial lesion might abort the 
 disease, but I do not think this idea holds now, and the local 
 treatment is chiefly antiseptic. Do not order iodoform for 
 your patient, or you convict him at once wherever he goes 
 among men about town, and no man reeking with the stink of 
 iodoform is fit to associate with his fellow-man. Chancroids 
 are not now, as a rule, cauterized, but treated with antiseptic 
 dressings, as carbolic acid, corrosive sublimate, solution of 
 formaldehyde, or the old black wash. For bubo after chancre, 
 constitutional treatment, and for bubo after chancroid, treat 
 antiseptically, and by injecting carbolic acid and such reme- 
 dies and dissecting out parts of glands not broken down by 
 suppuration. In the treatment of secondar}- symptoms we 
 still rely on mercury and the iodides, as of old. Inunctions 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 and ftimigations are still used. The newer form of treatment 
 is by hypodermic medication, and, if your patient will submit 
 to it, is useful, if your case is pressing. When you give 
 iodide of potassium alone, give it in milk ; it adds greatly to 
 its tonic and, I think, to its specific effect. If iodide of potas- 
 sium does not agree, give iodide of sodium; it is just as 
 effectual. Now and again you will find a case unable to touch 
 iodine in any form. This is unfortunate for the patient. 
 Coryzas, skin eruptions, and other troubles make his life 
 miserable whilst taking iodine. Mercury and some of the 
 antisyphilitic vegetable remedies are your only resource. 
 
 Decided advance has been made in the treatment of the 
 tertiary stages, especially in syphilis of the nervous system, 
 and wonderful results are obtained by heroic doses of the spe- 
 cific remedies. One thing we know in regard to the acquire- 
 ment of syphilis : it is often acquired by virtuous people inno- 
 cently. The secondary as well as the primary lesions are 
 contagious, and the only wonder is that it is not spread much 
 more generally than it is. A knowledge of this fact should 
 make us impress on all the absolute necessity of great care in 
 using public drinking-cups, of the danger of promiscuous kiss- 
 ing, and all such useless modes of greeting mere acquaint- 
 ances ; in fact, let it be generally known that the most loath- 
 some of diseases lurks wherever human beings congregate. 
 When your boy is growing up, teach him to confide in you, 
 and if ever troubles of this kind cause him suspicion, have a 
 course laid out for him to pursue, either to come to you or go 
 to his physician, and thus avoid what probably may be to him 
 absolute ruin, for this comes to many a good boy, who is un- 
 fortunate in this respect, and most are victims to the cupidity 
 and ignorance of quacks or the ever-ready drug-store clerk. 
 I have practised medicine too long not to have met scores of 
 sad cases. The best advice I can give to the young man is 
 contained in two short lines : 
 
 " Pollute not with a harlot's cheek 
 Those lips made sacred by a mother's kiss." 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 In the siirg'cry of the eye j^rcat advances liave been niarle 
 since 1 entered the pn^fession, and date from about the time 
 when Von Graefe gave to the profession his classic on " Glau- 
 coma: Its Nature and Treatment." As to glaucoma, I have 
 seen in consultation a number of cases, especially of acute 
 glaucoma, where a failure to recognize the condition early 
 caused lamentable trouble and loss of vision. Careless or 
 ignorant practitioners are very liable to slip up on glaucoma, 
 and we cannot be too careful to have our wits about us when 
 such game is around. Another point here : where glaucoma 
 is suspected, or your patient is over forty years old, be careful 
 of the use of atropine as a mydriatic. There is an apparent 
 contradiction here, too, among experts, for atropine is said by 
 some to lessen tension of the eyeball, and this is what we 
 need in glaucoma. Horatio Wood says be careful of it, be- 
 cause the dilatation of the pupil causes the iris to press against 
 the spaces of Fontana, and that it may impede or stop the 
 lymph circulation in these spaces, which have been already 
 narrowed by disease. Hydrobromate of homatropine and co- 
 caine are better and safer mydriatics for general use, as their 
 effects pass off in a iew hours, while the effect of a thorough 
 application of atropine sulphate lasts a number of days. Eser- 
 ine has the opposite effect of atropine, and has been a great 
 help to the ophthalmic surgeon since its introduction. This 
 is such an important matter, and so much harm may be done 
 by general practitioners in the use of atropine, that I think 
 the following rules are worthy of study by all : ( i ) Use it 
 in iritis at any age, old or young, but in young children be- 
 ware of too strong solutions, or constitutional symptoms of 
 poison may arise. (2) Use it in ulcer of cornea and in kera- 
 titis. (3) In refractive work in patients under forty use it. 
 but homatropine is better ; also use it as a mydriatic in persons 
 under forty, but cocaine and homatropine are probably better. 
 (4) Do not use atropine in conjunctivitis. (5) Never use 
 it in glaucoma. 
 
 Antisepsis has also done as much to help the oculist in his 
 results as it has done in general surgery, and it is wonderful 
 8 113 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 what the eye endures in such appHcations. but the results jus- 
 tify the means used over and over. Local anaesthesia, since its 
 comparatively recent introduction, has been the great boon 
 to both patient and surgeon in eye cases. Cocaine is chief 
 among these, and it is wonderful to see the effect of the dis- 
 tillation of a few drops of a four per cent, solution into an 
 eye. In most operations it has taken the place of general 
 anaesthesia, and reduced pain and unfavorable results to a 
 minimum. Speaking of local anaesthesia, it has done just as 
 much for general surgery. Cocaine is the base of most of it, 
 but not all. Freezing mixtures which work by rapid evapo- 
 ration, like ethyl chloride, rhigolene, and such, are very useful 
 in minor operations. Schleich's method, by cocaine and mor- 
 phia and local distention by the subcutaneous injection com- 
 bined, is effectual, but has not yet generally commended itself 
 as practical. The late Professor Theophilus Parvin was a 
 strong advocate of this plan. Cocaine is not a remedy to 
 trifle with; it may cause serious trouble from subcutaneous 
 use, and one may soon become a cocaine fiend from frequent 
 application of a solution or powder to mucous membrane. 
 Beware how you recommend it in hay fever and such trou- 
 bles! 
 
 To return to the eye. Great advances have been made in 
 treating errors of refraction and such troubles by glasses, 
 and many are now made comfortable, where formerly their 
 inconvenience was ever present, and many a luckless school- 
 boy or girl, who thirty years ago would have been hustled 
 into a corner as a dullard, has now become the bright scholar 
 of the school-room and the fond hope of parents. 
 
 Ear surgery has made wonderful advances, and under the 
 leadership of C. H. Burnett, of Philadelphia, followed by 
 Randall and others, great relief has been afforded to sufferers. 
 Equally good work has been done in throat work, and all 
 such work has been taken from the domain of general surgery 
 and become special work. 
 
 During the last forty years we have seen a new branch of 
 surgery entirely, and since the introduction of antisepsis we 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 have seen the most wonderful results. Operations have been 
 clone never even dreamed of before, and thousands of lives 
 saved which before this advent would have been doomed to 
 cruel suffering and premature death, i refer to gynaecology. 
 J. Marion Sims was the great pioneer and master here, and 
 his great work was done for the cure of vesico- vaginal fistula. 
 Dr. T. A. Emmett has also been a shining light in this branch 
 of surgery, and first performed vaginal cystotomy for the 
 relief and cure of cystitis in the female. McDowell made his 
 first ovariotomy in 1809, and no great advance was made 
 beyond this until within the last fifty years. Since then the 
 whole system of gynaecology has been really built up, and now 
 nothing is too hidden or intricate to be delved after, and an 
 exploratory incision through the abdominal walls is thought 
 no more of than would have been the amputation of a finger 
 when McDowell commenced the great w^ork. Gynaecology 
 is among the most alluring of all the specialties in medicine, 
 and where a few years ago there were only a few here and 
 there in the denser centres of population, to-day they number 
 many in the surgical corps of every city in the world, and the 
 merest tyros in the business perform operations which a short 
 time ago would have confounded a McDowell or a Sims. Ob- 
 stetrics and gynaecology are now combined, and the obstetri- 
 cian is necessarily a surgeon; very different from what it 
 was when I w^as a student at the University. Then the pro- 
 fessor of obstetrics rarely touched a knife, and, indeed, the 
 professional etiquette of the day compelled him rather to seek 
 the surgeon in surgical cases, as Charles D. Meigs sought 
 William Gibson in his celebrated Csesarean section case, the 
 case where Meigs delivered the woman twice after craniot- 
 omy, and Gibson delivered her twace by the Cassarean sec- 
 tion. Although no anaesthetic was used, the woman declared 
 the knife made the easiest delivery. Such operations have 
 since been much changed and modified, and the child, uterus, 
 and appendages are all frequently removed at one time, as 
 was first done by Porro. I made the eleventh Porro Caesa- 
 rean section in this country, in the case of a rachitic dwarf 
 
 115 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 with a collapsed pelvis, complicated with uterine fibroids. 
 The child weighed eight pounds, and the uterus, tumors, and 
 appendages weighed eight pounds. The woman died several 
 days after from exhaustion, but the boy is now a sturdy 
 youth, large and well developed in every way. 
 
 General surgery now attacks the abdomen in various ways, 
 and, wonderful, indeed, what appears to be almost super- 
 natural work is done daily; in fact, none of the cavities are 
 exempt from the surgeon's hand ; the skull, the chest, and the 
 abdomen are all within his circle. Brain surgery has as yet 
 not produced the most encouraging results, and operations 
 for epilepsy and such affections are unfortunately as yet far 
 from encouraging. In traumatic conditions wonders are ac- 
 complished. In the chest also great and successful work is 
 done daily, and anything may be expected as occasion arises. 
 In the abdomen the surgery of the kidney, and even of the 
 liver, is daily expanding, and great relief is now afforded in 
 cases only recently given over to hopelessness and despair. 
 Intestinal surgery shows the most remarkable results : wounds 
 are closed, long lengths of the intestines are removed and the 
 ends joined by various methods, as by Murphy's buttons and 
 such like, and recovery of organ and function follows as a 
 matter of course. Indeed, only recently the stomach has been 
 removed, the ends of the intestine and oesophagus joined, and 
 the patient recovered and enjoyed her food, thrived and did 
 well, thus upsetting all theories of physicians, surgeons, and 
 especially of the physiologists. 
 
 Speaking of Murphy's buttons, some time since a success- 
 ful operator took one from his vest pocket, remarking that it 
 had been through patients fourteen different times, and I 
 think in one of its journeys consumed forty days in its wan- 
 derings before passing out. What will not happen! When 
 Proctor Knott made his celebrated speech in Congress, poking 
 fun and ridicule on the young city of Duluth, it was consid- 
 ered a great hit and worthy of a great humorist. To-day 
 Duluth has grown to be a great town, and more than justifies 
 in its reality and greatness all that Knott said of it in fun and 
 
 ii6 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 satire, and more, much more. So it is in incdiciiie; it is a 
 progressive science truly, and in the futine nothing that may 
 happen can surprise or emharrass us. liven the exaggeration 
 of the old countryman's story, told in the wayside inns of 
 many years ago, may not startle us. lie iiad some bowel 
 trouble, and sent for the doctor. The doctor arrived, made 
 his diagnosis, and without further formality sent for a sheep, 
 cut open the man and also the sheep, cut ofT many feet of the 
 man's bowel, did the same to the sheep, attached the sheep's 
 to the man's, sewed him up and left, remarking that the sheep 
 would make good mutton. The doctor some time after, meet- 
 ing his patient, asked him how he felt. " Oh, first rate, doc- 
 tor, except the beastly hankering I have after grass." 
 
 Appendicitis is the trouble that has excited the most in- 
 terest among both physicians and laymen in recent years. 
 Of course, it has always existed and has always been treated, 
 and in many cases recovered through medical treatment alone, 
 as they do now, and doubtless many cases died that would 
 now be saved by operation. There are, of course a number 
 of troubles in the region of the right iliac fossa which do not 
 involve the appendix, but if inflammation goes on, every- 
 thing in the end becomes in^^olved. Many cases that for- 
 merly passed as obstruction of the bowels, and died as such, 
 probably involved the appendix and its surroundings. Is the 
 condition generally spoken of as appendicitis more common 
 than formerly? Personally I have little doubt but that it is. 
 The causes may be various. It appears to be rather common 
 in young, vigorous men, those who are given to athletics, 
 cycling, and such exercise, especially suffering, it appears to 
 me, although I have no statistics on the subject. Rheumatism 
 and gout are thought to contribute to the cause of true in- 
 flammation of the appendix. What effect toxines may have 
 in producing it, toxines introduced by the food or developing 
 from the food are to be taken into account, I think, aj- a cause, 
 for the reason that we are consuming food, cold-storage food, 
 canned food, and preserved foods of all kinds in large quanti- 
 ties, all of Avhich might be in shape to produce more or less of 
 
 11/ 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 toxine troubles as affecting the digestive tract, far beyond the 
 possibiHty of such action which the sound fresh foods of for- 
 mer years could possibly have produced. Probably the most 
 frequent cause of appendicitis is the bacillus coli communis, 
 and these very sources of food we have been speaking of, I 
 think, are surely one of the great causes of the increase of 
 such micro-organisms in the bowels of human beings. 
 
 Inflammation of the gall-bladder is another disease on the 
 increase, and is also doubtless most frequently caused by this 
 same bacillus coli communis. Thus we see how our knowl- 
 edge of the cause of disease advances just in proportion as 
 our knowledge of pathogenic germs grows. Appendicitis 
 and cholecystitis are probably the most frequent causes of 
 peritonitis, and both are now cured by the surgeon. This 
 colon bacillus may often cause embarrassment in diagnosis 
 of troubles within the peritoneal cavity. A healthy man may 
 bolt a lot of under-done beef. The digestive juices are nat- 
 urally antiseptic, and this undigested mass passes to the colon. 
 What a lovely host for the bacillus ! They are soon evolved 
 by the million, a subacute colitis is set up, which may or may 
 not run on and involve the appendix and its surroundings, or 
 the bacilli may pass up and involve the gall-bladder ; even a 
 rigor and fever may follow from toxaemia set up, and yet in 
 the end there may be no pus, but the patient will be lucky to 
 escape pus formation with all which that implies. The ner- 
 vous system will play a part; an urticaria may be set up; 
 urticaria is doubtless a vasomotor neurosis, and ptomaine 
 poisoning to a greater or less degree will be responsible for 
 these symptoms. There may be other factors, but I look on 
 these I have mentioned as some, at least, of the causes ren- 
 dering appendicitis, a grave trouble, of more frequent occur- 
 rence than formerly. 
 
 Since the developing of antisepsis there has been a revival 
 of operations for the radical cure of hernia. I remember 
 assisting Dr. Agnew in a number of his operations by his 
 method, and one or two did well for quite a long time; but 
 I never thought he greatly favored the procedure as a very 
 
 ii8 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 satisfactory one as to results. S. I). Gross never had any 
 faith in the radical cure; that is to say, he gave it little atten- 
 tion as a practical measure so far as my experience with him 
 went. I have seen the result of some good work recently 
 done by Dr. T. S. K. Morton, and so far it is good and very 
 promising as to later results. Halsted, of Johns Hopkins, 
 and Fowler, of the New York Polyclinic, have also lately 
 done some good work by modifications of Bassini's operation, 
 the anterior displacement of the cord. Fowler's modification 
 is somewhat complicated, but seems to greatly strengthen the 
 original procedure of Bassini. Injections of irritants into the 
 tissues about the rings have been advocated and practised, but 
 not with sufficient success in my experience to recommend it, 
 yet I am fully persuaded that sufficient progress has been 
 made in this direction to cause surgeons to give it very care- 
 ful attention and study. Time alone can show the results in 
 such work, and I trust, for the sake of suffering humanity, — 
 one in five suffering from hernia in some form, — general 
 relief may come in good time to all by operation. 
 
 Tracheotomy has seen quite a revival during recent years, 
 and by the work of Wharton, of Philadelphia, and others the 
 mortality has been reduced in these terrible cases of laryngeal 
 stenosis. Intubation, introduced and made an every-day prac- 
 tical procedure by O'Dwyer, has taken the place in a great 
 measure of tracheotomy, especially in children. The trouble 
 in tracheotomy in these cases is to get parents to consent to 
 the operation before it is too late. Intubation comes in most 
 opportunely in just such cases, for almost any parent is willing 
 to allow the use of the tubes, and they doubtless are destined 
 to save much agonizing suffering and many lives. Besides 
 the many operations on the eyes and ears, and the general 
 operations of the gynaecologist, which are comparatively re- 
 cent, I may mention excision of the lower end of the rectum 
 for malignant disease. This extensive operation is now- fre- 
 quently done, and W. W. Keen has been very successful in a 
 number of cases. It is wonderful how' long those who recover 
 from the operation live before a return of the original trouble. 
 
 IIQ 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 I kno\y of one case of Ransley's in good health after more 
 than six years. Of course, before the rectum operation a 
 colostomy is done. 
 
 Many operations on the brain are now done and are com- 
 paratively new, but, as before mentioned, cases other than 
 traumatic ones are not encouraging. Wyeth's method of 
 amputating at the hip is comparatively new, and an improve- 
 ment on old methods; and so is Gant's operation for defor- 
 mity after hip-disease. Electrolysis for aneurism, with the 
 addition of Stewart's method by wire, promises some good 
 results in these desperate cases, as does Massey's method of 
 cataphoric treatment in malignant disease. Litholapaxy is 
 an introduction of recent years, and is a great addition to the 
 armamentarium of the surgeon. Aspiration came to us from 
 France, and is one of those methods so simple and useful, the 
 wonder is we did not always have it. Sutures of tendons and 
 nerves, neurectomy, and radical operations on the ear, breast, 
 bones, and joints are among the advances of recent years; 
 and transfusion of blood and injection of normal serum are 
 in high contrast to Mackintosh's bleeding in the cold stage of 
 ague and his saline solution treatment of cholera. The treat- 
 ment of spinal deformities by application of direct force is 
 very new, and promises good results in the young. Removal 
 of the entire larynx has become an operation any surgeon may 
 now attempt, for Billroth and J. Solis Cohen have, among 
 others, established the precedent, and even an artificial larynx 
 has been supplied. The surgery of the thyroid has made ad- 
 vances, and Green has been a pioneer in method and practice. 
 I might name many other advances and improvements in 
 operative surgery, but what I have said is sufficient to indi- 
 cate its methodical and rapid advance as a science and an art. 
 
 The hot-air treatment, thermotherapy, is coming into ex- 
 tensive use in surgery, and bids fair to afford relief in selected 
 cases, especially in recent sprains and in many forms of joint 
 trouble, both acute and chronic. Each case is treated from 
 thirty to sixty minutes, and from one to five heatings are used, 
 depending on the condition present. The temperature em- 
 
FORTY YEARS IN THE MEDICAT, PROFESSION 
 
 ployed runs from 250^' to 350'' F., or even hij^licr. After the 
 heating a protective dressing is applied and immediate use of 
 joint recommended. Charles Lentz & Sons, Philadelphia, 
 manufacture an efficient apparatus. i'Vactures and disloca- 
 tions are becoming more and more generally and better un- 
 denstood, and the masterly work of Allis and Roberts and 
 Hamilton has added much to the simplicity of treatment aufl 
 to the attainment of good results. Indeed, the whole ten- 
 dency is to simpler methods and less cumbersome and less 
 complicated apparatus, and surgeons are every day beginning 
 to see and learn that because a man has a broken limb, he is 
 not necessarily to be strung up and bound on all sides like an 
 Indian papoose and made to suffer torture tenfold beyond 
 what his accident has imposed upon him. Among the great 
 improvements in apparatus have been the discarding of the 
 Physick Dessault and such splints, and their substitution by 
 sand-bags and weights, with adhesive straps for extension, 
 and the throwing away of the horrible perineal band, and 
 substituting position to bring about the counter-extension. 
 The fractures that are common, and which have given me 
 in my experience the most trouble and anxiety, are those of 
 the lower end of the radius, the condyles of the humerus, 
 which I have often seen mistaken for a dislocation, the neck 
 of the femur, the clavicle, the patella, and compound fractures 
 of all kinds. The jaw is frequently fractured, and in all con- 
 ceivable ways, but the jaw-bone is a wonderful bone, and, as 
 the pugilist says, difficult to knock out, and often when we 
 think, from the necessity of the case, we will have a bungle 
 in the cure, this grand old bone comes up smiling and in good 
 shape and ready for another round. The patella is often 
 troublesome, and wiring is now a favorite procedure, with 
 antiseptic precautions. The clavicle is especially apt to be 
 followed by deformity, and in children is particularly hard 
 to hold with the position of upward, outward, and backward. 
 The simpler the dressing the better, and this applies to all 
 fracture-dressings. In compound fractures antisepsis has 
 done wonders for us in relieving our anxiety and saving thou- 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 sands of limbs. In fractures at the lower end of the radius, 
 be sure and get in position at once, the sooner the better after 
 the accident, and you have won half the battle. In fractures 
 of the condyles of the humerus and of fractures involving the 
 elbow- joint, treat, as a rule, by placing the arm in strong 
 flexion and keeping it there. 
 
 The Rontgen rays are a great help in diagnosing fractures, 
 and the skiagraph picture generally shows the exact trouble. 
 Whilst it is a boon to the surgeon, it may be also a bane, for 
 doubtless many damage-suits will be brought on what it re- 
 veals, whether the result be good or bad, whether the surgeon 
 be fortunate or unfortunate, skilled or ignorant. 
 
 In surgical and other instruments since forty years there 
 has been great improvement in quality, in style, and general 
 make-up, besides the introduction of a great many new and 
 valuable inventions. During the decade between 1850 and 
 i860, Charriere was the great maker of Paris, and had a 
 world-wide reputation and clientage, and only second to him 
 was Liier, also of Paris. In New York Tiemann was the 
 noted manufacturer, and in Philadelphia were Schiveley, 
 Gemrig, Lentz, Kolbe, and others. Of all the new instru- 
 ments, counting from forty years back, there is no doubt in 
 my mind as to which has proved of the greatest use and help 
 not only to the surgeon, but to the patient as well. This in- 
 strument is the little haemostatic forceps, with the scissor 
 handle and the aseptic joint. Take, for example, a case of 
 excision of the mammary gland, and let one follow a rapidly 
 operating surgeon, and with the old-fashioned tenaculum and 
 forceps catch up the bleeding vessels. You stick, you jab, you 
 pinch, and after a while you get them, the surgeon or an as- 
 sistant stops and ties, and goes on; again you stick and jab 
 and pinch ; the surgeon stops and ties again ; and so on to the 
 end of the operation. Much time has been consumed, and 
 your patient has lost much blood, enough, indeed, possibly to 
 turn the scale against her. With the hsemostat all is changed ; 
 the surgeon operates rapidly, as a vessel bleeds, the hsemo- 
 stat clicks in the hands of an assistant, he drops it, the hem- 
 
 122 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 orrhage is cliecked, and the surgeon goes on, and soon com- 
 pletes his work. After this he leisurely ties off and removes 
 the hasmostat, and the whole operation is finished and an 
 infinitesimal amount of blood has Ijeen lost. The h^emostat 
 was a gift to the profession from the gynaecologists, I think 
 from the great French surgeon Pean, and they use them in 
 all shapes and in all sizes, and thus save themselves much 
 wear and tear, control their tempers, and rescue many imper- 
 illed lives. The Rontgen rays are coming more and more 
 into use as aids to diagnosis, both in medicine and in surgery, 
 and I have by me now a good illustration, where, among the 
 first in this country, and surely the first in the State of Dela- 
 ware, Dr. William H. Hancker, superintendent of the Dela- 
 ware State Hospital, at Farnhurst, in the suburbs of New 
 Castle, located a ball in a lad's foot, a patient of mine, that 
 had been buried there for several years. At the present time 
 it is possible to obtain a skiagraph of almost any foreign body 
 or lesion. 
 
 There has been a general evolution of electrical devices to 
 the benefit of medicine, which it is not necessary to refer to 
 here. In catheters there has been marked improvement, and 
 to-day the soft-rubber instruments are effective for all pur- 
 poses, and in great contrast to the wretched metal devices of 
 years ago. Professor Kelley, of Johns Hopkins, catheterizes 
 the uterus and thus assists greatly in the diagnosis of renal 
 troubles. The centrifuge is a great help in microscopic work, 
 and is one of the new and valuable instruments recently per- 
 fected. Uterine dilators are of many kinds, metal and rubber, 
 and serve their part as helps to gynaecologists and obstetri- 
 cians; so do cephalotribes, axis-traction forceps, and differ- 
 ent specula; wires of different metals, the animal ligatures 
 and sutures, atomizers, various new styles of tourniquets, and 
 elastic bandages are among the great helps to the modern 
 surgeon worth mentioning in this connection. The endo- 
 scope has been in use for some A^ears. We had it tried in 
 Blockley in 1864 in the urethra, but not with great practical 
 success. The laryngoscope was then new, and Dr. J. Solis 
 
 123 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Cohen first used it in that hospital, and as one of the masters 
 in that work has Hved to see its use extend to all parts of the 
 world where civilized man has a foothold. Different forms 
 of suspension apparatus and jackets for spinal deformities 
 have come with recent years, and are now indispensable in the 
 treatment of all such troubles, and success has increased pari 
 passu with their advent. The improvement in rubber goods 
 has given us very perfect stomach-pumps, stomach syphon 
 tubes, and feeding-tubes, and these have caused great ad- 
 vances in the treatment of stomach ailments and in feeding 
 the recalcitrant insane and those who from any cause are un- 
 able to swallow. 
 
 I will speak of one more instrument, one of the most valu- 
 able we possess, and one that has done so much to soothe the 
 pains and keep up the courage of suffering humanity, and 
 that is the little hypodermic syringe. The first one I ever 
 owned I bought of Liier, in Paris, in 1866, and to this day it 
 has served me well. It is first class in every respect, has gold 
 needles, and I have used it continually in all kinds of cases, in 
 all kinds of diseases, and with many and various fluids, and it 
 has never failed me. I have seen numerous patterns, and have 
 several, one without a piston, and easily made aseptic, but none 
 better than my old Parisian friend. During my experience in 
 the United States army of more than two years, from 1862 to 
 1864, I never saw one or had seen one, and I do not remember 
 that they were on the list of hospital supplies. I know, in Phil- 
 adelphia, in i860, the favorite anodyne was an enema of fifty 
 drops of laudanum in a tabespoonful of warm water or thin 
 starch, or a rectal suppository of butter of cocoa, with a salt of 
 morphia or extract of opium or powdered opium, in combina- 
 tion sometimes with belladonna or some such remedy. Where 
 the hypodermic syringe originated I do not know, but I have a 
 suspicion that the hypodermic method of administering rem- 
 edies was first used by a physician in Wisconsin or Iowa, or 
 one of our northwestern States; and if so, he probably had 
 the first instrument. 
 
 The clinical thermometer is another instrument not appre- 
 
 124 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 ciated by those wlio have entered the profession in recent 
 years as it is l)y those who can compare its every-day use with 
 the times when we were without its airl. ft is a help of the 
 very utmost importance, as every one knows, in the general 
 treatment of cases and in diagnosis. Take a case of suspected 
 appendicitis : here the thermometer is our right-hand weapon 
 in giving us hourly temperatures, and in from twenty-four to 
 forty-eight hours we can almost allay or confirm our suspi- 
 cions. So in suspected incipient tuberculous troubles, the 
 daily moderate evening use of temperature, should the case 
 present such a chart for a number of days, would go far to put 
 us on our guard for further confirmations. 
 
 125 
 
CHAPTER VI. 
 
 Post-Mortems, etc., Forty Years Ago — Treatment of Pneumonia Then 
 and Now — Heart-Troubles — Digitalis, etc. — Auscultation and Percus- 
 sion — Vivisection — Improvements in Pharmacy — Dangers in Drugs — 
 Sugar-Coated and Compressed Literature — The Blood — The Trolley 
 — The Bicycle — Preventive Medicine — Diagnosis — Wall Diseases — Ni- 
 trification — Malthusian Theory— Diphtheria — Croup — Sir Morrell Ma- 
 kenzie — Tetanus — Immunity as to the Sting of the Honey-Bee. 
 
 Forty years ago there was little known of bacteriology as 
 a science, and little heed was taken of such matters in medi- 
 cine. Pathology was in its infancy as compared with the 
 present day, although Wiinderlich and Rokitansky were lay- 
 ing the foundation for great advances along all lines. In the 
 post-mortems made in the hospitals in this country at the 
 period of which we are speaking, say previous to 1866, the 
 eye and the touch were the chief aids brought to bear in 
 examining specimens. 
 
 There were few expert microscopists available, and the 
 work done was of the most primitive kind. Learned profes- 
 sors had their own ideas and opinions, and these ideas and 
 opinions were generally derived from some one equally em- 
 phatic who had preceded them, probably amplified from time 
 to time as light gradually began to show itself on the medical 
 horizon. Yet most of their ideas and opinions had not fact, 
 scientific or otherwise, for their basis, but an absolutely em- 
 pirical origin; in other words, true science had not yet 
 dawned upon medical practice and medical thought; and 
 this was not long ago, either, but in full memory of many 
 of the most active men in the profession to-day. The treat- 
 ment of a case of croupous pneumonia at this period will well 
 illustrate the condition. Auscultation and percussion were 
 well understood, and the physical condition of the lungs 
 would have been carefully noted. Bleeding from the arm 
 
 had well-nigh yielded as a remedy, but wet cups would prob- 
 
 126 
 
FORTY YEARS IN THF^: MEDICAL PROFESSION 
 
 ably have been applied and veratnim viride have taken the 
 place of the lancet. The temperature wcnild have been judged 
 by the touch, if any thought had been given to it, and the 
 pulse at the wrist would have been the guide as to the pa- 
 tient's condition, together with the noting of the respiration 
 and the character of the sputa. Antimony would probably 
 have been given in the first stage, with the antiphlogistic diet, 
 but not too much water. In the second stage calomel and 
 opium would have come in, and in the latter part of this stage 
 blisters to the involved lung; and after this some increase of 
 nourishment, and alcohol, probably, to some extent, if the 
 physician in attendance was an advanced thinker. Note the 
 difference to-day : The physical and rational signs would be 
 most carefully noted, the temperature, as indicated by the 
 thermometer, would be scrupulously watched, so the pulse, 
 the respiration, the condition of the skin, the stools, and the 
 sputa, the latter studied microscopically and otherwise. The 
 jacket poultice, or, much better, the dry jacket, would take 
 the place of the wet cups and blisters, and ice-bags might pos- 
 sibly be applied, or cold sponging. Strychnine would be used 
 as occasion required, and digitalis with scrupulous care, 
 watching it when the heart is weak and the lung solid ; with 
 alcohol also, and probably the inhalation of oxygen, and pos- 
 sibly subcutaneous injections of cultures of the pneumococcus. 
 
 Liquid air, or, rather, liquefied air, — which is the air we 
 breathe deprived of its heat, which heat came originally from 
 the sun, — it is claimed, can now be produced commercially, 
 and this being true, we can get air absolutely free from 
 germs, can cool such apartments as hospital wards and keep 
 them at a temperature when germs of contagion will not prop- 
 agate, and if we need the stimulating effects of an excess of 
 oxygen free from the contaminations which now are so ob- 
 jectionable to its practical use, we can get it at will. 
 
 Now, as to the difference in mortality between the two 
 treatments. Medicine is now a progressive science, and I trust 
 the mortality in croupous pneumonia is decreasing, but it is 
 well to remember it is a self-limited disease, and not be too 
 
 127 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 active in treatment in all cases. I believe the sheet-anchor in 
 the treatment of this disease to-day to be good, sound, dry 
 champagne. If from any cause the inky dry French wine 
 cannot be obtained, get the dryest American wine you can 
 find. If this cannot be gotten, use the best sherry or other 
 wine you can get hold of, in equal parts of carbonic acid 
 water. The carbonic acid gives zest to the drink, whatever it 
 may be, and appears to me to have some specific action in all 
 diseases of the respiratory tract. 
 
 As to digitalis, one of our most useful remedies, I know of 
 no medicine which is oftener used ill advisedly, wrongfully, 
 and ignorantly. To speak of a remedy in heart lesions, or 
 functional heart disturbances of any kind, is a suggestion to 
 many medical men of digitalis, with no thought of scientific 
 or rational basis for its use. Improperly administered, it may 
 and perhaps does cause or hasten sudden death. Take a case 
 of aortic insufficiency : acting through the motor ganglia 
 of the heart, it stimulates the ventricular contractions, thus 
 overwhelming the heart by the increased back current of 
 blood and causing instantaneous stoppage and death. Thus a 
 man's chin drops, and he is dead whilst talking to you. In 
 aortic stenosis we probably always have compensatory hyper- 
 trophy; when this begins to fail, the patient's condition be- 
 comes very uncomfortable. Digitalis may be cautiously ven- 
 tured on here, for it undoubtedly has a tendency to hasten 
 and keep up compensatory hypertrophy, but I am very chary 
 of it in all lesions of the aortic valves. In pure hypertrophy 
 of the heart never use it. It increases blood-pressure fear- 
 fully, and puts a fearful strain on the capillaries and even 
 larger vessels of the brain, and the kidneys particularly. Some 
 combine it with nitroglycerin and strophanthus to counteract 
 its force. Although strophanthus itself lengthens diastole, 
 and thus increases arterial pressure, it does not change the 
 caliber of the vessels through the vasomotor system. In 
 mitral stenosis and mitral insufficiency digitalis is useful and 
 gives great comfort in these distressing cases so often accom- 
 panied by dropsy and cardiac asthma. In mitral stenosis the 
 
 1 23 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 orifice is narnm^cd, and is thercfcjre too small to let out the 
 coliinin of blood that must come through in a given time, 
 therefore the heart struggles and hurries and wabbles, of 
 course the auricle behind dilates, the right side of the heart 
 becomes congested, and on the left side the blood-pressure is 
 lowered. Here digitalis comes in : it gives force to the ven- 
 tricular contractions, and thus does away with the bad effect 
 of dilatation ; diastole is also lengthened, and the auricle can 
 now have time to empty itself. This action of digitalis is 
 also a tonic to the heart-muscle itself through the coronary 
 arterial circulation, and helps over the venous blood to the 
 red circulation, thus relieving congestion. In mitral insuffi- 
 ciency it is also of the greatest use. Here we want to make 
 contraction short, sharp, and decisive, and to lengthen expan- 
 sion. After this has been accomplished, in order to check 
 the too great effect of the digitalis in increasing blood-press- 
 ure, we may add nitroglycerin, or, as Da Costa does, nitro- 
 glycerin, belladonna, and strophanthus. 
 
 It has been suggested by Jacobi and other good authorities 
 to be very careful of the use of digitalis in the aged. Here 
 it has an unfavorable action on the arterioles of the heart, 
 interfering with its nutrition, and thereby interfering with 
 the general nutrition of the individual. Combining it with 
 nitroglycerin will in a measure remedy this defect. 
 
 My experience leads me to look upon strychnine as the 
 great heart tonic to be used in shock, and it should be used in 
 full doses subcutaneously. It acts by stimulating the vasomo- 
 tor centres, contracts the capillaries, also stimulates the vagus, 
 and thus checks too rapid action of the heart. The caffeine 
 in coffee is a good heart stimulus : it tends to lessen the num- 
 ber of beats in palpitation and increases their force. It does 
 this, perhaps, by its action through the vagus. \'eratrum 
 viride decreases vascular tension, but is a remedy to be 
 watched very closely. So nitroglycerin reduces blood-press- 
 ure and is quick and rapid in its action, and is a great boon 
 to sufferers from angina pectoris and other troubles caused 
 in part or altogether by high blood-pressure. Aconite also 
 9 129 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 acts in the same way, but is a depressant where nitroglycerin 
 is a stimulant to the action of the heart; and this is most 
 important to remember. Nitroglycerin acts like a strong- 
 man at a pump pumping fluid through hose ; with his brawny 
 arms he rushes the pump, and by this very force he expands 
 also the hose, and thus the pressure is less than it would be 
 should a weaker man have been at the pump, who had not 
 strength enough to expand the hose, which here may repre- 
 sent the blood-vessels. 
 
 I find the convallaria majalis, the root of the beautiful little 
 early spring flower, the lily of the valley, an efifective heart 
 tonic, and very useful in weak persons who are subject to at- 
 tacks of palpitation, or where there may be a suspicion of fatty 
 heart. It and strophanthus make a most useful combination. 
 In the very common trouble of intermitting heart of a purely 
 functional nature, — not the irregular heart, which is a very 
 different thing, — a combination of strophanthus and con- 
 vallaria will add to the tone of the heart where such a remedy 
 is needed, and is far preferable to digitalis, so often in- 
 advisedly used under these conditions. I know little of spar- 
 teine or broom-corn from personal experience, but would be 
 inclined to use it in hysterical palpitation. Quebracho bark 
 has been vaunted as a remedy in dyspnoea, but repeated trials 
 have always failed to produce any effect whatever in my 
 hands. The one generally used is the white quebracho, Aspi- 
 dosperma quebracho. Quebracho gum, the dried juice of 
 Schinopsis Lorent, two drachms, might be more effective by 
 increasing the oxygen in the blood-cells. In aortic regurgi- 
 tation, — one of the most difficult forms of valvular heart trou- 
 ble to make out by the ear, I think, but comparatively easy 
 when the additional symptoms of attacks of dyspnoea come 
 on, — cactus is the remedy. It shortens and makes systole 
 more snappy, lets up the blood-pressure, and makes the beats 
 fewer. This is what we want in this most serious trouble. 
 These patients may also drink strong coffee, as the effect 
 of the caffeine will be good, and cocaine is not contraindi- 
 cated; but look out for general anaesthesia. When we give 
 
 130 
 
FORTY YEARS JN 'I'lIE MEDICAL I'KOI' ICSSION 
 
 <)])iiini, wc increase tlie l)l()(i(l pressure, and with ergot vvc 
 do the same and decrease tendency to capillary hemorrhage 
 by its stimulating action on the vasomotor nerves; but some 
 deny this. When we wish to lessen the force and frequency 
 of the pulse and lower arterial tension, we take the nitrites, 
 the bromides, — particularly the strontium bromide, — and the 
 antipyretics, and thus gain the wonderful control we now pos- 
 sess over annoying and distressing troubles like angina pec- 
 toris, which formerly we and our patients had to grin and 
 bear. 
 
 Speaking of angina pectoris, my experience leads me t(j the 
 belief that it is most common among those who live sedentary 
 lives and do much brain-work. I believe it is more common 
 among students, literary and professional men, than other 
 people, and it is especially common among those who apply 
 themselves more or less constantly to desk work, the local 
 pressure here possibly acting as a cause. The Schott treat- 
 ment of heart disease by carbonic acid baths and muscular 
 movements is creating some stir in Germany, probably more 
 general than professional stir. I have had no experience 
 with it, nor can I altogether imagine its rationale. One thing 
 remember : in all cases of organic heart trouble, the first and 
 greatest of all remedies is rest of mind and body, and as near 
 perfect rest as it is possible to attain in the given case; and 
 next to rest, the proper climate for the individual, where his 
 environment gives us a choice of a mode of life. 
 
 Well, pardon me, I did not start out to write a treatise on 
 therapeutics, but such matters are of the first importance, and 
 we cannot give them too much thought to insure the safety 
 and comfort of those committed to our care. 
 
 Whilst auscultation and percussion have been elaborated in 
 different ways both by men famous in these specialties and 
 by the invention and adaptation of new instruments, we are 
 to-day not much more exact in our diagnoses than were 
 Avenbrugger, who invented percussion as applied to the diag- 
 nosis of disease, and Laennec. who invented auscultation. 
 Their work has been carried on by such men as Andral, Louis. 
 
 131 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 and Skoda, in Europe, and by Cammann, Gerhard, Da Costa, 
 and others in this country. Laennec's original instrument 
 was a single cylinder, and is the instrument that has been 
 used most in America. Cammann invented the double in- 
 strument. I started with this in my student days, and have 
 always used and preferred it. It is now gaining in favor, 
 which gain may be much ascribed to the fact that so accom- 
 plished and able a diagnostician as Osier, of Johns Hopkins, 
 recommends and uses it. A recent invention, the phonendo- 
 scope, with some of its principles modelled after the tele- 
 phone, is coming into use, and I can testify from personal 
 experience that it is of great use in differentiating sounds, 
 and making diagnoses in many cases easy. Auscultatory per- 
 cussion is growing in favor. I have used it myself for many 
 years. It can only conveniently be practised with the binau- 
 ral stethoscope. After all, we become accustomed to different 
 methods and different instruments, and of course we become 
 prejudiced in favor of those old friends who have served us 
 well for a long time, and are conservative as to adopting new 
 tools. This is the great reason why many really great im- 
 provements are slow of finding general favor. 
 
 With the introduction of auscultation, percussion, and other 
 and various methods, the diagnosis of disease became the most 
 fascinating part of medical study, and everything else yielded 
 to it. What little attention had been paid to pathology, his- 
 tology, microscopy, and therapeutics especially were neg- 
 lected. The great aim of the physician was to become an 
 accurate and acute diagnostician. Skoda was the great leader 
 in Europe. Alonzo Clark, Austin Flint, Gerhard, and Da 
 Costa, and later, Musser and Osier, in this country. I re- 
 member hearing it said of one of these eminent men, that 
 when asked why he did not write a work on practice, he re- 
 plied, he could not do it. for the treatment of disease he con- 
 sidered so imsatisfactory he could not conscientiously advise 
 in such matters in a work on the practice of medicine. 
 
 Even so great a man as Marion Sims had little faith in 
 remedies. I remember of hearing that his medical adviser 
 
 132 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 and friend, a few days before his sudden death, suggested 
 that he take some prescription for the heart lesion from which 
 he was suffering. Sims replied, " No, 1 have Httle or no 
 faith in remedies." But medicine is a progressive science 
 now, not a mere empirical art, as it once was, and not long 
 ago either, and happily this era of therapeutic nihilism is rap- 
 idly passing away, not from fashion, not as a fad, but it has 
 been driven to the wall by the onward march of progress and 
 reform. We are learning much from chemistry, from physi- 
 ology, experimental and otherwise, and from nature gen- 
 erally, and great credit is due to men like Horatio Wood, 
 Hare, Welch, Vaughan, and many others for the great work 
 they have done and are doing in practical therapeutics and 
 practical physiology. 
 
 There is an ill-advised movement now on foot engineered 
 by many good people with mistaken zeal to pass an act against 
 vivisection. If any wanton cruelty is practised by men en- 
 gaged in such experimental work, there is ample law now 
 possessed by the Society for the Prevention of Cruelty to 
 Animals. In this work there is no wanton cruelty, but it 
 would be wanton cruelty personified if the knowledge that has 
 been gained from such work and applied for the relief of 
 suffering in man should be cast off among the lost arts and 
 no longer be available for the use of physicians. Where would 
 intestinal surgery be, where would be our knowledge of 
 serumtherapy, or where would be all, or nearly all, we know 
 of bacteriology, which as it expands is surely leading to the an- 
 nihilation of all zymotic diseases which are now the great fac- 
 tors in sapping the lives of the fairest and often the younger 
 and most useful of the human race ? The honest vivisection- 
 ist works not for any selfish motive ; of all men, such experi- 
 menters are usually the most unselfish. Many of them live 
 in garrets, and their most elaborate repast is frequently a 
 crust. They have none of the motives urged on by insatiate 
 ambition and pride, such as Willis ascribes to Parrhasius 
 when he makes him say as he looks upon the writhings of his 
 poor old slave, whom he is torturing to death, the better to 
 
 ^35 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 get the expression of hopeless horror with which to adorn his 
 great painting, Prometheus, whom he was about to paint : 
 
 " ' Pity' thee ! so I do ! 
 
 I pity the dumb victim at the altar, 
 But does the robed priest for his pity falter? 
 I'd rack thee though I knew 
 
 A thousand lives were perishing in thine : 
 What were ten thousand to a fame like mine?" 
 
 Not on these hues does the scientific man work, but his only 
 ambition is to induce nature to give up the secrets she may 
 hold inimical to the health and comfort of man, and in this 
 great and noble work, practising constant restraint and self- 
 denial, he asks no reward beyond honest recognition and a 
 free and untrammelled going out and coming in among men, 
 such as is accorded to the meekest and most lowly among us. 
 
 Pharmacy and chemistry as applied to manufacturing have 
 made great strides in the last few years. The active princi- 
 ples of medicines, being of very small bulk, are now dispensed 
 in little tablets of almost infinitesimal size, and are in great 
 contrast to the great powders and pills and boluses of former 
 days. Think of a dose of quinine, and then think of the dose 
 of ground bark your grandfather had to take to get the equiv- 
 alent of the alkaloid in your small tablet. Pharmaceutical 
 preparations now are really artistic and beautiful to look at. 
 and I have no doubt when honestly prepared are far more 
 efficient than those prepared by the old methods. There is 
 one danger, and by no means an insignificant one, and that is 
 the palatable and attractive way preparations are put upon 
 the market containing stimulating remedies, such as opium, 
 cocaine, kola, alcohol, and so on ad infinitum. Physicians 
 cannot be too careful in prescribing such dangerous drugs. 
 Unfortunately the physician controls only a small part of the 
 output of such preparations. The general public takes them 
 self-prescribed, or recommended by the vender, and thus the 
 modern drug-store becomes an element of danger to the com- 
 munity, second only to the modern saloon. These matters 
 need attention. No proprietary preparation containing opium, 
 
 134 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 alcohol, cocaine, or such dangerous flrug, should be sold with- 
 out the fact of the amount of each in each prescribed dose 
 being plainly printed on the wrapper. Many good people 
 would stand in horror did they see such information on what 
 they are often buying and taking now as harmless " liver reg- 
 ulators" or innocent " blood-searchers." In fact, in many of 
 them they get a good morning eye-opener, a mid-day cock- 
 tail, or a composing night-cap in each dose; whether it be 
 composed of opium, chloral, alcohol, cocaine, or what not, it 
 brings the answer, and the poor deluded dupe is soon on the 
 road to some form of intemperance, with all that the name 
 implies. However, quackery and quack doctors have always 
 existed, and probably will continue to thrive until the people 
 are better informed and better educated in all that pertains 
 to the good and comfort of their bodies, the depth of their 
 pockets, and the salvation of their souls. 
 
 It is humiliating nowadays to pick up many of our daily 
 newspapers. Many of the most prominent ones have adver- 
 tisements in them that are utterly immoral, utterly obscene, 
 and utterly unfit to come into the home of any decent man; 
 indeed, some of them are unfit for the abode of strumpets. 
 The pictures of so-called distinguished men, of governors of 
 States, of Congressmen and clergymen, are especial favorites 
 in the picture column. Could anything be more vulgar? 
 Could anything be lower or more common? God save us 
 from such rulers, God protect us from such influences, and 
 purify at least in some small degree the newspaper press of 
 the world ! The literature put out by the great manufacturing 
 drug-houses is, some of it, very good, well written, well di- 
 gested, and gotten up by bright men, and, making due allow- 
 ance for the exaggeration of zeal for trade, is useful to the 
 profession, notwithstanding it has frequently been railed at 
 and derided as worthless and worse than worthless, and as 
 literature both sugar-coated and compressed, and warranted 
 not to pass the alimentary canal undissolved. 
 
 Many men in the profession have little time to read, and 
 do not take what time they have: some have no books, and 
 
 135 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 are unable to buy them ; some will not read. These little 
 brochures scattered about promiscuously from time to time 
 by the great drug-houses fill a want among these people and 
 disseminate much useful information. 
 
 Among the remedies introduced since I entered medicine, 
 amyl nitrite strikes me as one of the most useful. If it did 
 no more than relieve the pain and anguish of angina pectoris, 
 it would be an invaluable remedy, and we owe much to 
 Brunton, the great English physician, for having found out 
 its merits in this distressing disorder. It also gives instant 
 relief in those cases of hysteria where w^e find the patient suf- 
 fering acutely with the bolus hystericus, or with the convul- 
 sive form. A few whiffs from a few drops on a handker- 
 chief, a sudden flushing of the face, and the storm is over. 
 In true functional spasmodic asthma it is also effectual and 
 safe, and in the spasmodic pain of dysmenorrhoea and allied 
 troubles. 
 
 Nitroglycerin, trinitrin, or officially U. S. P. glonoin, is a 
 new remedy of great usefulness and power. It serves about 
 the same purposes as amyl nitrite, but is more capable of gen- 
 eral use, by the mouth and so on. In weak heart, in asthma, 
 and in convulsive troubles it is a wonderful remedy, and can 
 be used whenever we need to lower the blood-pressure. The 
 new antipyretics — the so-called coal-oil derivatives, antipyrin, 
 acetanilide, phenacetin, and such like — have proved great 
 boons to the medical man, and have given him effective 
 weapons with which to control many ills both great and 
 small, and whilst in the hands of the profession they have 
 done great good, done away with Dover's powder, sweats, 
 and all such abominations of the by-gone days, yet, neverthe- 
 less, they have been subjected to great abuse by laymen, and 
 doubtless are responsible for many deaths not directly traced 
 to them. Every drug-store, and, for that matter, even many 
 bar-rooms, have them for sale to any one coming in under 
 the guise of Dr. Somebody's headache powders, and guaran- 
 teed to be harmless. These preparations, above all others, 
 should not be taken without proper supervision, and their 
 
 136 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 promiscuous sale should be stoi)])cd. I can testify from per- 
 sonal experience to the p^ood effect oi antipyrin in strong 
 solution as a h.'emostatic in nose-bleed, bleeding after tooth 
 extraction, etc. 
 
 The introduction of the ductless j^^lands is also recent, and 
 wonders have been accomplished in myxcedcma by thynjid 
 feeding. It has also been used in certain forms of insanity, 
 but success to any extent has not followed this use of the 
 thyroid, and the same may be said of its use in syphilitic skin 
 affections; yet I believe I would try it in these troubles if un- 
 yielding, and also in obesity, with proper diet, if it amounted 
 to a disease. I have seen it do wonders in leg ulcers. The 
 thymus gland is also used as a remedy, but little success has 
 as yet come from it. The suprarenal capsules are used in 
 Addison's disease, and success enough has been recorded to 
 give us hope in a hitherto hopeless malady. The nose and 
 throat men are also using it as a haemostatic in their opera- 
 tions. The mammary gland has been recommended in the 
 treatment of uterine fibroids, and the parotid gland has been 
 used for the cure of ovarian disease. These applications will 
 doubtless be further elaborated. Indeed, all sorts of gland- 
 feeding appears to be going on, spurred up by the recommen- 
 dations of the late Browii-Sequard, with the result that a ten- 
 dency to quack the whole business has come about and thus 
 for a time done injury to true scientific investigation and 
 application. 
 
 Of all the introductions of remedies into the profession 
 since my advent into it, that of serum therapy has been the 
 most far-reaching, and, being based on true scientific princi- 
 ples, is the most astounding. I do not propose to discuss this 
 theme here, but will speak of it more at length farther on. 
 Nitrous oxide gas has been introduced within a few years, 
 and has proved a great boon to those compelled to have teeth 
 extracted, and may be used in minor surgical operations of 
 short duration. My experience leads me to decry its use 
 where we want muscular relaxation, as in the operation for 
 fistula in ano, for the sphincters are rigid, not relaxed under 
 
 13; 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 nitrous oxide gas, and this rigidity embarrasses us in such 
 operations. Sahcyhc acid, sodium saHcylate, salol, and stron- 
 tium saHcylate have been wonderful acquisitions to one who 
 was compelled to treat rheumatism particularly, and also gout 
 and uricacidaemia generally by the old remedies. Rheuma- 
 tism had about exhausted the pharmacopoeia, and rheumatic 
 fever often meant from three to six weeks' suffering, not to 
 speak of the sequelae. I find strontium salicylate, while less 
 soluble, to agree in some cases better than sodium salicylate, 
 and vice versa. Why I know not, but the same thing occurs 
 with potassium iodide and sodium iodide. In rheumatism I 
 appear to get the best and quickest results from ten-grain 
 doses of the salts, sodium salicylate, or strontium salicylate, 
 given in capsule or mixture. If in mixture, add sufficient 
 liquor ammonise acetatis to clear the liquid. Horatio Wood 
 recommends giving salicylic acid in officinal oil of gaulthe- 
 ria in ten- to fifteen-minim doses. In gout this acts well. 
 I am fond of a capsule containing twenty centigrammes of 
 methyl salicylate, C7 f^^ ^ O3, and one-quarter of one milli- 
 gramme of colchicine. I always like a little colchicum with 
 the salicylates in gout. Two of these may be given at a dose 
 as occasion requires. They are a French preparation. 
 
 Carbolic acid has been introduced of late years, and is so 
 useful in many ways, and another contribution from the won- 
 derful coal-tar. Trional and sulphonal are great helps, which 
 we who were in the profession twenty-five or more years ago 
 had to do without. Now with their use we can give a patient 
 comfortable and safe sleep, where before we had only opium 
 and its salts, whose sequelae are so seriously annoying, and 
 chloral, and even this last does not go back far. As between 
 trional and sulphonal, I prefer in every respect trional. If 
 there is great pain, add a grain or two of svapnia or a modi- 
 cum of codeine. Formaldehyde is a recent addition as an 
 antiseptic, but mostly used under the name of formalin. Ho- 
 ratio Wood says formalin is a forty per cent, aqueous solution 
 of formaldehyde. Merc's formaldehyde is a forty per cent. 
 
 solution of formaldehvde also, and therefore the same as for- 
 
 138 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 malin, which is a proprietary preparation, and therefore more 
 expensive. When you order, order merely a simple solution 
 of formaldehyde. One to twenty with water will give you a 
 two per cent, solution, strong enough for surgical work ; one 
 to forty a one per cent, solution, strong enough for gargles 
 or mouth-washes, or for applications t(j abrasions and skin 
 troubles, as a rule. A ten per cent, solution will harden speci- 
 mens for section for microscopical work. After using for- 
 malin or formaldehyde, two per cent, in surgical work, 1 find 
 it difficult to remove blood-stains at once, but they disappear 
 in a few hours, and everything looks clean. It is doubtless 
 a strong germicide in even one per cent, solutions, but whether 
 or not it will entirely take the place of heat and corrosive sub- 
 limate and other aids in surgical work, my experience with it 
 being limited, I cannot venture an opinion. I trust it will, for 
 it will save much trouble and make antisepsis and asepsis 
 easier and more pleasant. 
 
 Horatio Wood, in the last edition of his " Therapeutics," 
 speaks of formal-gelatin, brought forward by Dr. C. L. 
 Schleich, as a valuable wound-dressing. It is non-irritant, 
 non-poisonous, and when brought in contact with wounds 
 undergoes decomposition with the liberation of formalde- 
 hyde, and the consequent complete destruction of all septic 
 organisms. This, if effective, would be a grand addition to 
 the armamentarium of the surgeon. 
 
 As long as I can remember, the great tonic, and the one 
 almost universally in use, has been a combination of iron, 
 quinine, and strychnine. The formation of a proper portion 
 of haemoglobin in the red blood-corpuscles was thought to 
 depend on the amount of iron taken up by the corpuscles. 
 There is a disposition among physiological chemists to deny 
 that inorganic iron salts are absorbed, that they do not appear 
 in the urine, and that all go off in the fecal discharges, which 
 they blacken by meeting with sulphur in the alimentary debris. 
 These same chemists claim, of course, that iron organically 
 combined, as in foods, is absorbed sure. Thus claiming, these 
 men have gotten up. and are getting up, preparations of iron 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 organically combined. Such preparations are dried blood, 
 nncleo-albumins, hepatica-ferruginous preparations, and such. 
 Extended trial has not yet convinced me that inorganic iron 
 does not in some way influence the red blood-corpuscles for 
 good, and I am not yet convinced that the new preparations 
 are any more effectual, if as effectual, as the inorganic salts. 
 Let me say here that continued use of these new preparations 
 of iron and iron and manganese, as the peptonized albuminates 
 and such, organically combined, is beginning to give me great 
 confidence in them in many diseases, particularly of the 
 wasting diseases, and I begin to feel that we have a thera- 
 peutic weapon more powerful than any we have even dreamed 
 of before, which is destined to supersede all the inorganic 
 salts of iron and such materials. If this is true, real science 
 is driving out ignorance and mere conjecture. 
 
 Tincture of chloride of iron and Basham's mixture are the 
 best forms of giving inorganic iron, to my mind, and the 
 tincture of the chloride given in milk is among the greatest 
 of all organic tonics. Drop the iron in a little water first, then 
 add to milk, and it will not coagulate, and is pleasant to take. 
 Remember one thing : used in any way it is hard on the teeth, 
 should be taken through a tube run far back in the throat, 
 and the mouth should at once be rinsed with an alkaline wash. 
 
 Piperazin is a new remedy recently introduced, and one 
 which my slight experience in its use leads me to think is a 
 valuable addition to the Pharmacopoeia. I have no faith in 
 its dissolving stone already formed in the bladder, unless it 
 might be brought about by injecting directly, although it soon 
 passes by the kidneys. I am now using it in a case of diabetes, 
 where strictly non-starchy, non-saccharine diet cannot be kept 
 up. Since giving it in five-grain doses three times a day, the 
 specific gravity has fallen to 1028 and 1029, where before, 
 under the same conditions, it ranged at 1035 or over. It is 
 supposed to check some of the sugar-forming influences on 
 some of the blood ferments, I believe. I used it with great 
 apparent success in the most exaggerated and persistent case 
 of uric acid gravel I ever encountered. For several years 
 
 140 
 
FORTY YEARS IN Tfll- MEDICAL PROFESSION 
 
 a orentleman of forty, at the commencement of liis trouble, 
 had attacks of renal colic every two or three months. He 
 was temperate as to drink, but intemperate as to diet for one 
 afflicted as he was. I have known him to pass seventy small 
 calculi of uric acid in one attack, and altojji-ether T am afraid 
 to say how many he passed, but a very larj^e number. .After 
 this had been going on for several years, 1 put him on j)ipera- 
 zin, five grains, three times a day, in water on an empty stom- 
 ach. He took it steadily for nearly six months, then stopped 
 two months, then took it again occasionally for a week or 
 two at a time, and then stopped it altogether. He only had 
 one attack after he commenced the remedy, and now has not 
 had an attack for over two years, and has not been careful 
 with his diet either. It acted as a diuretic moderately with 
 him, darkened the urine, and reduced somewhat the quantity 
 of urea. No bad or unpleasant symptom of any kind resulted 
 from its use. 
 
 These uric acid cases are such peculiar cases ; a man is too 
 vigorous, as it were, to be healthy, the very opposite of the 
 feeble anaemic man, as can be so readily shown now by 
 our improved methods of diagnosis in estimating the blood- 
 strength as to its corpuscles and other constituents, all of 
 which is so readily shown by the improved microscopes, the 
 hsemocytometers, the hsematokrits, the h^emoglobinometers. 
 and so on, instruments and methods we who entered the pro- 
 fession forty years ago never dreamed of. The hsemoglobin 
 of the blood, of course, may be lessened by the lessening of 
 the number of red corpuscles or of the coloring-matter of the 
 red corpuscles, and an easy test of the amount of haemoglobin 
 is by the specific-gravity test, a table of which Dr. E. Barker, 
 the pathologist at the Delaware State Hospital at Farnhurst 
 has kindly prepared for me. Mix chloroform and benzole to 
 make a specific gravity of 1059. about that of normal blood. 
 Chloroform is heavier than blood, and benzole is lighter. 
 Drop a drop of blood from a pipette into the mixture of chlo- 
 roform and benzole. If the drop sinks to the bottom, add 
 more chloroform ; if it rises to the top. add more benzole until 
 
 141 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 the drop remains stationary in the body of the Hquid. Now 
 note the specific gravity of the Hquid, and this denotes the 
 specific gravit}^ of the drop of blood. Have all instruments 
 clean, and add chloroform and benzole drop by drop, stirring 
 with a glass rod. This test is not reliable in cases of dropsy. 
 
 .SCALE. 
 
 Specific Gravity 
 
 of Liquid. Haemoglobin. 
 
 1033 to 1035 gives 25 to 30 per cent. 
 
 1035 to 1038 gives 30 to 35 per cent. 
 
 1038 to 1040 gives 35 to 40 per cent. 
 
 1040 to 1045 gives 40 to 45 per cent. 
 
 1045 to 1048 gives 45 to 55 per cent. 
 
 1048 to 1050 gives 55 to 65 per cent. 
 
 1050 to 1053 gives 65 to 70 per cent. 
 
 1053 to 1055 gives 70 to 75 per cent. 
 
 1055 to 1057 gives 75 to 85 per cent. 
 
 1057 to 1060 gives 85 to 95 per cent. 
 
 Dr. William H. Hancker, Superintendent of the Delaware 
 State Hospital at Farnhurst, has given me an outline of a 
 method of determining approximately the deficiency in the 
 red blood-corpuscles which is simple and useful. The glass 
 tube of the centrifuge is graduated to 100; on turning it, say, 
 two and one-half minutes, the red corpuscles will gravitate to 
 one end. If it registers 50, or about one-half of the entire 
 amount, the blood is proximately normal, or between five and 
 six millions of red corpuscles to one cubic centimetre. If it 
 goes below that, the reading can readily be understood. In 
 other words, if the red corpuscles show only to about 25, it 
 means that the red corpuscles are only about one-half the 
 quantity they ought to be. 
 
 The practical application of the Rontgen rays, already 
 spoken of, to medical diagnosis is merely dawning, and time 
 alone can tell of the perfection to which it will be brought. 
 It is not safe to predict that we may not soon be able to see 
 clear through a stone wall. The centrifuge is another little 
 instrument of great use and recent introduction, and adds 
 greatly to our exactness in the examination of all fluids. The 
 aspirator is another great help, from the little hypodermic 
 
 142 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 syringe, which often makes a very good one for (hagnostic 
 purposes, to the one large enough to aspirate the larger cavi- 
 ties of the body. We are indebted to the French for this in- 
 strument, the invention of Dieulafoy. 
 
 The great discoveries in electricity and its application to 
 medicine have been of great help in many ways. I look upon 
 the introduction of the trolley as a wonderful therapeutic 
 agent. It is a cheap and, with its steady, even motion, a very 
 pleasant way of getting about. It is a great factor in per- 
 suading sedentary people to breathe fresh air, to mingle with 
 the crowd, and to take at least passive exercise. To a man 
 or woman fatigued by a hard day's work, and perhaps weak- 
 ened and enervated by excessive heat, a fanning up by an 
 hour's ride in the trolley has a wonderfully refreshing effect : 
 the tired, nervous feelings vanish, and sleep comes readily, 
 bringing renewed strength for the work of to-morrow. One 
 thing beware of, — the trolley cold is so often taken in the open 
 car. As a rule, this can always be avoided by wearing a silk 
 handkerchief around the neck whilst in motion, and never 
 getting on the car when perspiring. The electric fans are also 
 of great use for general comfort, and especially so in the hos- 
 pital or sick-room. Be cautious here, and avoid drafts from 
 these sources also. 
 
 The bicycle, too, I look upon as a great therapeutic factor 
 when used rationally under medical supervision. We are 
 bound to see the effects of its use apparent in the coming man 
 and woman. The bank clerk, the stenographer, and such 
 persons now have some resource for recuperation after long 
 hours of incessant labor, and a ride on the wheel sends them 
 home not exhausted, but rehabilitated in mind and body, their 
 organic functions are kept active, and the channels of excre- 
 tion and secretion are no longer clogged for want of the 
 proper stimulation of healthy exercise. Another great factor 
 in improving the health of communities, and thus reducing 
 the death list, is the improvement in the water supply of cities 
 and towns, and even of individual premises. 
 
 The driven wells, in place of the old-fashioned large dug 
 
 143 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 ■wells, are a great improvement in the low countries ; surface 
 contamination is thus avoided and pure water is more easily 
 obtained. The extensive filtering-plants now being put in by 
 cities are moves in the right direction, and the results are very 
 encouraging in decreasing the prevalence of zymotic disease 
 where such plants have been in operation. There is yet onl}'- 
 one way to have water absolutely safe, and that is to boil it 
 to absolute sterility ; but filtering — through sand particularly 
 — undoubtedly removes many and great dangers. 
 
 The intelligent physician, especially in communities re- 
 moved from centres, should have supervision over all these 
 matters appertaining to the economies of life. Indeed, I 
 think one of the great factors in the usefulness of the physi- 
 cian will be in preventive medicine. In public matters that is 
 now making great strides, but I refer particularly to the re- 
 lation to families in private life. All families should be under 
 the supervision of an intelligent all-round medical man. All 
 the environments of the home should be supervised ; the en- 
 vironments of the individual should be supervised ; then the 
 physician will know in time and have some warning of the 
 approach of many illnesses and be able to warn those inter- 
 ested. As it is now, often we are summoned to some fair 
 youth with a report from parents that a bad and persistent 
 cold is the only trouble, when examination reveals a broken- 
 down lung, and a condition of well-advanced pulmonary tu- 
 berculosis, and the case almost hopeless as far as remedies are 
 concerned. With competent supervision of a medical man 
 over that family, observation, with the finding of a slight rise 
 in the thermometer every evening, would have called atten- 
 tion to the true trouble months or years before, and this early 
 finding out of the cause gives the only shadow of hope in these 
 sad cases. Such a case illustrates the necessity of such gen- 
 eral medical supervision of families, and herein rests one of 
 the great usefulnesses of the physician, and in this sphere he 
 is bound to work more and more as the evolution of a perfect 
 civilization progresses. 
 
 The physician, of course, naturally should be an observant 
 
 144 
 
FORTY YEARS IN THE MEDICAE PROFESSION 
 
 man above all others, and, more than this, he should cultivate 
 habits of the nKjst careful observation. It is very easy to be 
 tripped up in diagnosis by very simple matters, and practice 
 alone makes perfect, but practice does not help unless backed 
 up by acute observation and general knowledge. No obscure 
 case, in fact few cases, should be treated without a thorough 
 examination of the urine. No one but the physician knows 
 how much knowledge of cases we gain here. What woful 
 mistakes are made by a neglect of this procedure, not only in 
 missing the direct cause of the disease in question, but also in 
 showing up collateral troubles and complications to give cases ! 
 How depressing to meet a case of renal asthma, for instance, 
 and find it has been treated for every other disease which may 
 possibly cause dyspnoea except the right and proper one! 
 How often do we have patients consult us, who are just a 
 little under the weather and want a little medicine to set them 
 up, and on investigation we find a contracted kidney and all 
 which that implies ! How humiliating to be called in consul- 
 tation for a case of obstruction of the bowels, and a thorough 
 examination reveals a strangulated hernial tumor as the cause ; 
 and how terrible it would be should it have passed beyond the 
 time of successful relief ! 
 
 In my experience, latent syphilis is the cause of a great 
 deal of obscure disease ; indeed, syphilis is a protean disease, 
 and how often in its latent form it is overlooked, and in most 
 cases how satisfactory the treatment! In nervous syphilis 
 what wonders we see ! I was once called to a fine young fel- 
 low under thirty, and found him helpless on the floor with a 
 complete hemiplegia. Under thirty and a paralytic ! I at 
 once knew the trouble, — only syphilis, or metallic poisoning 
 once in a thousand cases, and by all odds syphilis. A history 
 of the case soon revealed syphilis as the origin of his trouble 
 and enabled me to venture a favorable prognosis. In a few 
 months he was about, and in tw'o years was a strong, vigorous 
 man, with directions whenever he was sick, even from a bad 
 cold, to always tell his attending physician he was or had been 
 a syphilitic, and thus get proper treatment at an}' time. Large 
 10 145 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 doses of the iodides saved him. How many such cases are 
 sacrificed to ignorance and pretence ! 
 
 Many mistakes in diagnosis are made in malarial diseases. 
 Latent malaria, both civic and paludal, are very common dis- 
 eases, and the therapeutic test with the alkaloids of cinchona 
 unmasks very many of them, and the microscope is still more 
 effectual. There are many complications between typhoid 
 fever and other diseases, but in my experience it is well to be 
 very careful and not mistake appendicitis, tuberculous dis- 
 ease of different forms, trichina spiralis, melancholia, renal 
 troubles, and malarial troubles. Remember that diabetics 
 under thirty-five are apt to be tuberculous, so be careful to 
 be on your guard and differentiate here between the diabetes, 
 tuberculosis, and typhoid fever. Are there mingled types of 
 fever, for example, typho-malarial fevers? The prevailing 
 opinion in the profession appears to be against this mingling 
 of fever types. I do not know, surely ; probably no one does ; 
 I do know thg-t the autumnal fevers prevalent on the Dela- 
 ware and Chesapeake peninsula act in many cases like true 
 enteric fever, with a true mingling of malarial invasion, and 
 full antiperiodic doses of the alkaloids of cinchona are neces- 
 sary for their control and successful treatment. The Civil 
 War started this discussion as to fevers, and the present war 
 may do much to further elucidate the subject. 
 
 The more I see of our autumnal fevers of the Middle and 
 Southern States, which are usually diagnosed as enteric fever, 
 and which are many of them such as were spoken of during 
 the Civil War as typho-malarial, the more I am convinced 
 there is in these cases something more than the ordinary case 
 of typhoid or enteric fever. There is a malarial complication, 
 or some complication more than malarial, which will at some 
 future day be explained. There is in these cases evidently to 
 me, as it were, some auto-intoxication due to tissue waste, or 
 some such trouble, possibly to one or more of the pathogenic 
 germs occupying the intestinal tract. If no mingling of the 
 fevers, there must be a mingling of the causes of these cases 
 more than the one cause producing true enteric fever, and 
 
 146 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 these mingled cases may be due to a mingling of malarial or- 
 ganisms, of typhoid organisms, of unicellular animalcules, 
 together with the bacillus coli communis and its attendant 
 evils; thence follows a mingled fever; why not? 
 
 Just now, whilst writing these lines, 1 understand they 
 have discovered at the Pepper Laboratory of the University 
 of Pennsylvania the plasmodium malarias in the blood of a 
 case of a well-marked enteric fever, where the typhoid rash 
 was thoroughly developed and identified. Of course, in this 
 patient there must have been a malarial explosion within 
 twenty-four hours, to have found Laveran's characteristic 
 organism. I am not surprised at this discovery; it only con- 
 firms views I have long held on this subject. From experi- 
 ments made in new countries, Paget concludes that the ty- 
 phoid bacillus exists in virgin soil, but it requires educating, 
 — that is, to be transferred through a series of hosts, — before 
 it produces typhoid fever. The so-called typho-malarial fever, 
 he thinks, is produced by the typhoid bacillus before it has 
 gone through these various hosts. This is quite a pretty 
 theory, but the day of theories in medicine is fast passing 
 away, and giving way to exact science. My friend Dr. Rich- 
 ard Woods has kindly given me the hospital record of the case 
 of mingled fever referred to, as follows : 
 
 J. McK., twenty-three years old, single, admitted to Uni- 
 versity Hospital September 9, 1898. Previous history nega- 
 tive ; was first at Camp Alger and then transferred to Camp 
 Meade. Previous to admission, headache, lassitude, pain in 
 back, etc. ; enlarged spleen ; rose-colored spots ; bronchitis ; 
 iliac tenderness; plasmodium malarise found in the blood. 
 Widal test present. Highest temperature, 104.6° F. Had 
 a chill following admission. Quinine given, and no recur- 
 rence of the chill. Discharged October 10, 1898. 
 
 The microscope will help out as the Widal sero-diagnosis 
 becomes more generally accessible, and the spirillum in re- 
 lapsing fever now makes that clear, as does the malarial or- 
 ganism in malarial fever. In regard to the malarial organism, 
 there are probably three different kinds, and the recurrence 
 
 147 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 of the chills and fevers is believed to be caused by a large 
 number of the parasites coming to maturity at once. Thus 
 we have the quotidian type of parasite, the tertian type, and 
 the quartan type, each taking a different length of time to 
 complete its maturity, and then the storm comes. These 
 bodies destroy the red corpuscles and thus produce anaemia, 
 and as they pass on in their life pigment bodies are developed 
 in them, which are picked up by the white blood-corpuscles 
 and destroyed, and probably our specific remedies, as quinine, 
 act through these white blood-corpuscles and thus destroy 
 the organisms. As to their life history and hosts we know 
 very little. Some such organisms have been found in some 
 birds, and the mosquito has been suggested as a host. Some 
 use for the mosquito, anyhow, if true, even if a bad use. 
 
 Nothing shows the rapid advances in the study of medical 
 science more than the unfolding of our knowledge in refer- 
 ence to the malarial parasites, and in treating malarial dis- 
 eases it behooves us to take heed of the results furnished us 
 by the scientists to be at all successful. Osier claims malaria 
 to be the only disease for which we have absolute specifics. 
 We will find, as we treat cases, that all the types of the organ- 
 ism do not yield to bark alone, but require additions of other 
 remedies. Dr. Charles Dewey Center, of Illinois, has given 
 us a good resume of the subject. In 1879 Lewis discovered 
 a malarial parasite. Laveran made his discovery in 1880. 
 Thayer claims it is not a single and polymorphous organism, 
 but the three forms represent distinct varieties : ( i ) There 
 is a variation arising from difference in the parasites; (2) 
 a variation of individual dififerences ; ( 3 ) variation of place 
 and season; (4) variation as to what remedies have been 
 used or omitted. 
 
 If we recognize the quotidian organism of Golgi, which is 
 not yet admitted by all, there are four forms of the organism, 
 — the quotidian, which gives attacks every twenty-four hours, 
 and may possibly not be a distinct species, but a mixed species 
 of the other three; the tertian, the quartan, and the crescent, 
 or estivo-autumnal, the name denoting its time of appearance, 
 
 148 
 
FORTY YEARS IN THE MEDICAE PROFESSION 
 
 from (cslds, siininicr, and auliiumus, autnnin. My experience 
 in looking for these parasites shows it of importance to recog- 
 nize the type from the symptoms, and in all cases it is proba- 
 bly important to use the microscope as soon after the chill or 
 explosion as possible, and not to delay in any case over a few 
 hours. The flagellae are active in all forms, and are, accord- 
 ing to Koch, the spermatozoa. They all inhal)it the blood. 
 The crescent lives in the blood chiefly of the bone marrow and 
 the spleen, and this form produces probably relapsing fever, 
 pernicious fever, and the irregular malarial fevers. The 
 practical point to bear in mind is the remedy for each form of 
 malarial fever, depending on the examination of the blood by 
 the microscope at the proper time, thus showing us the organ- 
 ism we have to treat, whether it be the quotidian, the tertian, 
 the quartan, or the crescent or estivo-autumnal. The differ- 
 ent alkaloids of bark are probably specifics for the first three 
 types, but if we do not add arsenic to the bark alkaloid we 
 will fail in treating the crescent form. There is where we 
 probably often fail in our treatment of stubborn cases. Of 
 course, when I say bark, I mean Peruvian bark. In spleen 
 cases and in cases where we have the fearful bone-aches, head- 
 aches, and nausea, we likely will not succeed with bark alone, 
 but will succeed wath arsenic and bark, and with the iodides 
 and iodine and bark, and such remedies. 
 
 Especially since our newer and nearer relations to the home 
 of yellow fever, we may often be embarrassed in our diagno- 
 sis of fevers. Take a case of a man on our first seeing him 
 with coma, jaundice, and high temperature, probably from a 
 yellow fever district ; bacteriolog}' is the only help to save us 
 from embarrassment. The presence of a malarial organism 
 and the absence of the bacillus icteroides would go far to clear 
 up the diagnosis. Whether these organisms coexist in the 
 same individual has probably not yet been determined, but it 
 looks as though the bacillus icteroides had been defined as the 
 cause of yellow^ fever. 
 
 Now^ for antitoxins or specific remedies in all of these pests. 
 I believe the tertian malarial organism to be the one found 
 
 149 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 generally in the Middle States and upper Southern and West- 
 ern States. We do not often see the quartan on the Delaware 
 and Chesapeake peninsula. In the tropics and in the jungles 
 look out for the crescent form with all of its horrors, and re- 
 member we may find it well to the north too. 
 
 Let me repeat, when we have a case of malarial fever, and 
 find the quotidian, tertian, or quartan organism, we will at 
 once relieve the case by a mercurial purge and one of the 
 alkaloids of bark, followed at proper intervals by bark salts 
 to prevent a recurrence, and then by attention to a proper 
 change of environment and general tonics. Let the estivo- 
 autumnal or crescent parasite be present, and you will surely 
 need arsenic added to your bark salts, and probably iodine 
 and the iodides. It is a common belief in our extreme South- 
 ern States that if a person run down by malarial fever goes 
 to the mountains he will most probably develop typhoid fever. 
 Can this be so, and what is the relation here? The Western 
 mountain fever is probably an enteric fever. 
 
 Another link in the chain in the diagnosis of enteric fever 
 is Ehrlich's reaction, or the diazo reaction, as pointed out to 
 me by Dr. E. Barker, now of the State Hospital at Norris- 
 town, Pennsylvania. Tyson gives full directions for this test 
 in his " Practice of Medicine," and says it is symptomatic, not 
 diagnostic, certainly not pathognomonic, as it occurs in many 
 diseases with high fever, among which measles and miliary 
 tuberculosis are conspicuous. If not present, the case is prob- 
 ably not typhoid fever. In typhoid fever it appears from the 
 fifth to the fourteenth day, and disappears later on. There is 
 one important point : it is said sometimes to appear in malarial 
 fever. These are probably cases of typho-malarial fever, as 
 we now know such to exist. The cause of typhoid fever is 
 now generally recognized as the bacillus of Eberth, and it is 
 found in many parts of the body besides the intestines, as in 
 the blood, the mesenteric glands, the spleen, the gall-bladder, 
 and even in the rose-colored spots. It is often found in the 
 fecal discharges, and here, of course, is diagnostic, if the pa- 
 tient has fever. The bacilli have been known to live in water 
 
 150 
 
FORTY YEARS IN TIIJC MEDICAL PROFESSION 
 
 three months, in soil six months. They have been known to 
 have Hved in a vacuum over two hundred days ; in fact, they 
 are most tenacious of hfe. Sunh'ght, next to lieat, is most 
 destructive to them. What effect electric h^ht rays may liave 
 on them I do not know. This effect of hght is a practical 
 point ; keep the house open to the sun, and air all dark corners. 
 Why houses are ever built with cellars I do not know. I 
 do not think the coming man will be fool enough to dig a 
 hole as a resort and home for all kinds of germs, pathogenic 
 and other kinds, and then build his house over such a pest- 
 breeder. 
 
 The bacillus of typhoid fever enters the system of man 
 most frequently through milk and water, but it may enter 
 through any kind of food or drink, or with the dust from 
 rooms or other sources by inhalation. The bacillus of Eberth 
 and the bacillus coli communis have been found together in a 
 room where typhoid fever had existed months before. I be- 
 lieve the Eberth bacillus can be inhaled from sinks and such 
 places containing contaminated dejecta; at least, I have prac- 
 tical reasons for thinking so. 
 
 It is possible to spread the bacillus to soil and water-courses 
 by spreading night soil, but I have practised medicine a long 
 time in a community where the night soil from seventy thou- 
 sand people is spread on the soil of the suburban surround- 
 ings, and although I have watched this point closely, I cannot 
 say the people in this neighborhood suffer from typhoid fever 
 to a greater extent than those living on other farm lands. I 
 may remark here that my experience with the application of 
 cold in typhoid fever has been very satisfactory, both by bath 
 and by cold sponging, but in private practice, as cases usually 
 occur to us, the use of the bath is so inconvenient to patient 
 and attendants as almost to prohibit its use and drive us to 
 cold sponging and other means of applying cold, as the cold- 
 air current, etc. Thayer has shown that after a Brand bath 
 the leucocytes are doubled, or more than doubled, and that the 
 medicinal antipyretics have the effect of decreasing the leuco- 
 cytes, and we all know how they depress the heart. Believing 
 
 iSi 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 siich testimony, no one can fail to choose the Brand method, 
 or some modified form of it, and Hmit decidedly the use of 
 medicinal antipyretics, though not absolutely, as undoubtedly 
 small doses of acetanilide are often safe and most useful. 
 Some claim the high temperature is only evidence of the com- 
 bustion of the materies morbi, the germs. Beware! do not 
 let the high temperature go to the point of roasting the host 
 whilst it cooks his guest. 
 
 As to the antiseptic treatment of typhoid fever by intestinal 
 antisepsis, neither my reason nor my experience has led me to 
 give it my unqualified approval. If the pathogenic germs be 
 alone and only in the intestinal tract, we might reach them. 
 In a healthy individual, the normal intestinal fluids being anti- 
 septic and germicidal, there is little or no need of germicides 
 from without. When we see a person ill with typhoid fever 
 for the first time, the pathogenic germ has long before doubt- 
 less left the intestinal tract and is swarming in the spleen, the 
 liver, the blood, and other parts. Can these be reached by a 
 small dose of an antiseptic administered per orem? Most 
 probably not. Such practice leads to empiricism and routine 
 practice, — a pellet for this and a pellet for that. God save 
 the intelligent physician from such methods ! Notwithstand- 
 ing this, I usually give an antiseptic in typhoid fever. It may 
 reach some of the pathogenic germs in the intestinal tract, 
 and if salol is used, it splits up into carbolic and salicylic acids, 
 and may even act farther on as a germicide, but I doubt it. I 
 scarcely believe, for instance, such can sterilize the blood. 
 There is one use for intestinal antisepsis in typhoid fever 
 where I advocate it ardently for its local action, — in the sec- 
 ondary cases, we may call them, where the case has apparently 
 run its course and is going on to recovery, but recovery does 
 not come. In these cases we have probably an example of 
 auto-intoxication, caused by poisonous ptomaines, alkaloids, 
 or what not, generated in the alimentary tract. The proper 
 treatment here is undoubtedly antiseptics locally applied, per 
 orem, and, if necessary, per rectum. These are the post- 
 typhoid fever cases some authors speak of. Watch them 
 
 152 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 keenly. Constipation from milk diet may be the cause; the 
 causes, especially in young uatients, may be purely nervous. 
 Above all things, watch for the creeping upon your ])atient of 
 some tuberculous trouble. Occasionally laryngeal trtjubles 
 come on in the later stages of typhoid fever. They may be 
 inflammatory and run a usual course. Again, they may not 
 be inflammatory at all, but a true paralysis of the laryngeal 
 muscles, particularly of the posterior crico-arytenoid and lat- 
 eral crico-arytenoid muscles. The muscles paralyzed cannot 
 perform their functions of widening the glottis by relaxing 
 the vocal cords, and thus breathing may be greatly interfered 
 with or stopped altogether. Tracheotomy is usually necessary 
 in these cases, and the tube may possibly need to be worn a 
 long time, or even indefinitely. 
 
 I look with some hope for the victims of typhoid fever 
 from inoculation from cultures of the pathogenic germ, Pfeif- 
 fer's and Jez's bactericidal serum, accounts of which are just 
 beginning to be whispered towards medical circles. Even the 
 blood-serum of convalescents from the fever is being used. 
 Typhoid fever is mildly contagious, doubtless, and for this 
 reason patients should be isolated as much as possible, and put 
 in absolute aseptic surroundings. Disinfect stools and urine 
 with chlorinated lime one pound, and carbonate of soda two 
 pounds, to the gallon of water. This is Labarraque's solution, 
 or very near it, and years ago I have seen it sell for one 
 dollar for a bottle holding less than one quart. Cover all dis- 
 charges with this and allow them to stand thus covered for 
 three hours, and they will then be aseptic. If this is not done, 
 flies wall surely convey the pathogenic germ. I am sure fever 
 is often spread in this w^ay, especially where many human 
 beings are congregated, as in camps. Keep the defecating 
 and urinating organs of the patients aseptic externally. As a 
 rule, do not give your patient animal broths, they are culture 
 media for the pathogenic germ, and should not be used as 
 food for typhoid patients. Watch your patients keenly, feed 
 them liberally with liquids and semi-solids only; be particu- 
 lar not to starve them ; especially giA'e them now" and again 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 hot coffee or tea, if they crave it ; do not spare alcohol when 
 needed ; it is not always needed ; and above all things do not 
 over-drug your patients. 
 
 Such methods as the foregoing have been very successful 
 with me. If symptoms of perforation appear and they be 
 verified, there is only one slight hope, — promptly appeal to 
 surgery. Not all cases of typhoid fever have diarrhoea. This, 
 I think, is more apparent in later years, showing the distribu- 
 tion of the pathogenic germ from some cause to be more 
 general in the system and not so thoroughly confined to the 
 intestinal tract. I doubt if three-fourths of the cases have it, 
 but in every case of typhoid fever, where there is no diarrhoea, 
 or even where there may be constipation, you give a mild 
 cathartic and you will have excessive action of the medicine 
 as a diagnostic sign, as a therapeutic test. 
 
 In my early professional life I was always taught to avoid 
 purgatives in typhoid fever as I would avoid poison, and I 
 cannot conceive but that the eliminative treatment by purga- 
 tives, as advocated by Dr. Thistle, may be accompanied by 
 great danger. Such treatment cannot get rid of all the germs, 
 for they are not all in the tract swept by the purgative, and the 
 local lesions cannot help but be greatly disturbed by constant 
 irritations set up by the cathartics. I have never seen the re- 
 sult of a post-mortem in one of these cases, nor proved one 
 bacteriologically, where there was no diarrhoea. Diarrhoea 
 is the serious symptom and its sequelae, and the case is serious, 
 as a rule, as the diarrhoea is serious, and I suppose the diar- 
 rhoea is serious as the intestinal lesions are serious. 
 
 In my experience I have only seen two undoubtedly thor- 
 oughly authenticated cases of typhoid fever occurring in the 
 same individual twice. Both cases were young men. In both 
 the first attacks were very severe. In one there was a compli- 
 cation of phlegmasia alba dolens. The attacks in both were 
 about three years apart; the last attacks were mild in every 
 way, but marked ; the effect of the first attacks appeared to 
 me to establish at least some tolerance, but to establish no im- 
 munity, at least after three years had intervened. Another 
 
 154 
 
FORTY YEARS TN TTTR MROICAL PROFESSION 
 
 point in typlioid fever : the diagnosis may be obscure, because 
 some cases run only a few days and are very lij:?lit, with no 
 symptoms beyond a furred tongue and general malaise, no 
 diarrhoea, enlarged spleen, or rose spots. The Widal test will 
 usually differentiate these cases. These may be ambulant 
 cases and scatter the pathogenic germs by their urine and 
 fecal discharges, and thus distribute the disease through camps 
 and such places. Such cases exist, so be on your guard. We 
 may have also what Osier calls acute typhoid septicaemia, cases 
 overwhelmed by the pathogenic germs. Here we have intense 
 headaches, furious mania, and even cerebro-spinal convul- 
 sions. The Widal test is our resource again here. Beware 
 of the cases in which you have jaundice. Here the pathogenic 
 germ has invaded the gall-bladder and set up a toxaemia, local 
 and general. Intestinal hemorrhage and epistaxis are com- 
 mon in these cases, and death is the usual outcome with these 
 complications. 
 
 Dr. C. N. B. Camac, of New York City, has given us a 
 classical essay on the involvement of the gall-bladder in ty- 
 phoid fever. (See Johns Hopkins Bulletins.) 
 
 Whilst on this subject let me say something of the use of 
 saline infusion, or normal salt solution. The true normal 
 salt solution approaching nearest to the blood-serum is seven- 
 eighths of one per cent. I have seen some reports of its 
 successful use by merely throwing it into the large bowel in 
 threatened collapse from hemorrhage, etc., in typhoid fever. 
 Anyhow, it is wonderful, even by our old methods, how 
 many cases of hemorrhage from the bowels in this fever re- 
 cover. This method is worth trying. Dr. Thomas E. Reilly. 
 of New York City, has given us the best paper on the tech- 
 nique and use of saline infusions. He gives ninety-two grains 
 of ordinary table salt to a quart of water as making a solution 
 of six-tenths per cent. For all practical purposes, one tea- 
 spoonful to one pint of water will make the normal solution. 
 and I think is the easiest to remember. Now boil and filter 
 the solution. In using the solution have it at a temperature 
 of 1 00° F. The ways of getting this into the system are by 
 
 155 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 the veins or the arteries subcutaneously, and by injections 
 into the bowels. I should say that even into the peritoneal 
 cavity might be worthy of trial. Whichever way it goes, use 
 absolutely antiseptic precautions, even if used per orem. 
 
 In advanced heart disease do not use the method by the 
 blood-vessels. By the subcutaneous method attach an aspi- 
 rating needle to a Davidson's syringe or to a fountain syringe, 
 or, as Dr. H. A. Kelly suggests, by reversed aspiration; and 
 I see no reason why the old-fashioned antitoxin syringes 
 might not do. Put the fluid into the loose connective tissue of 
 the abdomen, the axilla, under the breasts. You can intro- 
 duce, Reilly says, from six to ten ounces in one place. He 
 says no accident in his experience has followed this operation, 
 not even cellulitis. I, myself, have seen sloughing in a run- 
 down hospital case, so be careful to observe the proper tech- 
 nique. 
 
 For the intravenous method Reilly uses a glass funnel con- 
 nected by a piece of rubber tubing three feet long to a canula 
 four inches long by one-eighth of an inch in diameter, 
 curved at its point one inch, to better introduce it into the 
 vein. This should have a stop-cock. Now supine the fore- 
 arm, cleanse it, bandage it tightly at its middle to distend the 
 veins at the elbow, and incise one inch over the median basilic 
 or cephalic vein. This goes through skin and fascia ; with a 
 grooved director tear away fat and tissues over the vein and 
 raise it; pass two catgut ligatures under the vein; now tie 
 the distal one, or, better, wait until the vein has been opened. 
 To open the vein make a clean longitudinal cut three-eighths 
 of one inch long ; now introduce the canula one-half inch up- 
 ward; use the upper ligature to tie the canula in place, and 
 take off the bandage, sure. After the canula is removed tie 
 the vein with the ligature and close wound. 
 
 Dr. Dawbarn has injected the fluid into a large artery by 
 an aspiration needle, but this is not considered safe. There 
 are many modifications of intravenous methods, hooking up 
 the vein in any way you are able and using even a medicine 
 dropper, and I do not see why any vein in the system you can 
 
 '156 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 expose will not answer. There is little or no clanger of air 
 entering to cause sudden death; this is now well proved. It 
 takes about five minutes for one (juart of s(jlution to run in. 
 The quantity to be used is from a few ounces to several 
 quarts. Guides to quantity are, return of pulse or increase of 
 pulse, return of color and consciousness, etc. Rarely use more 
 than one quart to a sitting, but it can be frequently repeated, 
 and the canula can be kept in place for this purpose. There is 
 little danger of using too much after severe hemorrhage. 
 Watch the bladder, as it may distend enormously. Its great 
 use is in loss of blood from various causes. Shock is another 
 great cause for its use; so also is uraemia, especially in ursemic 
 convulsions. Draw ten to twelve ounces of blood from the 
 arm and introduce a quart of salt solution, and in a few hours 
 you can give if necessary as much more. QEdema of lungs is 
 not a contraindication. In suppression of urine it may be 
 used. In diabetic coma it may save life in this almost hopeless 
 condition. In sepsis of all kinds it is doubtless the great rem- 
 edy. In Asiatic cholera it is useful. In pneumonia it will 
 save life, especially in double pneumonia with dyspnoea, etc. 
 Use it here as soon as pulse flags. It has been used success- 
 fully in various other troubles, including purpura hemor- 
 rhagica, ulcerative endocarditis, pyelitis, coal-gas poisoning, 
 mushroom poisoning, after venesection, after extensive burns, 
 in acute alcoholism, toxaemia from colon bacillus, painter's 
 colic, carbolic acid poisoning, tetanus, and epilepsy. 
 
 Reilly thinks it will do great good in arsenic poisoning. 
 He speaks of it going into the blood at a temperature higher 
 than that of the blood, and it thus increases the antitoxins of 
 the blood and cures, or keeps the patient up until the crisis has 
 passed. In his summar3\ Reilly recommends its use in all 
 cases of severe hemorrhage, external or internal ; in shock 
 of all kinds it fulfils all indications. In all toxaemic condi- 
 tions, bleed first and then use it. There is nothing like it in 
 uraemia and septic conditions, and in all cases of vegetable or 
 mineral poisonings. In any pathologic state attended with 
 feeble pulse due to lessened blood-pressure, use it, and as a 
 
 157 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 last resort in all cases of imminent death from any cause of 
 an accidental nature, use it. 
 
 The sheet anchor in diagnosis is tact. Do not jump at con- 
 clusions too rapidly. The special diagnostician, the older he 
 grows, becomes more non-committal, and leaves a loophole 
 of escape. This makes him no less a diagnostician, but he has 
 learned that diagnosis is not an exact science, but is one grow- 
 ing and expanding every day, and is one making great and 
 rapid strides to a perfect development, and one that requires 
 all the strength, all the force, and all the senses of a man. 
 
 Among the many nice points in diagnosis, my experience 
 leads me to refer to the very frequent occurrence of movable 
 kidney, especially in women, and to differentiate this from 
 other abdominal lesions. Dr. Charles P. Noble, surgeon-in- 
 chief of the Kensington Hospital for Women, at Philadelphia, 
 is entitled to great credit for original work in this lesion. 
 Sometimes small-pox and chicken-pox may cause anxiety for 
 a time as to the diagnosis, and people are liable to press for an 
 immediate opinion. So in measles in the negro, as to the pos- 
 sibility of its being of the variola type. Is the trouble an 
 aneurism, a tumor, or an abscess? My experience leads me 
 to advise great care in any trouble where the lines are not 
 definitely marked in this trio. Drunkenness, uraemia, and 
 apoplexy are another trio demanding care, knowledge, good 
 judgment, and tact; and opium and other narcotic poison- 
 ings may be added to the list, and also malingering, a very 
 common failing under certain conditions, especially among 
 soldiers, sailors, prisoners, paupers, and hospital bummers. 
 
 In general diagnosis, do not forget the microscope, and 
 especially do not forget its use in the urine, the sputa, and the 
 blood, and very frequently in the alvine discharges. When 
 you have a constant, continued, wearing pain, well localized, 
 study it thoroughly ; examine all parts, far and near, possible 
 to be involved, and especially do not dismiss it as a form of 
 rheumatism or neuralgia. It is probably not functional, but 
 of organic origin, and some serious formidable trouble is apt 
 to show itself sooner or later. An aneurism, a malignant 
 
 158 
 
FORTY YEARS IN TJII': MJ'DICAL PROFESSION 
 
 growth, or some serious lesion of the nerve-centres may be- 
 come the sequel. J3iagnosis as it was is a very fascinating 
 art. I say art, for I can scarcely call it a science. Diagnosis 
 as it is, is still a fascinating art, but true science is just begin- 
 ning to shed its indistinct rays of light on it, sufficient to 
 mystify it and take somewhat from its fascination, for fascina- 
 tion comes from mystery and from conjecture more than from 
 demonstrated fact. 
 
 As we go on higher up the mountain to the goal of perfect 
 knowledge, we are giving up, must give up, our reasonings by 
 inductive methods, and diagnosis as it soon will be commences 
 to unfold itself as a true science. Even to-day the general 
 practitioner needs continuous recourse to bacteriology ; he 
 cannot practise medicine and be just to himself and do jus- 
 tice to his patients without such recourse. A diagnosis cannot 
 be made any more from sight alone, from touch alone, from 
 hearing alone, from the sense of smell alone, or from the 
 sense of taste alone. We must have the help of the bacteriolo- 
 gist, and our diagnosis must be biologic wherever possible, 
 not mere deductions, not mere inductions. In the future, 
 diagnosis is to be a true and progressive science, not a mere 
 art, and in making this advance it is only in keeping with 
 other great advances in the business and scientific world. 
 
 I may close this rather desultory talk on diagnosis, and 
 quote two practical mistakes which I know were made many 
 years ago by practitioners of medicine, and which go to show 
 want of thoroughness, want of tact, and, possibly, want of 
 knowledge, all three essentials to the successful physician. 
 A physician was called to see a young unmarried woman 
 (and these are the cases which usually throw the doctor off 
 his guard) on a hot summer night. He found her in a room 
 surrounded by anxious female neighbors and her own mother. 
 He made a hurried diagnosis of cholera morbus, and pre- 
 scribed a mustard plaster and a narcotic and retired. \Mien 
 he called in the morning he was met at the door by an old 
 granny, who complimented him on his success, and showed 
 him a bouncing boy. The doctor retired without in any way 
 
 159 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 covering his retreat, and in a rather short time left the town 
 for other fields of conquest. The other case was a similar 
 one, except that the doctor had tact, got out of the scrape 
 gracefully, and long afterwards the family never knew, when 
 he paid his second visit and found the child born, that on his 
 first visit he had left without an idea of what was coming; in 
 other words, had made a hasty call, a hasty diagnosis, and a 
 humiliating error. To the diagnosis of pregnancy in any 
 stage the greatest embarrassment is apt to come to a physi- 
 cian, and if the subject be a young unmarried woman, among 
 the very greatest of all embarrassments confronts him. Here 
 you will have use for all your skill, all your care, and all your 
 tact and knowledge. In these unfortunate cases it is always 
 prudent to call a medical friend in consultation. 
 
 As not altogether out of place here, I will refer to a peculiar 
 condition as a cause of disease which the originator. Dr. E. 
 Vallin, calls " wall disease." He speaks of the presence of 
 saltpetre in the walls of inhabited houses. On the brick walls 
 of houses in Philadelphia, Wilmington, New Castle, and sur- 
 rounding towns we often see a white deposit, especially on 
 the chimneys. This, I think, has been demonstrated to be 
 sulphate of magnesia, and comes from the magnesia in the 
 clay from which the bricks have been made, in connection 
 with the sulphur compound from the coal burned in the 
 houses. Vallin describes this trouble as a disease of the walls, 
 due to the presence of micro-organisms. He seeks to " cure" 
 the walls, as he puts it, to save those living in the houses. 
 The disease is caused by the penetration into the walls of the 
 bacilli of nitrification, and consequently the houses become 
 damp and unwholesome. This is likely to occur, says the 
 London Lancet, the account of which I take from the Phila- 
 delphia Medical Journal, in damp localities and in the pres- 
 ence of nitrogenous organic matter. From a sanitary point 
 of view this disease of the walls should be cured, as we cure 
 or prevent virulent diseases among men and animals. Vallin 
 says, first, thoroughly drain the ground around the walls, and 
 isolate them from the surrounding earth by a trench and by 
 
 i6o 
 
FORTY YEARS IN 'I'lllC MICDICAF. PROFESSION 
 
 the use of aspliall cement or coal-tar. Thus the access oi 
 water heariuj^ nitrifying hacteria that are aerohic vvfniUl be 
 prevented. It is also necessary to mix the mortar used with 
 antiseptic solutions, such as dissolved copper sulphate, etc. 
 Where these precautions had not been taken, and the disease 
 had already broken out, then he advocated the ffjllowing 
 treatment: Mrst, scrape off and wash awa\' all superficial 
 traces of the saltpetre (and magnesia, too, 1 should say, if 
 the deposit should be magnesia and not potash). Then inocu- 
 late the walls with active cultures of the anti-nitrifying bacilli, 
 the kind which impoverish farm manure by decomposing the 
 nitrates, and by throwing off in the atmosphere a great part of 
 the nitrogen which they contain. These walls should then be 
 covered over with impermeable paint, so as to retard the pro- 
 cess of nitrification of the aerobic germs, and on the other 
 hand to stimulate the growth of the anaerobic and anti-nitri- 
 fying germs which remove the oxygen from the nitrate, and 
 from the ammonia, when they cannot supply themselves with 
 oxygen from the atmosphere. 
 
 This ingenious theory has made quite an impression. The 
 idea of applying the principles of inoculation to the preser- 
 vation of material used in buildings opens a vast field of pos- 
 sible progress in the domains of sanitary engineering and 
 architecture. I will add that many things of this character 
 are being done, and many discoveries have been and are being 
 made in regard to the nitrification of plants, etc. Take the 
 leguminous plants. It is now known that they are provided 
 by nature with little tubercles on their roots, nitrogen-traps, 
 which generate little micro-organisms through which, or bv 
 the aid of which, or both, these plants receive nitrogen from 
 the atmosphere, and thus store it up. not only for their own 
 use, but for the use of other crops to follow on these plants 
 turned under the soil. Where a soil becomes sick as to nitro- 
 gen and will not bear the legimiinous plants, it is a custom 
 now to supply soil from a field not thus sick and where 
 legimies are growing, and thus revivify the sick soil. The 
 German chemists are now supplying bacteria which thev 
 II t6i 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 call nitrigin for such purposes, and this may become a com- 
 mercial business. Take a jar, fill it with earth, thoroughly 
 kill all organic life in it, and sterilize it by heat. Plant peas 
 in the jar, and the peas will not grow. Go to a bed in the 
 garden where peas are growing, and take a very little of the 
 earth from the pea-bed and add it to the sterilized earth, and 
 at once the peas start off and grow. Why? Because you 
 bring the micro-organism from the garden soil and add it to 
 the sterilized soil, and at once they increase, as only such 
 organisms can increase, and we have the essentials for the 
 growth of the peas by the addition of this microscopic life. 
 Just as we add a little yeast to the bread, and the prolifera- 
 tion of the yeast-plant acting with the gluten raises the bread. 
 So with all ferments : some are necessary to organic life under 
 certain conditions, and some are fatal to organic life under 
 certain conditions. 
 
 All of this is of the utmost importance in medicine. When 
 we can supply to the human organism at will a micro-organ- 
 ism constructive, as it were, and when we can supply to the 
 human subject at will a micro-organism destructive, as it 
 were, then will we be approaching a definiteness and an exact- 
 ness in medical science which will raise it from the empiricism 
 and uncertainty of the past, and make the physician what he 
 is rapidly nearing, one who can get definite results from defi- 
 nite means, and these definite means being in great measure 
 the application of nature's laws. It being undoubtedly true 
 that every organic thing in nature generates its own organic 
 poison, which really means limits its own life, the converse 
 may be true, that every poison thus generated by an organic 
 body may prove in some way a factor in making life possible 
 in other organic bodies. 
 
 All of these things go to show the wonders of life, and how 
 dependent every life is on other life, until we come to man, 
 who holds everything in the organic world subservient to his 
 own existence and to his own comfort, and how this whole 
 scheme of life is beginning to dawn on him. Whilst, for 
 instance, he has always held the ox as one of the great re- 
 
 162 
 
FORTY YEARS JN Till': MICDICAL I'ROl-ESSION 
 
 sources of his food and comf(jrt, he has taken Httle account 
 of the mere microscopical point, a Httic thinj^ scarcely defined 
 as to its place in nature, whether where the vegetable ends or 
 the animal begins, the bacillus of diphtheria, which under 
 favorable circumstances has the power literally to drive him 
 from the earth. He is just beginning to sec that he has 
 power also over this little unseen enemy; that he can abso- 
 lutely control its development and can absolutely render its 
 danger to himself nil ; and this history of this little germ 
 shows the lines upon which medicine is working, and gives 
 an insight into the great progress now dawning on the medi- 
 cal horizon. 
 
 Now, suppose we obtain absolute control over zymotic dis- 
 eases ; suppose we absolutely control all epidemics heretofore 
 so fatal ; we have confronting us great questions in political 
 economy. The Malthusian theory confronts us, — that popu- 
 lation when unchecked by wars, vice, epidemics, and other 
 depopulating causes, increases in a geometrical ratio, whilst 
 food can only be made to increase in an arithmetical ratio. 
 Well, let us shut our eyes to all coming troubles of this kind, 
 knowing full well that the future will take care of itself, and 
 that Providence will provide a way. If medicine brings 
 about this complicated condition by putting off death to old 
 age, what a compliment to medicine would such a state of 
 affairs be, and what man would be so great a man as the 
 doctor ! 
 
 Serum Therapy. — Among the recent introductions into 
 medicine, the therapeutic serums have been the most remark- 
 able and promise the most wonderful results. First of all, 
 the diphtheria antitoxin is probably best known, for it has 
 undoubtedly passed the experimental stage, and none of our 
 specific remedies to-day are probably more sure than is the 
 antitoxin of diphtheria in that disease. We have no right 
 now to treat a case and fail to give its use due consideration. 
 There is no doubt but that the illustrious Washington died of 
 diphtheria. On a visit to Mount Vernon, when I was ac- 
 corded special privileges I examined the house and premises 
 
 163 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 thoroughly. I know not wh}'-, but in the good old times the 
 thrifty housewife seldom allowed the best quarters to herself 
 or her family, but the desirable apartments were guest-cham- 
 bers, which were often full owing to the generous hospitality 
 of the day. The quarters occupied by the general and Mrs. 
 Washington were the smallest and meanest of the establish- 
 ment, very near the kitchen apartments and near the servants' 
 quarters, just the part of the premises furnishing teeming 
 hosts for all pathogenic germs, and a home and surroundings 
 just as acceptable and lovely to the deadly Klebs-Loeffler ba- 
 cillus as it was to the great man and his wife, — at once, their 
 home, their monument, and their tomb. 
 
 As to its discovery, manufacture, etc., I do not propose to 
 treat of them here, for they are now fully described in all 
 works on Materia Medica. When it first came out, in Eu- 
 rope, I sent to Germany and procured a quantity from Behr- 
 ings', and before I had had possession of it more than a very 
 few days I was called in consultation by Dr. H. G. M. Kol- 
 loch, of Newark, Delaware, to see a child of eighteen months 
 suffering from laryngeal diphtheria which had produced ste- 
 nosis and serious embarrassment to the breathing. We used 
 one injection of about seven hundred and fifty units. In 
 twenty-four hours there was marked relief, and after that 
 prompt recovery. From that day I had confidence in the 
 diphtheria antitoxin. Those now made in this country by 
 Mulford, of Philadelphia, and by Parke Davis & Co., of De- 
 troit, are among the best, and the price is getting within reach 
 of all. I have never seen any ill effect beyond now and then 
 a rash, which soon fades away. 
 
 The true secret of success, in my experience, is to use it 
 early and use plenty of it. Do not be afraid of it. Especially 
 in laryngeal cases use large doses. I have seen it do won- 
 ders in these cases. Before its introduction I lost a great 
 many of these cases, notwithstanding I performed a number 
 of tracheotomies, with poor success. Although many in the 
 profession held out a long time against what we called true 
 membranous croup being true diphtheria, few now deny it, 
 
 164 
 
FORTY YICARS IN TIIJC MI':i)IC.\L PROFESSION 
 
 The opponents now acknowledge ninety-five per cent, to be 
 genuine, and I have nr) don1)t but that the r)thcr five per 
 cent, contain the l)acilhis. 
 
 Some years ago, when this matter was being discussed 
 warmly, I had a number of cases in which 1 had made trache- 
 otomies which bore on the matter and confirmed the views of 
 Sir Morell Mackenzie in a marked degree. I prepared some 
 notes of the cases, and sent them to Sir Morell, and I had 
 several very nice letters from him in the matter, telling me 
 he had used the material for his new book then in press, and 
 the manuscript of which was destroyed by fire while in the 
 printer's hands. I never give less than five hundred units to 
 an infant under twelve months, and repeat it as often as neces- 
 sary. Children require larger proportionate doses than adults, 
 for they are more susceptible to the disease and carry more of 
 the toxine. In laryngeal cases over two years of age. never 
 start with less than two thousand units, and do not hesitate 
 to repeat in eight to twelve hours, and re-repeat as necessary. 
 These are the cases to be bold in, and are the cases which 
 give us the Avonderful results and are making tracheotomy 
 and even intubation less and less necessary. I think it best 
 to immunize all the children in the family if there is a case in 
 the house, and do not use less than five hundred units, as a 
 rule, for immunization. Begin as soon as you detect the case, 
 and do not wait for microscopic confirmation. If the case 
 goes on over thirty-six hours, you begin to have streptococcus 
 toxine poison. 
 
 I have not used the combined treatment of diphtheria anti- 
 toxin and streptococcus antitoxin, but such is recommended. 
 Do not let your case go on to secondary infection. As to local 
 treatment, do all you can with it. One to two per cent, solu- 
 tion of formaldehyde will do wonders in most cases. This 
 local treatment is all very well in adults and in children old 
 enough to be reasoned with. In children where you have to 
 fight them and exhaust them by your eflforts to use local treat- 
 ment, drop it when you come to this point. I am sure they 
 lose more than they gain by their efforts at resistance and by 
 
 i6= 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 fright. , All the tact and all the skill of a good nurse will not 
 overcome these troubles in many children. Food and nour- 
 ishment and absolute recumbent rest are most important, and 
 where necessary tracheotomy and intubation are to be enter- 
 tained. Watch the heart for weakening, particularly, and 
 keep in mind digitalis, trinitrin, strychnine, atropine, and 
 alcohol. Champagne is the best stimulant, or heavy wines 
 in carbonated waters. If your patient be a negro you will 
 usually find the disease of virulent type. 
 
 Another point : the antitoxin as now furnished comes much 
 more potent as to quantity than formerly. Mulford puts up 
 five hundred units to one cubic centimetre. At this rate it is 
 easily used in a first-class hypodermic syringe, and there is 
 no necessity for the large quantity of fluid and the large cum- 
 bersome syringe which first came out. Of course, in its use, 
 observe on every hand the most perfect antiseptic precau- 
 tions. In tuberculous troubles, I believe I have used almost 
 all the serums that have come out and one or two of my own 
 ideas, but have no real success to report, and will refer to this 
 matter again, when I come to speak of tuberculosis in gen- 
 eral. 
 
 In tetanus I have had experience only with one case, — a 
 boy of fifteen, who had wounded his foot with a rusty nail 
 some days before, and who had marked premonitory symp- 
 toms of tetanus when I saw him. In twelve hours I saw 
 him again (having treated the wound medicinally before I 
 left him), and during my absence he had taken chloral and 
 potassium bromide in full doses. Having obtained the anti- 
 toxin of tetanus from Dr. Gibier, of the Pasteur Institute, 
 New York City, I used it according to directions. The boy 
 was really better when I commenced the use of the antitoxin, 
 but still had marked symptoms. He gradually improved and 
 got well. 
 
 An editorial in the University Medical Magazine, February, 
 1899, gives a good synopsis of the treatment of tetanus to date 
 by serum. Wasserman, it says, showed that a mixture of teta- 
 nus toxine with the brain or spinal cord of a susceptible ani- 
 
 166 
 
FORTY YIOARS IN Till-: Mi":iJlC,\l. PROFESSION 
 
 mal could l^e injected into a guinca-pij( siibctitaneously with- 
 out causing tetanus, while the same quantity of toxine without 
 the admixture of brain or cord, invariably caused fatal teta- 
 nus. This gave Roux and Borrel a pointer, and they treated 
 forty-five guinea-pigs in which tetanus had been produced 
 artificially by injecting tetanus antitoxin into the brain, thirty- 
 five of which recovered. Of seventeen treated by subcuta- 
 neous injections of antitoxin, in much larger doses than was 
 thrown into the brains of the forty-five cases, only two re- 
 covered. Of seventeen animals tetanized and allowed to go 
 without treatment, all died. 
 
 It is a serious matter to throw anything into the brain, but 
 these are serious cases. Use two and one-half centimetres 
 of double strength tetanus antitoxin serum. Do everything 
 antiseptically. Trephine with a small trephine or Archime- 
 dean drill. The spot to choose is two and one-half inches 
 above the external angular process of the orbit and one and 
 three-quarters inches from the median line. Introduce the 
 needle two inches into the frontal lobe, and inject drop by 
 drop, allowing ten minutes for the injection. At the same 
 time inject twenty cubic centimetres of ordinary tetanus anti- 
 toxin subcutaneously. 
 
 Heckel and Reynes thus group tetanus : Where incubation 
 is fourteen days or more, temperature below 39° C, and a 
 little dyspnoea, here serum treatment will cure. In subacute 
 cases running a rapid course, with dyspnoea and irregular 
 pulse, intracerebral injections may cure if used promptly. In 
 acute cases beginning in from five to seven days, temperature 
 over 40° C, with rapid appearance of spasm, oleguria, rapid 
 breathing, and rapid pulse, use serum therapy subcutaneously 
 as soon as trimsus appears. Puerperal tetanus, tetanus ne- 
 onatorum, and the cephalic tetanus of Rose are not favorable 
 cases for serum treatment. The first essential of treatment 
 is early diagnosis. When trismus appears, the disease has 
 passed far along. It then becomes a question of intracerebral 
 injection of antitoxin. Our great eft'ort should be to find 
 something to make out the form before trismus appears. 
 
 167 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 The bacillus of tetanus, in my experience, is common in 
 low countries and in marshy places, and is especially common 
 about horse-stables and on farms on river-sides. It is an 
 aerobic, and hides in the dark. The bacilli and not the toxine 
 is usually the matter inoculated, and it takes some days for 
 the toxine to form in the system as a result of the bacilli inoc- 
 ulation. One thing remember : the bacilli of tetanus have 
 probably more tenacity of life than all other of the disease- 
 producing germs, and the tetanus toxine is the most virulent 
 of toxines. Bichloride of mercury solution one to one thou- 
 sand will not destroy them in an hour or more. They will 
 stand more boiling than all other of the disease germs. Be on 
 your guard; remember this as a practical point in surgical 
 operations and in treating the local wounds in cases of trau- 
 matic tetanus (indeed, even trivial wounds) : boil all water 
 used at least one hour, if it comes from a source suspicious 
 as to tetanus bacilli, or you may have tetanus following your 
 operation, and wonder where it came from. Tetanus has also 
 been treated by carbolic acid, known as Baccelli's method. 
 A two per cent, solution is used hypodermically, at intervals 
 of two to three hours, using three grains a day, rapidly in- 
 creasing to six to eight grains a day. The system is very 
 tolerant of carbolic acid in tetanus. This is claimed to give 
 better results than the antitoxin treatment. Dr. D. F. Woods, 
 of Philadelphia, has reported a very interesting case cured 
 by the carbolic acid treatment. 
 
 I have had little experience with transfusion and infusion, 
 but will mention it later on, in Chapter IX. Lentz & Sons 
 have a very efficient apparatus for the latter work. My expe- 
 rience leads me to advise great care in injecting fluids into 
 the cellular tissues in large amounts, as, in such a case, where 
 the patient was weak and run down, I have seen very trouble- 
 some sloughing follow. The normal saline solution is a sim- 
 ple one : add one teaspoonful of common salt to one pint of 
 water previously boiled one-half hour ; boil this ten minutes, 
 strain it thoroughh^, and inject it at a temperature of about 
 1 00° F. Where we have oedema of the lungs, — a patient 
 
 168 
 
FOin'Y YI'lAkS IN 'I'll I'. MIJJICAL i'KOI-'ICSSION 
 
 drowiiinj;', as it were, in his own lluids, — be careful of jabo- 
 randi and pilocarpine; sudden dcitli may follow from any 
 but its very careful use. Hot baths and sweats are safer. 
 Here intravenous saline injections may come in, especially 
 where there is uraemia, say a (|uart into the most convenient 
 veins; hut be very guarded at every point in this work. In- 
 traperitoneal injection in these cases really might be the safer, 
 and either may be used after shock from extensive burns. 
 
 Much has been said and written about the imcleins and 
 the nuclein preparations, and great disappointment so far in 
 my experience has followed their quite extensive use. In 
 one well-marked case of expanding sarcoma of the femur a 
 free use of proto-nuclein, both hypodermically and by the 
 mouth, did really appear to retard the advance of the lesion. 
 but then we all know such cases often remain dormant for a 
 time after rapid growth, and then after a time advance again 
 and go on to death, as did the case I am speaking of. In 
 lympho-sarcoma, after faithful trial, I have never seen the 
 nucleins or any other treatment retard the growths, and I 
 have had the same experience after trials of the bacillus pro- 
 digiosus and erysipelas toxine in malignant disease. I have 
 never had the opportunity of trying the method, but it has 
 been recommended to me from a source worthy of regard, in 
 the case of a hsemophilic bleeding, to apply blood from a 
 healthy person, and thus check the hemorrhage. 
 
 Whilst on this subject, let me refer to the effect of the 
 sting of the honey-bee on human beings. I ha\'e made some 
 practical study of this subject, and am prepared to affirm that 
 from frequent stings the individual becomes immune to the 
 poison, in many cases absolutely immune, and this stud}- of 
 the efifect of bee-stings has impressed me forcibly as to the 
 possibility of rendering man and other animals immune to all 
 organic poisons of creature origin or vegetable origin, whether 
 pathogenic or otherwise. I know of one bee-keeper, with a 
 wife and several children, who are all more or less immune 
 to the poison of the sting. In all of them, immunity has come 
 by degrees, after frequent stings. The man assures me he 
 
 169 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 can now be stung two hundred times in twenty-four hours 
 and feel no ill effects, locally or constitutionally. From his 
 first stings he suffered acutely. He is always careful to brush 
 off the stings so they wall not be held by the little saw-like 
 teeth at the end. The poison is a transparent fluid of sweetish 
 taste and acid reaction, and the antidotes are potassium per- 
 manganate and ammonia or other alkalies. The queens and 
 workers have the stings, whilst the males have none. When 
 it is known that very numerous stings have killed horses, and 
 would probably kill a man, the fluid compares in virulence 
 with many of the serpent poisons when we consider the com- 
 parative amounts involved in bee-stings and serpent-bites, and 
 these comparative studies become most interesting and useful. 
 I have never met any one naturally absolutely immune to 
 the sting of the honey-bee, but have seen such cases reported. 
 I have never met a bee-keeper who was not more or less im- 
 mune after frequent exposures, but I have heard of some few 
 cases where no tolerance ever became established. The possi- 
 bility of causing immunity in the individual to such troubles 
 as the bites of serpents and such creatures by the use of the 
 poison of the sting of wasps, bees, and such, is beginning to 
 attract attention, and my friend, who can endure two hundred 
 honey-bee stings in twenty-four hours, may have, from the 
 toxines of these stings, sufficient antidotal and antitoxic prop- 
 erties developed in his system to withstand the bite of the 
 rattler, or even of the cobra. Who knows? Who wall make 
 the trial? No one willingly, probably, but some poor jungle- 
 dw^eller ma}^ yet be the subject to demonstrate the fact. There 
 is another interesting question as to the honey-bee, and maybe 
 to other stinging insects so far as I know. I refer to the 
 action of its sting poison on the poison of rheumatism in man. 
 It has been quite well established, as we know, that rheuma- 
 tism has its pathogenic germ, and hence we may infer that 
 this has its antitoxin either in nature or artificially produced. 
 As before stated, the poison of the bee is a clear fluid, with a 
 sweetish acid taste, with an acid reaction, the acid being prob- 
 ably formic acid. Organic toxines usually lose their viru- 
 
 170 
 
FORTY YEARS IN THIC MEDICAL PROFESSION 
 
 lence in the presence of an (jr^anic acid. Possibly here may 
 be the secret. Be it as it may, from my talks with experi- 
 enced bee-keepers and bee experts, and from my own experi- 
 ments with the action of the bee-sting upon human beings 
 suffering from rheumatism, I am satisfied there is some an- 
 tagonism between the bee-poison and the toxine of rheuma- 
 tism, and that not only does the bee-poison neutralize in a 
 measure the rheumatism toxine, but it also for a time at least 
 renders the system immune to a greater or less extent to said 
 poison. I look upon the matter as worthy of fuller investiga- 
 tion both as to rheumatism and to gout. 
 
 I gather from the report of the Secretary of Agriculture 
 and from an article in the Philadelphia Medical Journal on 
 " Diseases and Abuses of Animals in the United States," by 
 Dr. D. E. Salmon, the accomplished head of the National 
 Bureau of Animal Industry, most encouraging statements of 
 the serum treatments in the diseases of the lower animals ; 
 and these statements go far to confirm and strengthen all such 
 treatments in man now in their very infancy, but which soon, 
 mark my words, are destined to give to the results, when 
 compared with all that has heretofore been done in the science 
 of medicine, a brilliancy and success the most sanguine among 
 us have little dreamed of. The matters referred to, among 
 others, are swine plague and hog cholera. In the Bureau of 
 Animal Industry they have demonstrated these as distinct in- 
 fectious diseases. They have shown, having found the germs 
 of each, ho\v they leave the bodies of sick animals, and are 
 disseminated, and how they get into the bodies of healthy 
 animals and make them sick. They have experimented with 
 medicines and disinfectants; they have tested the method of 
 killing all diseased animals and burning them. They have 
 tested vaccination, inoculation, and serum treatment. Salmon 
 says the practicable and efficient plan has been found in the 
 serum treatment. 
 
 Ten millions of hogs die annually of these infectious dis- 
 eases. Think of such a terrible slaughter by disease, and how 
 easily such a holocaust might fall on man ! Such might easily 
 
 171 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 be the case ; the material is all about us in nature for just such 
 plagues, and to think that by science everything points to the 
 fact that man can control such an outbreak, whether in man 
 or in the lower animals. Think how Pasteur pointed the way, 
 and how his great helpers are day by day working to the per- 
 fect end. In these hog epidemics — or rather epizootics — the 
 serum treatment, used in herds where seventy-five per cent, of 
 them were too sick to eat, caused many in twenty-four hours 
 to eat, and on the third day a great part of the herd would be 
 wonderfully improved. In herds treated, seventy-eight per 
 cent, were saved. In untreated herds, fifteen per cent, only 
 recovered. In a few days, in treated herds, the disease is 
 stopped. All this means the saving of ten millions of hogs a 
 year. How many animals, how many human beings, does it 
 mean annually saved, and what an improvement in the eco- 
 nomics of animal industry when these true scientific princi- 
 ples are successfully applied, as they surely zvill be, to all 
 zymotic diseases, to all diseases caused by pathogenic germs, 
 not speaking of the possibility of immunizing both man and 
 the lower animals to all such germs, as Jenner did in his small 
 way many years ago ! How can we help but become enthu- 
 siastic as science unfolds her mysteries ! 
 
 172 
 
CH A PT IC k VII. 
 
 Nervous Diseases Forty Years Ago — Soninamlnilisni — Hypnotism — 
 Motor Disorders — Lunacy — Delirium Tremens — Kpilepsy — Chorea — 
 Diseases of the Cord and its Membranes — Tetanus — Hydrophobia — 
 Hysteria — Neurasthenia — Dr. D. D. Richard,son's Views on the Treat- 
 ment and the Care of the Insane — The Fceble-Minded — Notes by Dr. 
 Martin W. Barr — The Deaf and Dumb — Colonel William Boiling — 
 John Brainwood — Thomas Hopkins Gallaudet — Edward Miner Gallau- 
 det — Hon. Amos Kendall — Dr. Crouter — Peet — Rogers — (iilletl — 
 Noye.s — Fay — Manual Method and Speech — Swedish Movements — The 
 Bath — Electricity — The Masseur and the Masseuse — Hypnotic Sugges- 
 tion — The Dangerous Classes — The Degenerates — How shall the Prob- 
 lem be solved? 
 
 Forty years ago the nervous system and its diseases, com- 
 pared with the present time, were little understood, and it was 
 a great field in medicine, little worked and less tilled. Take 
 the classification of nervous diseases in a popular work on the 
 practice of medicine at that period, and it ran perhaps in this 
 fashion : Diseases of the brain, under which we would get 
 inflammation of the brain and its membranes, acute and 
 chronic, cerebritis, tuberculous troubles ; organic diseases of 
 the brain; softening, hypertrophy, tumor, apoplexy; func- 
 tional diseases of the brain ; nervous irritation, vascular irri- 
 tation, depression ; then morbid phenomena, as headache, 
 stupor, sunstroke ; then came mental disorders, ecstasy, som- 
 nambulism, artificial somnambulism or animal magnetism, or 
 mesmerism, now called hypnotism ; then came motor disor- 
 ders, convulsions, catalepsy. The next division is lunacy, and 
 under it the different divisions of the day, as monomania, 
 insane impulse, etc. ; then comes delirium tremens, and what 
 student in the days of Professor George B. Wood and William 
 Pepper, Sr., does not remember the horrible imaginings dis- 
 played on canvas by a recovered patient as among the recol- 
 lections of his visions and dreams during his illness. At the 
 
 ^73, 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 close of the lecture, with what form and ceremony and much 
 ado did Levick remove the cover and expose them to the ex- 
 pectant gaze of an applauding audience. Then came epilepsy 
 and chorea, then diseases of the cord and its membranes, and 
 then functional diseases of the same, as tetanus — so it was 
 placed in those days — and hydrophobia; then inflammation 
 of the nerves, under which came, chiefly, neuralgia; then a 
 sub-section, paralysis, and lastly hysteria. Such was about 
 George B. Wood's classification. 
 
 The causes of the troubles, the pathological conditions, 
 were, comparatively with the present day, little understood, 
 and the treatment was on the general principles then in vogue. 
 Read su'ch descriptions to-day, — and they were good descrip- 
 tions, too, for their time, — and then compare them with ner- 
 vous diseases in a standard work on practice at the present 
 time; or, better still, with the grand work of Mills, just out, 
 or even with Rosenthal's work of twenty years ago, and we 
 see at once what a great branch of medicine has arisen based 
 on the nervous system and its diseases, and what great work 
 has been done by such men as Charcot, Rosenthal, Weir 
 Mitchell, Sinkler, Mills, Dercum, Taylor, Dana, Horatio 
 Wood, Seguin, and other equally able and zealous men. A 
 grand system has been built up from a beginning so small as 
 to be almost insignificant, and in proof of this it is only neces- 
 sary to refer to the great improvements in classification, in 
 our knowledge of the causes of nervous troubles, of their 
 pathology, and of their treatment. 
 
 I may mention the knowledge we have gained of the local- 
 ization of cerebral functions as a great step in advance in 
 general medicine and surgery. The knowledge we have 
 gained of neurasthenia, the American disease, so called, is 
 another great advance and practical help in every-day prac- 
 tice. 
 
 It is not my purpose here, nor does it come within the 
 scope of this work, to go into details of any kind in ref- 
 erence to nervous diseases, but I propose, in showing the 
 contrast between the past and the present, to give in detail 
 
 174 
 
FORTY YEARS IN THE MEDICAE PROFESSION 
 
 statements made to me showing such contrasts by three oi the 
 <'il)lest men we have in the profession in their several special- 
 ties to-day. T will refer first to matters pertaining to the in- 
 sane. Dr. 1). D. Richardson, the well-known alienist and 
 superintendent of the State Hospital at Norristown, Penn- 
 sylvania, has kindly given me the following answers to my 
 inquiries connected with his specialty : " The changes in the 
 treatment of the insane for the past thirty-eight years has 
 consisted in the amplification of the methods dating back to 
 1844. Physicians have arrived at the unanimous conclusion 
 that insanity comes of disease. The courts do not stand 
 wholly on this solid foundation, though I am glad to say 
 there are many of the learned bench who hold with us that 
 insanity is the outcome of sick physiology or pathology. Hip- 
 pocrates taught that insanity is caused by disease. The 
 mythical notion that the insane were possessed of the devil 
 was not countenanced by this most celebrated physician of 
 ancient times. Gymnastic and calisthenic exercise holds a 
 foremost place in the physical culture of the insane. Herodi- 
 cus, an ancient physician of Thrace, and one of the medical 
 educators of Hippocrates, insisted upon the application of 
 gymnastics in the prevention and treatment of disease, and 
 the spark has been caught up and kindled the enthusiasm of 
 alienists to such an extent that there is hardly a hospital of 
 any pretensions where physical culture is not advocated and 
 promulgated. The ramifications have led to the dance, the 
 bowling-alley, the billiard-table, foot-ball, base-ball, racing, 
 and jumping. Then, too, it has extended its usefulness to 
 horticulture and to agriculture. Fifty per cent, of the cures 
 at the Norristown Hospital may be attributed, I think, to 
 exercise in-doors and out-of-doors. From 1839, when Con- 
 nolly began the non-restraint system, to the present time 
 alienists have favored less and less all forms of restraint. 
 Some hospitals claim to have entirely discarded it, others to 
 have modified it to the minimum. Very much pro and con 
 may be said upon this important subject. My own practice 
 has been to avoid it if the best interest of the patient justified 
 
 175 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 it. It is due to Connolly's love of his fellow-man to say that 
 his noble efforts have borne good fruit. Blood-letting in the 
 treatment of the insane has seen its day. It was practised too 
 frequently in early times, and now, though seldom used, is 
 used quite often enough. The supporting plan, feeding often 
 and to repletion, meets with better and more satisfactory 
 results. Purgatives do not constitute an essential part of the 
 treatment of the insane, but it is believed to be indispensable 
 that the contents of the alimentary canal should be evacuated 
 daily. This treatment has gained favor in hospitals, and 
 nurses are especially instructed as to the evils of constipation 
 and the necessity of instructing their patients as to the pro- 
 priety of after-breakfast visits to the water-closet. Opium 
 and its constituents are used less frequently than formerly. 
 Chloral, introduced in 1871 and freely administered, is used 
 with more caution now. Hyoscine is a reliable remedy, and is 
 to be recommended, its tastelessness facilitating its adminis- 
 tration. Paraldehyde acts well in many instances. Sulpho- 
 nal is a safe remedy, producing sleep quite like ' nature's sweet 
 restorer.' Trional is looked upon with favor by many physi- 
 cians. All of these remedies are regarded with suspicion by 
 some of the profession, and are substituted by feeding night 
 as well as day. The therapeutics of insanity have come to be 
 more like the therapy of other diseases. Physicians know 
 now that there is no specific remedy for this ' ill that flesh is 
 heir to,' and that the physical condition should receive our 
 first attention. We have learned to regard physical improve- 
 ment as the sine qua non which brings, sooner or later, the 
 dawn of ' the perfect day' of mental restoration. Occupation, 
 diversion, encouragement, — these three words are more deeply 
 engraven upon the minds of the superintendents of the pres- 
 ent day. Of recent years considerable attention has been 
 given to electricity and massage, in the hope that muscular 
 tone might be developed. This practice, supplemented with 
 nutritious, assimilable food, open-air exercise, followed by 
 several hours' rest in bed, has made good showing, and bids 
 fair to continue to bring favorable results. The thermometer 
 
 176 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 is in general and more satisfactory use. y\nalysis of the 
 urine and blood are more and more engaging the attention of 
 ahenists. Thorough physical examinations on admission are 
 mucli more thoroughly prosecuted. Entertainments are fre- 
 quent and diversified. Schools for training attendants have 
 been organized in many of the hospitals, and thus a more 
 intelligent and competent class of nurses is secured, and the 
 outlook becomes more favorable as we work on hoping and 
 trusting." 
 
 What Dr. Richardson has thus hastily written is sufficient 
 to show the advances made and being made in the treatment 
 of those who have lost the use of their reason, and chains and 
 bolts and bars are not even alluded to, so thoroughly have 
 they gone out and their places been taken by custodial care, 
 the patient being always or nearly always under intelligent 
 observation. The feeble-minded are an interesting class to 
 the physician, indeed to all intelligent people, and when we 
 compare the condition of those gathered in our thoroughly 
 supervised institutions devoted to the care of such unfortu- 
 nates with the poor imbeciles we encounter in private homes 
 and those we see daily on the streets of our cities and towns, 
 or, more unfortunate still, those who shamble along the vil- 
 lage walks, the butt of the boys, loved by few and respected 
 by none, it is then and only then we see the grand work such 
 schools are doing, and at once we stand in awe and admira- 
 tion at the self-sacrifice of their teachers and of those un- 
 selfish men and women who have given time and money with- 
 out stint to help these poor and weary ''children of a day," 
 
 Dr. Martin W. Barr, the distinguished physician-in-chief 
 of the Pennsylvania Training School at Elwyn, and the suc- 
 cessor of the lamented Dr. Kerlin, one of the great pioneers 
 in the work, has kindly given me a few notes in reference to 
 these people, and I take great pleasure in giving them at 
 length, with the assurance that they will prove most inter- 
 esting. 
 
 " The imbecile is traced through all the ages, all climes. 
 We find him as the Fatura of Rome, the Tardivi of Italy, Les 
 12 177 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Enfants Arrieres of France, Geistig Zuriick-gebliebene of the 
 Germans. The Koran gives this special charge to the faith- 
 ful : ' Give not unto those who are of weak understanding 
 the substance which God has appointed you to preserve for 
 them, but maintain them thereout, and clothe them and speak 
 kindly unto them." 
 
 " The first recorded attempt to educate an idiot was made 
 in the year 1800 by Itard, the famous physician in charge of 
 the National Institution for the deaf and dumb at Paris, upon 
 a boy known as the Savage of Aveyron. In the year 1818 
 and for a few years afterwards several idiotic children were 
 instructed in the American Asylum for the Deaf and Dumb 
 at Hartford, and fair results were obtained. In 1828 Ferret, 
 of the Bicetre, near Paris, attempted to teach the imbecile, 
 and his success was also fair. In 1831 Fabret tried the same 
 at the Salpetriere, and in 1833 Voisin founded his private 
 school for idiots in Paris. In 1837 Seguin, the pupil of Itard 
 and Esquirol, took under his protection a number of idiots 
 and instructed them at his own expense. Exiled from his 
 native France during the revolution of 1848, he came to 
 America, where he was instrumental in establishing schools 
 for idiots in various States. In 1848 a private school for im- 
 beciles was opened at Barre, Massachusetts, by Dr. H. B. 
 Wilbur. In 1851 the State of New York appropriated six 
 thousand dollars annually for two years for the purpose of 
 establishing a school for imbeciles, and in 1853 the school 
 was formally opened. Pennsylvania was the third State to 
 take up the work, and in 1852 a private school for idiots was 
 opened in Germantown by Mr. J, B. Richards, of Massachu- 
 setts. This school was incorporated April 7, 1853, as the 
 Pennsylvania Training School for Idiotic and Feeble-Minded 
 Children, and in 1855 it was removed to its present site at 
 Elwyn. The Ohio institution at Columbus was established in 
 1857, the Connecticut School for Imbeciles in 1855, and the 
 Kentucky School at Frankfort was opened in i860, followed 
 by the erection of a school in Illinois in 1865. 
 
 *' Thus, in 1874, twenty-six years after the recognition of 
 
 178 
 
FORTY YEARS IN TJli': MI':iJ)ICAL PROFESSION 
 
 the fact tli.'it an imbecile could be trained, institutions liad 
 been established in seven States. At the present time there 
 are twenty-four large institutions in the United States caring 
 for eight thousand four hundred and ninety-four children, 
 besides many small private schools. In the training of the 
 feeble-minded a correct classification is most important. As 
 Wilbur forcibly put it, we do not propose t(^ create or supply 
 faculties absolutely wanting, nor to bring all grades of idiocy 
 to the same standard of development or discipline, nor to 
 make all capable of sustaining creditably all the relations of 
 a social and moral life; but rather to give to dormant facul- 
 ties the greatest possible development and to apply these 
 awakened faculties to a useful purpose under the control of 
 an aroused and disciplined will. At the base of all our 
 efiforts lies the principle that, as a rule, none of the faculties 
 are absolutely wanting, but dormant, undeveloped, and im- 
 perfect. Broadly considered, the feeble-minded are divided 
 into two classes, — the imbecile, improvable; the idiot, unim- 
 provable ; which, modified, stands thus : 
 
 " I. The imbecile, trainable in three grades, low, middle, 
 and high, 
 
 " 2. The moral imbecile, found in all these grades, train- 
 able only under rigid custodial care. 
 
 " 3. Idio-imbecile, improvable as regards cleanly living, 
 and trainable in a very limited degree. 
 
 " 4. The idiot, except in rare cases and by expensive meth- 
 ods, absolutely unimprovable. 
 
 " The imbecile, the only trainable class, divides into low, 
 middle, and high grade. The first of these may be brought 
 to give, always under direction, fairly good service for farm 
 or house, if training be begun early, before apathy or indo- 
 lence becomes a settled habit. He rarely if ever learns to 
 read, and very soon reaches his mental limit. The imbecile 
 of middle grade is capable of making slow' progress in pri- 
 mary school work. I might say in about four years, especially 
 if he has had previous training in the kindergarten, he will 
 attain some proficiency in reading, w-riting, and number work, 
 
 179 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 together with such a knowledge of form, color, and practice 
 in free-hand drawing as shall materially aid him in learning a 
 trade. Indeed, mental development for him is best attained 
 through simple handicrafts having their initiative in the kin- 
 dergarten. 
 
 " The high grade shows children but slightly mentally defi- 
 cient, who progress slowly as far as the ordinary grammar- 
 school grade, frequently developing an aptitude for music, 
 drawing, and the various industries. These are the backward 
 children that the schools complain of, the feebly gifted ones 
 of England, the ' Tardivi' of Italy, les enfants arrieres of 
 France. These are they so often not recognized in seminary 
 or college life, until under excessive pressure or excitement 
 of competition comes complete breakdown, idioc)^ insanity, 
 or early death. So nearly normal are many of these, that 
 their defect would perhaps be noticed only by the initiated, 
 and the question is often asked, why are these who do so well 
 accounted feeble-minded? The public little knowing that 
 the time and labor has been double that expended for like 
 results with a normal child. 
 
 '' The moral imbecile, generally of high or middle grade, 
 quick of apprehension, crafty, and cunning, or, if of low 
 grade, sullen and cruel often to brutishness, absolutely desti- 
 tute of the moral sense, — what might be termed immoral or 
 unmoral, — is too dangerous an element to be permitted in the 
 schools. This, the saddest victim to a fatal inheritance, is 
 he who claims most at the hands of society and who gets the 
 least, because, precocious and often abnormally bright, he is, 
 as a certain jurist once delighted in saying, ' The kind we 
 hang.' As intellectual training does but add to his armament 
 of ill, for him should be provided, within strongly guarded 
 asylum walls, all the benefits of a manual training school and 
 its outcome in the various trades, which shall at once give vent 
 for his superfluous energy and render him self-supporting; 
 but this should be coupled with all the ameliorations of cheer- 
 ful living that humanitarianism owes to this scapegoat for 
 the sins of others. Hard labor and life-long sequestration is 
 
 i8o 
 
FORTY YRAKS IN THR MEDICAI. PROFESSION 
 
 the only medicine for his ill, a disease loo often fhic to the 
 sins of a normal ancestry. 
 
 "The i(Ho-imhecile, who, as the name implies, partakes of 
 the nature of hoth the ichot and tlie imhecile, is generally 
 undersized, with very defective speech and a limited vocabu- 
 lary confined to a few scattered words, never a full sentence ; 
 his improvement is hut limited. The most we can hope to do 
 is to keep his nervous, restless fingers employed ; he can some- 
 times learn to knit, to weave mats, or do simple housework, 
 hut never to read or write. For him, as for the idiot, but 
 little can be done beyond giving him the custodial care best 
 adapted to his peculiar needs, the genuine benefit being found 
 in the family relieved of such a burden, as it has been com- 
 puted that, for every case sequestrated, two if not more mem- 
 bers are released to society. The idiot is usually but poorly 
 developed, and in most cases unable to stand or even to sit 
 alone, hardly conscious of his physical needs ; he has no lan- 
 guage but a cry; he rarely learns to talk; indeed, in all my 
 experience of idiocy, do I recall but two ; of these, one, after 
 much effort, was able only to speak his brother's name, and 
 the other acquired three words in three years. 
 
 " A word as to methods. These, based upon the theories 
 of physiological education dictated by Pestalozzi, Froebel. 
 and Rousseau, were first successfully practised with mental 
 defectives by Itard and by Seguin, and include all the means 
 that modern thought and experience have gathered. Kinder- 
 garten, nature studies, object-lessons, Sloyd, and the many 
 occupations included under the name of manual training all 
 lend a successive and continuous stimulus, the one underlying 
 principle and aim of the schools being to induce observation 
 and comparison as a basis of thinking and doing. Calisthen- 
 ics and military drill induce physical development and muscu- 
 lar co-ordination, quick observation, and prompt subordina- 
 tion. These vital principles of physiological education have 
 practical and intellectual application in the exercises in free- 
 hand drawing, modelling in clay and wood, in Sloyd. in 
 basket and straw braiding, and in the phonetic and articula- 
 
 i8i 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 tion drills and musical exercises of the class-room, each being 
 the initial of a life-long occupation. 
 
 " Believing, as we do, that ' the working hand makes strong 
 the working brain,' there is always something for the child 
 to do, some object to be made, not an abstract thing to be put 
 out of sight when finished, but something of use to himself 
 or to one for whom he cares. Work constantl)^ stimulated 
 through the emotions is his all along the line, from kinder- 
 garten, class-room, and Sloyd, to shoe-shop, printing-office, 
 and other useful trades. Should his limit of application be 
 soon reached, and the avenue of happiness and safe living be 
 for him reduced to one simple groove, the more active pur- 
 suits of the farm, the garden, laundry, or household service 
 will interest and provide vent for superfluous energy, or by 
 constant stimulus keep him from retrograding or lapsing into 
 apathy. For these varied occupations he is all the better fitted 
 by the previous training of the senses received early in the 
 schools, and if, happily, he should have there learned to read 
 or to draw, to color, to carve, or has acquired any skill in 
 music, he will have many avenues of recreation closed to his 
 less fortunate brother, to whose comfort and pleasure he him- 
 self will be the better able to minister. 
 
 " In regard to the medical treatment of mentally defective 
 children, the treatment is not essentially different from that of 
 the normal, except, perhaps, they are not so sensitive to drugs, 
 and we generally increase the doses. They need many tonics, 
 and I find that punch, or even plain whiskey, combined with 
 strychnine, quinine, and iron, is about the best. They are 
 peculiarly susceptible to lung and cutaneous diseases. Some 
 ten years ago the medical world was agog with accounts of 
 brains liberated from compressing skulls by the surgeon's 
 knife. The press was filled with sensational articles on the 
 subject of craniectomy, and every alienist caring for feeble- 
 minded children was besieged with applications from parents, 
 who, notwithstanding the certain risks attending surgical in- 
 terference, begged that the operation might be tried upon 
 their children. I have seen a number of cases operated upon, 
 
 182 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 and in only one case have I seen the shghtest improvement, — 
 this an idiot, to whom I have referred before in these notes as 
 having learned three words in three years. Was this post 
 hoc or propter hoc ? 
 
 " We must always take into consideration the amount of 
 extra care a child recjuires after an operation. While abroad 
 I examined with Bourneville the mag-nificent collection of 
 skulls operated upon at the Musee Anatomo Pathologique of 
 the Bicetre, and the skulls healing without enlargement show 
 the hopelessness of the operation. Victor Horsley, Shuttle- 
 worth, Beach, and Telford Smith agree with the rest of us in 
 the opinion that it is the brain that moulds the skull, not the 
 skull the brain." 
 
 THE DEAF AND DUMB. 
 
 There is another most interesting class of unfortunates, the 
 deaf and dumb. In 1890 the census of the United States 
 showed that there were over forty-one thousand of such peo- 
 ple in the country. Much has been and is being done for 
 their comfort, education, and training. Millions of dollars 
 have been expended in buildings, and now almost every State 
 of the Union has its training-school for the deaf and dumb, 
 and the Gallaudet College for the deaf, at Washington, D. C, 
 which grants diplomas and degrees, after a full college course, 
 is a fitting monument to the country and to the great men who 
 founded it. The first record of efforts to teach the deaf and 
 dumb in this country was by Colonel William Boiling, in 
 Goochland County, Virginia, in the year 181 2. Colonel Boi- 
 ling had three deaf children, and employed John Braidwood, 
 a Scotchman, a grandson of Thomas Braidwood, who had a 
 school for the deaf and dumb in Scotland. Colonel Boiling 
 did much for Braidwood, but his intemperate habits rendered 
 him worthless for practical work. 
 
 The real introducer of successful teaching of the deaf and 
 dumb into the United States was that distinguished man, 
 Thomas Hopkins Gallaudet, and the place Hartford. Con- 
 necticut. His first pupil was Alice Cogswell, a daughter of 
 Dr. Mason F. Cogswell, of that citv. Dr. Gallaudet has a 
 
 183 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 worthy successor in his son Edward Miner Gallatidet, Ph.D., 
 LL.D.," the distinguished head of the Gallaudet College for 
 the deaf, at Washington, D. C, and to whom I am indebted 
 for the data I am using in this writing. Hon. Amos Kendall 
 should not be forgotten in this connection, for it was from his 
 goodness of heart that the first funds and efforts were sup- 
 plied towards the establishment of this great institution. 
 
 In America at present there are many able and eminent 
 men engaged in educational work among the deaf and dumb, 
 and in addition to those already mentioned I may name Dr. 
 Crouter, of the Philadelphia Asylum at Mt. Airy, Peet, 
 Rogers, Gillett, Noyes, and Fay, connected with different 
 institutions. Why are so many children deaf and dumb? 
 That is what concerns us as physicians. Can we as physicians 
 do anything to prevent it? Doubtless in many cases we are 
 at fault, not by doing harm directly, but possibly by neglect 
 and careless indifference. Physicians should watch infants 
 under their care during the first few days after birth, and see 
 that nurses understand something of the anatomy and pathol- 
 ogy of the ear. A child may be kept in a draught of cold air, 
 and acute inflammation may arise and do serious harm; or 
 water may be carelessly thrown into the ear by the nurse 
 whilst washing the child, and may pass back to the mem- 
 brane, remain there, and cause pain and inflammation, and 
 end by serious disaster to the hearing, or, by passing to the 
 brain, to life itself. Inflammation from a catarrhal cold, or 
 from teething, may extend to the ear and cause great trouble. 
 Thus it behooves the physician to be always watchful of such 
 conditions, which may arise at any time and in any case. 
 
 As to the methods of teaching the deaf and dumb, the 
 manual method prevailed entirely up to the year 1867, and 
 very little speech was taught. Since that time great progress 
 has been made, especially in speech. It seems strange that 
 the deaf and dumb should both hear and talk, but practically, 
 now, they do both, and the lips are helping out the hands in 
 the work. A deaf mute can now deliver an oration that would 
 do credit to a Demosthenes or to a Webster. Speech will not 
 
FORTY YEARS IN TIN". MICDICAL PROFESSION 
 
 take the place of the iiiaimal nietlifKl, nor will the manual 
 method entirely prevail. The present American method, 
 which is doubtless the best in the vvorUl to-day after thirty 
 years of trial, is the combined system, in which the best 
 effects of both methods may be secured. In all the schools of 
 the United States to-day every pupil is given an opportunity 
 to learn to speak, and with these pupils, where substantial 
 success cannot be attained after examination and fair trial, 
 instruction in speech is not continued. As far as I can ascer- 
 tain, probably less than one-half the deaf and dumb are taught 
 speech so as to use it with practical success. 
 
 Many methods have been brought to bear upon, and are 
 used in the treatment of those suffering from general nervous 
 troubles which not many years ago would have been looked 
 upon as doubtful in every way, as verging on quackery, or 
 even on the supernatural. The movement cures, as first 
 taught in Sweden, have been made wonderfully effective ; all 
 forms of the bath are used ; electricity and the masseur and 
 masseuse are in constant demand and doing acceptable and 
 effective work. Learned professors hold seances frequently, 
 and mesmerism, now dignified by the name of hypnotism, 
 is brought into frequent and useful therapeutic use. This is 
 right and as it should be. Whatever this potent influence is. 
 whatever hypnotic suggestion may be, it should be taken from 
 the hands of the charlatan, the magnetic healer, the mesmeric 
 doctor, and used by legitimate medical men. If you ask for 
 a definition of electricity, now so much and so deservedly and 
 successfully used as a therapeutic measure, the answer is, ' a 
 subtle fluid.' Any answer as to what hypnotism is will prob- 
 ably convey nothing more definite. It is spoken of as animal 
 magnetism, as partial cerebral inhibition, sleep produced in 
 one waiting anxiously for suggestions from another, or any 
 condition produced by the same. We have it under the name 
 of telepathy, or mind reading, the motility of the neuron to 
 explain it. and here we are again. — the motility of the neuron 
 may be a subtle fluid, and that is about all we know of this 
 force. After all, it and electricity may be one and the same. 
 
 185 ' 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Hypnotism has been practised in the East for centuries, 
 and has there great influence on the ignorant, and is thus 
 used to sway the minds of men, and not with the higher ther- 
 apeutic aim. Probably we see its result every day and do not 
 recognize it. The influence of one man over another, or over 
 many men, in personal matters, in religious matters, in politi- 
 cal matters, in social and other matters, is undoubtedly hyp- 
 notic, a result of hypnotic suggestion. In nervous diseases 
 its action is little short of miraculous, and here it finds often 
 willing subjects. Whether it exerts any permanent influence 
 for good, as in the case of the dipsomaniac or other victims 
 of the passions, I am not personally sufficiently informed to 
 answer. The mistake is to look on it as a panacea. That it 
 reaches some cases not reached by drugs there is no doubt. 
 There may be danger in it. Harmful suggestions may be 
 given, but it probably does not weaken the will. Possibly 
 the best subjects are those with weak wills, and these are the 
 ones whom, as a rule, hypnotism may benefit and who suffer 
 from such troubles as are relieved by hypnotic suggestion. 
 
 One of the great problems confronting us is, what to do 
 with the defective classes, or, rather, how shall we stop their 
 increase and reproduction? We well know they are rapidly 
 increasing, and increasing in proportion far more rapidly 
 than the race is increasing. There are many ways to account 
 for this : the increase in luxurious living and general invita- 
 tions for dissipations, with absolute lack of restraint by the 
 State on the marriage law and the violations of the marriage 
 rite, both by omission and commission. Epileptics are in- 
 creasing, the insane are increasing, the dangerous classes are 
 increasing; in fact, all degenerates, all moral imbeciles, are 
 increasing at a startling rate. These cases are all cases below 
 the type of normal man, and because of them, and for them, 
 this great branch of medicine has developed and grown up. 
 The magnificent race of Spartans, or Lacedaemonians, of an- 
 cient Greece was made in a manner possible by allowing only 
 the fit to survive. Even to-day among us the question of 
 unsexing the defectives in early life is discussed; not only 
 
 i86 
 
FORTY YEARS IN TllIC Ml'JMCAL I'ROFESSION 
 
 behind closed doors, it is talked of and advocated openly, yes, 
 has been actually practised, with asserted good effect to the 
 individual and surely to posterity, to the evolution of a perfect 
 race. 
 
 Under the defectives come the tuberculous, and particularly 
 to these should apply the supervision of the marriage laws by 
 the State, argue the advocates of such supervision, and there 
 is no doubt of the soundness of their arguments, as we now 
 understand the pathology of this the greatest scourge to man- 
 kind. y\ll this matter of heredity comes in under this law 
 of advance or retreat from the normal type. The syphilitic, 
 — and with the syphilitic should go gonorrhoea, the other vene- 
 real type, which we now know causes untold suffering and 
 race degeneracy, through the female particularly, and she not 
 the sinner, either, — the alcoholic, the drug-taker, all tend to 
 lower the tone, the type, and the vigor of the race, and come 
 under the neurotic class. It is the part of the physician to 
 care for and improve the condition of these unfortunate 
 beings, and by building up this great system of medicine de- 
 voted to nervous diseases most nobly has he accomplished his 
 task, and most nobly does he continue to expand, to improve, 
 and to unfold his work. 
 
 This is not all that interests mankind in the work of de- 
 struction of the race now surely going on. even to the threat- 
 ening of the extinction of the normal type. Can the increase 
 of the defective classes be restrained? That is, can they be 
 restrained in the reproduction of their kind, and can the nor- 
 mal type be restrained from producing abnormal and not the 
 normal type? These are the problems confronting us. these 
 are the problems confronting the physician, the alienist, the 
 statesman. Wg must grasp them ; posterity must solve them. 
 
 tS7 
 
CHAPTER VUI. 
 
 Ptomaines — Definition of, etc. — Composition of, etc. — Vegetable Alkaloids 
 — Changed Food Supply — Canning, etc. — Poisonous Gases in the Sys- 
 tem — The Different Ptomaines — A Growing Evil — Fatigue and Pto- 
 maine Poisoning — Chronic Ptomaine Poisoning — Ice-Cream and 
 Cream-Puff Poisoning — Personal Experience in Ptomaine Poisoning 
 — Auto-intoxication in Disease — The Reflexes from Ptomaine Poison- 
 ing and Auto-intoxication — Pathogenic Poisons — The Death Struggle 
 an Auto-intoxication. 
 
 Among the most interesting matters brought to the atten- 
 tion of the medical profession in recent years is the knowl- 
 edge of the presence of what are called ptomaines in organic 
 food-products, and much of this work has been done by 
 Vaughan and other scientists in this country. Billing's defi- 
 nition of a ptomaine is that it is a strongly basic compound, 
 the result of putrefactive changes in animal tissues closely 
 simulating vegetable alkaloids. It may be liquid, containing 
 no oxygen, and of peculiar cadaveric odor, or solid, crystal- 
 lizable, containing oxygen, soluble in water but insoluble in 
 alcohol, chloroform, etc. All ptomaines are precipitated by 
 phosphomolybdic acid, but there is as yet no general test dis- 
 tinguishing ptomaines from vegetable alkaloids. They all 
 have conspicuous reducing power. Here, observe, is a cada- 
 veric alkaloid. Now let us give Billing's definition of a vege- 
 table alkaloid. It is an organic basic substance in its behavior 
 with acids, resembling ammonia. They all contain nitrogen, 
 and are the active principles of most poisonous plants. Here, 
 then, are two great sources of poison to human beings always 
 present with and surrounding us ; given large doses, and the 
 acute attack makes known at once their presence ; given small 
 and constantly repeated doses, and chronic poisoning besets 
 us. Just this danger confronts us in these cadaveric alkaloids. 
 It is not the large dose and acute poisoning that is so threat- 
 ening, but it is the constant small dose, the coup sur coup, the 
 blow upon blow, that is undermining the health of so many 
 
FORTY YIOARS IN THE MJ':i>>ICAL I'KOFESSION 
 
 of the human race at the present day and makes their acti(jn 
 so much hke the slow poisoning we often see in the con- 
 sumers of the vegetahle alkak)i(ls, as tliose frfjm opium ruid 
 otlier phuits, like the nicotine from tobacco; they cause the 
 slow poisoning, the weakened, intermitting heart, which al- 
 lows a slight regurgitation of blood through the imperfectly 
 closed valves, thus preventing complete oxidation in the lungs, 
 and allowing poisonous gases to accumulate in the system. 
 
 The great change in handling the food-supply of the more 
 advanced countries, the system of cold storage, the system of 
 canning or, as the English say, of tinning the animal foods, 
 all tend to the increase of ptomaines in such supplies, for 
 although in canning the bacteria are destroyed by heat and 
 the contents once sealed hermetically will remain sound until 
 again exposed to the air, the ptomaines, if present at canning, 
 are not destroyed by the process, and remain to taint those 
 eating them. The mere fact that meats, fish, milk, and such 
 products are kept much longer before consumption than for- 
 merly, even though our methods of preservation are so im- 
 proved and superior, makes us all more exposed to these 
 poisonings. Such discoveries are causing the art and the 
 science of medicine to be rewritten, just as chemistry and 
 electricity have been and are being rewritten. 
 
 As to the origin of ptomaines. I am not certain that we 
 know surely about it. They have been isolated and named, 
 many of them, as tyrotoxicon, or cheese poison, found in 
 milk ; halichthytoxin, found in fish ; mytilotoxine, found in 
 mussels, and others. Some deny that ptomaines are the 
 product of putridity and that the matter in which they exist 
 is necessarily tainted. From what I know of them I am in- 
 clined to believe that ptomaines are alkaloids, the result of 
 bacterial action in matter undergoing putrefactive change. I 
 have seen one definition of them as of one of the temporary 
 forms through which matter passes in changing from bacte- 
 rial life to dead inorganic matter. This makes them the 
 result of bacterial action whatever the cause. I have no doubt 
 but that their increased presence is due to the changed meth- 
 
 i8q 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 ods in handling the general food-supply, to filth, to lack of 
 attention to details in large packing and canning establish- 
 ments, to long distances by which food products reach the 
 consumer, and last, but not least, to the rapid increase of pop- 
 ulation in the great centres, producing the classes of people 
 likely, owing to their condition and environment, to furnish 
 numerous subjects for these poisons. It is doubtless a grow- 
 ing evil, and one that must be carefully supervised both by 
 the medical profession and by the police power. 
 
 Ptomaines lurk particularly in milk, the albumin furnish- 
 ing a good medium for the growth of the bacteria which give 
 rise to them. Take out the fat and they still thrive, for 
 some of the worst cases of poisoning I have seen have been 
 from buttermilk. Put aside a can with some left-over butter- 
 milk, let it stand twenty-four hours, and then fill with fresh 
 buttermilk, and you will almost surely have ptomaines devel- 
 oped. I have seen severe cases from the tyrotoxicon in cream 
 puffs. Investigation showed me lack of cleanliness and lack 
 of attention to the details of cooking, in all these cases. No 
 maker of such pastries will poison his patrons who is abso- 
 lutely careful to provide good and reliable materials, and who 
 practises absolute cleanliness, with strict attention to all minor 
 details as regards place and utensils. Ice-cream frequently 
 is the villain causing the trouble. Not the ice-cream from a 
 first-class place, even though it claims to be such, but circus 
 ice-cream, picnic ice-cream, washed-over ice-cream, is always 
 the offender. 
 
 As to the chemical nature of ptomaines we know but little, 
 and it follows we as yet know of no antidote. Some crystal- 
 lized substances have been found, and various fungi or fun- 
 gous growths, differing as their hosts differ. In the acute 
 cases I have seen the symptoms have been usually about the 
 same, — nausea, vomiting of frothy fluid in profusion, free 
 purging, with thin soapy stools, anxious countenance, with 
 great pallor, sweating, and pain in the bowels, in fact, a gen- 
 eral tendency to collapse. The feeling of fatigue and exhaus- 
 tion are referred now by some physiological chemists to a 
 
 190 
 
ii'Ok'I'V VI'.AKS IN Till'. i\I1'J)I(.;AI, I'KCJl'I'.SSlOX 
 
 form of ligliL pUjiiiaiuc poison, making il rather in its milder 
 forms purely a physiological act, and a regular storm of it 
 is when it passes the danger line. The treatment, of course, 
 is to get rid of the offending matter from the digestive tract 
 in all possil)le ways, drinking warm water, washing out the 
 stomach and bowels, and supporting the heart, above all 
 things, while nature is making her desperate fight for su- 
 premacy. Collapse and coma may end the scene, but in my 
 experience death is not frequent in these acute cases where 
 the heart, liver, and kidneys are sound, the efforts of nature, 
 with the little assistance we can give, generally proving ef- 
 fective. 
 
 What shall I say of the chronic cases ? Well, I don't know, 
 but I know enough to warn the profession to be on its guard 
 and to take into consideration chronic ptomaine poisoning as 
 one of the coming, one of the dangerous, one of the threaten- 
 ing ills of mankind. By a strange coincidence, just after I 
 had written the foregoing I myself had a personal experience 
 with ptomaine poisoning. I had been well and very busy. 
 At about eight o'clock in the morning I ate a light breakfast, 
 consisting of a small portion of boiled mackerel, surely not 
 over a tablespoonful, eating it with stale bread, and butter to 
 give the bread a flavor. This, with a cup of coffee, composed 
 my breakfast. At ten o'clock I left my office and was busy 
 out and in my carriage for five hours. When I came home I 
 had a natural movement of the bowels, when a slight nausea 
 came on, with a tendency to taste the fish. I took no luncheon, 
 and rarely do. The nausea increased, and by the time my 
 usual dinner-hour (six o'clock) came I was very sick, vomit- 
 ing and purging, more particularly purging, continuously. I 
 may say, before this commenced, coincident with the onset of 
 the nausea, I noticed attacks of irregular heart-action and in- 
 termitting heart. As I grew worse the intermitting and 
 rapid heart-action increased, and before I commenced to come 
 around I was verv weak generally. For fifteen hours the 
 purging kept up, a passing of thin, soapy, frothy, almost 
 colorless, looking fluid, perfect rice-water discharges. I could 
 
 TQI 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 not imagine one passing more in quantity during the same 
 length of time. There was great general uneasiness in the 
 stomach and bowels throughout the attack, but only for a time 
 was the pain very severe, when a true colic came on, which 
 was relieved by vomiting. After the diarrhoea ceased the 
 nausea remained for about thirty-six hours from the com- 
 mencement of the attack, with a horrible general tight binding 
 headache. The temperature never went over ioo° F. Alto- 
 gether I was inexpressibly miserable, and had I been on a 
 rack of torture I could not have suffered more in joints and 
 muscles than I did. The mackerel was undoubtedly the cause 
 of the trouble, as I had eaten nothing else to cause it during 
 the twenty-four hours preceding. Fortunately no other mem- 
 ber of my family partook of the fish, and the uncooked part of 
 it after I was taken ill was made away wath before I was able 
 to give a thought to its examination. 
 
 Having spoken of ptomaines and their actions brings us to 
 another subject germane to them, and one of very great im- 
 portance to both physician and patient, and one which has 
 but recently assumed a position of importance, owing to the 
 W'Ork and writings of Bouchard, more particularly. I refer 
 to auto-intoxication in disease, or self-poisoning of the indi- 
 vidual. This is one of the parts the alkaloids chiefly play in 
 the causation of disease and diseased conditions in man, and 
 are greatly the result of ptomaines in one shape or another. 
 We would probably all die sooner or later from these poisons, 
 generated from complex digestive processes going on chiefly 
 in the small intestines, w^ere it not from the fact that their life 
 is self-limited, being destroyed by the poisons they themselves 
 generate, thus fulfilling that relentless law of nature that 
 every living thing generates its own poison, to which rule 
 man even is no exception. 
 
 According to Bouchard self-poisoning in man is only pre- 
 vented by the action of the liver and kidneys, and the result- 
 ing fluids are poisonous as they pass out of the system. The 
 ferments formed outlive their parents, the bacteria. Alienists 
 are now giving much attention to the part auto-intoxication 
 
 192 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 plays in mental diseases. The injection into the lower ani- 
 mals of urines of those suffering from different types of in- 
 sanity gives results characteristic as to the form of insanity. 
 The delirium of fevers is probably much of it owing to auto- 
 intoxication from pathogenic organisms. Bouchard believes 
 many of these germs are innocuous in the intestinal tract of 
 the animal forming them, but may be harmful when taken 
 up by an animal of another kind. The white blood-corpuscles 
 may destroy them and the liver may check them. Asphyxia 
 is an intoxication. 
 
 Uraemia is an interesting condition to all observant physi- 
 cians. It is a complete intoxication according to Bouchard. 
 Formerly urea was considered the chief or only poisonous 
 agent. Now many other matters are known to be more the 
 cause, as alkaloids, and are found as extracts in evaporated 
 urine. Ammonia, soda, and potash are poisons in urine. 
 There are two substances causing convulsions, — potash and 
 the other an organic substance. If this is correct, how im- 
 portant to avoid potash, in all renal insufficiencies particu- 
 larly; substitute iodide of sodium for iodide of potassium, 
 and avoid potash in the salines so much used in renal trou- 
 bles. Putrefaction plays a great part in auto-intoxication, 
 coming from imperfect changes in digesting matters, and 
 also from micro-organisms in the intestinal tube. These 
 are the nitrogenous substances already peptonized, which 
 are excellent culture media for microbes ; additional micro- 
 organisms go down with each swallow of saliva from the 
 dust of the air. etc. Fermentation does not go on continu- 
 ally in the stomach, because the hydrochloric acid which is 
 always being secreted by the healthy stomach when food is 
 being introduced stops it ; going on through the pylorus, this 
 acid is neutralized by the intestinal alkaline fluids, which are 
 only feebly acid, when acetic fermentation begins. Bile 
 only feebly opposes fermentation in the small intestine, and 
 can have no influence on the active fermentation of the large 
 intestine. Thus the small and large intestines both pass 
 products of putrefaction into the blood. These matters are 
 13 193 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 toxic; they enter the blood and act at once. If infectious, 
 they would not act at once, for infection implies time for in- 
 cubation. We find the alkaloids in the fecal contents of the 
 large intestine, for here putrefaction goes on unchecked by 
 any jDresence of hydrochloric acid. Fecal matter is toxic in 
 a general way to living cells. The aqueous extract is toxic; 
 the alcohol extract is more so. Here is a great source of 
 auto-intoxication, if such accumulations are allowed to re- 
 main beyond the proper time. Let the kidneys be diseased, 
 and here is another prolific source of intoxication. They 
 may be doing badly and the patient do pretty well. If they 
 be diseased so much as no longer to eliminate in twenty-four 
 hours the quantity of poison sound kidneys should eliminate 
 in this time, the consequences must be serious. Sound kid- 
 neys can do more than is normally required of them, as in 
 the amount of water they eliminate in diabetes. They may 
 go further; they may eliminate substances that should not 
 come off by them, as peptones and albumin, and the blood is 
 impoverished. Twelve grammes in twenty-four hours is 
 much albumin to lose by the kidneys, especially if we do not 
 recruit it by healthy digestion. The poverty of the blood 
 caused by these intoxications is frequently the cause of retini- 
 tis, amaurosis, phlegmons, oedema of the glottis, hemor- 
 rhages, and such. 
 
 These auto-intoxications of intestinal origin come chiefly 
 from reabsorption from the intestines. Constipated people, 
 as a rule, all suffer from such, and among them vertigo, dizzi- 
 ness, headaches, disturbances of sight, etc., are common. 
 Many are hypochondriacal. Among the insane are many suf- 
 ferers; some may have almost constant diarrhoea and yet be 
 sufferers from accumulated masses in the large intestines. 
 Diarrhceal discharges may pass through a hole bored through 
 the centre of such masses, making quite a lumen. Wash 
 out the bowels fully and often is the remedy, using antisep- 
 tic injections. Common salt is among the best and safest. 
 Be careful of carbolic acid in large doses. The danger in its 
 use does not often compensate for its advantages. 
 
 194 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 After such trc'itnicnt fevers will f)ftcn abate and comfort 
 return to your ])atienls. Many of these people have dilated 
 stomachs. Treat such stomachs hy diet, and locally wash 
 them out as you wash out the bowels, and improvement and 
 cure comes. In dilated stomachs we liave all sorts of fer- 
 mentations, and so intoxications and reflex troubles come, as 
 headache, urticarias, and such. As l^efore said, I believe 
 urticarias and such are vasomotor neuroses coming from 
 auto-intoxication from ptomaine poisonings of more or less 
 chronic character. Bouchard speaks of a form of dilated 
 stomach, accompanied l)y albuminuria, the albuminuria being 
 caused neither by heart nor kidney trouble. In the treatment 
 of typhoid fever he cautions care in watching for ^uto-intoxi- 
 cation, and believes in intestinal antisepsis here, using naph- 
 thalin, iodoform, arid carbolic acid, with lavage of the large 
 bowels. The fever causes the withdraw^al of the blood-cor- 
 puscles to the spleen, and thus enlarges it. According to this 
 we should have enlarged spleen in all fevers. 
 
 This matter of intestinal toxaemia is a most interesting 
 subject, and its development and elucidation by study and 
 observation must work great good to suffering humanity. It 
 is always to be taken into account in the diagnosis of fevers 
 and of all obscure cases, especially the enteric fevers, the 
 fevers arising from tuberculous disease, from renal troubles, 
 from slow^ poisonings of different kinds, especially the min- 
 eral poisons, and from litheemia and lith?emic troubles. It 
 is common in children, more especially in bottle-fed children. 
 Here in the retained matters in the intestines, both large and 
 small, we have fermentation and putrefaction going on with 
 the formation of acids, as butyric and lactic; gases are also 
 developed; these pressing on the filaments of the pneumo- 
 gastric nerve give rise to local troubles and also to reflex 
 troubles involving the brain and general nervous system. 
 The albumin of the milk and other nitrogenous substances 
 eaten gives rise to the development of indol, one of the aro- 
 matic series, resulting from the decomposition of albumin ; 
 skatol. ty rosin, a product of pancreatic digestion ; with phe- 
 
 195 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 nol in the urine. From all these troubles we have many reflex 
 symptoms arising and expressed in bronchial attacks, local 
 and general convulsions, spasm of the glottis, circulatory ir- 
 regularities, with skin troubles and rashes of different kinds. 
 In such cases do not forget to watch the kidneys, remember- 
 ing that whatever troubles may arise in them are usually 
 functional. Remember the cause of all these troubles is in 
 the digestive tract. Remove it and the cure is assured. 
 
 Pathogenic poisons exist in the sick man, and the death 
 struggle prolonged is an auto-intoxication. In certain dis- 
 eases there are certain morbid poisons engendered by the nor- 
 mal life of microbes or the diseased life of human cells, what- 
 ever these may be. Light is gradually dawning on pathologi- 
 cal conditions, and man is thus paving a better way for the 
 rational treatment of his own ills and the prolongation of his 
 own life. 
 
 196 
 
CHAPTER IX. 
 
 Diet now on a Scientific Basis — Study the Individual — Idiosyncrasies — 
 Teach Diet in the Schools — Diet in Youth and Old Age — Carlsbad 
 and its Doctors — Diet and the Poor — Division of Foods — Animal and 
 Vegetable Foods — Tissue-Builders and Force-Producers — Uses of 
 Food — Oxidation and Health — Water — Rations for Individuals — Chil- 
 dren and Proteids — Atwater and Woods on Composition of Foods — 
 All about Eggs — Fish compared with Beef, etc. — White Potatoes, 
 Spinach, Asparagus, etc. — Lead Poisoning — Coflfee and Tea — Choco- 
 late and Cocoa — Dietary Studies among the Plain People — The Ger- 
 mans and German Thrift — Study of a Family as to its Diet, Cost of, 
 etc. — Diets for Corpulency and Leanness — Systems of Diet — Banting 
 and Others — Different Kinds of Breads — Toast, etc. — Kissingen and 
 Vichy Remedy for Fatness — Food consumed per Person per Year in 
 Different Countries — Time required for the Digestion of Various 
 Foods — Sterilizing and Pasteurizing Milk — Infant-Feeding — Artificial 
 Infant Foods — Diet for the Old — Ward McAllister— Infantile Scurvy 
 — Concerning Milk — Tests for Milk — Regulating the Milk Trade — 
 Graded Milk. 
 
 At the present day I believe the profession is coming more 
 and more to appreciate the importance of diet. Surely forty 
 years ago, when I entered the profession, little was said about 
 it and less was taught concerning it in the medical schools. 
 All or nearly all at that time believed, empirically believed, 
 in the antiphlogistic system of treatment, and almost every 
 sick man, or wounded man, or crazy man, for that matter, 
 was put on a diet of as near bread and water as possible, and 
 because women were fortunate enough to have babies, for 
 that they were generally starved for six weeks, much to their 
 own injury and the inconvenience of the luckless offspring. 
 Why were they starved? Oh, to prevent inflammation. 
 What was inflammation? Too much blood. Thanks to 
 Professor W. Oilman Thompson, Liebig. Sir Henry Thomp- 
 son, Fothergill. Horatio Wood, and others, the matter of 
 
 197 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 diet to-day has advanced from mere empiricism, from the 
 mere didactic, thoughtless, even ignorant assertions of the 
 school men, to something approaching an exact science, and, 
 like general therapeutics, is no longer a mere assertion or 
 pill-giving calling, but is a well-studied scientific profession. 
 
 Professor Thompson's recent work on Practical Dietetics 
 is a timely and most useful gift to the medical profession, 
 and I wish here to acknowledge the generous use I shall make 
 of the information gained from its pages in this little sketch 
 of modern dietetics I am writing. When we order this thing 
 and that thing to a sick person to eat, do we do it thinkingly 
 or unthinkingly? Surely we should think in carbon and hy- 
 drogen, oxygen and nitrogen. Given a patient with con- 
 tracted kidneys and hypertrophy of the left ventricle, and 
 other ills perchance following in the wake of these, of what 
 use is medicine, of what use are pills and powders and po- 
 tions, if we allow such a patient to stuff himself with an 
 excess of nitrogenous food? 
 
 These are cases of commencing or confirmed arterioscle- 
 rosis from which arise aneurisms, apoplectic seizures, and so 
 on. The first symptoms are usually increased steady heart 
 action and an excessive flow of urine of low specific gravity, 
 soon followed by renal contraction. How useless are medi- 
 cines in these cases if the eating and drinking of the patient 
 are not supervised and rigidly controlled ! When we order 
 our pills and potions and powders in such a case, let us think 
 in carbon and hydrogen and oxygen and nitrogen, and see to 
 it we do not increase his blood-pressure by food whilst we 
 are endeavoring to control it by drugs. In such a case, if I 
 must abandon one course of treatment and keep only to the 
 other, give me diet, " throw physic to the dogs." 
 
 Another practical point in dietetics is, study the individual. 
 It is very true that what will nourish one man will poison 
 another, and, further, what will be proper for a well man 
 may kill a sick man. Some individuals can live on milk alone 
 when they try; with others it is impossible. Many a man 
 can eat mutton and grow fat on it, so he can eat eggs and 
 
 198 
 
FORTY YEARS IN 'JIN' MICDICAL PROFESSION 
 
 tlirivc; to others, a^aiii, these are poison. Such are mere 
 idiosyncrasies, and it is well lo remember them. I believe 
 the principles of (het and nnlrilion, the effects of alcohol and 
 tobacco and such, should be tausj^ht to some extent in the 
 schools, not fanatically, but reasonably. Sf)me general 
 knowledge on this score would add much lo the general 
 health of a people and be of assistance to physicians in treat- 
 ing the average man. There is a diet for the young, for the 
 man of middle age, and for the aged ])erson. We commence 
 with milk, the complete food, the balanced ration. We go 
 through all of the luxuries of a lifetime, and as we approach 
 toothless old age we come back again to childhood and to 
 childhood's ration, milk, and in extreme old age the nearer we 
 adhere to the simple milk diet the better and happier we are, 
 and the longer and more satisfactorily we live. My observa- 
 tion and experience lead me to believe, as intelligent persons 
 grow to middle age and beyond, they, as a rule, become care- 
 ful as to diet. Indeed, many become cranky or full-fledged 
 cranks, especially the idle and well-to-do. This is all right 
 so they do not a|)proach melancholia. These people are the 
 ones who often take and who often benefit by the course at 
 Carlsbad and such resorts. 
 
 I do not approve always of Carlsbad diet for the given 
 case, and have been familiar with some diagnoses made by 
 resident physicians of Carlsbad that I did not by any means 
 agree with. I once knew of an ardent temperance woman 
 who took her young son, a boy of seventeen, to Carlsbad, 
 thinking the course might relieve him of some dyspeptic trou- 
 ble, too many sweets in his diet, probably. She called with 
 John at the office of a prominent consultant, who was very 
 affable and very painstaking, asking many questions, finally 
 coming to diet. " Veil, Shon, vhat do you drink?'' " Drink," 
 said John. " Yes, vhat do you drink?" " Water, of course," 
 answered the mother. " Nothing stronger, I assure you." 
 " Vaser! Vaser!" said the doctor, in wild amazement. " My 
 Got! it vill kill him. madame ; it vill kill him." It is safe to 
 say madame did not take the doctor's advice as to John's 
 
 199 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 beverages, and left Carlsbad with a poor opinion of its doc- 
 tors. 
 
 There is, no doubt, much suffering from improper diet, 
 and bad cooking is responsible for many ills and, doubtless, 
 many deaths. A little observation of the inner life of the 
 poor v^ill cause one to realize in a high degree the utter dis- 
 comfort and utter misery, even unto death, which come to 
 those untutored and unskilled in providing, in choosing, and 
 in preparing properly for the table even the simplest of foods. 
 Education, supervision, the evolution to a higher plane of 
 living for these people is the only corrective for such pitiable 
 ignorance and carelessness. These people need supervision, 
 they need instruction. The principles of cooking practically 
 taught in schools would help out in this work. Call it pater- 
 nalism if you choose, but as we grow wiser in government 
 such matters must come up and be taken up before we reach 
 the highest civilization. 
 
 Thompson divides foods, say, into solids, semi-solids, and 
 liquids. Next into fibrous, gelatinous, starchy, oleaginous, 
 and albuminous. He speaks of eggs and milk as examples 
 of complete foods which alone will support life ; others, again, 
 as starches, will not alone — absolutely alone — support life for 
 a length of time. The sources of food are animal foods and 
 vegetable foods. Animal foods are meats, poultry, fish, shell- 
 fish and crustaceans, eggs, milk and its products, animal 
 fats, and gelatin. Vegetable foods are the cereals, vegetables 
 proper, fruits, sugars, and vegetable oils. The simplest chem- 
 ical classification is Liebig's nitrogenous and non-nitroge- 
 nous. The nitrogenous group are tissue-builders or flesh- 
 formers. The non-nitrogenous group furnish the body with 
 the fuel and keep up the animal heat, and are the force-pro- 
 ducers. The tissue-builders also produce some force and 
 heat. There is some nitrogen in the vegetables, though not 
 a great deal. The outside coverings of the starch granules 
 contain some nitrogen, for example. Nitrogenous foods also 
 are not absolutely nitrogenous, as they contain some fat and 
 glycogen. The uses of food are to serve the body with ma- 
 
FORTY YEARS IN Till': MEDICAL PROFESSION 
 
 terials for <^rowth and renewal, and with power, much as fuel 
 does for the steam-engine. The consumption of the fuel 
 furnishes the power. The starches and sugars furnish much 
 of the power to man. The original force is in the heat of the 
 sun; this is stored by the plants in the latent form of chemical 
 compounds, as Professor Thompson says. The main source 
 of power is oxidation, chiefly of carbon. Wherever it goes, 
 or any waste product goes, it is not destroyed, it only changes 
 its form ; you cannot destroy matter. Take urea : it is mat- 
 ter merely of our food in a changed form, something like 
 ashes from coal. This urea and other debris, if not gotten 
 out of the body, blocks the system and prevents the normal 
 processes of oxidation, which must go on properly to give 
 one good health. 
 
 Thompson says it is still difficult to trace in the case of all 
 foods their final uses in the body and determine accurately 
 what proportion of each goes to power, what proportion to 
 tissue repair, and what proportion to furnish heat, for tissue 
 metabolism is very complex in its chemistry. The daily al- 
 lowance of nutritive material allowed by Professor Egleston 
 as given by Thompson for a healthy man is seven hundred 
 grammes, divided into carbohydrates, four hundred grammes ; 
 fats, one hundred and fifty grammes; proteid, one hundred 
 and fifty grammes, yielding in all three thousand six hundred 
 and fifty calories, or units of heat, a heat unit being the 
 amount of heat required to warm one gramme of water one 
 degree centigrade. 
 
 Water is to be looked upon as food, composing as it does 
 seventy per cent, of the weight of the body, and much of it 
 passes through the body unchanged. Withhold it, and life is 
 impossible. I am sure as a remedy it is not half appreciated. 
 Many persons do not drink water enough, and suffer accord- 
 ingly, whether sick or well. Others, again, may take too 
 much, and it is the duty of the physician to study each case 
 and set his patient right on so important a matter. Of course, 
 much of the water we take goes in as part of our food, and 
 this fifty to sixty per cent, of water in our solid foods must 
 
 201 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 be taken into account. The salts, such as lime and mag-nesia, 
 abound in the body, and they, with many others, have their 
 uses in tissue formations, etc. 
 
 Thompson, quoting from Von Pettenkofer and Voit, 
 shows that during the performance of hard labor the con- 
 sumption of albumin remains practically the same as during 
 rest, whereas three and one-half times as much fat is con- 
 sumed, and the amount of carbohydrates is the same, hence 
 for hard laborers give plenty of fat pork, butter, oil, and such. 
 A workingman will take from fifty to seventy-five ounces of 
 solid food in twenty-four hours, and about the same amount 
 of w'ater by weight. The ration should contain one part of 
 nitrogenous food to three and one-half parts of non-nitroge- 
 nous food. The average albuminous food gives about six- 
 teen per cent, of nitrogen. Again quoting Thompson, for a 
 man weighing sixty-seven kilogrammes the daily allowance 
 of food ranges from six to nine grains of carbon, and .25 to 
 .36 grain of nitrogen per kilogramme of body weight. Cow's 
 milk and wheat flour approach nearest to a balanced ration 
 of all food as to their nitrogenous and non-nitrogenous pro- 
 portions. In cow's milk the proportion is one to three, and in 
 W'heat flour one to four and one-half. 
 
 These are matters of great practical importance, and all 
 physicians should be more or less familiar with them. The 
 destruction of the carbohydrates in the body is very complete 
 when eaten in excess, and they do not produce fat like fatty 
 foods taken in excess. This is an important practical point. 
 The carbohydrates are more or less fattening when eaten with 
 albumin and fats, because they check the consumption of al- 
 bumin and fats and leave more of them to be converted into 
 tissue fats. Eaten alone they are not so fattening. For ex- 
 ample, the Chinaman, living mostly on rice, is not usually 
 over-fat. Another practical point : when you have children 
 growing rapidly and using their force in the ceaseless activity 
 of the young, see that they get sufficient of proteids in their 
 daily ration. The food value of certain articles of diet is 
 most important to the physician, whether to make up a ration 
 
FORTY YEARS IN TTIK MEDICAL PROFESSION 
 
 for the soldier, for the laborer, the professional man, or 
 women or ehildren, or, more than all, of the sick intrusted 
 to his care. (3f alhiiniinons matters used as food, one-third 
 of it is excreted as urea. This is impf)rtant to remember 
 when the kidneys are diseased and cannot get rid of this 
 urea, although, as before said, some are beginning to deny 
 that urea unexcreted is the great offender it has heretofore 
 been given credit for. 
 
 Probably most persons over thirty-five years of age con- 
 sume too much nitrogenous food, especially those who inherit 
 gout. These gouty, bilious people are usually the strong and 
 healthy, and, as a rule, have ravenous appetites; they live 
 to eat, rather than eat to live. They often incline to be good 
 drinkers of wines, spirits, and malt licjuors, but, as a rule, 
 much to their disadvantage, are light water-drinkers. If 
 they drank more water the ill effects of a vicious metabolism, 
 of vicious tissue change in nutrition and secretion, would be 
 carried out of the system more generally in the various secre- 
 tions and excretions. It is surprising to see how soon one 
 who has been a free meat-eater can come down to almost a 
 non-nitrogenous diet and enjoy life and feel lighter and better 
 and more contented in every way, provided the excess of ni- 
 trogen he had been taking was doing him harm. One must 
 know something" of the chemical composition of foods to lay ' 
 out such a diet, for it will not do to tell a patient to live on 
 milk and eggs and fish and all manner of vegetables, and to 
 avoid only red meats and the black meat of poultry, etc. 
 
 Professor W. O. Atwater and Charles D. Woods, of the 
 Agricultural Department at Washington, have given us some 
 interesting tables of the percentage of protein, fat. etc.. in 
 common e^'er}--day food-stuffs, and it is surprising to see how 
 nearly what some consider light diet approaches to heavy ni- 
 trogenous diet. Roast ribs of beef contain 16.9 per cent, of 
 protein and 26.8 of fat; sirloin steak holds 18.3 protein and 
 20.2 of fat; beef liver. 21.6 of protein and 5.4 only of fat; 
 corned beef, 15.3 protein and 2;^.;^ of fat; beef tongue, 21.5 
 protein and 23.2 of fat; loin of veal. 19.4 protein and 10.4 
 
 203 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 fat; loin of lamb, 17.6 protein and 28.3 fat; leg of mutton, 
 18.2 protein and 18 fat; loin of pork, 16.8 protein and 30.3 
 fat; salt ham, 15.5 protein and 39.1 fat; bacon, 10 protein 
 and 67.2 fat; pig's feet, 16. i protein and 14.8 fat; pork sau- 
 sage, 12.8 protein and 45.4 fat. Of course, sausage may con- 
 tain protein and fat just as the maker chooses to put in each 
 ingredient. Soups : Bouillon, 2 protein and i fat ; con- 
 somme, 2.5 protein, no fat; mock-turtle, 5.2 protein and 9 
 fat; chicken soup, 3.6 protein and i fat. Roast chicken, 22.8 
 protein, 1.8 fat; this is the average of all edible parts; white 
 meat would contain less protein. Tripe, protein 13, fat 16, a 
 good morsel, low in protein but quite high in fat. Sweet- 
 breads, the thymus gland of the calf, protein 15.4, fat 12. i. 
 Brains of the calf are very fatty and not very nutritious, and 
 contain a high percentage of cholesterin. The liver and kid- 
 neys of the calf are very palatable and fairly nutritious; the 
 former contains protein 16.6, fat 7.4, and ash 1.3, and the 
 latter about 18 protein and 5 fat. All pork, as a rule, is indi- 
 gestible on account of too much fat in proportion to other 
 matters. Goose, 13 protein and 49.9 fat; turkey, 20.6 pro- 
 tein and 22.9 fat; quail, 21.8 protein and 8 fat. As a rule, 
 all game is high in protein. 
 
 It is interesting to compare fish with the meats and to see 
 how they compare in percentage of protein, particularly with 
 our strong foods, such as roast beef and mutton. The aver- 
 age fish diet is surely not the light diet we unthinkingly are 
 apt to take it to be; nevertheless fish is a safer and lighter 
 diet than red meats and such, even if we take the stronger 
 fish like cod. Fish diet does not load the blood with as much 
 waste as the heavy meats do, requiring the getting of more 
 oxygen by exercise to eliminate them from the system. Thus 
 fish diet does not render the over-fed man dull like heavy 
 meats, nor is there any truth in the common belief that fish 
 diet is the best brain-food from the excess of phosphorus it 
 contains. Black fresh-water bass, 20.4 protein and 1.7 fat. 
 These proportions are all from the edible portions alone, and 
 so with the meats we have been speaking of, and thus give 
 
 204 
 
FORTY YiCARS JN THJ': Ml':i)ICAL I'KOI-IiSSION 
 
 higher percentages than though all parts were taken in 
 making the percentage. Sea bass, 18.8 protein and .5 fat; 
 fresh shad, 18.6 protein and 9.5 fat; shad roe, 20.9 protein 
 and 3.8 fat; rock, 18.3 protein and 2.8 fat; bhie fish, 19 pro- 
 tein and 1.2 fat; "salt cod, 21.4 protein and .4 fat; sheeps- 
 head, 20.3 protein and 6.7 fat; fresh cod, 15.8 protein and .4 
 fat; flounder, 13.9 protein and .6 fat; haddock, 16.8 protein 
 and .3 fat; hahbut, fresh, 18.3 protein and 5.2 fat; smoked 
 herring are well up in nitrogen, and so are white fiish ; fresh 
 mackerel, 18.2 protein and 7.1 fat; salt mackerel 22 protein 
 and 22.6 fat; white perch, 19. i protein and 4 fat; pike, 18.6 
 protein and .5 fat; fresh salmon, 19.9 protein and 7.4 fat; 
 salmon trout, 18.2 protein and 11.4 fat; smelts belong to the 
 salmon family, and have a little less protein and fat than 
 salmon ; salt sturgeon and caviare are very high in protein, 
 fresh sturgeon not so high; weak fish, 17.4 protein and 2.4 
 fat; clams, 8.6 protein and i fat; lobster, edible portion, 
 16.4 protein and 1.8 fat; oysters, 6.2 protein and 1.2 fat; 
 scallops, 14.8 protein and .1 fat; shrimps are very high in 
 protein; terrapin is high in protein, the dressing makes it 
 higher; crabs, edible portion, protein 16.6, fat 2. Average 
 cow's milk, protein 3.3, fat 4, water 87, carbohydrates 5, salts 
 .7; cream, protein 2.7, fat 26.7, water 66, carbohydrates 2.8, 
 salts 1.8; skim-milk, protein 3.4, fat .3. water 90, carbohy- 
 drates 5.1, salts .7; condensed milk evaporated in vacuo to 
 about one- fourth its bulk, water 30.5, protein 8.2. fat 7.1, 
 carbohydrates 52.3, ash 1.9, carbohydrates being increased 
 by the sugar added ; human milk, albuminous matters 2.04, 
 fat 2)-7^^ milk-sugar 6.95, mineral matter .14, water 87.11; 
 buttermilk, water 91, protein 3, fat .3, carbohydrates 4.8, 
 ash .7; goat's milk is stronger in sugar and fat than cow-'s 
 milk. Koumiss is a useful food, and very light, and con- 
 tains after twenty-four hours' fermentation about 18 alcohol, 
 milk-sugar 15, fat 20, salts 4, lactic acid 5, albumin 2t,, car- 
 bonic acid 7, etc. To make koumiss from cow's milk, take 
 one quart of new milk, one-third compressed yeast-cake or 
 dessertspoonful fluid yeast, one heaped tablespoonful pulver- 
 
 205 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 ized sugar; mix and warm this, put in a champagne bottle, 
 and tie cork down. Do not use a thin bottle. Ten hours' 
 standing at a heat of 90° will make it. A pint patent-stopper 
 beer-bottle is a proper utensil to make a pint in. Keep on 
 ice or in a cold place. Ordinary cheese,* 33.5 protein and 
 24.3 fat. 
 
 The following complete analysis of hens' eggs has been 
 compiled at my request by the Director of the Delaware Col- 
 lege Agricultural Experiment Station : A hen's egg of me- 
 dium size weighs 50 grammes, the shell 6 grammes, the yolk 
 16 grammes, the white 28 grammes; total, 50 grammes. Of 
 one hundred parts of the edible portion of the egg, 36.3 parts 
 equal the yolk, 63.7 parts equal the white; total, 100 parts. 
 The white of the egg consists of water 86 per cent, (protein), 
 albumin 14 per cent. ; total, 100 per cent. The yolk consists 
 of water 53 per cent, (protein), albumin 16 per cent., fat 30 
 per cent., salts i per cent. ; total, 100. The Bulletin of the 
 Agricultural Department at Washington makes the edible 
 portion of the whole egg 14.9 per cent, albumin on the basis 
 of the whole egg; 32 parts in 100 represent yolk, 56 parts in 
 100 represent white; of the 32 parts of yolk, 16 per cent., or 
 5.12, equal albumin; of the 56 parts of white, 14 per cent, 
 or 7.84, equal albumin; total, 12.96 albumin. From this it 
 will be seen that the whole egg is fairly high in nitrogen and 
 the yolk has considerable fat. The yolk is fairly low in nitro- 
 gen, and the gouty man may eat it moderately, but not the 
 whole egg. For some reason some persons cannot eat eggs 
 at all, and with the sick they often disagree. During intes- 
 tinal digestion sulphuretted hydrogen and ammonia are 
 evolved, and an intestinal storm ensues. The yolk here pro- 
 duces the disturbance. 
 
 If there is any difference in the nutritive value of eggs as 
 to color, the white eggs are the most nutritious. The salts of 
 the whites are chiefly chlorides. The eggs of chickens, tur- 
 keys, ducks, guineas, and geese are ntost used for food. The 
 duck- and goose-eggs have most fat; the eggs of the plover 
 are said to be the most delicate, and are a rare treat. Eggs 
 
 206 
 
FORTY YEARS IN THE MICDICAL PROFESSION 
 
 are most coini)Ietely dii^ested, and hence are very nutritious 
 as to their weij^'ht, and make a well-balanced ration with car- 
 liohydratcs alone. The yolk is rich in fats, containing olein, 
 palmitin, yellow pigment, and lecithin. It also contains grape- 
 sugar in very small amount, phosphates, iron comp(junds, 
 and sulphur. 
 
 Notwithstanding the general belief to the contrary, experi- 
 ment shows five minutes' actual boiling to be the proper time 
 to boil hens' eggs to make them most digestible. A ten- 
 minute boiling is better than three minutes. Fifteen minutes 
 makes the yolk very digestible. As to the shape of eggs, 
 those of hens, ducks, geese, crocodiles, and snakes are mostly 
 oval ; those of guineas and most sea-fowls are pear-shaped ; 
 those of ov\-ls and turtles and the like are spherical. Yellow 
 or lirown colored eggs are laid by the dark Brahmas, part- 
 ridge Cochins, black Langshans, Wyandottes, and barred 
 Plymouth Rocks; brown Leghorns, buff Leghorns, white 
 Leghorns, and the white and black Minorcas lay the white- 
 shelled eggs. The fresher the egg, the more digestible and 
 more palatable it is. The albumin becomes less digestible as 
 time passes. The odor of spoiled eggs comes from the for- 
 mation of hydrogen sulphide from the sulphur in the yolk. 
 As an egg becomes old it gets lighter in w^eight. Look 
 through a fresh egg towards the light, and it is homoge- 
 neous. If spoiled, it is opaque at the top, owing to the forma- 
 tion of an air-space. In salt and water, two ounces to the 
 pint, a good egg will sink. To coddle an egg, put it in cold 
 water and heat it up to 167° F., and keep it there until the 
 albumin is cooked to the centre, say five to seven minutes. 
 The wdiite coagulates at 163°, and the yolk at 167°. A cod- 
 dled egg is never boiled, for then the heat must reach 212^. 
 At fifteen cents per dozen, hens' eggs are cheap food. At 
 thirty cents per dozen they are expensive food. 
 
 The special cheeses are stronger than ordinary cheeses. 
 Butter contains 3 protein and 92 fat. Of course, in milk and 
 cream there is some little carbohydrates. Sugar is nearly 
 pure carbohydrates with a little water, about three per cent. 
 
 207 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Boiled unpared white potatoes contain 2.'j protein, .2 fat, and 
 22.3 carbohydrates ; white potatoes have considerably more 
 protein when boiled with the skins on than when boiled with 
 their skins off. In boiling with the skins off the Department 
 of Agriculture at Washington finds that there is loss of or- 
 ganic nutrients and mineral salts. The potassium compounds 
 particularly are lost, and these are very necessary for health. 
 The loss is suffered by the abrasion of the soft parts while 
 cooking. Here nearly three per cent, of the carbohydrates 
 and four per cent, of the available flesh-forming nitrogenous 
 matter are lost. Boil them with the skins on, and there is 
 only a little loss of non-albuminoid nitrogenous substances 
 and mineral matter. Let the young and strong preserve the 
 skins in cooking. Let the gouty man discard them and 
 thus reduce his nitrogen. The proper way, after all, to 
 cook all potatoes is to bake them, and thus better break up 
 the starch. Unpared boiled white potatoes also contain 73.7 
 of water. In these analyses the ash does not appear to vary 
 greatly, and is composed of the potassium, sodium, calcium, 
 and magnesium chlorides, sulphates, and superphosphates. 
 These are important to take into account, and in such dis- 
 eases as angina pectoris, where the hardening and deteriora- 
 tion of the blood-vessels is to be taken into consideration, we 
 want as much as possible to eliminate lime and such constitu- 
 ents from the diet. 
 
 Wheat flour gives protein 10.4, fat i, carbohydrates 75.6, 
 and little ash. Macaroni gives about the same as wheat flour, 
 so it is not a gluten preparation by any means. Barley, pro- 
 tein 9.3, fat I, carbohydrates 77.6, about the same as wheat 
 flour. Buckwheat flour has only 6.1 protein and 77.2 carbo- 
 hydrates. Corn-meal has 8.9 protein, 2.2 fat, 75.1 carbo- 
 hydrates, and little ash. Corn hominy, about the same as 
 corn-meal. Oatmeal, protein 15.6, very high, fat 7.3, also 
 high, and carbohydrates 68, less than corn and wheat. Boiled 
 rice has only 5 protein, .1 fat, 41.9 carbohydrates, and 52.7 
 water, with little ash; it is easily digested, and if not eaten 
 with too much fat is not very fattening. Rye flour is less in 
 
 208 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 protein than wheat Hour, but is hij^her in fat and carbohy- 
 drates. Tapioca is nearly pure starch. Dry beans are very 
 strong in protein, carbohydrates, and fat. Fresh hma beans 
 have much water, and only 7.1 protein and 22 carbohydrates, 
 not much stronger than white potatoes. Green peas have 
 much water, and only 3.6 protein and 9.8 carbohydrates. 
 Potato chips have 7.6 protein, 35.5 fat, and 50.6 carbohy- 
 drates, a very fattening morsel. Sweet potatoes have i)rotein 
 3.6, fat 1.3, carbohydrates 49.1, ash 2; these excel the white 
 potatoes very much in fattening properties. Fresh radishes 
 are nearly all water and refuse; so is rhubarb, but it has 
 oxalic acid, and bears watching. Onions are chiefly water 
 and a small percentage of carbohydrates, mostly sugar, and 
 so are parsnips. Lettuce is mostly water. Okra has 2 protein 
 and 9.5 carbohydrates. Egg-plant is mostly water, but is 
 generally cooked with too much fat. Celery is mostly water 
 with I.I ash, where its virtue lies. Cauliflower has over 90 
 water, cabbage about the same. Artichokes have considera- 
 ble carbohydrates. Beets have over 90 water and little pro- 
 tein, but considerable carbohydrates in the shape of sugar, 
 depending on the variety of the beet. Graham wdieat flour 
 has 8.5 protein, 1.8 fat, 55.9 carbohydrates, 1.5 ash, and 32.3 
 w^ater. The average fruit of the market has water 16.9. pro- 
 tein 6.2, fat 10.5, carbohydrates 64.7, ash 1.7. 
 
 In looking over this list it is interesting to note how nearly 
 alike they run in nitrogen, how much they vary in fats, and 
 how little they vary in ash. Roast beef is scarcely as strong 
 as sirloin steak in protein, but excels it in fat as usually cut. 
 Boiled beef is much less in protein than roast beef, and loin 
 of lamb is also low^er. Pigs' feet are a delicacy, and rather 
 low comparatively in protein. The average pork sausage is 
 not very strong in protein, but has too much fat. Of the 
 soups, consomme is the weakest and mock-turtle the strong- 
 est, and therefore the least desirable where nitrogenous diet 
 is objectionable, as in gout and such troubles. The seeker 
 after light diet might take a little goose, avoiding as much as 
 possible the fat, whilst he will find turkey and chicken, if he 
 14 209 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 eat the dark meats, a little strong in protein. When we come 
 to fish, we find them disappointingly high in protein. Tell 
 your gouty patient to take a fish diet, and he goes unwittingly 
 to salmon. He gets 19.9 protein and 7.4 fat. He might as 
 well eat roast beef, except he gets less of the salts and other 
 strengthening ingredients of the beef. Fresh mackerel are 
 nearly as bad, and salt mackerel worse, except here one eats 
 less in weight. Smoked herring are very high in protein and 
 fat, but I think one takes so little of it, we may indulge in a 
 little of the flesh and roe in order to give an exquisite flavor 
 to a simple breakfast or tea of stale bread and butter. Fresh 
 herring are about like shad in protein and fat. If you are 
 gouty, avoid cod, especially salt cod. May your gouty friend 
 eat of codfish and potatoes? Well, Sunday morning only 
 he may partake sparingly of this New England luxury, pro- 
 vided they have not absorbed too much grease in the cooking. 
 Flounders are among the lowest in protein and fat of all the 
 fish, and may be eaten more freely where we wish to avoid 
 too much nitrogen. Smelts are a delicacy in cold weather ; in 
 fact, are one of the few fish whose flavor is not affected by 
 freezing, but alas ! they are of the salmon tribe, and are very 
 strong food. Lobsters and crabs are reprobated by some au- 
 thorities for the gouty, but why I know not, if eaten with 
 plain dressing only, as they are not over 14 to 16 protein and 
 very little fat. Some good authorities give lobster too low 
 in protein. It is surprising how high in protein those elegant 
 fresh-water fish, the white perch, and black fresh-water bass 
 are, the perch giving 19.1 protein, but only 4 fat, and the bass 
 20.4 protein, but only very little fat. That king of edible 
 fish, the shad, has 18.6 protein and 9.5 fat, quite a strong 
 food, but we must allow shad now and again, though very 
 sparingly. The roe is another luxury, but is very strong in 
 nitrogen, but not so very strong in fat. 
 
 How disappointing all this! Everything good is high in 
 nitrogen, and nitrogen is poison to so many of the good and 
 brave in this world. Where shall we send them for luxuries ? 
 
FORTY YEARS IN TIIK MEDICAL PROFESSION 
 
 Well, thank God for g'iving- us the oyster, and the clam, and 
 milk. The oyster has only 6.2 protein and little fat. The 
 clam has 8.6 protein and i fat. Scallops are stronger, having 
 14.8 protein. Now, with milk and oysters and clams, a few 
 scallops now and again, a little consomme, — very little, for 
 a few tablespoonfuls of soup are sufficient as a prelude to a 
 dinner always, — milk ad libitum, even if it must be skimmed 
 or partly skimmed or separated, or alkalized, with rice and 
 white potatoes as vegetables, surely one cannot starve. 
 
 White potatoes are, I think, a much-abused vegetable. 
 They contain comparatively only a little protein, and, if well 
 baked, a very little, and only a little over 20 carbohydrates, 
 and lots of water, which harms no one. I look upon them as 
 among the most innocent of the starchy foods, with a ten- 
 dency to increase the alkalinity of the blood. When baked 
 almost to a crisp, I allow them now and again to diabetics, 
 to keep them in even humor, and never see cause to regret it. 
 Do not forget, it all depends on the cooking, though. No one 
 dieting to cut down weight can afford to eat potato chips as 
 usually cooked ; remember that. 
 
 For the day laborer oatmeal is a generous food, but for the 
 gouty man it is to be shunned. Too much of it is eaten by 
 those leading sedentary lives, especially by those having at- 
 tained middle age, but when sugared and creamed, oh, what 
 a dose! Oh, my liver! — except for the young, active, and 
 vigorous, or those suffering from wasting diseases, and often 
 I think it too much even for some of them. Think of it: 
 protein 15.6, fat 7.3, and carbohydrates 68, and to this add 
 more fat in cream and more carbohydrates in sugar. As to 
 the non-starchy vegetables, spinach, asparagus, tomatoes, and 
 the like, they are mostly water, with very little protein and 
 little carbohydrates, and fulfil various indications in diet. 
 The only trouble about them is, most of them have considera- 
 ble oxalic acid, which is not desirable in renal irritations. 
 Be)'^ond this, they undoubtedly serve a good purpose in the 
 economy. As fruits and nuts will be referred to at length 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 farther on, I will not stop to consider them now as an article 
 of diet. Green corn boiled is a vegetable much used, and 
 deservedly so. To those who need a food low in proteids it 
 is very acceptable, and to those who suffer from slowness of 
 the bowels it is a great help, the refuse of the corn helping 
 here very much. Green corn fresh runs about thus : water 
 88.2, protein i.i, fat .4, carbohydrates 9.2, ash i.i; green 
 corn canned has water 75.7, protein 2.8, fat 1.3, carbohy- 
 drates 19.3, ash .9: the sugar always put in canned corn in- 
 creases the carbohydrates ; there is also the antiferment, prob- 
 ably salicylic acid. 
 
 In all canned vegetables and in much of the other canned 
 stuffs will be found some antiferment, most probably salicylic 
 acid. Whilst probably these antiferments do no great harm 
 directly to the individual consuming such foods, they doubt- 
 less do harm in the end to those who eat them continuously, 
 for they slow digestion and in other ways interfere with its 
 normal processes. There is another trouble not to be over- 
 looked by those eating canned products, — the danger of lead 
 poisoning, a condition which entails a horrible state of suf- 
 fering and broken health. In properly conducted canning 
 establishments no solder should ever be allowed to get into 
 the can, and all solder- joints should be made absolutely on 
 the outside of the seam of the can, and no low-grade tin 
 should be used for cans, for it is nearly all lead and iron, and 
 little tin. Canned products are very universall}'- used, not 
 only by those at sea, and by travellers who are cut off from 
 fresh supplies, but hotels and boarding-houses and even pri- 
 vate families use them almost exclusively as being" cheaper 
 and more convenient, in the very midst of summer, and in 
 the heart of the vegetable-producing country. I believe this 
 practice to be in violation of good sanitary methods. 
 
 Speaking of lead poison, I believe it to be in one degree or 
 another the cause of a great deal more of suffering and ill 
 health, not to mention its evident tendency to increase the 
 evils of uric acid troubles, with all that this implies, than is 
 
FORTY YEARS IN Till-: MEDICAL PROFESSION 
 
 usually thought. It is particularly a cause in the water sup- 
 ply, and the increased use being made of it in the trades, such 
 as in packing tobacco and like matters. Rubber also, it is 
 well known, contains lead, and should be used carefully with 
 that in view. I have personally met with some interesting 
 cases where the diagnosis was very obscure, until the water 
 supply was looked into, and then all was plain. Watch for 
 lead poison in doubtful and obscure cases ; it is easy to get 
 tripped up on it, my medical friends. 
 
 In the part of Delaware where I reside the surface water 
 is very pure and free particularly from lime, and hence no 
 insoluble coating is formed on the pipes, as in limestone dis- 
 tricts, hence lead pipes for the water supply almost invariably 
 cause poisoning. I have met with a number of cases. Insolu- 
 ble compounds of lead may produce poisoning as they break 
 up and disintegrate ; even when insoluble coatings are formed 
 on lead water-pipe, after a time the pipe corrodes and disinte- 
 grates by age, and is dangerous. Fortunately iron, for eco- 
 nomical reasons, is taking the place of lead in furnishing the 
 water supply, and thus much lead is being eliminated as a 
 menace to the good health of families and communities. 
 There is one thing yet that should be stopped. In Philadel- 
 phia, for example, I notice that when they lay new mains of 
 iron, the connecting pipe leading from the street main to join 
 the pipe leading to the house to be supplied, say one, two, or 
 three feet in length, is made of pure lead. This should not 
 be. x\s this pipe gets old it disintegrates, and notwithstand- 
 ing it is covered by an insoluble coating of lime, etc., which 
 the Schuylkill water furnishes, these disintegrated portions 
 become a menace to the health of those using the water. 
 Every State should pass a law forbidding the use of lead 
 water-pipes, at least, under any and all conditions, and the 
 use of lead under all circumstances where it may become a 
 factor for harm should be placed under most thorough super- 
 vision, as should all other substances which may cause similar 
 trouble. 
 
 213 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Coffee, so universally used as a beverage and an article of 
 diet, cannot be passed without mention. Haig condemns it 
 for the lithsemic individual, but condemns tea more. Its com- 
 position is given as follows : Water, 1.15; fat, 14.48; crude 
 fibre, 19.89; ash, 4.75; caffeine, 1.24; albuminoids, 13.98; 
 other nitrogenous matter, 45.09; sugar, gum, and dextrin, 
 1.66. This is the analysis of the coffee-bean; of course the 
 beans vary in quality and strength. In excess it produces 
 restlessness and tremulousness in man, according to Horatio 
 Wood and other authorities, but these troubles are rather 
 spinal than cerebral. In proper doses, not too large, caffeine 
 stimulates the heart; in poisonous doses, overcomes it. It 
 increases arterial pressure independently of the vasomotor 
 centres, according to Horatio Wood, so altogether it may do 
 good in some neurotic conditions, in some heart affections, 
 and where we want diuresis. Where we wish to avoid in- 
 creased blood-pressure, watch it. If very strong, it retards 
 digestion and puts away sleep from weary eyes. Like all 
 others of its kind, it has many good uses, and may be, and 
 doubtless is, subject to much abuse in excessive use. 
 
 Tea may be classed with coffee, and we use it both green 
 and black. For green tea, the leaves are steamed before they 
 are rolled and dried, also green tea contains more astringent 
 matter than black tea. Thompson gives this analysis of 
 Kozai. Green tea: Crude protein, 37.43 ; fibre, 10.06; ash, 
 4.92; theine, 3.20; tannin, 10.64; total nitrogen, 5.99. 
 Black tea: Crude protein, 38.90; fibre, 10.07; ^sh, 4.93; 
 theine, 3.30; tannin, 4.89; total nitrogen, 6.22. If theine is 
 identical with caffeine, as it is said to be, then, as far as theine 
 is concerned, tea acts like coffee on the system. There is not 
 much difference apparent, and authorities differ upon which 
 is best to help on the soldier in his marches, but all agree that 
 one or the other is essential to get the best results. Tea, if 
 taken in excess, retards digestion by precipitating the diges- 
 tive ferments, just as coffee does. When you make tea do 
 not boil it, do not stew it. In the early days of the advent of 
 
 214 
 
FORTY YI'lARS IN 'I'lll'; Mi".I)ICAI. I'l<OI''I<:SSION 
 
 the Japanese to the outer world, from the members of the 
 great Japanese Embassy whieli left Japan after the Perry ex- 
 pedition I learned to make tea. Put, say, one teaspoonful of 
 tea-leaf for each half-pint of tea you want; pour on this boil- 
 ing hot water; let it stand tightly covered two minutes, then 
 stir it thoroughly with, say, six to eight revolutions to the 
 right and as many to the left, using spoon or chopsticks ; the 
 tea is then at its best, and the sooner you drink it the better. 
 You get little tannin and none of the disagreeable bitter ex- 
 tractive matters of the tea. Boil your tea, you get tannin, 
 bitter extractives, and altogether an indigestible, unwhole- 
 some dose. Stew it, — well, don't throw it to your pigs, they 
 won't eat it or drink it, and the pigs are right. 
 
 Again, we have cocoa and chocolate, both prepared from 
 the cacao-beans, which come from the tree, TJieobroma cacao. 
 Theobromine is the alkaloid of cocoa, and is very much in 
 every way like caffeine and theine. The kernels of the cocoa- 
 beans are, when ground, called cocoa nibs. Cocoa is made 
 from these, and starch, or sugar, or both, are added in the 
 making. A German analysis is as follows : Theobromine, 
 1.73; total nitrogenous matters, 19.88; fat, 30.51; water, 
 3.83; ash, 8.30; fibre, etc., 37.48. In recommending cocoa, 
 remember it is fattening from fat and sugar, and also con- 
 tains starch usually. Chocolate is made, according to Thomp- 
 son, from the husked, dried, ground, and fermented cocoa- 
 seeds, which are then roasted and made into paste. Sugar is 
 added, at least fifty per cent., and various flavorings. Choco- 
 late is less fatty than cocoa, and altogether not so rich. The 
 husks of the seeds make cocoa-shells, and a decoction of these 
 is often used for a light drink, where we want something near 
 to water. 
 
 Before leaving the subject of coffee, tea, and cocoa, let me 
 enter a plea for their close study by the physician as an article 
 of diet so universally used. Whilst they may be abused by 
 the masses generally, they are all strong weapons in the hands 
 of the profession for good. Remember their stimulating 
 
 215 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 properties, their comforting properties, and the habit so uni- 
 versal with our patients. Remember, in your fever cases, in 
 your cases with wasting disease, you will often find in these 
 products a very useful ally. Remember that because people 
 are ill is by no means a reason they should not drink tea or 
 cofifee. Study the case and decide it properly. 
 
 The dietary studies made by Atwater and Woods in New 
 York City in 1896 show many interesting facts for the phy- 
 sician and statesman. They show in a glaring manner the 
 average want of thrift among the plainer people and the utter 
 ignorance, especially of the women, of the value of one food 
 above another, of the kind of food to purchase, looking to its 
 food value, and of the proper method of preparing it. Our 
 people need general instruction in all of these matters, and it 
 should commence in the schools, and some general system 
 should be devised in communities to teach the average house- 
 wife at least the first principles of food values, of the differ- 
 ence between a food that will furnish fat and one that will 
 furnish muscle and endurance, and thus give her some insight 
 how to dispose of her money to the best advantage when she 
 goes to purchase her supplies. Atwater and Woods show the 
 result of such ignorance very plainly as they progress in their 
 studies. Physicians should be able to instruct the families 
 they attend as to their food supply and the nutrients required 
 by different families to keep them in strength and good health. 
 A family where most of the members are laboring men and 
 women surely requires a different food supply from the fam- 
 ily of men and women living a quiet life of ease and comfort. 
 Practically no thought is taken of this either by families or 
 b}'- physicians. I am sure, as society goes on to the evolution 
 of a higher civilization, it will be the duty and the every-day 
 work of the family physician to take charge of such matters 
 in the families they attend, and thus lead to a more general 
 rational living, and to better, happier, and healthier lives for 
 the individual. 
 
 The lower classes of Germans and French at home have 
 
 216 
 
FORTY YI':/\RS IN Till". MKDICAL I'ROI' lOSSION 
 
 more of thrift, of meth(^<lical saving, of home thrift, than 
 have our people. The paternal governments they live under 
 and their habits have most to do w^ith this. The German 
 lives close and is not reckless as to running into del)t as are 
 our people. He is not mean, he is close and careful ; most of 
 the food of his family is purchased ready to eat. He, as a 
 rule, keeps no fire to cook by, because it is expensive. When 
 he gets too cold to sit up he goes to bed. He has little home 
 life. His recreation is taken at the beer-garden, and his family 
 goes with him. His native thrift follows him there. He 
 does not guzzle beer, nor pay for it, as our people do. for 
 others to guzzle. If he has children at work, they get up in 
 the morning and eat their breakfast cold, probably bread, 
 sausage, and beer. On their way to work they stop and buy 
 their dinner, — a roll, a slice of meat of some kind, and very 
 little of it; this, with a glass of beer from a near-by shop, 
 completes their dinner. Their supper does not differ from 
 their breakfast. The cost of living per individual is low, very 
 low^ It is their life custom, and they keep it up. Many of 
 the Germans are dyspeptic from this way of living, and, as a 
 rule, too much beer in their ration keeps it up. At the same 
 time this ration is about correct as to its protein, carbohy- 
 drates, and fat, and serves its purpose better than a more 
 elaborate one not so well balanced. 
 
 Our people are dyspeptics too. not because they are frugal, 
 but because they, as a rule, violate every law of gastronomic 
 hygiene, and keep at it, because from ignorance and want of 
 proper teaching they know no better. As preventive medi- 
 cine asserts itself more and more, and becomes more and more 
 a science, the physician wdll become a teacher and more and 
 more the confidential friend and adviser of his patients, not 
 more during the illness of his patients than during their good 
 health, and thus man will approach nearer and nearer the 
 ideal man science is now more than dreaming of. 
 
 To return to Atwater and Woods. They give the result 
 of a ten days' study of the diet of a family, consisting of 
 
 •21/ 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 father, a mechanic, mother, and three girls, one eleven years 
 old, one eight years, and one eight months. The family was 
 poor, and the eleven-year-old daughter did the marketing, 
 and, of course, was imposed upon. The cost of the food pur- 
 chased for ten days was $10.22, very high for their means. 
 The rent was $12 per month. The man when at full work 
 made $50 per month. Deducting cost of food and rent from 
 this, it only left $7 per month for fuel, lights, clothing, and 
 other requirements. By proper expenditure for proper food, 
 $15 to $20 should have kept this family, instead of $30 per 
 month. The cost of the animal food was fifty-six per cent., 
 and of the vegetable food forty- four per cent. • Beef, veal, 
 mutton, and fish composed more than one-half of the cost of 
 animal food. The cost of the vegetable food was enhanced 
 by the use of high-priced self-raising flours and the like, show- 
 ing want of management in buying. Bananas and oranges 
 were extravagances for them to indulge in, considering their 
 food value, being mostly water. The girl bought peanuts, 
 and thus unconsciously made a good bargain. You get much 
 protein for a small price here, and also much fat and carbo- 
 hydrates. For this family the food purchased per man per 
 day furnished one-fourth more nutriment than is needed for 
 a man at moderate work. Three per cent, of the total food 
 was thrown away in the table and kitchen waste, and thus 
 one per cent, per man per day of protein was wasted. De- 
 ducting this, and there was still an excess of food. The food 
 eaten contained at least 25 grammes of protein and a fuel 
 value of 600 calories per man per day more than was needed 
 by a man at moderate work. When the man was out of 
 work he and his family would have been well nourished if 
 the food had only contained 100 grammes of protein, and had 
 a fuel value of 3000 calories per man per day. The nutritive 
 ration of the food eaten (i : 5.5) was about equal to the 
 dietary standards. In this case Atwater and Woods suggest 
 that the amount of food purchased might have been reduced 
 twenty-five to thirty per cent, and a considerable saving of 
 
 218 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 money effected. A more judicious selection of food and 
 greater attention to details of marketinj^ and preparation of 
 the food might have still further reduced the cost. Such 
 carefulness in purchase and preparation would also have re- 
 duced the kitchen and table wastes, so that practically no food 
 would have been wasted. The more intelligent selection of 
 food, from both the nutritive and pecuniary stand-points, 
 would preclude the purchase at the prices paid of such foods 
 as chicken, cod, flounder, shad, condensed milk, canned as- 
 paragus, prepared flours, radishes, celery, cherry jelly, etc., 
 which this inexperienced little market-girl bought, and would 
 lead to the increased purchase of more economical foods, in- 
 cluding peas, beans, wheat flour, rice, and the cheap but nutri- 
 tious cuts of beef, veal, and mutton. In this way a large 
 proportion of the money spent for food could have been saved 
 with advantage to health and without interfering with the 
 palatability of the food eaten. 
 
 All this is interesting and quoted here to show in what a 
 slipshod manner such people live. Surely the physician must 
 be one great factor in bringing about a better system, and 
 should surely study all of these great economic questions. In 
 another case, to show injudicious division and expenditure of 
 an allowance of money, they give a family w-here it seemed 
 hopeless to attempt to express in terms of protein and fuel 
 value wdiat was needed for their better nutrition. The house- 
 keeping needed absolute revolution. With such carelessness 
 on all sides it is almost useless to suggest improvements in 
 the kinds and amounts of foods to be purchased. The dietary 
 needed more protein, and a much smaller expenditure for 
 butter would allow this family to procure it. They spent 
 about as much for butter, fish, and chicken as for beef and 
 pork, the amount spent for beef and pork being $3.57, and 
 for butter, fish, and chickens, $3.48. The former furnished 
 1645 grammes of protein and 41,950 calories; the latter, 743 
 grammes of protein and 35,700 calories. This case shows 
 the necessity for judicious buying and selecting to get the 
 
 219 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 best results for health and strength, and physicians cannot 
 know too much about it; patients and the people generally 
 surely know too little. 
 
 Great advances have been made in feeding the lower ani- 
 mals both for milk and meats by working up and studying 
 and feeding a balanced ration. How much more is it neces- 
 sary to work up and study and prepare for man a balanced 
 ration ! We would get all the required nourishment for man 
 from pork, stale bread, olives, milk, and cheese, but it would 
 not be a good combination for easy digestion, because there 
 are too many articles here of slow digestion. A man doing 
 hard work would enjoy life more and thrive better on pork, 
 beans, and corn-bread than he would on a steady diet of even 
 a balanced ration like corn-bread, milk, oysters, and rice, for 
 the latter would not last long enough in digestion, and leave 
 the organs too long inactive between meals. Oatmeal, bread, 
 and milk would do better, especially should some sugar be 
 added. The balanced ration is the important matter for man. 
 A man who does not eat enough often gets an unbalanced ra- 
 tion and does not thrive ; so does the man who eats too much. 
 Pork, butter, and eggs would be an unbalanced ration, — too 
 much fat and too little carbohydrates. A man cannot live on 
 potatoes alone and thrive; it would take a peck of potatoes 
 daily to give him enough protein. 
 
 Again, let me give the estimated food necessary for man 
 for twenty- four hours. A work ration: Protein, 125 
 grammes; fat, 125 grammes; carbohydrates, 450 grammes; 
 calories, 3500, with salts, 30 grammes. A mere subsistence 
 ration would be as follows : Protein, 75 grammes per day ; 
 fat, 40 grammes; carbohydrates, 325 grammes; calories, 
 2000, with salts, 25 grammes. An ideal ration (Mrs. Rich- 
 ards) would be, for twenty- four hours: Wheat bread, 16 
 ounces ; beef, 8 ounces ; oysters, 8 ounces ; cocoa, i ounce ; 
 cow's milk, 4 ounces ; broth, 16 ounces; sugar, i ounce; but- 
 ter, y^ ounce. This for a man doing average work, and 
 would furnish 2575.52 calories. So far as we know, basing 
 our ideas on chemistry and physiology, so far as developed, 
 
 220 
 
FORTY VICARS IN Till'. MEDICAL I'KOI-KSSION 
 
 we arc riji^ht in tlic views of diet here taken. We have ^onc 
 upon tlie theory that the nitrogenous or albuminous princi- 
 ples, after undergoing complete combustion, end in urea, and 
 incomplete combustion, end in uric acid, and are unfit diet for 
 diseases caused by excess of urea and of uric acid, whether 
 the cause be from damaged machinery of the body, or from a 
 peculiar diathesis. These nitrogenous foods, comprising 
 butcher's meats, poultry, fish, shell-fish, eggs, and milk, not 
 forgetting the vegetable albuminoids, as the coverings of the 
 starch granules of grains, etc., are the tissue-builders or flesh- 
 formers. Now, although we are so sure of this and so sure 
 we are right, yet there are those, and men of reputation, who 
 deny such conclusions as regards diet for the so-called uric 
 acid conditions, and advocate the exclusion of the carbohy- 
 drates rather than the nitrogenous group. All we can say to 
 such criticism is, w^e believe we are right, yet we wall strive 
 to learn more, even to the rewriting, if necessary, of ever- 
 changing uric acid literature; but we shall not despair, for 
 there are those living who deny the virtue of diphtheria anti- 
 toxin or the protection from small-pox by vaccination. We 
 have also gone upon the theory that the non-nitrogenous 
 foods, all the vegetables, fruits, cereals, starches, sugars, 
 gums, fats, and oils, being both animal and vegetable, and 
 the organic acids, are the maintainers of animal heat and 
 the force-producers. As before mentioned, these are also 
 tissue-builders in a small degree from the vegetable albumi- 
 noids they contain. We have also recognized as fact, that 
 certain salts also are taken from the foods eaten, the least from 
 fruits and nuts, next from meats, and most of all from vege- 
 tables, these salts being for the most part chloride of sodium, 
 potassium chloride, sodium carbonate, potassium carbonate, 
 potassium sulphate, sodium sulphate, magnesium sulphate, cal- 
 cium phosphate, sodium phosphate, potassium phosphate, and 
 others, these going to various uses in the economy, such as 
 regulating the specific gravity of the blood, checking putrefac- 
 tion of tissues, controlling osmosis, etc. 
 
 Vcgctariainsiii. — It has been pretty well established that 
 
FORTY YEARS IX THE MEDICAL PROFESSION 
 
 man cannot live in health and comfort and enjoy life on a 
 vegetable diet alone. As before stated, it would take a peck 
 of white potatoes a day to give a man sufficient protein for 
 laborious work. He may get everything from vegetables, 
 but not sufficient for a balanced ration from a reasonable 
 amount of food. Vegetarians are usually fanatics, non-pro- 
 ducers, but, as a rule, take great care of their health and do 
 not dissipate, commendable qualities, and if they would only 
 live on a scientific, well-balanced ration, they would, as a rule, 
 live longer, be happier, and be more useful citizens. Those 
 who live only on vegetable food, and on that food which de- 
 stroys no life to get it, such as eggs and milk, can get a well- 
 balanced ration, and surely will be better and happier than 
 those who take an omnivorous diet unscientifically chosen in 
 quantity and quality and ravenously eaten. We cannot argue 
 that the ancient Britons subsisted on roots and nuts and the 
 spontaneous productions of the ground, or that certain savage 
 tribes live on vegetables alone. Providence provided and does 
 provide a complete ration for them in some way and at some 
 time, if not regularly, or they would never be the sturdy 
 races they were and are. 
 
 Special Diets for Corpulency, and how to get Fat when too 
 Lean. — All of these special diets, or special systems, or fads, 
 or whatever you may call them, mean starvation in a greater 
 or less degree. Withhold a proper amount of food from the 
 animal, and you cause loss of weight. Excessive weight is a 
 great source of inconvenience, — a humiliation to some. It is 
 most frequently hereditary and a perfectly natural state for 
 the individual. After all, the philosophy of existence, in one 
 sense at least, is to feel good and well. Obesity may be a 
 disease, but if so, it is usually the fault of bad habits in the 
 individual. If one will live a sober, industrious, and in every 
 way a temperate life, restricting, as one surely must very de- 
 cidedly, the appetite for sugars, -starches, and fats in particu- 
 lar, and for all meats and drinks somewhat, but not beyond 
 the comforts of existence, as most of these special methods 
 do, then one will neither be overburdened with fat nor threat- 
 
FORTY YI^ARS JN TILI' MICIJICAI. PROFESSION 
 
 encd with evils of a more (laiij:^eroiis kind from unscientific 
 regimen. 
 
 The Banting system undoubtedly, if followed up. causes 
 loss of bulk, but has its dangers, and surely is most inconve- 
 nient and unpleasant to those following it. He allowed about 
 twelve ounces of lean meat per day, about two ounces of 
 bread, and about twelve ounces of fruit and green vegetables. 
 He allowed thirty-five ounces of fluids in twenty-four hours, 
 nothing like as much fluid as a man should part with in the 
 same length of time. As Thompson says, the fats and albu- 
 minoids are not well balanced here, and" constipation of the 
 bowels must ensue. 
 
 The Ebstein system, as given by Thompson, is, that ani- 
 mal food, as well as carbohydrates, particularly sugars and 
 starches, are capable of being turned into fat. The carbohy- 
 drates, he says, furnish force for the body, and by their com- 
 bustion spare the complete oxidation of the albuminates, which 
 are therefore stored in the tissues in a suboxidized form. His 
 theory is that fatty food does not give rise to the storage of 
 fat in the body, and he allows it, and particularly because it 
 causes satiety sooner and makes one eat less. He allows no 
 sugar, potatoes, rice, or other farinaceous food except three 
 ounces and a half of bread daily. He allows the non-starchy 
 vegetables and a moderate amount of any kind of meat. He 
 restricts fluids to about one-half normal. Breakfast, one cup 
 of black tea, no sugar or milk, with two ounces of buttered 
 toast. Dinner, at noon, six ounces of boiled or roasted fat 
 beef, W'ith drip gravy, one or two non-starchy vegetables in 
 moderation, and for dessert a salad and fruit, a little light 
 wine, and tea, no sugar or milk. Supper, tea. no milk or 
 sugar, one soft egg. a moderate allowance of fish. ham. or 
 cold fat meat, one ounce thin buttered bread or toast, and 
 fruit. On this diet one cannot work hard or take active exer- 
 cise and be thoroughly comfortable, for he only gets fourteen 
 » hundred calories potential energy in nutrients. 
 
 Here is a table b}" Atkinson of a comparison of dietaries 
 for corpulence, with ordinary dietaries, from Thompson : 
 
 223 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 I'lETARlES. 
 
 Banting system 
 
 Ebstein system 
 
 Playfair's standard for subsist- 
 ence diet 
 
 Voit's standard for laboring 
 man at moderate work . . . 
 
 Playfair's standard for adults 
 with moderate exercise . . . 
 
 Atkinson's standard for a man 
 with light exercise 
 
 Atkinson' s standard for a labor- 
 ing man at moderate work . 
 
 Poor sewing girl, London, diet 
 barely sufficient for subsist- 
 ence 
 
 University professor, Germany, 
 very little exercise 
 
 Well-to-do family, Connecticut, 
 food actually eaten .... 
 
 Mechanics and factory opera- 
 tives, Massachusetts, food 
 purchased 
 
 Food actually eaten by college 
 students — 
 
 From Northern United States . 
 
 From Eastern United States . . 
 
 Nutrients. 
 
 Protein. 
 
 Gramvtes. 
 171 
 102 
 
 57 
 118 
 119 
 
 125 
 
 53 
 
 128 
 
 127 
 
 104 
 
 Fat. 
 
 Grammes. 
 
 8 
 
 85 
 
 14 
 56 
 51 
 
 I(X) 
 
 125 
 
 2,3. 
 100 
 177 
 
 136 
 
 Carbohy- 
 drates. 
 
 Total. 
 
 Grammes. 
 
 Grammes. 
 
 75 
 
 254 
 
 47 
 
 234 
 
 341 
 
 412 
 
 500 
 
 674 
 
 531 
 
 701 
 
 360 
 
 560 
 
 450 
 
 700 
 
 316 
 
 402 
 
 240 
 
 440 
 
 466 
 
 771 
 
 531 
 
 844 
 
 622 
 
 944 
 
 421 
 
 661 
 
 Potential 
 Energy in 
 Nutrients. 
 
 Calories, 
 1085 
 1400 
 
 1760 
 
 3050 
 
 3140 
 
 2815 
 
 3520 
 
 1820 
 
 2325 
 4080 
 
 4430 
 
 4825 
 3415 
 
 From this table, the patients under Banting and Ebstein get 
 starvation diet sure. Whilst the student from the Eastern 
 United States gets too much, Atkinson's man at moderate 
 work gets well supported, the poor sewing-girl is ill nour- 
 ished, mostly on carbohydrates, as we should suppose, and 
 the German professor, how about him? Well, he does not 
 live high, but gets several glasses of beer, as his carbohydrates 
 show. 
 
 The QErtel system is a newer system, and I am indebted to 
 Professor Thompson's book for information in regard to it. 
 
 224 
 
FORTY YEARS TN TTTK MEDICAT. PROFESSION 
 
 The feature in (JCrlel's system is to strengthen the circulation 
 by strent^theninj:^ the heart, and then the fat, once j^fjtten rid 
 of, does not return. He makes two classes of the obese, and 
 regulates their diet accordingly : First, those in whom fat has 
 accumulated, but in whom the circulation and respiration are 
 not impaired and the person can use muscular effort and walk 
 or run. Second, those in whom, from advanced stasis and 
 hydrcTmia, and with a deficiency of h?emoglol)in in the blood, 
 ansemic, the amount of oxygen taken up from the lungs is 
 much reduced, and who are short of breath on exertion. For 
 the first class he allows 50 grammes of fat, carbohydrates 200 
 grammes, with 150 grammes albumin, or more, if needed. 
 For the second class — fat people, short-winded, and with 
 dropsical tendencies, I suppose, he mostly puts in this class, 
 yet with organs fairly sound — he allows 30 grammes of 
 fat daily, with 100 grammes carbohydrates, and considerably 
 over 150 grammes albumin, more, you see, than the first class 
 gets. In this second class he gives little fluid, and not over- 
 much to the first class. He thus, he says, reduces blood- 
 pressure, venous stasis is lessened, and thus the vessels in the 
 fatty tissue are drained, and nutritive changes occur here, the 
 fat is broken up, carried away, and cremated, as it were. 
 CErtel allows twice the amount of animal food that Ebstein 
 allows, double the amount of carbohydrates, and less than 
 half the fat. He also allows more fat and starch than Bant- 
 ing. He allows twelve ounces light wine, and as much water 
 at dinner, a very fair allowance, with six ounces of bread 
 daily. He allows eggs now and again. For those who are 
 able he prescribes the " terrain cure," mountain climbing, 
 watching the heart, which gets strength as the exercise pro- 
 gresses. For those who cannot climb or use exercise, he 
 prescribes massage, friction, and baths, here still further re- 
 ducing fats and starches. 
 
 The Schweninger system is about like QErters. but he al- 
 lows no drink at meals, but must wait until two hours after 
 meals to drink. He gives little bread, and restricts fluids gen- 
 erally. 
 
 IS 225 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Germain-See says much water is necessary in treating cor- 
 pulency. He allows meats, lean and fat, but no sugar or 
 starches. His drinks are hot, weak tea and an abundance of 
 water. He allows little or no alcohol. Thompson suggests 
 this treatment with plenty of fluids is best for gouty and 
 rheumatic cases where we desire to eliminate the waste from 
 the system. This, at any rate, is some encouragement to the 
 gouty, stout man, who so far has received little consideration 
 in this matter. 
 
 S. Weir Mitcheirs system for obesity consists chiefly in 
 rest, skim-milk diet, massage, and movements for passive 
 exercise. After a fortnight he begins to allow a little light 
 broth ; he is careful to watch the condition of the heart ; after 
 six weeks he allows some lean meats. This treatment re- 
 quires the abandonment of all labor, and is among the best of 
 treatments to amuse whilst at the same time it relieves, and is 
 especially applicable to women society-tired and suffering 
 from over-indulgence in various forms. 
 
 There are a number of other treatments, named for the men 
 first recommending them, but they differ only in degree from 
 those already mentioned. The principle in all is the same, — 
 semi-starvation, — and the end aimed at the same, — viz., to 
 cause those undergoing the treatment to oxidize and elimi- 
 nate the accumulated fat and to prevent its forming again. 
 There are many quack remedies, under various names ; all are 
 harmful and even dangerous, with just knavery enough in 
 the recommendations accompanying them, putting those using 
 them on a diet which avoids fat, starches, and sugars, to give 
 them a semblance of doing effective work in reducing flesh. 
 There is at present quite a fad going around, especially among 
 women fond of society, taking upon themselves some cure for 
 obesity. This is all wrong, unless they have intelligent medi- 
 cal supervision, and this intelligent medical supervision should 
 see to it that the heart and kidneys of these patients are thor- 
 oughly observed and looked after ; withholding fluids in these 
 cases is often attended with serious consequences. Renal cal- 
 culi may supervene, or gall-stones may form and great suffer- 
 
 226 
 
FORTY YEARS IN '11 1 1'. MI'DICAI, PROF F.SSJON 
 
 iiig" ensue, all because the elimination of waste has been inter- 
 fered with. 1 once knew a f^entleman, a n>yal gof>d fellow, 
 of middle age, who, being stont and, liaving a lung capacity 
 below the average, did not oxidize his fat fully by throwing 
 it off from his lungs in the shape of carbonic acid and water. 
 Hearing from some wise man that a dose of Epsom salt every 
 morning in a small portion of water wcnild make him thin, he 
 took it faithfully for several months. The consequences were 
 disastrous. This man had a strong appetite; in fact, he ate 
 meat like a bloodhound, starch like an ox, and fat like an 
 Esquimau, and the more salts he took the more he ate. All 
 of his fluids ran ofT, normal metabolism was interfered with, 
 the composition of the blood was altered, the elimination of 
 waste was interfered with, and of course the result, renal cal- 
 culi, one after another, stone in the bladder, and prolonged 
 suffering. Nature resents such unwarranted interference with 
 her laws. My own idea in these cases is, above all things, to 
 sttidy the individual, then arrange the diet, exercise, and the 
 habits of life generall3^ Watch particularly the condition of 
 the heart, the general circulation, and the kidneys. Age is 
 very important to take into consideration, and so is sex and 
 the environment of the patient. The gouty patient needs 
 different advice from one not so afflicted, and so does the 
 patient with dropsical tendencies. Explain to each what their 
 case needs. Explain the difference in the make-up of foods, 
 as to oxygen, hydrogen, carbon, and nitrogen, and the differ- 
 ence between proteids and starches, sugars and the like, and 
 fats, and the tendency of each in diet. Intelligent advice and 
 supervision are what these people want. Notice the superb 
 condition generally of the athletes of the University of Penn- 
 sylvania. How^ is it their condition, their fitness, excel ? The 
 answer is evident. It is the intelligent supervision and direc- 
 tion of strong and able men like Dr. J. William White, as- 
 sisted by such experts in diet and other accessories as Dr. 
 Horatio C. Wood and others, which bring this about. This 
 earnest, intelligent supervision is one of the great factors of 
 success in mnch that pertains to life. 
 
 2_V 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Leanness, the opposite of fatness, afflicts some persons, and 
 is often so extreme as to cause humiliation. The remedy is 
 to find out the cause, and remove it if possible. As to diet, 
 reverse the principles applied to obesity. Lean people are gen- 
 erally perversely lean, and will not get fat, even when in per- 
 fect health. Plenty of proper meat and drink, avoiding ex- 
 cesses, rational employment, sound sleep, a clear conscience, 
 and proper medical supervision is a good recommendation to 
 such people. 
 
 Woman without a StouiacJi! — What shall we say of the 
 woman without a stomach, now living in Switzerland, and 
 possibly of others in Europe and in this country? This case 
 of Dr. Schlatter's in Zurich is remarkable. The entire stom- 
 ach was removed, and she is enjoying good health and even 
 gets sick at the stomach (?) if, perchance, something does 
 not agree. How paradoxical ! From the start this woman 
 was fed on soup, oatmeal, brandy, and wine, and these were 
 digested. A month after the operation she became nauseated 
 and vomited ; in the vomit bile was found, which is against 
 medical theory. Here the entire theory of stomach digestion 
 is made to totter. These internal functions must be restudied, 
 and this part of physiology must be rewritten. We know the 
 intestines do a great deal of the work of digestion and assimi- 
 lation, but we did not know before, nor did we believe, com- 
 plete digestion and complete assimilation would go on with- 
 out a stomach. A new motto has been generated. What is 
 woman without a stomach? Much. 
 
 Whilst speaking of diet for obesity, it may be well to refer 
 here to the best form of bread, " the staff of life," without 
 which, in some form, it is almost impossible, for civilized 
 man, at least, to exist. The best form of bread is the bread 
 of wheat, white bread, as distinguished from rye bread or 
 graham bread. The white bread contains the least carbohy- 
 drates naturally, even if it has a little more fat. There is a 
 rage now among well-informed people, especially among 
 ladies endeavoring to reduce their avoirdupois, for over- 
 toasted bread, the twice-baked bread, it is familiarly called, 
 
 228 
 
FORTY YFCARS IN 'I'lll': MICDICAL PROFKSSION 
 
 which fcally appi'oachcs very near to the well-kiKJwn German 
 " zwcihack." 'Hiis twice-hakcd hrcad is quite palatahle and 
 quite nutritious, and if eaten in moderate quantity, one may 
 a])pease the a])petite for bread and find it much less fattening 
 than ordinary bread, and very much less likely to cause fer- 
 mentation durinj*- digestion. To prepare this twice-baked 
 bread, cut from the loaf (at least twenty-four hours baked) 
 thin slices, place them in a pan, and subject them to the heat 
 of a quick, hot oven for from twenty to thirty minutes. In 
 making toast, what happens ? The toasting destroys all yeast 
 germs and other germs which may be with the bread, and thus 
 the toast is sterile. Surely a great advantage. The starch in 
 the bread, of course, must be converted into sugar before it 
 can be assimilated. The toasting does this in part. Carry the 
 toasting still further, and we convert the starch into dextrin, 
 a gummy substance. Carry the toasting still further, and we 
 get the dark-brown and even black toast, the sugar being cara- 
 melized, and the flavor is improved. Steam the toast, and you 
 further dextrinize the starch. Butter it lightly, and you make 
 it more digestible by dijffusing it, as it w^ere, and the saliva acts 
 better on it, in first starting starchy digestion, which is con- 
 tinued after swallowing by the amylopsin in the pancreatic 
 juice and diastase in the intestinal juices with some other 
 digestive substances. 
 
 Another bread is very digestible : Take light dough, roll it 
 very thin, cut it into strips, roll it into hollow cylinders, and 
 bake ver}^ quick and dry. You here have bread cylinders, 
 very digestible, about the same as toast. Crackers are not, 
 as a rule, ver}^ digestible, because they are baked as very dry 
 dough, not much water being added, and thus the starch gran- 
 ules are not well broken up, and the cracker is thus more diffi- 
 cult to digest. To be digestible, all starches must be well 
 cooked, with sufficient water to soften the granules and break 
 up the cell-structure. Pretzels are superior to crackers as an 
 article of diet, because the dough is here first boiled well, 
 which breaks up the starch, and then thoroughly baked. 
 There is generally too much salt about them, for the carry- 
 
 229 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 ing of Avhich, it is said, they were invented, to make the 
 lounger drink two glasses of beer when otherwise one would 
 have sufficed. This, doubtless, is a libel on Boniface. 
 
 I applied to Dr. Neale, the director of the Delaware Col- 
 lege Agricultural Experiment Station at Newark, Delaware, 
 for his views on the effect of toasting on bread. He wrote 
 to Professor Atwater, the well-known expert on food analy- 
 sis. Professor Atwater referred the question to Professor 
 Woods, and I take great pleasure in appending Professor 
 Woods's very satisfactory reply. 
 
 " Maine Agricultural Experiment Station, 
 " Orono, Maine, December 13, 189S. 
 " Chas. D. WoodSj Director. 
 
 " Director Arthur T. Neale, Agricultural Experiment Station, 
 Newark, Delaware : 
 " Dear Doctor Neale, — Your letter of December 9 to Professor At- 
 water has been forwarded to me for reply. I wish I could tell you a 
 great deal more than I can relative to the changes which take place in 
 bread by toasting. While, as you know, there has been a very large 
 amount of work done upon bread, comparatively little of it has brought 
 definite information. As is well known to you, the difference between 
 fresh bread and stale bread is not due to a loss in water, but to a molec- 
 ular change. In the process of baking there is probably a distillation of 
 water from the surface which is recondensed in the more central parts of 
 the loaf. In cooling, the reverse goes on. It is believed, rather than 
 known, that in fresh bread the greater part of the water is free, while in 
 stale bread part of the water is combined with the starch, or perhaps with 
 gluten, and that these are again separated when the loaf is reheated. In 
 toasting, water is driven off and a greater firmness is acquired. If the 
 slice is thick, and the surface is merely scorched by the action of the 
 heat, as is the case in most restaurant- or hotel-made toast, the interior 
 changes are very much the same as when stale bread is rebaked. On the 
 other hand, when bread is thoroughly toasted, so that crispness extends 
 throughout the slice, there is quite a large loss in water, much of the starch 
 is changed to dextrin, and some of it is even converted into caramel, or 
 substances closely related thereto. The peculiarly pleasant burnt taste 
 is probably due to caramel, the sweeter taste and the apparently greater 
 ease of digestion is probably due to conversion of a considerable part of 
 the starch into dextrin. It is, however, probably true that much of the 
 apparent increased ease of digestibility of the toast over the bread from 
 which it was prepared is due to a change in mechanical condition, so that 
 in mastication it does not pack in the way that even stale bread does. I 
 think that the above includes all that is known of the chemistry of toast- 
 ing, as well as some things which are merely inferred. 
 
 " Respectfully, 
 
 230 " C. D. Woods." 
 
FORTY YEAKS IN Till". M\'A)\CA\. I'KOFESSION 
 
 The latest treatment for fatness is the alternate drinking 
 of Kissint^en and Vichy, tlie watci" of the (irande (jrille pre- 
 ferred. Dr. William T. Cathcll, in the Maryland Medical 
 Journal, recommends that a full ^lass of Kissinj:(en he taken 
 one-half hour after each meal, and the next day,jn the same 
 way, a glass of Vichy; alternating in this way, the artificial 
 waters may he used, or the waters ])re|)ared with the various 
 effervescing salts on the market. If the patient loses more 
 than two pounds in weight per week, take a small glass, or 
 omit the mid-day glass. If he loses less than two pounds per 
 week, add the juice of half a lemon to each glass of Kissingen, 
 or a teaspoonful of the aromatic spirit of ammonia to each 
 glass of Vichy. It is not necessary to restrict the diet, but 
 cut down somewhat alcoholics, starch, sugar, and fats, if 
 given to consuming large quantities of them. In other words, 
 avoid overeating and excesses at the table. Sleep on an empty 
 stomach as near as possible, so some of the surplus fat may be 
 burned up as fuel whilst we sleep. Take plenty of out-door 
 exercise, to promote tissue oxidation. If more convenient, 
 the patient may take one glass of Vichy before breakfast, and 
 a glass of Kissingen just before going to bed, and expect good 
 results. There is no doubt that even sipping the waters now 
 and again, to the amount of from three to four glasses per 
 day, alternating between Kissingen and Vichy by days, would 
 prove equally, if not more, effectual. Taking these waters 
 may be kept up from one to six months, or longer if necessary. 
 I may add here that this is not a new system of treating obe- 
 sity, but is a revival of the Dancel system, — giving sodium 
 bicarbonate with tartaric acid and water in the effervescing 
 state. How do they act? Well, they may act in several ways. 
 By merely inhibiting or controlling the disproportionate ac- 
 tivity of fat-cell nutrition, thus placing less fatty pabulum and 
 more blood, brain, muscle, nerve, and gland elements at the 
 disposal of the absorbents, whilst the fat and oil, being of 
 lower organization, are naturally the first to be removed by 
 the corrected physiological processes, or they may act as alter- 
 atives and restore equilibrium to the nutritive processes by 
 
 ^31 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 destroying or neutralizing some morbific fat-forming agency, 
 occult derangement of digestion, or perversion of assimilation 
 that have been causing diminished oxidation of fat and, con- 
 sequently, its accumulation. 
 
 Another supposition : Kissingen and Vichy, the former 
 acid and the latter alkaline, and both containing salts of lime, 
 magnesia, potash, soda, and other minerals, united with car- 
 bonic acid and other gases, may, when alternately mingled 
 with the chyme in the stomach and intestines day after day, 
 — their special combination of ingredients, — ^bring about re- 
 duction by some chemico-physiological readjustment of the 
 alkalinity and acidity of the blood and the visceral fluids, or 
 possibly of both humors and solids, and that this readjust- 
 ment makes the fat-yielding pabulum less plentiful and less 
 rich, less favorable for fat creation, and metabolically ex- 
 plains why increase of fatness ceases and why reabsorption 
 of the surplus contents of the fat-cells begins, and also why 
 this physiological reduction and reconstruction results, and 
 thus reduces the fat of the body to the normal proportion of 
 one to fifteen or twenty. Whether Dr. Cathell is correct here 
 or not, he declares that practically they work wonders, and 
 the individual losses are from fifteen to ninety pounds. My 
 experience in practice confirms somewhat Dr. Cathell's. 
 
 In matters of diet, we spoke of studying the individual in 
 ordering a course of diet for a patient. Climate is also an 
 important matter to take into consideration. The Esquimau 
 needs, from his environment, much fat to keep up the heat of 
 his body, but what would the inhabitant of Manila do with 
 blubber as a main article of diet, living constantly as he does 
 under the hot rays of an equatorial sun? Our soldiers in 
 Manila do not want blubber, but experience shows that 
 we must still keep the fat in their ration. According to 
 George Waldron, Ireland eats more white potatoes than any 
 other nation, consuming a daily average of four pounds per 
 person. Germany comes next, and Italy last, consuming only 
 forty-eight pounds per person per year. The United States 
 consumes two hundred pounds per person per year. In 
 
 232 
 
FORTY YEARS IN TIIIC MKDICAL I'RDFKSSION 
 
 wheat, France leads the hst, using f(>ur hun<h-e(l and sixty- 
 seven pounds per person per year. Canada comes next. The 
 United States cfjnsunies two liundred and f(jrty ])ounds per 
 person per year. Japan uses only tvventy-tvvtj jKnmds per per- 
 son per year, wiiich is just the amount of rye used by each 
 person in the United States. Norway uses the most oats per 
 person, being one hundred and twelve pounds per person per 
 year. England, including Scotland and Ireland, uses only 
 twelve pounds of oats per person per year, — very remarkable, 
 so much of it being used in Scotland, and such an ideal food 
 for the climate. In meats, the United States stands at the 
 head, using one hundred and forty-seven pounds per person 
 per year. Italy uses the least, as her climate might indicate — 
 twenty-four pounds per person per year. The United States 
 also uses more eggs than any other country per person, — one 
 hundred and twenty-three per year. In rice, the United States 
 takes only four pounds per person per year. Great Britain 
 takes nine pounds, and the province of Bombay, India, uses 
 five hundred and forty-seven pounds per person per year. 
 Here we see how climate comes in in diet. In sugar, Great 
 Britain uses the most. — eighty pounds for each inhabitant per 
 year. The United States uses seventy-three pounds, and 
 Spain only seven pounds. In tea. Great Britain leads, — about 
 five and one-half pounds per person per year. Russia uses 
 only nine ounces per person per year, and yet are supposed 
 to be a tea-drinking people. Here we see the condition as 
 shown by diet, — too poor to drink much tea. In coffee, the 
 Netherlands use the most, over twenty-three pounds per per- 
 son per year, whilst we use nearly ten pounds. Russia uses 
 only three ounces per person per year. In malt liquors. Great 
 Britain takes the lead, thirty gallons to each person per year. 
 actually leading Germany three gallons per individual. We. 
 in the United States, use fifteen gallons per person per year. 
 In the wine-drinking countries comparatively little is used, 
 although it is increasing in France, she now using six gallons 
 per person per year. Spain uses only a little over a pint, but 
 in wine consumption Spain leads the world, — thirty-five gal- 
 
 233 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Ions to each person per year. France, twenty-nine gallons, 
 and Italy, twenty-four gallons. It is interesting to note that 
 the United Kingdom uses less than two cjiiarts per person per 
 year. Her climate demands something stronger. Surprising 
 to say, Germany uses only a little over one gallon of wine per 
 person per year. In the United States the consumption of 
 wine is rapidly increasing, but it is yet only two quarts to 
 each person per year, making the respectable quantity of 
 thirty-eight million gallons. Great Britain and her colonies 
 and Russia are among the great spirit-drinking countries, and 
 climate here is the great factor in determining the quantity 
 consumed. 
 
 It has been said that " a piece of charcoal, some atmospheric 
 air, a little water, and some salt contain all the elements of a 
 typical diet, and in ample quantity," but we cannot live on a 
 piece of charcoal, some atmospheric air, a little water, and 
 some salt served in kind at least, but dress them up in palata- 
 ble dress, and we take them with avidity and grow fat, show- 
 ing it is not altogether the elements the food contains that 
 make it available, but how^ and in what way these elements 
 are contained is the important matter. Another thing it 
 shows : we must know something more than the absolute 
 chemical composition of food-stuffs before we can foretell 
 exactly the effect on the indivdual. 
 
 It is now autumn, and a lady, married, with no children,, 
 of middle age, of normal weight, and very bright, has just 
 asked me to recommend an average diet for her, not that she 
 is sick, for she is very well, has no vices and no fads ; she 
 merely wants to take good care of her present satisfactory 
 health. I suggested the following: For breakfast, she being 
 always ready for it at eight a.m., a baked apple or pear, not 
 very sweet, with, if she prefers, some milk that has been Pas- 
 teurized. If preferred, a few grapes or a peach may be eaten,, 
 without sauce, au naturcl. A plate of oatmeal, wheaten grits, 
 or corn grits, with Pasteurized milk but no sugar, stale bread 
 with butter, and a cup of coffee and hot milk. If preferred, 
 tv^o hen's eggs boiled from three and one-half to five minutes 
 
 234 
 
FORTY Yl'.ARS IN 'lillC MI-:i)ICAL I'KOI- MSSION 
 
 may be su1)slitutc(l for tlie oatmeal or ji^rits. I.iincheon, one 
 P.M. : some Hji^^lit soup, with stale bread and butter, some 
 boiled fresli fish, and some plain fruit. Pr()vided she is not 
 to take active exercise for an hour or two, a chop or some 
 minced meat or a bird may take the place of fish. If desired, 
 a well-baked white potato may be added to this meal. Din- 
 ner, six P.M. : a soup, not rich, such as consomme or a clear 
 vegetable soup, choice of roast or boiled beef, mutton, or poul- 
 try, or its equivalent; baked white potato or sweet potato, 
 and either rice or macaroni, with either cauliflower, spinach, 
 or cabbage, boiled, with a plain sauce. A light salad may 
 follow, with a taste of cheese and a taste of hard cracker 
 heated. If any wine is used, take claret and water. For des- 
 sert take plain rice-pudding, plain custard, or a little light 
 pastry, some fruit if desired, with a dcnii-tassc of coffee. If 
 the custom of her home, then a sociable cup of mild black tea, 
 without cream or milk, one hour after dinner, may take the 
 place of the coffee. 
 
 Merely as a matter for reference, I will give the time re- 
 quired for the digestion of some of the commoner articles of 
 diet. May I preface this with one admonition? In cooking 
 in general, avoid the frying-pan, as a rule, and rich, various- 
 flavored, wonderfully made sauces. The frying-pan makes 
 easy a cheap and indolent method of preparing food. It has 
 been said that words were made with which to disguise our 
 thoughts. The French, particularly, invented the various 
 sauces to disguise natural flavors and to enable them to serve 
 any dish from almost any material, thus serving two purposes, 
 — the satisfying the palate of the guest and establishing an 
 economical method in the kitchen. None of these methods 
 are conducive to the good health and prosperity of the indi- 
 vidual. Time required for the digestion, or rather, tJie eJiymi- 
 Hcation of various articles of food: Boiled beef, 2^ hours; 
 roast beef, 3 hours ; boiled mutton, 3 hours ; roasted mutton, 
 3^4 hours; turkey roasted or boiled, 2^4 hours; stewed 
 chicken, 2^/4. hours; fried beef, 4 hours; roasted chicken and 
 duck. 4 hours ; boiled chicken. 4 hours ; roasted fresh pork. 
 
 235 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 5^ hours ; soused pig's feet boiled, i hour only, and tripe the 
 same;' venison steak broiled, i^ hours; fried brains, i}i 
 hours; fried beef liver, 2^ hours; calf's liver, 1% hours; 
 roasted goose, 2^ hours; roasted young pig, 23^ hours; 
 roasted lamb, 2^ hours; boiled salmon, 13^ hours; boiled 
 salt cod, 2^/2 hours; stewed oysters, 3^/2 hours; raw oysters, 
 much less; cheese, 3^ hours; gelatin is digested in from 2^ 
 to 3 hours, cartilage in 4^ hours, and tendon, well cooked, in 
 6 hours; raw eggs, 13^ hours; roasted eggs, 2^4 hours; hard- 
 boiled eggs, 3^4 hours ; fried eggs, 3^ hours ; soft-boiled eggs, 
 2 hours; boiled lean ham is quite easy of digestion; boiled 
 white potatoes, 33^ hours; if well baked or roasted, 2 to 2}i 
 hours; boiled cabbage, 4 hours; boiled turnips, 3J^ hours; 
 boiled rice, i hour; boiled beans, 23^ hours, and the same 
 for boiled parsnips; carrots, boiled, from 3^4 to 3^ hours; 
 baked wheat bread, 33^ hours; boiled beets, 4 hours; boiled 
 or baked apple-dumpling, 3 hours ; raw apples, from i ^ to 2 
 hours, — sweet and mellow digest the soonest; corn-bread, 
 334 hours; hoe-cake, 3 hours; sponge-cake, 3 hours; boiled 
 barley, 2 hours, tapioca the same, and sago about the same. 
 Sugars are very rapidly absorbed from the stomach, and, as 
 a rule, so are fats. Of course, digestion may be retarded by 
 different causes, as by food that does not agree with one, such 
 as unripe fruit, badly cooked food, animal food too tough to 
 be eaten, etc., together with the stones, seeds, and skin of 
 fruits and such. 
 
 I cannot quit this subject without saying something of 
 7nilk as food for man, the support of his early infant days 
 and his last resource if toothless old age overtakes him. As 
 a general thing, unless otherwise stated the milk of the cow 
 is referred to in this connection. Another thing remember : 
 milk is really a complete food, and its indiscriminate use as a 
 beverage by those who already eat a full supply of regulation 
 diet is to be condemned as superfluous. When used properly, 
 by sick or well, under the guidance of proper medical advice, 
 there is nothing to equal it, and no tonic devised by man, as 
 tonics are understood, can in any way approach milk ; but as 
 
 236 
 
FORT^' YI'lAKS IN TinC AllCDICAI. I'Is'f )l'i;S.SIOX 
 
 a tonic milk cannot be used alone. Matured man cannot live 
 and thrive on milk alone; something else must accompany it 
 in the ration. Besides, if he lives alone on milk he soon gets 
 tired of the monotony, and for good reason. It takes nine 
 pints of milk at a specific gravity of 1030 or over to give him 
 the twenty-three ounces of dry food neerled for his daily al- 
 lowance, and whilst taking this much he gets too much albu- 
 min, fats, and water, for he does not need so much. This is 
 all right for the growing infant. It needs more of these, and 
 can live on milk alone for a considerable time, but it should 
 drink some sterilized water in addition, an important matter 
 very often overlooked, otherwise they become dyspeptic and 
 wretched and cross. I say sterilized water, for it is safer, 
 and the water of the milk keeps intact the cell protoplasm 
 if sterilized or distilled water will not accomplish this, 
 or even injures it. Hemorrhagic troubles, uric acid trou- 
 bles, and troubles of a pigmentous kind are common among 
 young children, and water is useful in carrying off the debris 
 of the system which accumulates rapidly, the red corpuscles 
 of the blood being rapidly destroyed at this age and lithic 
 formations frequent. I think three pints of good milk in 
 iwenty-four hours will support life in a natural man, but it 
 surely is not a working ration. The chemical composition of 
 milk has already been given, — protein, 3.3; fat, 4; carbohy- 
 drates, 5 ; ash, 7; and water. The lactose, or milk-sugar, is an 
 important ingredient in milk. It is ecj[ual. usually to half the 
 solids of the milk, leaving out the fats. It sours the milk by 
 being converted into lactic acid during the fermentation of the 
 milk, caused by nitrogenous materials in it. Great reforms are 
 still needed in milk inspection, from the environment of the 
 cow, through the cow, and through all of its phases, up to the 
 time it is used as an article of food. It is an ideal host for 
 most of the pathogenic and other microbes, and when we come 
 to think of their universal presence, under all circumstances 
 and at all times, we soon see how it is impossible to guard too 
 closety and too jealously all that pertains to this universal 
 nourishment of man. I believe that twenty per cent. — surely 
 
 237 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 not less than fifteen per cent. — of the cows furnishing the 
 milk supply to the people of the Middle States are tubercu- 
 lous, and some, at least, of these have tuberculosis of the 
 udder. These last, at least, surely furnish milk contaminated 
 by tubercle bacilli, and wdien I say I believe such milk unster- 
 ilized can reproduce tuberculosis in man in its various forms, 
 is it not right and proper, is it not our bounden duty, re- 
 gardless of expense, regardless of any obstacle whatever, to 
 do all in our power to eradicate such a menace to human 
 health, such a bar to human happiness? Can man be so base, 
 so mean, so low, as to reckon in dollars and cents the price of 
 any means to be used to eradicate this evil, probably the evil 
 of all evils now confronting him ? Oh, the fond friends, from 
 the darling prattling infants to those the brightest and love- 
 liest of matured age, we, all of us, without exception, are 
 mourning, have mourned, and will never cease to mourn, un- 
 fortunate victims of this greatest, most unrelenting of all the 
 scourges inflicted upon the human race ! 
 
 Milk being such a good host for pathogenic germs, I be- 
 lieve it should in some way be sterilized before it is taken for 
 food into the human stomach, and probably, in the end, Pas- 
 teurizing is the best method of accomplishing this. It surely 
 leaves the milk in the most palatable condition of any of the 
 methods, and there is only one loop-hole of escape for error, 
 and that is, are the spores thoroughly destroyed by Pasteur- 
 izing, as thoroughly destroyed as are the parent germs? 
 Therefore, if you keep Pasteurized milk any time, Pasteurize 
 it once every twenty- four hours, to destroy the spores as they 
 arise. To sterilize milk, bring it to boiling, 212° F. To de- 
 stroy the spores absolutely and surely, bring it to the boiling 
 point a second time. To keep it, put it in bottles, being sure 
 first to sterilize the bottles by boiling them. Stop them with 
 cotton which has been sterilized by baking in an oven from 
 twenty to thirty minutes. The cotton is better than a solid 
 cork, for it allows escape from within and checks entrance 
 of microbes from without. If you boil the milk twenty min- 
 utes, it will really digest better than if you only sterilize it. 
 
 238 
 
FOR'I'Y YIOAKS IN 'nil'. M l':i)ICAI, J'R(;I'l':SSIO\ 
 
 To young' infants raw milk is an anti-scorbutic, and Professor 
 IJartholow and others think sterilizinj^ it may take away this 
 ])ro|)crty in a measure. According- lo Leeds, as stated by 
 'Thompson, sterilizing- niilk destroys the amylolitic ferment, 
 checks the coagulating- of the casein by rennin, retards the 
 digestion of the casein, and checks somewhat the absorption 
 of the fat, and, if the boiling is prolonged, the lactose is de- 
 stroyed more or less. It takes more sterilized milk to nourish 
 an infant than it does of milk as from the cow. 
 
 To Pasteurise milk, raise it to a temperature of 170'^ F., 
 and keep it there twenty minutes. It digests easier than ster- 
 ilized milk, but does not keep so well unless repasteurized 
 daily. It is more palatable. Before any bottles in any way 
 used about milk are used the second time, they should be thor- 
 oughly sterilized by boiling twenty minutes. Bring the boiling 
 along slowly, and the bottles, as a rule, do not break. After 
 one or two boilings, they appear to become tough. Always 
 rinse them with boiling water just before use, putting some 
 borax or boracic acid in the water, and use a bottle-washer 
 that has been just sterilized. For a substitute for mother's 
 milk I can recommend the following : Milk, eight tablespoon- 
 fuls ; cream, two tablespoonfuls ; water that has been boiled, 
 eight tablespoonfuls; pancreatin, three grains; baking-soda, 
 ten grains; mix the milk and cream together, then add the 
 pancreatin and baking-soda to the water, and mix with the 
 cream and milk; then Pasteurize the whole mixture. Very 
 rich Jersey or Alderney milk will do without the addition of 
 cream, using that much more of milk. If baby does not 
 thrive on this, subtract half the amount of milk, and in its 
 place put the same amount of very strong barley-water, rice- 
 water, or oatmeal-water. Be particular and never forget to 
 add to this amount of nourishment as here given (a little over 
 half a pint) an even teaspoonful of refined cane-sugar and a 
 good pinch of table salt. I prefer cane-sugar to sugar of milk 
 to add to baby food. 
 
 There is a healthy evolution going on in the economics of 
 milk, from its production to its consumption by the consumer, 
 
 -o9 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 and people are beginning to see what a great benefit such evo- 
 lution Avill afford. In the larger centres of population per cent, 
 milk may be obtained, the physician giving his prescription 
 for the per cent, of fat, sugar, casein, etc., needed for an indi- 
 vidual case, and a scientific vender filling this prescription 
 by compounding the milk needed artificially, much as the 
 recipe for artificial mother's milk is here given. The world 
 moves. Medicine is a progressive science, and medicine moves 
 as the world moves, although it did appear to be a good while 
 starting. 
 
 Condensed milk is a useful product, and as it comes from 
 the original package should be sterile, for in closing it the 
 bacteria are destroyed by heat and all outside air is shut off. 
 Thus, with care in detail, we can get an article which some- 
 times serves a good purpose for the sick. For condensed 
 milk the condensation is usually to about one-fourth of the 
 original bulk. If condensation is carried still further, more 
 sugar is added. On an average, condensed milk has added 
 to it about forty per cent, of cane-sugar. This prevents fer- 
 mentation. Dilute condensed milk eight to ten times with 
 sterilized water for a baby at birth, and add some fat in the 
 shape of cream or olive oil. A formula, such as this, will be 
 found about correct : Condensed milk, one teaspoonful ; cream, 
 four teaspoonfuls, or olive oil, two teaspoonfuls ; hot water, 
 five tablespoonfuls. If oil is used, make up the deficiency by 
 two teaspoonfuls more water. Pasteurize for use. On ac- 
 count of the excess of sugar, condensed milk does not keep 
 long, and is more apt than normal milk to cause fermentative 
 troubles in those using it. Add an excess of fat, and it fre- 
 quently proves a serviceable food for consumptives. 
 
 Devonshire cream is cream skimmed from heated milk, so 
 the albumin is coagulated and comes off with the cream, and 
 may be substituted for cod-liver oil, when such disagrees. 
 
 Evaporated milk is extra strong milk, the water having 
 been driven off, and as it is for immediate use, it is au naturel, 
 no sugar or anti-ferment having been added ; at least, this 
 should be so. 
 
 240 
 
FORTY YEARS IN Till': MEDICAI. PKOFRSSION 
 
 Bullcnuilk is milk witli the fat removed for butter. There 
 is albumin and casein left in it, and water and the milk salts, 
 with lactic acid. A man cannot live lonf^ on buttermilk, nor 
 skim-milk, that is, absolutely. 
 
 Cottage cheese or schmierkase, or smearcase, is a very in- 
 viting- help to diet, especially in hot weather, but it is quite 
 hig-h in protein, contains less than half the fat of pure milk, 
 with much lactic acid formed from the sugar as fermentation 
 goes on. 
 
 Whey is another product, and with wine is often useful, 
 especially for the sick. It contains water, milk salt, some 
 albumin, and lactose or milk-sugar; it does not keep long, 
 and should be sterilized before use, which may coagulate some 
 of the albumin. 
 
 Let me add here that the distribution of the milk-supply 
 should be taken in hand by the police power in all communi- 
 ties, and so should its source, the cow, in all of its environ- 
 ments. A vicious distribution of a milk-supply to any neigh- 
 borhood may do more harm than a pestilence ; indeed, it may 
 start a pestilence. There should be a code of laws to govern 
 this distribution in every town, be it large or small, and this 
 must come sooner or later, as laws must come to eradicate 
 tuberculosis from the lower animal as the evolution of society 
 goes on to perfect government. Infected milk may cause ty- 
 phoid fever, diphtheria, scarlet fever, tyrotoxicon poisoning, 
 Asiatic cholera, in fact, all zymotic diseases, all fermentative 
 diseases. 
 
 A milk called the " Walker-Gordon"' milk, from the farm 
 on the golf links of the Philadelphia Cricket Club, W'issa- 
 hickon Heights, contains, on an average, according to Dr. 
 Samuel S. Kneass, only 354% bacteria per cubic centimetre. 
 This shows wonderful care in attention to detail, as well as 
 careful selection of dairy stock and attention to the environ- 
 ment. Where police supervision is fully carried out over the 
 milk-supply to a community, no milk is rejected where the 
 number of bacteria per cubic centimetre does not go o\er ten 
 thousand. The smallest number does not appear to be many, 
 16 241 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 but when we come to think of it, that two germs by simple 
 fusion' can produce two of its kind in one hour, and in the 
 next hour four, and in three days a mass not countable, — say, 
 4,772,000,000,000,000, — we begin to comprehend what the 
 lower order of life really is, and the great step between it 
 and the evolution of man. To check this formation of germs 
 many antiseptics or antizymotics are used by dealers, and it 
 makes us pause and reflect whether or not it is not better to 
 use them surrounded by proper guards than run the risk of 
 this auto-infection of the milk-supply. To the reckless and 
 careless and vicious antisepsis may be a protection, but the 
 enlightened citizen will use sterilization in its various forms. 
 Benzoic acid and salicylic acid uncombined with bases are 
 much used as antiseptics for milk, but borax and boric acid 
 are cheaper and more tasteless. These destroy the vegetative 
 activity of the various fungi and bacteria, and thus check fer- 
 mentation and decay. The dealer may extract five per cent, 
 of the cream and add ten per cent, of water, and escape detec- 
 tion, unless by experts. 
 
 In the milk-supply of London the average number of bac- 
 teria per cubic centimetre is 500,000, a bad showing surely. 
 Such figures startle us, and point with no uncertain hand the 
 direction to take to institute reforms that shall more than in 
 any other direction reduce the amount of zymotic disease, and 
 thereby check, in a large degree, the mortality among the 
 human race from this its greatest factor. We know that 
 normal milk in the udder of the cow is absolutely sterile, and 
 consequently we know just where the trouble begins. The 
 abnormal cow may, of course, produce abnormal milk from 
 the udder, — as the tuberculous cow. The most important 
 germs found in milk are the bacillus coli communis, com- 
 posing ninety per cent, of all in many cases, and this is indica- 
 tive of fecal contamination, and shows dirty stables and bad 
 environment of the cow. Liquefying organisms are also 
 found, and show one of two things, — dirty cans and uten- 
 sils or a needless exposure to a bad atmosphere in the stable 
 or dairy-house. I believe one source of evil is housing the 
 
 242 
 
FORTY YKARS IN Till'. MKDICAL PROFESSION 
 
 COWS too elaljorately and too closely. The finer Herd-book 
 herds, on which vast sums of money have been spent in selec- 
 tion and on their environment, are the sickly herds in the end, 
 are the herds in which we most hkely find tul)erculosis and 
 such troubles, and I am sure much or all of this vulnerability 
 to zymotic troubles comes from unnatural envir(jnment. In 
 palace stiibles, making allowance for all difiference in climate 
 and the environment of the plains, we see the difference and 
 the cause. 
 
 When we come to analyze the statistics of tuberculosis in 
 the East and in the West, the showing is altogether in favor 
 of the Western cow, and the same thing holds good of the 
 Indian, — house him abruptl3^ and you kill him. Never milk 
 a cow in its stable. Milk in the open air, or in an open shed, 
 and let no person with any zymotic disease go near her. 
 
 Another germ is found in milk, often abundantly, — the ba- 
 cillus fluorescens. This is that which oftenest lurks in impure 
 drinking water, and when found in milk it has probably been 
 reduced by water, and by infected water, too. The Experi- 
 ment Station Record gives as the solid impurities in milk the 
 following parts per million : In whole milk, 2.6 parts ; ordi- 
 nary skim-milk, 2.1 parts; separator skim, .3 part; cream, 
 1.5 parts. The impurities were largely particles of litter and 
 fodder, pieces of straining cloth, etc. In many samples were 
 found woollen and colored cotton fibres from clothes of at- 
 tendants. Separator skim-milk is the cleanest. Altogether 
 this is rather a cleanly showing. In London more pathogenic 
 germs were found than in the United States, including the 
 oidium albicans, the exciting cause of thrush ; this is well for 
 physicians to know, for it is very common in bottle-fed babies 
 everywhere. Sulphuric ether (as I pointed out thirty years 
 ago), locally applied, is a sovereign remedy. 
 
 Food adulterations, including milk, are encouraged by in- 
 tense competition, with low prices and small profits, and it 
 often becomes a question with a dealer whether he shall give 
 up his integrity or give up his business. This is a phase in 
 the evolution of bartering, and will in the end gi\'e way to 
 
 243 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 better methods as the development of the better laws of trade 
 unfolds. 
 
 Great advances have been made in the general treatment 
 and nourishment of infants in the last forty years. When I 
 was a resident at the Philadelphia Hospital, Blockley, I had 
 the opportunity of seeing something of the practical work- 
 ings of the day in a foundling hospital, but before I had time 
 to more than get a knowledge of the horrors of the system, 
 much less attempt to apply remedies, my term had expired. 
 At that day most of the foundlings of Philadelphia came to 
 this hospital, and there were quite a number of these poor 
 little waifs. In winter or in summer they nearly all died, 
 starved to death, as it were, from too much and ill-advised 
 feeding, paradoxical as that may appear. Indeed, if one lived 
 beyond infancy it was a curiosity. One or two in several 
 years did so survive, and one named after President Lincoln 
 was always looked upon with curiosity as a survivor of the 
 holocaust of infants at Blockley. I am sorry to say Lincoln 
 did badly as he grew up towards matured manhood, and the 
 last I heard of him he was a had man among bad men of Ches- 
 apeake oyster-men. Can you " make a silk purse of a sow's 
 ear" ? But, " revenons a nos moutons." There was no sys- 
 tem in caring for these bereft babies. A good, well-meaning 
 woman was at the head of it, and the doctors looked in if any- 
 body was ill, or if they took sufficient interest to go oftener. 
 Pauper inmates from among the women were the nurses. Im- 
 agine such a thing as asepsis, the use of antisepsis, or any 
 attention to detail with such a gang! You could not trust 
 them with forty drops of spirits, nor with one particle of a 
 narcotic. The baby-food was milk, generally diluted with 
 water, cold or hot, as best suited the convenience of the at- 
 tendant. There was no special care of the milk, no special 
 care of the bottles, and the same might serve for half a dozen 
 children, and, as a rule, were fitted with, as I remember, the 
 long hose nipples, an abomination, an invention of the devil. 
 The babies did not remain long, and the end was a death cer- 
 tificate of " Inanition" and a grave in " Potter's Field." 
 
 244 
 
FORTY YKARS IN TITF. MICDICAL PROFESSION 
 
 T remember about tbis time JJebij^ put fortb tlie formula 
 for bis food for infants. I Iiad it made, and tried it on these 
 Httle ones. Of course, 1 bad no success. The children were 
 too younji-, as a rule, and 1 commenced too far away from 
 bed-rock, — sterilization, asc])sis, and antisepsis, not only of 
 the food, but of the child, the whole environment from A to 
 Izzard. To properly care for a bottle-fed baby, to give atten- 
 tion in a proper manner to every detail (and in this attention 
 to detail lies the whole secret), is full and exhaustive work 
 for any strong, healthy, and vigorous woman. Think of this, 
 when we oftener see, yes, much oftener, one poor, frail crea- 
 ture caring for, in some fashion, with absolutely unsanitary 
 environment, not only one bottle-fed baby, but several chil- 
 dren besides ; and yet this is not half she does : she washes 
 and irons for the family, does the cooking and scrubbing, 
 makes the clothes, and does the mending of the children at 
 least, and entertains company in the evening in her best gown. 
 Poor little bottle-fed babies ! your lot is a hard one ; no won- 
 der you continue to die beyond the normal rate that should 
 prevail among you. Never mind, the good time is coming, 
 and zymotic disease shall less and less prevail among men. 
 Science is leading mankind as a beacon to a safer and better 
 harbor. 
 
 The physician, in looking after an infant under four months 
 old, should first consider the mother, as to the quality of her 
 milk, her family history, her present condition of health, etc. 
 An examination of her milk chemically is of prime necessity, 
 especially if the baby does not thrive. She should nurse the 
 bab}^ altogether as near as possible until it has reached the 
 age of one year at least. Whatever baby takes, starchy and 
 other foods, should be withheld until from four to six months 
 have passed since its birth, and no flesh should be given until 
 the teeth have come to chew and disintegrate it. Broths may 
 be used before meats, and sometimes water extracts of carbo- 
 hydrates may be necessary before four months of age. As in 
 older people, when looking- up the baby study the individual. 
 Nothing is truer than that every case of infant-feeding is 
 
 245 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 a Study, whether it is hving on the mother or artificially. 
 Everything conies in in this examination, — family history, 
 its general health, its form, the treatment it is apt to receive 
 in feeding, bathing, and general care, and its clothing. This 
 first six months of life is all-important to the baby, and has 
 much to do, very much, indeed, as to whether it may reach 
 vigorous maturity, and become a useful citizen of the com- 
 monwealth. If the baby cries, it is either hungry, cold, too 
 hot, or in pain ; a little food, a blanket, the removal of super- 
 fluous covering, or attention to the diet will usually work 
 wonders in the crying baby. Remember, in the improperly 
 fed infant nutritional diseases, scorbutus, marasmus, rickets, 
 and others, are apt to show themselves at an early age, and 
 if the infant should grow up to adult age, only misery and 
 wretchedness are in store for it and its kin. Remember the 
 size of the baby's stomach, and if possible regulate the diet so 
 it will not be necessary to vomit the surplus, and thus add to 
 the dangers of germ contamination. A child may starve, like 
 a man, even when stuffed, should it not get the properly bal- 
 anced ration. This is as essential to watch, even in children 
 well grown, as it is in man. See that they get a properly bal- 
 anced diet, and here is one of the great needs of the supervi- 
 sion of a family by a competent physician, now so little 
 thought of. After a while the doctor will be called to stop 
 the child before he gets sick from a mess of sweets, to see he 
 gets no such trash. Now, often, the well-grown child eats 
 the mess of sweets, and the doctor is called to cure him of the 
 effects of his indiscretion, much like " locking the stable door 
 after the horse has been stolen." 
 
 Most of the practice of medicine has now to do with women 
 and children, and no one will feel the good effect of the con- 
 stant care of the coming actors in preventive medicine so 
 much as these same women and children, and ages hence the 
 race will show the good effect in a strongly developed and 
 perfected manhood. If the baby has to be weaned, and 
 weaned prematurely, then comes the great trial. What shall 
 the food be? Well, this will depend much on the age and the 
 
 246 
 
FORTY YEARS IN Till': Ml'.DlCAT. PROFESSION 
 
 siirroiin(Hnj:^s. If under six months, it must, as a rule, be 
 liquid, and the nearer to mf)tlier's milk the better, and if this 
 be departed from a little animal broth is the best help to milk. 
 Fresh milk must be a good part of the diet. We know not 
 exactly why, but if we omit it, scorbutic troubles quickly show 
 themselves, and the physician must be cpiick to recognize 
 them. Remember, condensed milk will not take the place 
 of fresh cow's milk for artificial feeding of infants. Watch 
 it. The baby will thrive for a time, but for a time only. It 
 lacks freshness, and this lack of freshness predisposes to non- 
 thriving in the baby. That is as much as we know. Watch 
 the gain or loss of weight in the baby, and you learn much as 
 to its proper advancement. 
 
 As to infant foods of various kinds, some are good, after 
 the baby is old enough to take them ; some are vile and bad. 
 From idiosyncrasies one baby may thrive on one and starve 
 on another, and so it ever will be with man. An artificial 
 food for infants, and all invalids for that matter, should have 
 the following properties at least : It should have some fresh 
 cow's milk with it in feeding, most of the time at least, to 
 give it freshness, that which keeps away scurvy. In the pre- 
 paring of it at the laboratory perfect sterilization of every- 
 thing should be practised. It should have some chemical 
 approximation to mother's milk, and should also physiologi- 
 cally approach it. If it does not agree with the child at once, 
 do not persist in it; change to another; sometimes the coad- 
 ministration of digestive ferments and digestive enzymes may 
 help these foods. It will try the patience of any man as he 
 has to deal with the diet of infants deprived of their proper 
 food. After all, as science advances, various modifications of 
 milk must be our chief reliance. Science aids us much at pres- 
 ent, but mere empiricism is still a part of our dependence. The 
 coming artificial food will be one not for all babies, but will 
 probably be graded to age and must be one approaching more 
 or less the composition and effect of mother's milk. Com- 
 mercialism must not have a part in the coming baby food. 
 Honest men. satisfied with a moderate profit, must make it. 
 
 247 
 
FORTY YF.ARS IN THE MEDICAL PROFESSION 
 
 When baby is sick, let the physician investigate the source 
 of the food-supply, whether from the mother or from arti- 
 ficial sources, and he will probably find out the cause, even 
 if he has to take in the whole routine of the milk-supply in 
 the community, and the entire culinary details of the house- 
 hold. 
 
 We have spoken of the diet for childhood, and of diet for 
 the active, strong, and vigorous youth, and for vigorous mid- 
 dle age. When one reaches fifty years of age, having escaped 
 the pitfall of dissipation, and enters upon this stage of life 
 sound in mind and body, it behooves to pay great attention 
 to ^^•hat one eats and what one drinks. These remarks apply 
 more particularly to the idle and well-to-do, and to those who 
 do brain-work more than manual labor. For those working 
 with their hands the all-important part is a properly balanced 
 ration and proper preparation. Persons who reach fifty, of 
 the well-to-do class particularly, eat too much and eat too 
 often, and take insufficient exercise, and thus grow fat and 
 corpulent, not working off the excess as they did in the earlier 
 and more active periods of life. Especially is this the case 
 with men who retire to enjoy a well-earned competency, and 
 which so often ends in disaster to their health, giving us an 
 object-lesson that it is better to wear out than to rust out. No 
 one should go from an active, busy life and drop into a lazy, 
 useless one. It is never too late to take up some occupation, 
 no difference what, so it gives some rational employment to 
 body and mind. Some study and practical work in nature is 
 the best, — agriculture, horticulture, and such, and what comes 
 out of them and with them, as botany, etc. At fifty, remem- 
 ber old age is approaching, and the average man is sick ten 
 days in the year, only being sick four days at twenty. At 
 fifty the blood loses some of its richness and loses in quantity. 
 The blood-vessels enlarge and are not so elastic, and the 
 dangers of atheroma are upon us, causing liability to apo- 
 plexy, etc., the natural way for old people to die. The heart 
 weakens somewhat, probably a provision of nature to reduce 
 the blood-pressure and thus relieve the pressure on the blood- 
 
 248 
 
FORTY YI'.ARS IN 'II 1 1-. MI'IMCAL PROFRSSION 
 
 vessels, now beccjming weak like the tubes in an (jld steam- 
 boiler. At sixty a general shrinkage begins, or is well under 
 way, and continues on progressively into extreme old age, 
 accompanied by the loss of teeth, a weakened digestion, 
 causing distention of the stomach and bowels, thus pressing 
 up against the diaphragm and interfering with comfortable 
 and satisfactory respiration. Thus metabolism is interfered 
 with and tissue changes go on. Katabolism, retrograde meta- 
 morphosis, is active, anabolism — the building up of tissues, 
 the building up of living tissue, the forming of protoplasm, 
 without which there is no life, from nutrient material, in other 
 words, assimilation — becomes less active, and the body hence 
 thrives less and less as age increases. 
 
 Men and women at fifty should begin to cut down their 
 nitrogen particularly in their diet. 7\t this age one should 
 dine not more than twice a week : twdce a week we may live 
 to eat, five times a week w^e should eat to live. If w^e take 
 wine, one wine should suffice. If champagne, it should be 
 very dry. No one should take sw^eet champagne after fifty. 
 I am speaking of the w^ell-to-do and in good health, and not 
 of invalids. The clarets and light Burgundies would be bet- 
 ter. Port, Madeira, and sherry are most dangerous of all, in 
 the order here given. Remember, after fifty, avoid alcohol 
 as much as possible, and shade off your tobacco if you use it 
 to excess. As w^e come to sixty years, it is still more of im- 
 portance to be careful in diet and to take the proper ration. 
 Arteriosclerosis and its consequences are what Ave wish to 
 avoid. Milk or its equivalent becomes more and more an im- 
 portant and proper article of diet. If the appetite is very 
 strong, curb it. Do not eat richly and drink generously and 
 then complain you cannot breathe properly, are uncomforta- 
 ble. The reason is you cannot digest properly what you have 
 taken ; your diaphragm is pressed against your natural breath- 
 ing space, and you are in a condition of semi-sul¥ocation. and 
 are laying rapidly the foundation for a miserable old age or 
 early death. The gouty should take particular care not to 
 overeat. Semi-starvation for these people at times is pro- 
 
 249 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 longation of comfort in living. After that is gone what is 
 there in life? 
 
 To those growing old lavage of the bowels is of great im- 
 portance and a great comfort. Water in proper amount for 
 drinking is of great importance, not too much nor too little. 
 The skin does not throw off as much, but more is required to 
 carry off nitrogenous waste. After fifty the mid-day luncheon 
 should be dispensed with, or reduced to a mere bite, and twice 
 a day is enough for a hearty meal. As I said before, twice 
 a weak is often enough to dine; let the other dinners be 
 merely frugal repasts. The elaborate mid-day luncheon as 
 usually set for families or partaken of at the restaurant is an 
 abomination for those over fifty. I am speaking now of those 
 who breakfast in the morning and dine in the evening. For 
 those who dine in the middle of the day the tea should be only 
 a formal one. 
 
 The late Ward McAllister, a good authority on dining, 
 wanted a walk of ten miles and no luncheon as a preliminary 
 to a good dinner, and yet I do not think he took much thought 
 of the chemical composition of his dinners, but catered to his 
 tastes chiefly. I never met Ward McAllister, but in my early 
 days I knew most of the other members of the family welL 
 They were strong, staunch people. The father, the judge, 
 was a polished and accomplished gentleman, and the mother a 
 woman of lovely character and great accomplishments. The 
 sons adorned the professions of law, of arms, and the church, 
 and were polished men, all. Cutler was a Yale man, was 
 good company, quite a wit, could sing a good song, tell a good 
 story, and make a good salad. Peace to his ashes. They are 
 all dead, barring the possible exception of the sister, Mrs. 
 Francis, of New York City. Read Ward McAllister's book, 
 and, having read it and come to moralizing, you may gain 
 great good. You may see the dangers to the younger, at 
 least, among the smart set, of being carried away by dissipa- 
 tion in eating and drinking. Should they escape the shoals 
 here, you may see the dangers they run after fifty of gout, of 
 the horrors of dyspepsia, and of the possibility of death from 
 
 250 
 
FORTY YEARS IN Till-: MICDICAL PROFESSION 
 
 old age at sixty or under. Should they escape all these trou- 
 bles, or any of them, at the age given, you may no longer 
 wonder that some men and sf)me women are born with great 
 capacity for eating and drinking. But after all, it is only 
 carrying out and giving an object-lesson of Darwin's famous 
 law, that it is (jnly the " fit who survive," and no k^nger will 
 we wonder at the stories told of the famous days of ancient 
 Rome, of her feasts, of her fair women and more famous men, 
 and, whilst not forgetting the Roman senators, I am sure we 
 will modestly vote, in all that pertains to an accomplished and 
 polished host, Mr. Ward McAllister the " noblest Roman of 
 them all." 
 
 From a combination of causes, but, after all, on account of 
 the general increase of intelligence among the people at large, 
 and their more general intermingling, there is a tendency at 
 the present time to fads in food and diet in general far be- 
 yond what there formerly was. It will be well for physicians 
 to guard their patients against the pursuit of these fads too 
 zealously, for after a time it does harm to the individual. 
 People congregated in the sanatoria and sanitaria of the day 
 are prone to discuss such matters in connection with their 
 general infirmities, and to carry the same habits out into the 
 world with them and thus generate the custom. People should 
 depend more on their medical advisers, remembering that 
 " he who is his own lawyer generally has a fool for a client," 
 and I will add to this by declaring as my opinion that the 
 amateur doctor is usually a knave or a fool, or worse. 
 
 The efifect of a fanatical pursuit of matters pertaining to 
 one's diet, that is to say, of the diet of one who does and 
 should in a measure diet, is to produce a real fear of food, 
 which in the end may produce a genuine disease, a genuine 
 neurosis. It is not well to think too much over what one eats. 
 We must observe the general principles of diet according to 
 our condition of health, as I have endeavored to impress upon 
 my readers all along, but after these hygienic food principles 
 have been observed, the appetite and the food furnished us 
 may be more or less trusted, indeed must be trusted, to retain 
 
 251 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 our proper appreciation of food. The child teaches us many 
 things, and he teaches us something in diet. The stomach of 
 the child is delicate, as is the stomach of advancing age, yet 
 one reason why the child can eat and digest certain things 
 which the older person cannot is because the child never gives 
 it a thought after swallowing, whilst the older person, espe- 
 cially the one who has fads about eating, will have it disagree 
 with him because he thinks about it and expects it to disagree 
 and give him discomfort. The lesson to be learned from all 
 this is, do not become fanatical in matters of diet, do not 
 make them a matter of too general discussion, and rely more 
 upon your physician than you do upon your friend who has 
 visited all the great health resorts of Europe and America, 
 and who, to use a slang expression, " knows it all." Above 
 all things, take no advice from newspapers, quacks, or ama- 
 teur doctors. 
 
 Infantile Scurvy. — Adult scurvy is an acquired afebrile 
 disease, caused probably from the want of fresh vegetables 
 and fruits, and from too much salt, from bad water and bad 
 surroundings in general. There is even a possibility of its 
 being an infectious disease, caused by some pathogenic germ 
 as yet undiscovered- The salt used in preserving the animal 
 foods of soldiers and sailors and others may be a factor in 
 causation by extracting the native salts of meats along with 
 the water, and by its well-known antiseptic action changing 
 in some way the meat-fibres. The chief symptoms are debil- 
 ity, rapid heart action, iron hardness of the muscles, especially 
 of the gastrocnemii, hemorrhages deep-seated and superficial, 
 spongy and bleeding gums, loose teeth, and the " greenery- 
 yallery" look of Gilbert's young man in " Patience." 
 
 An entirely different trouble is infantile scurvy, scurvy 
 rickets, Barlow's disease, periosteal cachexia. This is a most 
 interesting disease, but recently recognized, and especially 
 increased, it is supposed, since the advent of the various pro- 
 prietary infant-foods now so common. Professor Roberts 
 Bartholow has given the best account of this trouble, and by 
 so doing has again made good his reputation as an original 
 
 252 
 
FORTY YKARS IN THl-: MKDICAI. I'RoFlCSSION 
 
 investi|:^"at()r. Infantile scurvy was really (|uite well described 
 by tlie late Dr. John S. Parry, one of the l)rif^htest men of his 
 day, who died prematurely of tuberculosis in 1876; but Parry 
 wrote only of infantile rickets, and unknowingly gave us a 
 good account of the disease we are Cf)nsidering. It is usually 
 confined to the first six years of life, but has been seen as late 
 as nine years and as early as four weeks. It comes more fre- 
 quently to those children who have a tendency from birth to 
 lack of normal bone-structure, and to those early deprivefl of 
 maternal nourishment and fed on artificial infant- foods and 
 sterilized milk. Pasteurized milk is less apt to be a factor in 
 its production, but remember, it has caused it. It has even 
 been seen in children fed absolutely from their own mother, 
 yet these cases are very rare. It is probably a combination of 
 scurvy and rickets, or rather, probably children predisposed 
 to rickets are more predisposed to scurvy. The symptoms are 
 numerous, l)ut the distinctive symptoms are pain on motion, 
 which is very acute, simulating rheumatism, or even paralysis, 
 and the characteristic spongy gums, there often being ulcera- 
 tive stomatitis, but rarely, if ever, gangrene of the mouth. 
 
 When connected with the Philadelphia Hospital, Blockley, 
 years ago, I probably saw cases of infantile scurvy and made 
 a study of these infantile mouth diseases. Among the symp- 
 toms are increase of blood-pressure, causing polyuria and 
 restlessness of the individual ; there is often periostitis about 
 the joints, particularly of the tibial, and a general hyperaes- 
 thesia of the whole body. The pains are supposed to be caused 
 by hemorrhages beneath the periosteum, and hemorrhage 
 causes much of the gum trouble. There may be h'emorrhages 
 under the skin in various places, there may be " black eye" 
 caused by hemorrhage into the orbit, and there may be hemor- 
 rhage from the nose, bladder, and bowels. An?emia and 
 marasmus may accompany infantile scurvy, without being 
 the cause, or in some cases the child may appear to be thriving, 
 and yet the leg-pains, the general hypersesthesia, and the con- 
 dition of the gums make the diagnosis plain or give us sutli- 
 cient hints to get at the trouble. As a rule, the child has a 
 
 253 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 dusky, sickly look, and there are frequent swellings of the 
 joints- and soft parts. Fever is seldom present, but has been 
 recorded as high as 105° F. There are other important points 
 in the diagnosis as distinguishing it from summer complaint, 
 so common in the Middle and Northern States and much less 
 common in the South and the West. Neither vomiting nor 
 constipation nor diarrhoea are constant symptoms, but I think, 
 most assuredly, cholera infantum as we see it predisposes to 
 infantile scurvy, and, as a rule, only bottle-fed babies have 
 cholera infantum, and, as a rule, only bottle-fed babies have 
 infantile scurvy. The report of Drs. J. P. Crozer Griffith, 
 Charles G. Jennings, and John Lovett Morse to the American 
 Pediatric Society, as published in the Philadelphia Medical 
 Journal, shows that about an equal number of males and fe- 
 males have the disease. A majority of the cases developed 
 from the seventh to the fourteenth month, and a large major- 
 ity of the cases were among the well-to-do. I should draw 
 from this that it was due chiefly to artificial feeding, for the 
 best mothers for nursing are not, as a rule, among the higher 
 classes. 
 
 Now, as to the causes of the trouble. Whilst we must 
 frankly admit that infantile scurvy has been seen in the child 
 who has never been fed otherwise than from its mother's 
 breast, this milk coming up to the average standard of human 
 milk, and whilst we must equally frankly admit that a satis- 
 factory explanation of the etiology of infantile scurvy has 
 not yet been given, yet I confess, to me the most important 
 etiologic factor is the use of the common every-day baby- 
 foods sold in the shops. Next comes the use of sterilized 
 foods, more particularly milk. There is evidently something 
 in the cooking of foods, of destroying all life in them, which 
 has something to do with causing this disease, showing that 
 nutrition in general may be affected in human beings by lack 
 of at least some of the natural elements of food in a raw and 
 natural state when these natural elements are driven out by 
 cooking or sterilizing. Probably sixty per cent, of the cases 
 have been caused by proprietary infant-foods, leaving forty 
 
 254 
 
FOR'J'Y Yi'ARS IN 11 1 1-. MIODICAI. i'R(;FIiSSION 
 
 per cent, to other causes. It may be well to state here that 
 from the reports family history has not been an important 
 factor ill the disease. In ;l large majority of the reports re- 
 ceived by the physicians before mentioned, those making the 
 reports thought the nature of the food used caused the trou- 
 1)le. In 406 cases the food used when the scurvy developed 
 was as follows: Breast milk alone, 10 cases; raw milk and 
 amylaceae, 1 case; sterilized milk with amylacea;, i case; 
 total, 12. Raw milk alone, 4; with breast milk and amylaceae, 
 I ; total, 5. Milk alone, nothing said about heating, 8; pep- 
 tonized, 4; with amylaceae, 4; total, 16. Sterilized milk 
 alone, 68 ; together with proprietary foods, 2 1 ; with amy- 
 laceae, 8; peptonized, 10; total, 107. Pasteurized milk alone, 
 16; with proprietary foods, 2 ; with amylaceae, i ; peptonized, 
 i; total, 20. Peptonized milk, 3 ; sterilized, 8; Pasteurized, 
 I ; with proprietary foods, i ; with amylaceae, i ; total. 14. 
 Amylaceous food (not proprietary) alone, 6; with breast 
 milk, 3 ; with milk, 5 ; with sterilized milk, 8 ; with Pateur- 
 ized milk, i ; with peptonized milk, i ; total, 24 (nine of these 
 were oatmeal). Table food, nothing else mentioned, 11; 
 with condensed milk, i ; total, 12. Mellin's food, nothing 
 further stated, 42 ; Mellin's food and condensed milk, 22 ; 
 with sterilized milk, 16; with Pasteurized milk, 2; with 
 other proprietary food, i ; total, 83. Malted milk, nothing 
 further stated, 44 ; with cream and malted milk, i ; with amy- 
 laceae, I ; with other proprietary food, 2 ; total, 48. Con- 
 densed milk alone, 32 ; with milk, i ; with cream, i : with 
 other proprietary foods, 3 ; with table-food, i ; total, 38. 
 Reed and Carnrick's soluble food, 13. Imperial Granum, 6. 
 Liebig's food alone, i ; with condensed milk, i ; total, 2. 
 Lactated food alone, 3 ; with condensed milk, i ; total. 4. 
 Nestle's food alone, i : with sterilized peptonized milk, i ; 
 total, 2. 
 
 In a number of reports proprietary foods were given with 
 no name, making sixty per cent, of the cases fed on proprie- 
 tary foods. The farther away the diet of the child is from 
 mother's milk, the more likely is it to develop scurvy. 
 
 255 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Whether it is an infections disease or not we cannot yet 
 say, bnt in the end some pathogenic germ may show np ex- 
 plaining all of the symptoms and thns giving ns a rational 
 cause for the trouble. The mortality is not great. Twenty- 
 nine reported cases out of three hundred and seventy-nine 
 died ; two of these, at least, died of other diseases, leaving 
 only twenty-seven deaths due to scurvy. The autopsies 
 showed the following lesions : Hemorrhagic spots on the peri- 
 cardium and on the liver surface, subperiosteal hemorrhages 
 of long bones, subpleural hemorrhages, separation of the 
 lower epiphysis from the shaft of the femur, bronchopneu- 
 monia, hemorrhage into the muscles of the thigh, swelling 
 of knee and both ankles, exudative nephritis, the right leg 
 from the knee to the ankle stuffed with a puffy mass replacing 
 the normal tissue, separation of both bones one inch above 
 the ankle, blood-serum in the pleural cavity, perforating ulcer 
 of the stomach, tuberculosis of the peritoneum. 
 
 It may be proper to state here that Dr. Augustus Caille, of 
 New York, presented a minority report, being on the com- 
 mittee with Drs. Griffith, Jennings, and Morse. Dr. Caille 
 believes infantile scurvy to be a chronic ptomaine poisoning 
 due to the absorption of toxines. It follows the prolonged use 
 of improper foods, and abnormal intestinal fermentation is a 
 predisposing factor. Sterilizing, Pasteurizing, or cooking of 
 milk-food is not per sc responsible for the scurvy condition. 
 A change of food and the administration of fruit- juice and 
 treatment of any underlying cause is the rational therapeutic 
 procedure in scurvy. Here Dr. Caille gives a definite cause, 
 which differs from others, among them Dr. David Bovaird, 
 of New York City, who has given us a good article on this 
 disease in the Philadelphia Medical Journal for August 20, 
 1898, and from which I have now and then quoted in this 
 article. Dr. Bovaird concludes as follows : " Sterilized milk 
 evidently does cause infantile scurvy." He says the evidence 
 presented in his article is not conclusive, but it renders it 
 highly probable that persistent sterilization of the food by 
 boiling may produce scurvy. It must even be admitted that 
 
 256 
 
FORTY YEARS TN TTTK MEDICAI. i'KOl'KSSION 
 
 scurvy may ])c developed in luirslinji^s. The admission of this 
 proposition carries with it a frank confession of inability to 
 accept as adequate any theory of the causation of scurvy thus 
 far advanced. Practically the only theory that has of late 
 commanded any general support is that which attributerl the 
 production of scurvy to the absence of some vital principle 
 from the food, the life of the food being destroyed by some 
 process of preparation. If, now, we admit the possibility of 
 infantile scurvy developing in nurslings, we must abandon 
 even this hazy attempt at the elucidation of the problem, and 
 frankly confess that a satisfactory explanation of the etiology 
 of infantile scurvy is still to be sought. 
 
 Personally I think something may be gained in getting at 
 the etiology of this disease through thorough and systematic 
 examinations of the urine. Dr. Churchill, of Chicago, among 
 others, has given us some information useful as to the renal 
 secretion of children in general, and this may serve as a com- 
 parison in clinical studies in such diseases as we are dis- 
 cussing. According to Churchill's observations, infants pass 
 highly concentrated urine, small in amount, with a high per- 
 centage of urea and, of course, high specific gravity. The 
 amount of urea per kilogram of weight might be an impor- 
 tant point. It grew less towards the seventh year, when the 
 average was only 0.296. At three years the average was 
 from 0.468 to 0.655. Different diets may give different re- 
 sults, and surely will, and may lead us to detect the trouble 
 through the amount of nitrogenous and other waste of the 
 system, and thus check it before serious harm comes to the 
 individual. 
 
 Treatment. — If the child is weak and debilitated see that 
 it has proper support by stimulants and by the administra- 
 tion of the salts of potash. The best I know of -and which 
 has served me best is the bitartrate of potash, cream of tartar. 
 Give this diluted with a large amount of water, both to get 
 the potash and the water, which is of great importance. 
 Whatever the child has been feeding on, change that diet. 
 Stop proprietary and prepared amylaceous foods. Give raw 
 17 257 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 cow's milk, keenly watching its source. If this should not 
 agree, Pasteurize it only, do not sterilize it; give beef-juice 
 from fresh beef and no other, that is to say, no prepared beef- 
 juices, as they may be as bad as proprietary amylaceous foods. 
 Orange-juice from fresh oranges is best because it takes up 
 the basic salts during digestion and thus serves its good pur- 
 pose of supplying potash and such salts. Fresh, ripe, soft 
 peaches are a food par excellence for these little sufferers. 
 
 I had a little patient which was brought to me in very hot 
 weather, supposed to be a sufferer from cholera infantum. 
 Much to the horror of his friends, I ordered him all the soft, 
 ripe peaches he could eat. He took six and eight every 
 twenty-four hours, and the improvement that child made 
 was a revelation. If you cannot get oranges or peaches, get 
 apples, pears, strawberries, plums, and any fruits in market. 
 There are always some kinds. Always choose the softest and 
 juiciest. 
 
 Just here remember one thing, the possibility of developing 
 such a trouble as infantile scurvy in your typhoid fever and 
 other tedious cases from a prolonged use of sterilized milk 
 and such food-stuffs. I say keep it in mind, if your patient 
 from some hidden cause ceases to advance properly towards 
 convalescence. Remember, above all things, all the food or- 
 dered must have the element of freshness. Canned peaches 
 will not do; canned beef-juice will not do. In canning we 
 sterilize first, we destroy all bacteria, and all the elements of 
 freshness are taken from the food, thence such food is scurvy 
 breeding. So it is with the preserved fruit-juices: they are 
 not fresh, hence are neither food nor medicine for infantile 
 scurvy. Keep these principles in mind, and you will soon 
 cure all of your patients. Heed them not, and you will prob- 
 ably lose both your patients and your professional reputation. 
 
 In " Paediatrics" Dr. Cotton suggests the following as the 
 essentials of a good baby-food : ( i ) Does this food contain 
 all the constituents in about the same proportions as they are 
 found in mother's milk ? ( 2 ) Can this food be administered 
 in a form suitable to the physiological requirements of the in- 
 
 258 
 
FORTY YEARS IN Tfll-: MEDICAL PRr)FESSION 
 
 fant's (lif^estion? (3) Can it be .i^iven in cjnantities aflapted 
 to the capacity of the infant's stomach? (4.) Does it possess 
 the antiscorbutic property, or has that been destroyed by cook- 
 "iR? (5) '•'^ t^'c food wliolly or ])artly of animal origin? 
 (6) Is it free from pathogenic micro-organisms? 
 
 Concerning Milk. — Ex])erience teaches mc the great impor- 
 tance of physicians Icnovving much a1)ouL niilk, lliat great 
 staple article of diet for all, and especially for the very young 
 and for the very old. A physician should be able to advise 
 housekeepers and nurses on all points concerning its compo- 
 sition already spoken of, of the different grades, of the roguery 
 of dealers as practised, of the tests to detect such deceit, of 
 the proper methods of keeping and marketing the article ; in 
 fact, all about it. The details I am about to give will be found 
 best set forth in " Farmers' Bulletin," No. 42, United States 
 Department of Agriculture, by R. A. Pearson, B.S., As- 
 sistant Chief, Dairy Division, Bureau of Animal Industry. 
 Ten years ago the value of the milch cows in the United 
 States was three hundred and seventy millions of dollars. 
 This shows the importance of the industry. There is a cow 
 in this country to every four of its inhabitants, but much of 
 the product goes abroad as cheese and butter and condensed 
 milk. Americans do not appreciate the product of the cow 
 as much as they do in most parts of Europe where they use 
 more milk per capita than we do here. One reason doubtless 
 is, we use more meat here. The average consumption of milk 
 in the United States is one half-pint per day to each inhabi- 
 tant. Milk to the ordinary observer appears to be a perfect 
 solution, and is bought and sold by liquid measure. Under 
 the microscope it is seen to consist of a clear, transparent 
 fluid containing many minute globules of various sizes. The 
 fluid part, called the milk serum, consists of water and all of 
 the other constituents except fat, and all of these constituents 
 except the fat are in solution. The globules are little bodies 
 of pure fat in the serum and not dissolved. They are semi- 
 solids and form with the serum an emulsion, and therefore 
 milk as we see it is a true emulsion. The solid constituents of 
 
 259 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 the serum are sugar and casein mostly. Albumin and min- 
 eral matter are present in small quantity, and there is also a 
 little fibrin. There is more sugar in milk than any other 
 solid, and this when separated is the well-known sugar of 
 milk. It is not so sweet as cane-sugar. When milk sours it 
 is the sugar that undergoes the greatest change. The casein 
 and albumin of milk are its nitrogenous constituents, and are 
 comparable to the white of egg. Acid or rennet causes ca- 
 sein to coagulate, forming curd, and as such this forms one- 
 fourth of cheese. The mineral matter is the ash when burned, 
 and consists chiefly of phosphates and chlorides of soda, pot- 
 ash, and lime. Milk may be compared to a thin syrup with 
 many fatty and light particles floating in it. Milk is sticky, 
 and this retards the too rapid rise of the cream or fat. The 
 fat globules are very, very small. A single drop contains 
 many millions, — the number is too large to be appreciated. 
 The globules average one-ten-thousandth of an inch in diam- 
 eter. The Jersey and Guernsey cows have the largest fat 
 globules, and thus their cream rises more readily and their 
 skim-milk is poor. The larger the globule, the sooner and 
 easier it rises. These are very important facts for physicians 
 to know. One hundred pounds of good milk contain 87 
 pounds of water, 4 pounds of fat, 5 pounds of milk-sugar, 3.3 
 pounds of casein and albumin, and .7 pound of salts. The 
 solids vary in milk from 10 to 18 parts in 100. Here is the 
 important part which distinguishes good from poor milk. 
 
 TOTAL 
 SOLIDS. 
 
 Showing relative parts of milk. 
 
 Sugar. 
 
 
 
 
 
 Fat. 
 
 
 
 
 
 
 Casein. 
 
 
 Ash. 
 
 Most of the States have a standard for milk. The laws 
 usually require from three to three and one-half per cent, of 
 fat and from nine to nine and one-half per cent, of " solids 
 not fat." When we speak of " solids not fat," the trade 
 
 260 
 
FORTY VI'.ARS IN T]\]: MEDICAL PROFESSION 
 
 knows this to mean all S(jli(ls not fat. The avcraj^e law then 
 requires at least twelve to thirteen pounds of solids to every 
 one hundred pounds of milk. It is wrong to think fat the 
 only good in milk. Skim-milk has great value ; the casein 
 and albumin of skim-milk are very cheap forms of nitroge- 
 nous food. There is one thing true, though. — the more fat 
 in milk, the more " solids not fat" there arc. Jersey and 
 Guernsey cows produce the best milk for cream, but not for 
 use as milk. Durham and Ayrshire cows are better cows for 
 milk for use as milk. The Holstein cows give the largest 
 quantity of milk ; some of them give good milk, whilst the 
 milk of others is blue and poor. The feed of the cow influ- 
 ences some, but the breed more. The feed influences quantity 
 more than quality. 
 
 Remember that the colostrum, the first milk given by a cow 
 after calving, contains much albuminoids and is laxative, and 
 is not fit for human food. Nature designs it for the calf 
 alone. The albumin and casein in colostrum may form fifteen 
 per cent, of the milk. The sugar percentage is low. the fat 
 normal. In a week after calving the cow produces natural 
 milk. The dairyman in his greed does not usually wait this 
 long, but he should be made by law to wait at least seven days. 
 
 The percentage of fat in milk varies from day to day in the 
 same cow, and any variation in her food does not account for 
 it, and this and other such causes make it appear better to 
 use for children's food the milk from a healthy herd rather 
 than from one healthy cow. The longer a cow milks from 
 her calving, the more solids there are in her milk, and the less 
 easily the cream rises. A cow can be milked ten months in 
 each year, and should go dry two months. 
 
 The term " extend the milk" is used in the trade to denote 
 adulterating the milk by different methods. ^Nlilk is a cheap 
 article of food at a fair price, and cheap milk cannot, as a rule, 
 be good milk. When the dealer has delivered you good milk, 
 remember it is easily contaminated after you have received 
 it. If dust settles on it, or flies or other insects have access 
 to it, or if placed in a badly ventilated cellar, or in a refriger- 
 
 261 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 ator with other foods, or in a place too warm, it goes to the 
 bad in a few hours. To have milk in proper condition for 
 food it should be kept in an apartment absolutely to itself, 
 and at a temperature of as near 50° F. as possible. Remem- 
 ber well this injunction : there is only one class of vessels fit 
 to keep milk in, and these are glass or porcelain vessels. Use 
 no tin, no iron, no patent wares, no earthenware ; use only 
 glass or porcelain. I wonder the trade does not supply glass 
 or porcelain milk-pans and such like useful articles. 
 
 In cities, if you have trouble with the milk furnished your 
 patients, investigate the milk-man and the servants, and see 
 if any possible connivance may be going on between them or 
 between rival dealers. Thunder-storms, impurities, warm 
 temperature, and other conditions may change milk, but these 
 are indirect causes only ; bacteria are the great causes. There 
 are various bacteria in milk, and various fermentations which 
 go on in it. Milk becomes blue, bitter, slimy, ropy, according 
 to the species of bacteria, etc., present. Any milk with sedi- 
 ment is suspicious. Where you have dirt you have micro- 
 organisms. Those who attend to cows and milk in all of its 
 phases should be clean, morally and physically, and healthy. 
 It is of equal importance that the cows should be healthy. 
 Discard all milk of an unnatural appearance or odor. Bac- 
 terial action may cause odors, as well as garlic and such pun- 
 gent vegetables. Watch for the adulteration of milk. Water 
 may be used, part of the cream may be extracted, or it may 
 be blended, good with bad, and very bad. Impure water used 
 in adulteration may bring pathogenic germs to the milk; do 
 not forget this. Even rinsing the cans in impure water may 
 distribute pathogenic germs on the milk route. All milk-cans 
 and bottles should be absolutely sterilized before each time of 
 use. Prohibit as physicians the use of artificial preserva- 
 tives in milk. Salicylic acid, boric acid, borax, and formal- 
 dehyde are used. They all slow digestion even in small doses, 
 and formaldehyde interferes with the digestion of albuminoids. 
 All of these remedies should be used as remedies under care of 
 physicians, not in trade by ignorant venders of food-stuffs. 
 
 262 
 
FORTY YJ'.ARS IN Till': iVli'UICAL I'KOFICSSION 
 
 Do not have iiiill< delivered early in hot weather and left 
 exposed to the sun, as is often done. It should be cold when 
 delivered, and at a temperature of 50' I'', will keep sweet and 
 pure for thirty-six to forty hours, f.et every household keep 
 a floating- dairy thermometer, and see that the milk is kept at 
 about 50", and it will i^ive no (rouble by .souring and spoiling 
 prematurely. To raise cream on milk, put it in a cold place 
 as soon as received. When you need cream, raise the tem|)era- 
 ture of the milk to 100°, and then lower it quickly by placing 
 the dish in cold water. To do this the milk must be in good 
 condition, or it will sour before the cream rises. The cream 
 rises quicker in jars than in pans. 
 
 As to the use of glass milk-jars for delivering milk. There 
 is much to be said on both sides here. It would be an ideal 
 method if we could depend on the average milk-dealer to ab- 
 solutely sterilize each jar each time before delivering milk in 
 it. This you cannot do. The jar may have been in the room 
 of a typhoid fever patient, or even of a small-pox patient, and 
 you may be the next customer to get your milk in it loaded 
 with these unwelcome pathogenic germs. I confess I rather 
 oppose these milk-bottles for general use, but there are milk- 
 supply people whom I would trust to distribute milk in them, 
 and these are the people I would patronize, and be willing to 
 pay them an extra price for their product. This is the only 
 way I know of to get pure milk, or milk any way near pure. 
 Each bottle should be sealed, not hermetically, when received, 
 and no bottle with a broken seal should be accepted. 
 
 Detecting Impure Milk. — Here is a matter of the greatest 
 importance to physicians, and how many know about it as 
 they should know ? Pure milk is the product of healthy, well- 
 fed cows, properly handled and cared for by individuals mor- 
 ally and physically clean and healthy. Good milk should have 
 a slightly yellowish-white color, a slight odor, if any, and 
 should have a distinctly pure taste, as Pearson says. When 
 it has stood quietly for several hours, cream should rise natu- 
 rally, and if the separation is thorough the cream should be 
 from one-fifth to one-eighth of the bulk. No sediment should 
 
 263 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 appear at the bottom. When poured from a tumbler it should 
 cling to the glass some, and not run off clear like water. 
 Skim-milk is thin and bluish in color. The yellow shade of 
 milk is due to the fat, but color is not a safe test, as some 
 cows give rich milk of a lighter color than milk from cows 
 which give poor milk ; and milk may be artificially colored. 
 
 To test Milk. — First get a fair sample. To do this it will 
 not be fair to take all from the top or bottom of the can ; mix 
 it thoroughly by pouring from one vessel to another several 
 times. No lumps must appear on the surface. If small lumps 
 of butter are floating on top a fair sample cannot be taken. 
 Of course, if you want a thorough test, employ a chemist and 
 have a complete analysis. There are ordinary tests, sufficient 
 for the practical purposes of physicians. 
 
 The Creamometer Test. — Creamometers, as well as lac- 
 tometers and all ordinary testing apparatus, may be purchased 
 at any well-conducted dairy-supply house. The creamometer 
 is a long, graduated glass tube with the zero mark near the 
 top. It gives a fair test, but not always exact, as age of milk 
 and method of handling it may make some difference. Fill 
 the tube to the zero mark with milk and allow it to stand in a 
 cool place for twenty-four hours. Warm the milk to ioo° F. 
 and set the tube in cold water to bury the cream, or fill the 
 tube with half milk and half warm water, which raises the 
 temperature and reduces the viscosity; now only half as 
 much cream will appear as you are to give the milk credit for, 
 on account of the water used, so double the per cent, shown 
 and you get the true per cent. If the milk does not vary from 
 day to day in the amount of cream, it shows you are getting 
 milk of regular quality. In this test you also have good op- 
 portunity to look for sediment. Always use the tube quietly. 
 
 The Lactometer. — Milk is heavier than water. Its specific 
 gravity varies from 1029 to 1033, and a departure from this 
 standard, as to skimming or watering, can be measured by 
 this instrument, which every physician should own and every 
 household should have at hand. The Quevenne lactometer is 
 one of the best, and has a thermometer combined. It can be 
 
 264 
 
FORTY YEARS IN Til I'. MIChlCA!, I'ROFKSSION 
 
 purchased at any good dairy-supply house, willi full (hrec- 
 tions for use. These instruments can only show specific grav- 
 ity. If cream has been removed which is lighter than whole 
 milk, the specific gravity is increased, and if water has been 
 added, the specific gravity is of course lower. Now, if we 
 get a high specific gravity, we suspect .skimming, and if a 
 low specific gravity watering. 
 
 There is also another test, which combines mathematical 
 formulae in its'carrying out, — the Babcock fat test. This is 
 a reliable test for the fat of milk, ,-md is much used by cream- 
 eries and other houses using milk and cream commercially. 
 The milk is centrifuged, if 1 may be allowed to coin the word. 
 Only about a tablespoonful is required, and fifteen minutes 
 sufifices for the test. The instrument can be purchased of 
 dealers for a few dollars, with full directions, and is simple 
 and easy in its operation. 
 
 TJic Acid Test. — Professor Farrington's acid test is simple, 
 and should be recommended by physicians to those engaged 
 in the care of children. Acid commences to form in milk soon 
 after it comes from the cow. This test will show if it is too 
 near the souring-point for use for delicate stomachs. Tablets 
 containing a definite amount of alkali, caustic, potash, or soda, 
 say, are dissolved in water and added to a definite amount of 
 milk. The tablets contain a little phenolphthalein, which is 
 colorless in acid solution and pink in alkaline solution. A 
 solution of these tablets is slowly added to the milk, and the 
 mixture is stirred until it becomes pink. It is known now 
 that enough alkali has been added to neutralize the acid in 
 the measured amount of milk, and the amount of solution re- 
 quired indicates the acidity of the milk. Fresh milk has little 
 acid, and turns pink on addition of a small amount of alkali, 
 while milk nearly sour requires more alkali to turn it pink. 
 These Farrington tablets can be found in the shops, with full 
 directions for use, and every house should have them on hand. 
 They are made of definite strength. Should a solution of two 
 tablets turn one ounce of milk pink, that milk should keep 
 from twenty-four to thirty-six hours with proper care. If 
 
 26s 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 the milk remain white after the addition, it will soon turn 
 sour. ■ 
 
 Test for Colosfntni. — If milk coagulates on boiling, it 
 shows the probable presence of colostrum, because colostrum 
 is highly albuminous, and here it is the albumin wdiich has 
 coagulated. The cow furnishing this milk has been milked 
 too soon after calving. The calf, not the baby, should get 
 this milk. It will probably give the baby diarrhoea, among 
 other troubles. We have no reliable test for micro-organisms 
 but the microscope, and this should be brought to bear when 
 necessity points in that direction. Percentage milk I have 
 spoken of before whilst speaking of diet in general, and I 
 trust its use may grow rapidly, for it is capable of being put 
 to great therapeutic advantage under many and various con- 
 ditions. 
 
 I append Pearson's rules, to follow in choosing your milk- 
 man and milk-supply. He should show a quarterly certificate 
 from a veterinarian of good standing, — a licensed veterina- 
 rian, by all means, — stating that after a careful examination 
 of his cows — if he is a producer as well as a vender ; if only a 
 vender, then from the herds supplying him with milk — they 
 were all found to be healthy; that if there were any doubt- 
 ful cows, they had been removed; that the quality of the 
 feed and water, the sanitary conditions of the stables and sur- 
 roundings, and the health of the employees were approved. 
 If you believe your milk-man is honest, let him know it. If 
 not honest, get another at once. 
 
 Pearson recommends consumers to visit the dairy farms 
 and general sources of supply of their milk, as apt to do good. 
 On a well-conducted dairy farm he would expect the visitor 
 to see a roomy, de^n, dry, light, and well-ventilated stable or 
 cow-house. To produce good milk, cows must be comforta- 
 ble, and these conditions not only add to their comfort, but 
 are absolutely necessary to keep them in the best health. Let 
 me add here, do not make them too comfortable; do not 
 change their natural environment too radically. Give cows 
 palatial stables, Axminster carpets, and modern heating ap- 
 
 266 
 
FORTY YI'lAKS IN 'lllh: M l.l M( :.\ L l'KOI''l':.SSfON 
 
 pliaiiccs, ;iii(l ^-ou will (Icvclop lubcrculosis in eighty j^cr cent, 
 of tliem in a twelvemonth. Tlie cow.s must be healthy, well 
 fed, and contcntccl. An a1)nndan(c (»f jinrc water twice a day 
 I would add here after each milkinj^', when the system has 
 been drained, h'ced should be of j^oorl fjuality. The grain 
 and coarse fodder should be free from dirt, decay, or musty 
 condition. A spirit of kindness tcnvards the stock and gen- 
 tleness of the animals themselves is necessary, as well as pro- 
 vision for washing and sterilizing all utensils which come in 
 contact with milk. 
 
 Provision for straining, aerating, and cooling the milk in 
 a clean atmosphere, free from stable and other odors, is ab.so- 
 lutely essential. This treatment should take place immedi- 
 ately after the milk is drawn from each cow. Facilities for 
 storing the milk and keeping it cold must be at hand. Espe- 
 cially great cleanliness in regard to everything connected with 
 the dairy slKuild be observed. The atmosphere of the stable 
 should be pure and free from dust when milking is being 
 done. Employees should carefully wipe the udders and wash 
 their hands before milking, and should be in clean clothes. 
 Whitewash is a good disinfectant, and should be seen in 
 many more stables; and land plaster (sulphate of lime) 
 should be sprinkled about to absorb moisture and odors. The 
 cow should stand on clean litter only. If the milk is handled 
 through a store, the building should be kept scrupulously 
 clean, with no dust or dirt in the milk-room. There should 
 be provision for keeping the milk cold when stored, and appa- 
 ratus for sterilizing utensils after washing. 
 
 Pearson suggests, as improvements in the business, that 
 graded milk be sold, graded as to its fat test particularly. Let 
 the people learn there is as much difference in milk as there is 
 between the better and coarser cuts of beef. This is all right. 
 Let us think of milk not as milk in the abstract, but as to its 
 composition, and that when we buy it we pay for what we get, 
 knowing what we get. knowing there are high-priced and 
 low-priced milks. Such methods are followed in France and 
 Germany. Doctors should know all about such things, not 
 
 267 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 ouly as to milk, but all about marketing in general as to the 
 cuts of beef, mutton, and veal, how to judge poultr}'- and 
 game and fish and vegetables and fruits ; in fact, all domestic 
 supplies ; and he should know how to prepare them for cook- 
 ing and how to cook them, too. The milk-supply should be 
 rigidly inspected in all communities, and derelictions should 
 be punished by radical laws enforced without fear or favor. 
 Such laws are necessary to the well-being of society, and are 
 not by any means sumptuary, and do not interfere, when 
 properly looked at, with the liberty of the individual. Even 
 if they do, the liberty of the individual should not stand in the 
 way of anything which brings death and destruction to com- 
 munities. 
 
 Pearson suggests that milk-carts carry graded milk, put- 
 ting different grades in different cans, plainly marked with 
 their grade, and with separate taps on the outside of the cart 
 leading to each can. Purchasers would then see what they 
 were buying, and know exactly what they were paying for it. 
 He suggests the following grades. The grades of milk should 
 be numbered with the whole numbers nearest to the percentage 
 of fat contents. Thus a separator skim-milk with but a trace 
 of fat would be o ; skim-milk, with from one-half to one and 
 one-half per cent, fat, would be i ; and so on. Whole milk 
 would be of three grades, 3, 4, and 5, and extra rich and for- 
 tified milk, to which cream has been added, would be 9 or 10. 
 Cream would run from 13 to 50. No more grades of milk 
 or cream need be carried than is the custom now, but each 
 should be marked with its appropriate number. While the 
 idea of the percentage of fat thus indicated might not be clear 
 to all, it would soon be understood that the higher numbers 
 meant the richer milk. If this practice were observed, it 
 would be difficult for drivers to tell their customers one thing 
 and the milk inspector another about the quality of the con- 
 tents of the same can. The signs should be so attached to the 
 wagon-side or can that they could not easily be changed. If 
 bottles are used, the number representing the quality should 
 be attached to each one. 
 
 268 
 
CHAPTER X. 
 
 Origin of Alcohol, Whiskey, Brandy, Port Wine, Sherry, Champagne, 
 Burgundy, Claret, Rhine Wine, Porter, Ale, Beer — Per Cent, of Alco- 
 hol in Each — Effect of Alcohol on the System — Effect of Alcohol on 
 Bodily Temperature — Alcohol as Food — System consumes more in 
 Disease than in Health — Strength of Wines — Colors of Wines — Na- 
 tional Drinks — Methods of artificially aging Whiskey, etc. — Rum, Gin, 
 Cordials, Malt Liquors — Method of making, etc. — Malt Extracts — 
 Wines — Grapes, Varieties of, etc. — The Wine-Taster — Peculiarities of 
 Wines — Sherry, Madeira, Port — Ward McAllister — Burgundy, Sau- 
 ternes, Hock, Johannisberg — Champagne " a Drink for the Gods." as 
 well as an Invention of the Devil — Vin Brut, Vin Sec, Vin Tres Sec, 
 Sparkling Moselle — German and Italian Wines — American Wines — 
 California Wines — Care in prescribing Alcoholics — Value of Fruit 
 and Nuts as Articles of Diet — Value of Fruit as Food from 
 an Economic Stand-Point — The Lesion in Rheumatism — Is 
 Fruit Healthy Diet ? — The Divisions of Fruits — Special Fruit 
 Cures — The Ripening of Fruit — The Most Digestible Fruits 
 — Fruit Syrups and Fruit Juices — Canned or Tinned Fruits and Vege- 
 tables — Fruits in Colonial Times — Fruit in Florida, California, and 
 Australia — Medicinal Properties of Fruits and Nuts — Why Leaves 
 change Color — The Apple — Varieties of Apples — Varieties of Peaches 
 — Varieties of Pears — Grapes — Apricots — The Plum — East India Fruits 
 — The Mangosteen — The Durian, Pine-Apple, Banana. Plantain, Or- 
 ange, Shaddock, Olives, Lemons, Mulberry, Melons — Partridge-Berry 
 and Salicylic Acid — The Haw-Berry — Gooseberries, Currants, Cran- 
 berries, Cherries, the Quince, Blackberries, Raspberries, Strawberries — 
 Decay of Fruit — Mushrooms, Morels, and Truffles — Nuts — Chestnuts, 
 Peanuts, Almonds, Filberts, Pecans, Shellbark or Shagbark. Brazil 
 Nuts, Chilean Nuts, Betel Nut, Pistachio Nut, Kola Nut. Guarana. 
 Butternut, Walnuts — Eucalj-^ptus Globulus. 
 
 It is not to my purpose here to speak particularly of alcohol. 
 Absolute alcohol is used only for chemical purposes, as a rule. 
 The Pharmacopoeia recognizes alcohol containing ninety-four 
 per cent, by volume of absolute alcohol, and having the spe- 
 cific gravity of 0.820. Deodorized alcohol contains 95.1 per 
 cent, alcohol by volume, with a specific gravity of 0.816. 
 Dilute alcohol U.S. P., contains 48.6 per cent, by volume of 
 absolute alcohol, with a specific gravity of 0.936. Alcohol 
 
 269 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 comes from sugar by fermentation, as is well known, or from 
 the destructive distillation of organic bodies. Chemically it 
 is an ethyl hydrate. CoH-O.H. 
 
 Whiskey is distilled from fermented grains, and brandy is 
 distilled from fermented grape-juices, and each undiluted 
 should hold from forty-eight to fifty-six per cent, of absolute 
 alcohol. As sold in the markets, whiskey and brandy carry 
 from thirty-five to forty-five per cent, of alcohol. Port wine 
 carries from eighteen to twenty per cent, alcohol ; Madeira, 
 about the same ; sherry, about sixteen per cent. ; champagne, 
 ten to eleven per cent. ; Burgundy, ten per cent. ; claret, six 
 to eight per cent. ; Rhine wines the same ; porter, five to six 
 per cent., and beers and ales, from three to six per cent. 
 
 According to Wood, alcohol increases the frequency of the 
 pulse and increases blood-pressure. It is a cardiac stimulant, 
 and in overdoses is a heart depressant. There is one thing 
 well to remember : there is an apparent contradiction in the 
 effect of alcohol on bodily temperature. When a man takes 
 just sufficient to slightly increase his heart action, there is a 
 very slight rise in temperature. After a full dose there is a 
 slight fall of temperature, and when a man is fully intoxicated, 
 his temperature may fall as much as 3° F. The explanation 
 here is simple : the full dose drives the blood to the surface 
 where it is cooled, and the temperature of the whole body 
 falls. It then follows, actually, that a man may take a drink 
 to w-arm him up, and may take a drink to cool him off, and 
 science supports him in both. 
 
 A drink of spirits makes the breathing freer and fuller. 
 An overdose weakens respiration, and this is often seen in the 
 case of drunken men, exclaiming they cannot breathe prop- 
 erly. There is here a tendency to centric respiratory paralysis 
 from alcohol poisoning. I have always been taught to believe 
 from my own experience that alcohol was not directly a food, 
 but that a man could live longer with it than without it, be- 
 cause he did not die so rapidly ; that is to say, with a certain 
 amount of alcohol daily, destructive change of his tissues did 
 not go on so rapidly as when that certain amount of alcohol 
 
 270 
 
FORTY YJCARS IN 'I'll I". MICDICAL PKOFJCSSION 
 
 was withheld ; but the recent experiments in detail by Pro- 
 lessor Atwater and others appear to give to alcohol direct 
 food value, but this is not yet fully settled. 
 
 Horatio Wood sums up as follows : For a person in health, 
 alcohol must be considered as one of the most wasteful, un- 
 certain, and often deleterious of known substances which are 
 considered foods. In disease, however, where its stimulating 
 and narcotic purposes favor its usefulness, its capability of 
 being rapidly burnt up without undergoing any primary as- 
 similation, and of thus yielding force to an exhausted system, 
 may well make it an in\ahial)le assistant to the physician. 
 The human system will burn up much more alcohol in disease 
 than when in health. What 1 will have to say of alcohol will 
 be altogether as to its therapeutic use in the various forms of 
 spirits, wines, and malt liquors. These in moderate amounts 
 improve digestion, whilst in large amounts they retard or 
 stop it altogether for the time being. 
 
 Being articles of the materia medica, there is no reason why 
 physicians should not know as much of wines and liquors as 
 the}^ do of the other matters therein contained, but such is 
 apparently not the case. The practitioner should at least 
 know that brandy should be not less than six years old before 
 it is fit for medicinal use. and whiskey should be five years 
 old. He should know that port, sherry, Madeira, and cham- 
 pagne are the stronger wines, and that the Burgundies, 
 clarets, and hocks are the weaker. He should know that the 
 important ingredients of wine are the alcohol, the sugar, the 
 flavor and aroma, and the relative quantity of these in each 
 kind. He should know the relative colors at least : that port 
 has usually a color of its own. the port-wine color, approach- 
 ing purple, although there are some white ports ; that sher- 
 ries vary in color from very pale to dark red, and so do the 
 Madeiras; that clarets and red Burgundies vary in red or 
 claret colors, and that Burgundies are many of them white, 
 but true clarets never ; that the hock wines are usually straw- 
 color or white; that champagnes vary from almost white to 
 pink, the color being, as a rule, at the fancy of the maker : 
 
 271 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 and that whiskeys, brandies, ales, and beers vary as to the 
 demands of trade for this or that color, whiskey and brandy 
 being colorless when first distilled, but are colored by the 
 addition of caramel or burnt sugar. Gin, as a rule, is white, 
 and the Irish and Scotch whiskeys are either colorless 
 or of light or dark straw-color. The cordials are usually 
 colored to suit the fancy of the manufacturers. Whiskeys, 
 brandies, cordials, and all artificially colored liquors should 
 be left as nature intended them, — entirely free from artificial 
 coloring or artificial flavoring. Such will never be ; coloring 
 for the eye, flavoring for the palate, and blending for both 
 will always be carried on so long as " water shall run and 
 grass shall grow." It is said that the Esquimo has no alco- 
 holic drink, for the climate is too cold for fermentation, and 
 he cannot make it there; but I have no doubt that his more 
 southern brothers have long ere this supplied him, even though 
 alcohol may lessen his powers to resist cold. 
 
 Going south, we find all nations have their favorite tipple, 
 and far south we find only those drinks which are fermented 
 in a hurry and drunk in a hurry, for they will not keep over 
 thirty-six hours, as the Mexican pulque. Brandy is, we all 
 know, distilled from wines, while wines are fermented grape- 
 juice. Brandy in the market is of various colors, owing to 
 the amount of coloring-matter put in it, — some very dark, the 
 pure being colorless. The best brandy I ever tasted was made 
 in California and sent to me from the vaults of General H. 
 M. Naglee. It was selected stock from the time the grapes 
 blossomed until it was barrelled in the vaults. It had no 
 color whatever, no artificial flavoring, but had the rich aroma 
 of the grape, and no headache in it. This is the kind of 
 spirits we should dispense for our sick, but we cannot always 
 get it. To make brandy we must add color and the true 
 brandy flavor, in addition to the natural ethers, sold in any 
 quantity, to give it the hon gout. 
 
 Whiskey. — Probably whiskey is the safest of the spirits to 
 use in the United States for the sick, as it at least ought to be 
 the purest, and it should be the cheapest. Age regulates its 
 
 272 
 
FORTY YEARS IN TTTR Mi'.DICAI. PROFESSION 
 
 price, and the fusel-oils in it decrease by aj^e, so old whiskey 
 is the best and safest, provided it has been kept in vvrKKb 
 There are artificial ways of af:(in<;- whiskey, as runninjj^ it 
 down a woollen string from the higher stories of a building 
 to the lower stories, each running down evaporating it and 
 losing its fusel-oils, equivalent to one year passed in the bar- 
 rel. This is roguery and not true aging. The ])rice of whis- 
 key, as a rule, is too high to the retail purchaser, but the trade 
 controls it and the good people must bear it. Rye whiskey 
 is probably the best in this country, although whiskey is made 
 from wheat, barley, corn, and other grains. The flavor comes 
 from the process of kiln-drying of the grain or grains of 
 which it is made. The Scotch and Irish whiskeys get their 
 flavor from the peat used in drying the grains. The mashes 
 used in making whiskeys are the sweet and the sour, and corn 
 and rye are often mixed in given parts with malt. This 
 makes sour mash if scalded with the refuse liquor used be- 
 fore, this containing the ferment to start the alcoholic fer- 
 mentation. Sweet mash is made by adding water only and 
 yeast to start the fermentation. 
 
 Rum comes to us from Jamaica, Santa Cruz, and New 
 England chiefly. Molasses is fermented, and then from this 
 the rum is distilled. Santa Cruz, with the lime fruit, makes 
 the best punch, but it does not compare with a punch made 
 from the pure California brandy. Let me digress here. We 
 often hear the doctor say he is giving the patient milk punch 
 when he is giving him whiskey and milk. There is no such 
 thing as milk punch made from whiskey and milk. Milk 
 punch is made from brandy and milk. Milk toddy is made 
 from whiskey and milk. 
 
 Gin is usually colorless and has some diuretic properties, 
 owing to the juniper and other aromatics in it, which also 
 give it its peculiar flavor. Gin is distilled from almost any 
 fermented grain, but the grains are not previously kiln-dried. 
 Then, to get a neutral spirit, there is a second distillation, 
 and to this the flavoring of the aromatics is added. Gin is 
 a strong liquor. The English call it Hollands, and Old Tom 
 1 8 273 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 gin, a favorite brand, is sweeter than ordinary gin. Indi- 
 vidually, I do not cotton to gin, and I do not advise any one 
 else to cotton to it. I never indulged in it but on three occa- 
 sions, as I remember, — once at college, when it made me 
 quite ill; the next time when I took a cocktail with the cap- 
 tain of a clipper-ship just starting on a long voyage, and we 
 were shipwrecked within a week ; and the last time with a 
 friend, on the birth of his long-wished-for son, and on my 
 next visit the son was dead. These last two cocktails were 
 taken before breakfast, that heathenish time to consume spir- 
 its, although it has been the custom of my lifelong environ- 
 ment. Thanks, I don't take gin, even though Lord Byron 
 gave it renown in poetry as the poor man's substitute for 
 riches ; nor do I drink before breakfast, nor before noon, and 
 never did but twice in my life. 
 
 There are other spirits, but not in general use, and it is not 
 worth while to take space to enumerate them. Cordials are 
 not often of use to the sick, but if needed, the best are char- 
 treuse, hot and peppery, and probably the best. Maraschino 
 is toothsome, but too sweet. Curagoa is of orange-peel flavor 
 and quite useful for flavoring unpleasant medicines, but there 
 should be no use for it now, for we should no more give un- 
 pleasant potions; there is no necessity for it. There are 
 some West India cordials, as parfait I'amour and others, but 
 they have no place in medicine. As to cordials, they are 
 merely sweetened and artificially flavored spirits. 
 
 Beer. — The English, as a rule, speak of all malt liquors as 
 iDeer. All malt liquors are fattening, and there are few better 
 mild tonics than lager beer, and given in connection with or- 
 ganic iron and manganese, you have a combined tonic par 
 excellence. The same remarks may apply to all malt liquors 
 and malt preparations. Lager beer is made from infused 
 malt, which is barley dampened and allowed to germinate 
 and then kiln-dried, and the whole flavored with hops. The 
 temperature to which the malt is brought in the kiln deter- 
 mines the color of the product. If the temperature runs below 
 140° F., you get pale beer; increasing the temperature gives 
 
 274 
 
FORTY YEARS TN TIIP: MRDICAL I'ROFESSION 
 
 you (lark hcer, or ale, up to porter, vvliicli is almost hiack. Of 
 course, by the maltinjj;' process the starch of the grain is con 
 verted into dextrin, and so on up to sugar. The brewer, tcj 
 make beer, first infuses the mah, then boils it with hops, which 
 give flavor and bitterness and keeping (juality, and lastly cools 
 it rapidly and adds yeast to start fermentation. In three or 
 four days the fermentation is comi)leted, the alcohol of the 
 beer is developed (if lager beer, about three per cent.j, and 
 carbonic acid is given off. The product is then allowed to 
 clarify of its own accord, or beech-wood or isinglass is used, 
 which carry down by physical laws all the particles which 
 render the fluid turbid. Lager beer should be stored in dark, 
 cool vaults for from four to eight months, or even longer, to 
 give it the best form. As now produced, it is said to be put 
 on the market at a much earlier stage of its life, both to the 
 detriment of the beer and of the consumer. Ale is made from 
 light-colored malt usually, more hops are used to give it a 
 more bitter taste, and all of the sugar goes to alcohol, giving 
 it an average of six per cent, alcohol. Porter is strong, dark 
 ale really, the malt used being dried at a greater heat. Brown 
 stout is stronger still, both porter and brown stout containing 
 more of the carbohydrates extracted from the grains from 
 which they are made than either ale or beer. In alcohol they 
 are about equal to ale. Malt liquors fresh from the wood are 
 better and more healthy than the same products bottled, be- 
 cause in bottling malt liquors, especially for exportation from 
 the countries in which they are made, antiferments, in the 
 shape of salicylic or boric acid and such, are apt to have been 
 added, all of which slow digestion. For the same reason 
 many of them are reinforced, and thus contain more than 
 their normal proportion of alcohol. So it will be seen that it 
 is usually better, provided the Boniface keeps his pumps and 
 environment clean, to " rush the growler" when we want 
 pure beer, than to purchase it bottled. 
 
 Now, as to the malt extracts, so called, of which the shops 
 are full, and many of which are not even good porter. To 
 make true malt extract, you rapidly evaporate an infusion of 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 malt to the consistency of thick honey at a temperature not 
 above 130° F. It should contain all of the diastase in the 
 malt. If should be sweet in taste and of acid reaction, and 
 should mix easily with water. Some of these malts are really 
 only glucose, and some, as stated above, not more than beers. 
 To be right it should not contain the least alcohol. If it does, 
 the fermentation has gone too far. If it contains glucose or 
 alcohol, it is a food. It is of no good unless it contains only 
 diastase, as far as aiding digestion is concerned; that is to 
 say, its claimed merits depend on diastase and not on glucose, 
 alcohol, and such. Acids of the stomach destroy the diastase, 
 and therefore it must be taken before meals, before the stimu- 
 lus of the food draws out the gastric juices. Of whatever 
 use it is, it is to aid in digestion of starches, and it can only 
 do this when it meets with alkaline or neutral surroundings, 
 and this is not often, for starchy indigestion always brings 
 its acidity. As a rule, then, the malt extracts of the shops are 
 trash, and worse than trash. Have your patients spend their 
 money for good beer, ale, or porter, and get some return 
 for it. 
 
 Wines. — The grape is renowned in song and story ; in his- 
 tory, both sacred and profane, it holds a leading part, and 
 Bacchus, its mythological god, is the father of all the ills it 
 has brought to the world and the hero of all who worship at 
 his shrine. What a power for good and what a weapon for 
 evil environ its luscious juices ! Botanically, it is of the genus 
 vitis, the type of the order vitacese. In the wild state the 
 flowers of some specimens are imperfect but very fragrant, 
 but in cultivated specimens they are always perfect and have 
 the delightful odor of the mignonette. 
 
 The horticulturist now divides grapes into the European 
 and American varieties. The European varieties will not 
 grow in open air in America east of the Rocky Mountains, 
 and they have been so long cultivated in Europe for flavor 
 and size, that the vine has become delicate and the prey of 
 insects and fungi, and to rehabilitate it, it has become neces- 
 sary to grow the European varieties on true American stocks 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 to restore tlicm to vi^or. This same fact is often shown in 
 nature, not only in fruits and vegetables and such, but in ani- 
 mals as well. In American grapes the seeds are held together 
 by the pulp, which slips from the skin easily. In foreign 
 grapes the seeds are easily extracted and the skin adheres to 
 the pulp, and all are eaten together. The grape is subject to 
 many enemies, botli in this country and in Europe, of which 
 I know practically something, for I have a vineyard of my 
 own which has often demonstrated to me the truth of the 
 saying, " There is many a slip between the cup and the lip." 
 The phylloxera — Phylloxera vastatrix — is the great Euro- 
 pean enemy, and also in California, whilst in the East the rots 
 fungi and anthracnose are the serious troubles. You camiot 
 raise grapes now without spraying with copper solutions and 
 arsenites. and what effect these sprayings are going to have 
 on the yeast fungus which nature develops on the stems of 
 grapes to set up the wine fermentations is for the future to 
 decide. If we are to get these ferments from yeast, the flavor 
 of the product must suffer. 
 
 Wine is the fermented juice of the grape. The finer wines 
 are probably still made in Europe, where the experience of 
 ages gives them every advantage, but x\merica is now pro- 
 ducing the ordinary wines of good flavor and purity, and 
 these are far better, and within the reach of all pecuniarily, 
 than the doubtful and expensive foreign wines, unless you can 
 get these out of the line of general trade, from special sources, 
 and at enormous prices, as, for instance, champagne of a cer- 
 tain year and certain vintage at one hundred dollars per dozen, 
 which is frequently paid by those having the taste and the 
 means with which to gratify it. 
 
 Forty years ago I drank clarets and the other lighter wines 
 in California. Invariably they had an earthy taste, as though 
 filtered through earth. They had not the least idea then what 
 particular soil and what particular location gave certain fla- 
 vors to the grape and thence to the wine, a fact which they 
 are rapidly learning now. To illustrate this point. I once 
 visited the celebrated Schloss Johannisberger. less than fifty 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 acres in extent, on the Rhine, where that fragrant, aromatic, 
 and much-sought-after wine is made from the grapes grown 
 on the hill, and is equalled by no other wine of its kind except, 
 perhaps, a fine old Tokay. The gentleman with me, an at- 
 tache of the place, showed me much as to the intricacies of 
 getting true Johannisberg. They knew the soil, every foot 
 of it. He showed a place on the hill-side, say thirty feet 
 square. In this square were arranged a number of small plots, 
 and every one of these small plots produced a grape which 
 gave a wine of a different flavor. The best gave a wine worth 
 its weight in gold, — the genuine Schloss Johannisberger, — 
 and only a Metternich, or the friends of the house of Metter- 
 nich, ever tasted it, and so on down, until the poorest quali- 
 ties went to the general trade ; but, he added, " No one ever 
 gets a bottle even of the poorest Johannisberger from the gen- 
 eral trade. If he thinks he does, he has been defrauded." 
 
 The United States Pharmacopoeia now divides all wines 
 into two classes, the white and the red, and leaves off special 
 names, by reason of our native wines coming more into promi- 
 nence. The light wines are those which contain the smaller 
 per cent, of alcohol, as clarets and hocks, and do not keep 
 after they have been exposed to the air. These have about 
 eight per cent, of alcohol. The heavy, or fortified, or rein- 
 forced, or brandied wines are another division, and keep in- 
 definitely when exposed to the air. Sherry and Madeira are 
 examples of these, and they contain from seventeen to eighteen 
 per cent, of alcohol. We have sweet wines and dry wines. A 
 sw^eet wine is sweet, and a dry wine has very little sugar. We 
 speak of a sweet or a dry sherry. We speak of champagne 
 as dry, extra dry, as sec, or tres sec, and of Vin Brut, a wine 
 fermented absolutely naturally, without artificial interference ; 
 no sugar is added, and the natural sugar of the grape has 
 nearly all gone to alcohol. True dryness is a result of age, 
 the sugar being slowly converted into alcohol, but the wine 
 man is full of tricks ; in fact, wine is subject to trickery from 
 the grape to the consumer. To hurry up dryness, an artificial 
 acetous fermentation is started and the sugar is nearly all 
 
 278 
 
FORTY YEARS IN 'I'lII': MF:[)1CAI. PROFKSSION 
 
 consumed by this in a comparatively short time, say six 
 months, whilst liu' natural process may take years. Thus 
 is champagne dry because it is sour frcm the development of 
 vinegar, and is not dry because the sugar lias been naturally 
 converted into alcohol as it should be to be good wine. Take 
 this wine, let it become exhausted by losing all of its free car- 
 bonic acid, and it will still tinn litmus blue to red, showing 
 its acidity is not altogether due to the carbon dioxide. 
 
 There are various terms applied to wines by the connoisseur 
 which it is well to be familiar with. There is the aroma or 
 bouquet ; there is the body, that which makes us feel as though 
 we were swallowing something better than water, and the 
 nearer wine approaches, in swallowing it, to water, the less 
 bod}^ it has. Then wine has color, fruitiness, astringency; 
 strength, due to its alcohol ; its acidity and its sparkle, due to 
 its carbon dioxide mainly. If it were not for the sparkle, 
 there would be much less consumption of many palatable 
 drinks than there is at present. What would beer be wdthout 
 its sparkle, or champagne? Try exhausted beer or exhausted 
 champagne, and you will see. 
 
 Wine properly used has a good efifect on the system. Its 
 abuse entails untold evils. Liebig said, " Wine is unsurpassed 
 by any product, natural or artificial, as a restorer of the 
 vital forces when they have been exhausted ; it animates and 
 revives the saddened spirits, it serves as a corrective and anti- 
 dote in all irregularities of the animal economy, which it pre- 
 serves from the passing ills to which inorganic nature sub- 
 jects it." In wine there is a union of alcohol with an acid 
 liquid ; the acid holds the alcohol in check, especially the 
 effect of the alcohol on the nerves: the tannin and coloring 
 matters favor rather than retard digestion, and the bouquet 
 serves to soothe and quiet restlessness. Wine has a density 
 nearly equal to water ; it is absorbed much less rapidly than 
 spirits, and thus its effects come less rapidly and last longer 
 than the effects of spirits. Hence, as remedies, when you 
 want rapid action, use spirits, not wine. Wine enters the 
 system with no change except being mixed with the digestive 
 
 2/9 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 jiiices, and absorbs none of the digestive ferments in its own 
 digestion, and hence its nsefuhiess in dyspeptic troubles. 
 
 The expert wine-taster is an important man, and few can 
 individually be of more use in the world. Their powers of 
 discrimination by taste and smell are beyond belief, and such 
 men are absolutely necessary to protect both dealer and con- 
 sumer, for chemistry has become such a science as to make 
 possible the imitation of all beverages without the presence 
 of any of their natural constituents. It is responsible for 
 nearly all of the frauds which deceive both the eye and the 
 palate and overturn the digestive processes. The wine-taster 
 is the bulwark here which separates honesty from fraud. Red 
 and white wines differ materially in their composition and 
 effect upon the system, and it is important for physicians to 
 know this, and it is growing more important from year to 
 year, for America is becoming more and more a wine-pro- 
 ducing country, and it follows that we are becoming more and 
 more a wine-drinking people, and less a spirit-drinking people. 
 Statistics show this undoubtedly. 
 
 As a rule, red wine is fermented in contact with the stems, 
 seeds, and skins of the grapes, and the white wines are fer- 
 mented separately from these. Guyot says the difference in 
 color is an accident. The real difference consists in the spe- 
 cial and often opposite hygienic qualities of these two kinds 
 of wine. If white wine is fermented from white grapes in 
 conjunction with their seeds, stems, and skins, we may get a 
 white wine having the hygienic qualities of red wine, not 
 otherwise. White wines made without using the stems, 
 seeds, or skins of the grapes are diffusible stimulants to the 
 nervous system. If they are light, they act rapidly on the 
 physical organization, of which they intensify all the func- 
 tions ; they escape rapidly through the skin and mucous mem- 
 branes, and above all through the kidneys. Red wines are 
 more tonic and persistent stimulants of the nerves, the 
 muscles, and digestive organs ; their organic action is slower 
 and longer, they are not eliminated so rapidly from the sys- 
 
 280 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 tern, and their g'encral action is astrinj:(cnt, persistent, and 
 concentrated. 
 
 Now, here are the well-defined differences between red and 
 white wines, and physicians can ])rofit g-reatly by heeding 
 them in prescribing. Among foreign wines we will first take 
 up sherry, which is a Spanish wine, named for the town of 
 Jerez de la Frontera, in . Andalusia. It is a heavy wine and 
 improves by age; the older the slierry the better it is, pro- 
 vided it is brut, — that is to say, if nature, not art, has been 
 allowed to work it out. As it ages it gets dryer, because the 
 sugar is converted into alcohol, and if old enough it becomes 
 inky dry for the same reason. Its color varies from dark red 
 to almost white. By the makers the flavor, which is a pecu- 
 liar ether flavor, the sherry flavor, is formed by the soleras 
 or stock wines. This stock is kept up and used to flavor wines 
 in bulk. Solera wine is no more palatable than sulphuric 
 ether, but gives the flavor to all sherries as it is added in larger 
 or smaller quantities. Sherries are all reinforced or forti- 
 fied by brandy, and physicians should know this. The Amon- 
 tillado sherries have the ether flavor most strongly marked. 
 The presence of aldehyde causes this flavor. The Manza- 
 nilla sherries are so named from their flavor resembling the 
 Manzanilla or chamomile flower. These are the white or 
 nearly white sherries. The sherries we get in the shops, or 
 from dealers, often are known by the names of the commer- 
 cial houses which deal in them, as the Gordon sherries, etc. 
 Sherry is often too alcoholic and has the effect of spirits, and 
 it is not, as a rule, a good wine for the sick, except used as 
 wine whey, and I do not recommend this, as a rule, except 
 when we are, as often happens, at our wits' end for something 
 palatable to the patient. There is one place it comes in, and 
 that is as a substitute for champagne when that wine is too 
 expensive for the sick one, or good champagne cannot be ob- 
 tained. Mix it in definite proportions with the common soda- 
 water of the shops, the carbonic acid water, made by charging 
 water with carbon dioxide up to fifteen atmospheres at least. 
 
 28 1 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 and served to customers in glass siphons which preserve it 
 well charged until all of the contents have been used. Such 
 a mixture will often be found of the greatest benefit, and 
 should be much more used among the sick than it is. 
 
 Madeira, so far as medicine is concerned, is a passed wine, 
 but it is, as Ward McAllister called it, the king of wines. A 
 physician should be a connoisseur in wines, or at least know, 
 of all men, something about them and their merits and their 
 history when they are discussed, as they often are, so cheerily, 
 at a pleasant dinner. In times past I have tasted some of the 
 good ones, and the flavor of a Butler i6, or of a Thorndyke 
 Sercial, or a Charleston Blandy of 1828, lingers still close to 
 my palate, and I wish I could enjoy them still, and that my 
 throat was as long as a gun-barrel and I could taste them all 
 the way down. I cannot do it, even if I could find such in 
 existence, for the old stocks must have nearly passed away, 
 and the long lapse of the Madeira grapes from disease has 
 made impossible the replenishing of the old stocks, and the 
 new wines are as yet unfit to drink, and if they were, probably 
 modern methods will make impossible the old wines of the 
 honest old days. Madeira is the most gouty of wines, and 
 many among us cannot touch it, even if we get it, and it is 
 not, as the French would say in regard to Madeira, " chacun 
 a son gout," but rather, " each one as to his gout." 
 
 Ward McAllister said Madeira was a national wine, and 
 only matured well in our Southern States. It raises man's 
 vitality and leaves no headache. McAllister said age always 
 improved a good Madeira but never a poor one. There are 
 stock Madeiras in this country to-day over one hundred years 
 old, but if always in glass, I do not see how they have im- 
 proved much, unless they have been recorked every seven 
 years and allowed access to air for a time. McAllister's best 
 way of keeping Madeira was in the garret, with a corn-cob 
 for a stopper. Light and air do not injure its flavor. He 
 always said that the thin pipe-stem wine-glass was the only 
 glass from which to drink Madeira. 
 
 282 
 
FORTY YEAKS IN THE. MEDICAL PROFESSION 
 
 Tlic old stock Madeiras were, most of them, named from 
 the ships which hrout^ht them over, and the famous ones were 
 the Marsh and Henson 1809, tlie Coles, the Stuyvesant, the 
 Clark, the EHza. In Philadelphia the lUitler 16 was famous. 
 In Boston, the Kirby, the Amory 1800 and [811, and the 
 Otis. In Baltimore, the Marshall, the Meredith or Great 
 Unknown, the Holmes Demijohn, the Mob, the Colt. In 
 Charleston, the Rutledge, the Hurricane, the Earth(|uake, the 
 Maid, the Tradd Street. In Savannah, the i\ll-Saints 1791. 
 the Catharine Banks, the Louisa Cecilia 18 18, the Rapid 
 1817, and the Widow. I will add the Blandys as among 
 the noted and better stock wines of their day. One of the 
 Blandy brothers was the head of a well-known Delaware 
 family, some of whom reside here now. 
 
 Cheese and nuts bring out the flavor of sherry, port, and 
 Madeira, and this is why they come in so well and cause a 
 cheery lingering over the wine. This all may appear to be 
 fudge and gossip as introduced here, but I assure you it is 
 history and worthy of being preserved. In the old days many 
 of the gentlemen imported their pipes of Madeira, even from 
 the days of the early settlements on the James River in colo- 
 nial times, where the old planters exchanged their grain for 
 supplies for their families and plantations, and the pipe of 
 Madeira was a frequent article in the exchange. Again, 
 should any professional friend at any time have one of the 
 old boys '* with a toe" for his patient, and on one of his visits 
 find him suffering and cast down and even emphatic in his 
 remarks condemnatory of gout. I advise him to give the old 
 gentleman these lines to read, not whereby to do penance, 
 but to bring to his mind possibly visions of the good old days 
 now past and gone, and to help assure him and to reassure 
 him that there had been other sufferers, too. who had passed 
 through it all. and that again, even to him, dark as the pres- 
 ent may look, Ic bo)i temps z'icudra. 
 
 Port wane is a very gouty wine, in which fermentation has 
 been arrested by adding a certain amount of alcohol. It im- 
 
 283 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 proves greatly by age and in the bottle, it only being neces- 
 sary to watch the corks and recork it about, as a rule, every 
 five or six years. It is an astringent wine, and is used in 
 diarrhoeas when wine is indicated. It is often used for 
 making the famous "' mulled wine," which is a good tonic 
 taken with a cracker. The sweet wines are of little use in 
 medicine ; in fact, should rarely be ordered. The Tokays, 
 Malagas, lachrymse Christi, etc., contain more sugar and less 
 alcohol. Age renders them dryer as the sugar goes to alcohol, 
 but even this does not recommend them, even for sick women, 
 who. as a rule, defy all the rules of hygiene in their love of 
 sweets, especially the cordials, Malagas, and sweet cham- 
 pagnes. There is one thing to remember about all wines : a 
 sound wine may be acid, but this acidity is owing to the 
 natural acid of the wine, tartaric acid. A spoiled wine, or 
 turned wine, is sour because it contains acetic acid or vinegar, 
 which has developed because the fermentation has gone too 
 far, and it has soured just as cider or perry sours after a short 
 keeping. 
 
 What is the difference between a claret and a Burgundy? 
 Clarets are not known in France as clarets, but are known 
 as Bordeaux wines, and common wine is vin ordinaire, 
 which may apply to any of the cheap every-day wines. 
 The Burgundies are stronger wines than the Bordeaux or 
 clarets, and are therefore more gouty, and are both red and 
 white, but the true and best Burgundies are red. True Bur- 
 gundy, as the French understand it, is made from the grapes 
 raised in the department of Burgundy called Cote d'Or, the 
 golden side, which is only thirty-six miles long and reaches 
 from Chalon-sur-Saone to Dijon. Chambertin we rarely see 
 in America, or Corton, or Clos de Vougeot, or others of the 
 true Burgundies. Burgundies do not travel as well nor keep 
 as well as the clarets, and hence clarets are much more fre- 
 quently seen here. The best white Burgundy of the Cote 
 d'Or is the Montrachet. The most common of the white 
 Burgundies we see in America are the Chablis wines. They 
 
 284 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 are good, have good flavor, and are desirable for the sjck 
 where a Burgundy is needed, yet they are not absohitely true 
 Burgundies, are not wines made from the Cote d'Or grapes. 
 
 The Bordeaux or claret wines are named Bordeaux from 
 the city of Bordeaux, the capital of the department of Gironde, 
 France. The city of Bordeaux is the centre of this wine trade. 
 The vineyard name of the district is the Bordelais. The name 
 claret is taken from the French clairet, which means a clari- 
 fied wine, and, as before mentioned, is not used in France as 
 a name for wine. The Bordeaux wines are mild, not very 
 astringent, pure and fragrant, provided you get fairly good 
 ones. There are among them high-class wines, fine wines, 
 and ordinary wines. As a rule, a sea voyage improves them, 
 whilst it deteriorates Burgundies. The high-grade clarets 
 should always be warmed to the temperature of the room, in 
 order to bring out their bouquet and flavor. They gain in 
 bouquet by keeping in bottle, if properly corked. The Medoc 
 wines, named from a province of the Bordeaux country, are 
 among the best of clarets. The Chateau Margaux, the Cha- 
 teau Laffitte, and the Chateau Latour are rarely seen here in 
 their true form, but good Medoc wines may be found. Medoc 
 wines are natural wines, are not reinforced w^nes, and are 
 therefore mild clarets. We do not know now what we get 
 when we buy foreign clarets, as there is so much roguery at 
 Bordeaux, and the remedy is to use those made in our own 
 country, unless we get the better French wines from some 
 favored source. Among the best of the red wines of Bor- 
 deaux is the Haut Brion. 
 
 The Sauternes are white and are sweeter than the clarets, 
 but have good flavor and pure aroma. The poor grades are 
 sour. Barsac is among the best of them, if Barsac is a Sau- 
 terne. A bottle of the renowned and famous Chateau Yquem 
 would be a curiosity in America, or would have been some 
 time since. The great fortunes accumulated in this country 
 can now buy the best of the world's luxuries, and the high- 
 priced luxuries will follow the accumulated money. Chateau 
 
 28s 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 la Tour Blanche is another famous brand. The best of the 
 sweet wines are the Muscatelles, Malvoisie. and the Macca- 
 beo. They are sweet, full of aroma, and full of vim. They 
 go principally to Russia, where they doubtless turn to vinegar 
 in the stomachs of the unfortunate subjects of the great Czar. 
 
 The Rhine or German wines are usually of the lighter 
 character, both white and red, but the white far predominate. 
 They are low in alcohol, but yet keep well, as a rule. They 
 have much free acid and tartar salts, and are considered allow- 
 able in patients who are afflicted with calcareous troubles. 
 Hock wines are so named from the district of Hockheim, 
 from whence they come, near the banks of the Main. Johan- 
 nisberg is the prince of the Rhine wines, and I have already 
 spoken of it. If any one wishes the best, let him get Johan- 
 nisberg. The Riesling grape is one of the great Rhine grapes, 
 and we will see more about it when we come to speak of the 
 California wines. It is most interesting to visit the Rhine 
 region, the Rheingau, and to ponder and study the surround- 
 ings, where the work of ages has been carried on with the 
 grape as the chief factor. Steinberg is a brand next in flavor 
 to Johannisberg, and in some seasons is better. That is really 
 the case with all brands of wine. The grape of the brand 
 makes good wine this year and poor wine next year. Ask a 
 judge of wine about a brand, and he will first ask you to tell 
 him the year of the vintag-e of the particular specimen. That 
 makes a mighty difference. Other brands of Rhine wines 
 are Rupertsberger, Deidsheimer, Diirkheimer, Liebfrauen- 
 tnilch, the Fenerberger, Laubenheimer, Bodenheimer, Nier- 
 steiner, and many others. 
 
 The Moselle wines are light in alcohol, have much fra- 
 grance and an aromatic flavor, resembling elder-flower, which 
 is said to be artificial. The Moselle wines make good spark- 
 ling wine. Sparkling Moselle I have drunk frequently on 
 the Rhine, but rarely see it here. Some German hocks are 
 also fermented and made to sparkle ; in fact, a sparkling wine 
 may be made of almost any still wine by the arts of the wine- 
 
 286 
 
FORTY YEARS IN Tllli MEDICAL PROFESSION 
 
 maker. The Italian and ilnn<j^arian wines do not come to 
 us in any quantity except they come in wines hom France, 
 for much of the wine of Italy and Mun,t;ary f^nas to France 
 for blending- purposes. The wines of Italy are chiefly red, 
 at least those from Northern Italy are, and they are, as a 
 rule, rough and badly made, the skins, stems, and seeds being 
 macerated too long. Some of llic i lungarian light wines are 
 of fine flavor, have good aroma and smooth taste, and are 
 growing in favor in the United States. The white Italian 
 wines come from middle and southern Italy, and Tuscany; 
 as a rule, they are also rough and badly made. 
 
 Champagne. — Professor S. D. Gross always spoke of cham- 
 pagne as a " drink for the gods," and it was his custom, when 
 he came home weary and tired out from hard work, to open 
 a pint bottle of Mumm's Extra Dry, and sit down and enjoy 
 it. Whilst champagne is undoubtedly a " drink for the gods," 
 for the gouty individual or for the diabetic it is an invention 
 of the devil. For the delicate or for the weary valetudinarian 
 it is a generous and acceptable tonic, and as old age comes 
 over us, provided there is no contraindication, it is here that 
 alcohol in some form is so acceptable, and champagne be- 
 comes a remedy par excellence. Owing to the carbonic acid 
 it contains, it is a rapid stimulant, and is rapidly and com- 
 pletely absorbed, and this quality makes it of great use in so 
 many of the acute diseases wdiere we need rapid action and 
 where the digestive processes need just the spurring up that 
 the carbonic acid and alcohol give. In acute croupous pneu- 
 monia confine me to one remedy, and I believe I \\ould choose 
 champagne. 
 
 There are true champagnes. " Vin Brut," as the French 
 call it, \vine made without any artificial additions what- 
 ever, and fermented absolutely in the bottle. Then there are 
 the ordinary champagnes, when the maker hurries up the 
 acetous fermentation, by which all of the sugar is quickly 
 converted into alcohol. This is done by adding from four 
 to eight per cent, of sugar. Four per cent, makes the wine 
 
 287 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 sooner, and it is ready to sell sooner, but if it be a dry wine 
 it is dry because of the acetic acid in it, and not because the 
 sugar has gone to alcohol naturally. Here, then, is the distinc- 
 tion between " Vin Brut" and a sec or dry wine, or extra dry. 
 We get probably little *' Vin Brut" in the United States, but 
 we get plenty of dry and extra dry. Good sec (dry) or extra 
 dry (tres sec) can be bought for from twenty-five to thirty- 
 six dollars per dozen in this country, whilst true Brut, if of a 
 fashionable vintage, will sell for one hundred dollars per 
 dozen, or more, and is usually imported by the consumer. The 
 only wine I know of, sold by the general trade in this country 
 as " Vin Brut," is the wine of Ruinart Pere et Fils, Rheims, 
 France. Roosevelt & Schuyler are sole agents for the United 
 States and Canada. It is a good, sound, decidedly dry wine, 
 but I do not see how it can be a true Brut wine at the price, 
 although it is a high-priced wine as champagne is sold in the 
 United States. I am in error as to Ruinart being the only 
 reported Brut wine sold here. Moet et Chandon, one of the 
 very best French makers, offer a Brut wine as Brut Imperial, 
 together with their White Seal. Their green seal pink wine 
 has always been one of their best. Piper-Heidsieck also of¥er' 
 a Brut extra. The genuine Heidsieck wines are among the 
 best, but this brand is most frequently counterfeited of all 
 wines, probably, coming to America. Pommery and Greno, 
 sec, is another of the good brands, and so are the Veuve 
 Cliquot, but these are usually too heavy and sweet for the 
 sick. The wines of the house of G. IT. Mumm & Co. are 
 among the best and most reliable of champagnes in the gen- 
 eral market in this country, and are particularly well bottled 
 and corked, and this is of great importance when you have 
 wine on hand any length of time. Mumm's Extra Dry is a 
 very fair wine and safe for therapeutic use. 
 
 After these wines come champagnes of many kinds and 
 sorts, until you reach the vile stuff with sugar and any alco- 
 holic mixture for a base, with carbon dioxide forced into it 
 soda-water style. I will not speak of our domestic cham- 
 
 288 
 
FORTY YEARS FN THE MEDICAL PROFESSION 
 
 pagnes until I come to speak of our domestic wines in gen- 
 eral. Artificial champagnes, as a rule, besides being vile 
 mixtures, are heady; that is to say, the carbonic acid goes 
 rapidly to the head and produces an unpleasant fulness, differ- 
 ent from that produced by alcohol. God help the man who 
 drinks too much at one time of the best champagne ! It is a 
 sickening dose, but if the stuff is artificial, do not mention the 
 great misery which overcomes him. Sparkling Moselle is a 
 fairly good light wine, and if it can be obtained it can be 
 recommended for the sick when such a wine is needed. 
 
 The making of good champagne is a tedious and expen- 
 sive process, and consists of vatting, curing, bottling, racking, 
 disgorging, and handling. The bottles must be of the best, 
 and even then fifteen per cent, are broken in the process. I 
 remember having seen men testing bottles by the eye and 
 by the hands, in the famous cellars of Moet et Chandon, £per- 
 nay, France. The only wonder to me was, they did not all 
 fly to pieces in the mere testing. The slightest bubble in the 
 glass condemned the bottle. All champagne bottles are made 
 in clay moulds, and have no mould-marks on them. These 
 bottles must stand a pressure of one hundred pounds to the 
 square inch, thus reaching near the point of an explosive, 
 although not a high one. This is in the first fermentation. 
 The bottles must really stand a pressure of twenty atmos- 
 pheres, or three hundred pounds to the square inch. Cham- 
 pagne is a blended w^ine. The cuvee, literally a vat, is the 
 mixture or blend of the wine from which the champagne is to 
 be made. The cuvee is the most important part of the work 
 of making champagne, and requires great experience and tact. 
 It is necessary to ascertain the exact proportion of alcohol, 
 sugar, and acid, or the mousse or sparkle will be too violent, 
 or not violent enough. The blend of the wine gives the color, 
 lightness, its sweetness or dryness, and the strength, in a 
 great measure. 
 
 Now the corking is done by machinery, and it is an inter- 
 esting process. Formerly, string and wire both were used 
 19 289 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 to hold the corks ; now much wine is tied by wire alone. 
 After the bottles have been filled, they are tied with one string, 
 and are then kept at a temperature of about 80° F. for several 
 months. During this time the albumin and natural sediment 
 of the wine goes to the lower side, the bottles having been 
 kept on their sides. At the end of several months the carbon 
 dioxide has formed, and probably ten per cent, of the bottles 
 have exploded, yet the wine is not always lost, but is caught 
 in gutters and used sooner or later. 
 
 After fermentation has gone on for months the bottles are 
 put into racks and turned every day for several months. This 
 brings the sediment down to the neck, the racks holding the 
 bottles cork down. After this, the bottles are stood up per- 
 pendicularly on their corks. All champagne bottles have their 
 bottoms pushed up into a cone, as is well known. This is not, 
 as is generally supposed, to reduce the contents in quantity, 
 but is necessary for the strength of the bottle. After fermen- 
 tation has been completed the sediment must be gotten rid 
 of, technically called disgorgement. A man does this very 
 expertly, and loses very little of the wine. He wears a wire 
 mask, as do all who enter the champagne vaults during the 
 cure of the wine. If the wine is to be helped, and is not abso- 
 lutely natural, or brut, as soon as the disgorger has finished, 
 another man puts in the proper amount of syrup, and thus 
 arranges for the dryness or sweetness of the wine. The 
 syrup is cold process syrup only, and made with grape sugar, 
 and may have some flavoring added, but this is really not 
 proper. If too much wine has been lost in disgorging, more 
 is added, and the waste goes off into some such by-product 
 as vinegar. Nothing is wasted. 
 
 After the wine has been corked and wired it is put away 
 for probably a year in the cellars, and is then ready for label- 
 ling and packing. I think there is a difference of opinion as 
 to the improvement or non-improvement of champagne by 
 age. If it can be kept absolutely quiet and air-tight, and with 
 a proper environment, it may improve by age, certainly, at 
 
 290 
 
FORTY YEARS IN TIIF. MEDICAL PROFESSION 
 
 least, until all of the sugar has been converted into alcohol, 
 the wine then becoming" as dry as it can ever be. The life of 
 the cork must measure the life of the wine, and this is prob- 
 ably not over five or six years on an average. 
 
 France makes most of the champagne for the world, and 
 the true champagne district cann(jt supply grapes sufficient 
 for one-tenth, probably, of what France exports. Fortu- 
 nately, there are other places which furnish grapes for good 
 champagne, and this wine is utilized. Champagne is sup- 
 posed to have been invented by monks, and resulted from 
 the bottling of new wine and its exploding the bottles whilst 
 undergoing fermentation. The true champagne country of 
 France is the department of the Marne, east of Paris, and 
 which one passes through in going from Paris to Strasbourg, 
 on the way going through fipernay, Rheims, and Nancy. The 
 German army went by this route on their way to Paris after 
 Sedan. The surface soil is shallow, the subsoil calcareous and 
 chalky. The subsoil analysis is, carbonate of lime, 80; car- 
 bonate of magnesia, 2; silica, 18. Surface soil analysis : alka- 
 line salts, .985; carbonate of lime, 28.862; magnesia, 1.401 ; 
 oxide of iron, 4.545; phosphoric acid, .147; alumina, .849; 
 soluble silica, .095; organic matter, 3.750; insoluble resi- 
 due, 59.366. 
 
 Dealers in wine will tell you that brands of wine, especially 
 of champagne, like brands of cigars, are likely to deteriorate 
 after the brand has been well established, and recommends 
 the newer brands as often the best. This may be the case, 
 but I think the character of wines is most frequently deter- 
 mined by the year of the vintage, as the grapes differ so much 
 in different years, one year making good wine, and another 
 year making very inferior wine. 
 
 American Wines. — Within fifty years wine-making has be- 
 come quite an industry in the United States, and to-day Cali- 
 fornia, Missouri, New Jersey. Ohio, and Virginia furnish a 
 great deal of very good wine, especially of wines of the lighter 
 kinds. These wines are doubtless purer, and often better. 
 
 291 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 than the foreign wines, for they are so cheap that it does not 
 pay to take the trouble or expense either to change them or to 
 counterfeit them. In 1894 the producer, for his hghter wines 
 in CaHfornia, could barely command six cents per gallon in 
 his vaults, scarcely the price of good cider as we find it in the 
 general market. California is our great wine-producing State. 
 In 1898 she exported fifteen millions of gallons of wine, and 
 there the business is in its infancy, and doubtless, as years go 
 by, there will be a wonderful development, and a great rival 
 will arise to France and Germany and all of the other great 
 wine-producing countries of the world. 
 
 It is the duty of our physicians to know all about our native 
 wines and spirits, for, as a rule, they are within the reach of 
 all in price, and equal to any we can buy in efficiency, and 
 there is every reason why we should use them therapeutically 
 almost exclusively. When we ferment the grape the sugar 
 of the grapes is transformed, on an average, into alcohol, 
 48.4 per cent. ; carbon dioxide, 46.6 per cent. ; glycerin, 3.3 
 per cent. The malic acid is converted into succinic acid, .5 
 per cent., and the yeast ingredients 1.2 per cent., making in all 
 100 per cent. The germs come from the atmosphere, where 
 they exist always in the lower strata. On tops of mountains, 
 perhaps, natural fermentation would not start owing to the 
 absence of yeast germs, but here we could start it by adding 
 old must or yeast. Natural fermentation is best. Here is 
 an important point: if the fermentative germs do not exist 
 on mountain-tops, it is reasonable to suppose the pathogenic 
 germs do not exist there. Indeed, I have my doubts if tu- 
 bercle bacilli flourish at an elevation of over five thousand 
 feet above sea-level. The same may be the case on the high 
 seas and in deep canons and such places. In California wines 
 mature much more rapidly than they do in Europe. In the 
 future, we may expect wines from the Pacific coast of a high 
 character, especially of the Medoc type, and Burgundies, true 
 Sauternes, and those of the cognac type. I have never yet 
 seen a real good sherry among them ; there is too much sugar 
 
 292 
 
FORTY YEARS TN THE MEDICAT. PROFESSION 
 
 in tlieir sherries, and the same may be said of those oi the 
 Madeira type. Some of tlie |K)rt wines are fair, and arc par- 
 ticularly to be recommended for therapeutic use. California 
 sherries and ports are usually sold in the shops, not by any 
 particular name, but by the vintage, which really means noth- 
 ing, as choice old port 1885, pure port 1880, extra port 1870, 
 and so on ; and the same with the slierrics and those of the 
 Madeira class. 
 
 The California wine business has fallen into the hands 
 of trade entirely, and the wine, after it leaves the cellars of 
 the producers, is subject to all the arts and manipulations of 
 a not over-scrupulous set of dealers, and those who drink it 
 must take the best they can get. 
 
 This is really the case with all wines, even down to spu- 
 rious and artificial wines. The California hocks, Rhine wines, 
 and Sauternes, as we find them in the trade, take the names of 
 the true hocks, Rhine wines, and Sauternes, as Haut Sau- 
 terne, Choice Old Liebfrau Milch, Rudesheimer, Hockheimer, 
 and such. Of these wines, I like the true California Rieslings 
 the best. The sweet wines of California are sold as Choice 
 Old Muscatel, Choice Angelica, and such, and are among the 
 best of these wines obtainable, if they come from a good 
 source. California Burgundy we find in our markets as Bur- 
 gundy 1885, Burgundy 1880, and so on. The clarets come 
 under a number of names. The Zinfandels, to my mind, are 
 much the better. The Zinfandel grape has a peculiar flavor 
 of its own, which pervades the claret and grows on one rap- 
 idly. Of course, to get the best results in flavor, etc., the 
 wine is blended with the red and white Zinfandel and other 
 wines, Zinfandel predominating largely, until the desired re- 
 sult is obtained. These California clarets are stronger in 
 every way than the foreign clarets, and approach near to the 
 Burgundies, and need water added to them when used as or- 
 dinary table wine. The Cabernet Sauvignon makes a high- 
 class Bordeaux wine alone, and the Burgundy Pinot grape 
 does the same, but these are among the few on the Pacific 
 
 293 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 coast that do not need blending. We find in the shops clarets 
 under the names of Medoc, Cabernet, St. Jnlien, Larose, Pon- 
 tet Canet, Santa jMonica, and others. The Zinfandel grape 
 has been very extensively planted in California; it is hardy 
 and flourishes everywhere, and for this reason, among others, 
 it is the greatest claret grape, and properly blended, as Zin- 
 fandels we get the best of the California clarets, although the 
 Medoc class might possibly be better could we get them from 
 first hands. The Zinfandel has a bouquet of its own, is of 
 light astringency, and has a light color. 
 
 There is no manner of doubt, as we purchase medium- 
 priced clarets in the general market, that the California and 
 other American clarets are far better than the adulterated 
 stuff we usually get from abroad. I do not hesitate to advise 
 their use generally. Some very good clarets are made in New 
 Jersey near the coast, and among the best of American clarets 
 I have ever tasted are those made in Virginia, — near Char- 
 lottesville, I think. Physicians in seeking for good sound 
 wines of this class should not overlook these Virginia clarets. 
 Should we need a sweet wine, the Virginia Scuppernongs 
 are worth testing. Of the hock varieties of California, I 
 prefer the Rieslings. The Riesling is the noble grape par ex- 
 cellence of the Rhine, and predominates in the famous Johan- 
 nisberg vineyard. I believe a true Johannisberg will be made 
 in California much better than we can buy of European origin 
 in our market, if you can buy any at all. If you wish one of 
 the best wines of the Rhine wine type to-day, buy the Califor- 
 nia Riesling in preference to the average foreign wine. 
 
 This brings us through the list of American light wines 
 and other wines, except the sparkling wines, — champagne, the 
 true " Vin de luxe." Let me add here, that Calif ornians ac- 
 cuse the dealers who buy their wines of shipping them in 
 bulk to Europe and bringing them back here with European 
 high-sounding labels on them, and selling them to us as genu- 
 ine European wines. The way for us to stop this is to drink 
 our own wines, as we should do, whenever possible. As to 
 
 294 
 
FORTY YEARS IN THE MEDICAL PROFESSIOr: 
 
 American clicinii)agnc, 1 caniu^t say much for it. After look- 
 ing into the matter quite thoroughly, I have come to the con- 
 clusion that tliere is very little true chani])agne — that is, cham- 
 pagne fermented in the hottle — made in America. We have 
 plenty of soda-water champagne, and some of this is quite 
 pleasant, and serves a good part in taking the place of the 
 more expensive European wines. It is easy to make artificial 
 champagne from the natural dry wines. An Italian, Carpene 
 by name, has invented a simple and cheap apparatus. The 
 result of Carpene's apparatus is a fairly good sparkling wine, 
 at a very moderate cost. 
 
 Old Nicholas Longworth, of Cincinnati, years ago made a 
 sparkling Catawba, which was probably fermented in the 
 bottle. Arpad Haraszthy some years ago made a good cham- 
 pagne in California, which he called the " Dry Eclipse." I 
 believe this wine was fermented in the bottle. Haraszthy's 
 " Eclipse Champagne" is yet on the market, but I think he 
 is probably dead some time since. It is yet one of the best 
 of our domestic sparkling wines, but whether it is bottle fer- 
 mented now or not I do not know. " Golden Age" is one of 
 the better domestic brands, and so is Urbana and the Great 
 Western of the Pleasant Valley Wine Company. Cook's 
 Imperial Extra Dry is a fruity wine, and pleasant. As a rule, 
 our domestic champagnes lack body and are too sweet. They 
 sell by the case at from twelve to fifteen dollars per dozen for 
 quarts, and for pints they cost a trifle more. No good reliable 
 house can or will sell a domestic champagne fit for one to 
 drink much below these prices. The stufifs in the market 
 under these prices are slops, and w-orse than slops. 
 
 American brandies are chiefly made in California. They 
 are, as a rule, cheaper and much better than the ordinary 
 French brandies. If some one in the business in California 
 would supply physicians and their patients with a natural 
 brandy, — a brandy distilled from good pure wine, and bottled 
 without adding artificial flavoring or any coloring matter 
 whatever. — he would do a great good to suffering humanity, 
 
 295 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 and undoubtedly be rewarded by large financial returns. The 
 resultant liquor would be better than all the whiskeys, rums, 
 and other spirits on the market for its special purposes. 
 
 Unfermented grape- juices are now much used by soda- 
 water men and temperance people, so called. Grape- juice, 
 fresh, may be very nice and quite palatable. To prepare it, 
 it is boiled more or less, and bottled and sealed. Much of 
 it, to keep it, has some antiferment added, and this is done 
 particularly when it is retailed in small quantities ; and under 
 these conditions it is unwholesome and adds another turn to 
 the screws that Satan will give the soda-water men when he 
 gets hold of them for all the vile stuffs they have cunningly 
 devised for credulous humanity. 
 
 Adulterated wines and spirits of various flavors are used 
 and wholesale adulteration is carried on, and no law appears 
 to check it. You can buy any wine, brandy, or whiskey in a 
 general market, or receipts for making them, and no genuine 
 juice of the grape or grains will in any way enter into their 
 composition. Such concoctions are called " rot-guts," but 
 they do not appear to kill more rapidly than the better and 
 truer stuffs. Those who take them are generally the poor 
 among the dissipated, who have not the means to overeat 
 and over-drink which those have who are more prosperous 
 financially. The drunkard with unlimited means often goes 
 sooner and more rapidly than the tramp and " bum" with no 
 means whatever. As adulterants, ginger and peppers are 
 used, cocculus indicus, quassia, aromatic seeds, wormwood, 
 ammonia, nux vomica, gentian, juniper, chamomile, almonds, 
 orange-peel, licorice, honey and other sweets, and astringents. 
 In wines there is great roguery. According to Thompson, a 
 fair imitation of Chateau Latour can be made with almonds 
 and other nuts, and a Chateau Lafitte with violets and nuts; 
 and to other grades cherry- juice is added. Artificial pig- 
 ments, alum, tannin, fusel-oils, cider, pear- juice, and lime salts 
 are often added to wines. Logwood is frequently added to 
 make clarets and Burgundies. It is the fusel-oil in liquors 
 
 296 
 
FORTY YliAKS IN 'JllIC MEDICAL PROFESSION 
 
 that usually causes headache, ioul mouth, and dyspeptic symp- 
 toms following their use; and if carried on too long the hob- 
 nail liver comes with all its succeeding horrors. There is no 
 longer taste for even Chambertin or Chateau Yquem. 
 
 Wines are made from almost any fruit or vegetable con- 
 taining sugar, — as fn »ni rhul)arb, the tomato, the fig, the 
 strawberry, the blackberry, the raspljerry, and the currant. 
 That made from the latter is among the best. If such an 
 excess of sugar were not usually added, these wines might 
 be useful in sickness. As usually seen, they are a sorry dose 
 for sick or well. 
 
 Cider and perry — the first from the juice of the apple, and 
 the other from that of the pear — are common drinks. They 
 contain a small amount of alcohol, malic acid, some extrac- 
 tives, sugar when new, and some salts. When first fermented 
 they are very palatable, but soon get sour and go to vinegar. 
 Cider in France is used as a gout cure. For the life of me, I 
 cannot see why or how it can add to the alkalinity of the 
 blood, except by forming salts in the system with the bases it 
 meets, and even then not enough to have any practical effect. 
 I have known one or two gentlemen who lived in France 
 to declare it did them great good. Those of our patients who 
 need cider had better always drink fresh cider. All bottled 
 cider, as a rule, is cider in which fermentation has been lim- 
 ited by the addition of antiferments, and is neither palatable 
 nor proper to drink. 
 
 It is wonderful the number of articles made from the wine 
 residues, and many of them are of every-day therapeutic use. 
 Those products that furnish the greater number of articles 
 are the pomace, the lees, and the tartar. Tartaric acid is ob- 
 tained from the pomace by a complex process. Spirit is made 
 from the pomace by distilling it. Frankfort black is made 
 from the pomace. Oil and tannic acid are extracted from the 
 seeds, and vinegar is made from the pomace; but true wine 
 vinegar — the best vinegar — is made from true wine gone on 
 to the acetous fermentation. QEnocyanin. a coloring matter, 
 
 297 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 is made from the skins, and is much used in wine-making" 
 for coloring purposes. Verdigris is made from the pomace 
 and copper. Grape pomace is also used for food for stock 
 and for fertilizing purposes, I suppose from the salts of 
 potash, nitrogen, and phosphoric acid formed in it. The lees 
 contains alcohol and tartrates, and is valuable as to the quan- 
 tities of these contained. The common raw tartar, or argol, 
 is a very valuable by-product of the grape, and is precipitated 
 on the lower side of the barrels. This tartar salt is usually in 
 composition as potash or lime salt. There are two kinds of 
 raw tartar, the white and the red. Raw tartar is a great com- 
 mercial product, and it is therefore, like many other articles, 
 much adulterated, sand being used, and also steam-boiler 
 crusts. Physicians should know about such matters. Tar- 
 taric acid is made from the raw tartar by an interesting 
 process. It is first changed to calcium tartrate, then by sul- 
 phuric acid all the tartrate of lime is made into sulphate 
 of lime and tartaric acid, the calcium sulphate precipitating. 
 The tartaric acid is then crystallized out. Tartar emetic is 
 a double tartrate of potash and antimony. The acid tartrate 
 of potash, cream of tartar, a bitartrate, is a very important 
 by-product from the grape. The neutral tartrate of potash 
 is also a well-known substance. There is another salt, a very 
 valuable one, and one deservedly used in medicine, the double 
 tartrate of soda and potash, called the Rochelle salt. This 
 has a mild, not unpleasant, salty taste, and we all should know 
 that it is one of the good things coming from the grape as a 
 by-product in the art of wine-making. 
 
 From the official reports of the British Board of Trade 
 we can compare the consumption of alcoholic drinks in Eng- 
 land, Germany, France, and the United States. In France the 
 consumption of wine increased from 21.3 gallons per capita in 
 1885 to 29.5 gallons per capita in 1896. In Germany the 
 consumption of wine is 1.06 gallons per capita per year. In 
 England it is four-tenths of a gallon per capita per year, and 
 in the United States it is twenty-two-hundredths of a gallon 
 per capita per year. All these show a slight increase from 
 
 298 
 
FORTY YEARS IN TIJE MEDICAL PROFESSION 
 
 former years. All wine consumed in England is imported. 
 In the United States, seventy-eig^ht per cent, of the wine used 
 is made at home. This is an important showing. Germany 
 consumes 25.5 gallons of heer per capita per year, and in this 
 there is a tendency to increase. England consumes 30.7 gal- 
 lons of malt liquors per capita per year, and the United States 
 consumes fifteen gallons per capita per year. The French, 
 among whom wine is the national drink, consume five gallons 
 of beer per capita per year, and beer-drinking is increasing 
 in France. Belgium consumes forty-three gallons of beer 
 per capita per year, and Bavaria fifty gallons per capita per 
 year, and Bavaria makes the best beer in the world. Of 
 spirits, Germany consumes 1.94 gallons per capita per year. 
 France consumes 1.85 gallons per capita per year. England 
 consumes i.oi gallons, and the United States .83 of one gal- 
 lon per capita per year. In Holland and Belgium the con- 
 sumption is two gallons per capita per year. England collects 
 as taxes from spirits, wines, and malt liquors $449,820,000. 
 Our country collects $444,116,123. The French govern- 
 ment at large only collects from these sources $102,400,000 
 per year, but there are other taxes by cities and towns, just 
 as we have in the United States, and are not included in the 
 general government tax. Germany only collects directly 
 $57,969,040. The average German at home or abroad rebels 
 when you tax his beer, for it is the main-spring of his pleas- 
 ure, not only of his palate, but of his wdiole social life. The 
 old lady said to her son, who had left his American home 
 to reside temporarily in Germany, " Henry, I hope you go 
 to church on Sundays." '' Yes. mother," said Henry. 
 " Henry," said the good mother, " I trust you visit the pas- 
 tor now and again at his home." " That is not necessary, 
 mother, I always meet and chat with him at the beer-garden 
 on Sunday after service." 
 
 I think there is one thing we may truthfully say : the con- 
 sumption of spirits as a beverage is gradually declining in 
 this country, and that mania a potu is more and more be- 
 coming a rare disease. Such is my individual experience. 
 
 299 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 and it has been and still is considerable, having been con- 
 nected during much of my professional life with various elee- 
 mosynary and criminal institutions where such cases abound, 
 and I have seen it in men and women of all colors and na- 
 tionalities. The increased consumption of beer and wines 
 accounts for much of the decrease of consumption of spirits, 
 and it looks to me as though the coming man would gradu- 
 ally cease to use spirits as a beverage, a condition greatly to 
 be wished for truly. I think man begins to realize the fact 
 that the consumption of spirits as a beverage is the greatest 
 bane to his health and happiness that lies in his path of life. 
 Instinct tells him this, just as instinct teaches the lower ani- 
 mals to avoid certain plants as poisonous. The ancients in- 
 vented spirits (probably the Arabians), and I mean by spirits 
 the brandies, whiskeys, rums, gins, and such, not the much 
 less harmful malt liquors nor the mirth-provoking mellow 
 wine. The ancients used these spirits as medicine alone. 
 May we who live after them, and may those who live after 
 us, gradually come to use them in no other way; and as 
 medicine may we of the medical profession learn to guide and 
 guard their use. 
 
 I add here an important table taken from an article in the 
 University Medical Magazine for October, 1898, by Dr. B. 
 Franklin Stahl. The table is by Roberts, and shows the re- 
 tarding effects of wines and spirits on digestion, both pep- 
 tic and salivary digestion. Let me first quote from Stahl's 
 conclusions, using his quotations from Chambers, Osier, and 
 others. 
 
 " Wines and beers, a glass or two taken with a meal, will 
 help gastric digestion. When consumed in quantities, as not 
 infrequently used, a pint of claret or a large amount of beer, 
 they retard digestion more or less. As to time of adminis- 
 tration, they should be given with food, or a part in certain 
 instances taken just before food. Osier says the man who 
 drinks before noon is lost. As a beverage, I say, a man 
 should postpone his libations until the dinner hour. Cham- 
 bers says the laborer, whose limbs are stiff with his day's toil, 
 
 300 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 and the brain-worker, who still more acutely feels the wear 
 and tear of bread-winning, are not wasting the money they 
 earn with which they buy a fair ration of beer or wine for 
 their evening meal. 
 
 " The malt liquors are indicated as fattening agents, to 
 stimulate digestion, and as mild tonics and stimulants. The 
 spirituous liquors are required in acute illness, and are bene- 
 ficial in old age. The wines are most useful in convalescence 
 and in those cases where we are unable to give the stronger 
 liquors, because of their unacceptability to the stomach. Fur- 
 thermore, they have a fixed place in our dietetics. They are 
 to be avoided in atheromatous conditions of the blood-vessels, 
 and particularly in angina pectoris from the free salts they 
 contain, and this is why spirits is the drink of old age 
 when the blood-vessels have deteriorated. Finally, consider- 
 ing some special conditions where selection must be made, 
 it may be said that in anaemia, in conditions included under 
 the term malnutrition, and in convalescence, you will do well 
 to order a good claret, Burgundy, or Sauterne. The lighter 
 wines of good quality are best for daily consumption for 
 brain-workers who lead sedentary lives, and who need a 
 digestive and stimulant. 
 
 " You will hasten recovery in many by ordering a light 
 luncheon, accompanied with wine, betw^een meals. Gout is 
 regarded by many as the child of port w-ine. Next in order 
 as causative of gout comes champagne, especially the sweet 
 wines. A gouty person should drink only the dryest of the 
 dry champagnes. Then come sherry, Madeira, Burgundy, 
 and malt liquors. Cider is almost as potent in its causation 
 of gout as are the wines. Some differ from this assertion, 
 as I have explained. Claret is almost the only safe wine in 
 gout. I will say that water is safer and better than any of 
 the alcoholics. In diarrhcea and dysentery you will find 
 brandy of service, especially in the old. Claret is also valua- 
 ble here ; in Germany and France it is frequently used to the 
 exclusion of w-ater. Very Httle water the French and Ger- 
 mans drink, anyhow. In diabetes, claret is safest, but Bur- 
 
 301 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 gundy, hock, or dry sherry and some whiskey will be found 
 to agree. I would say, drop the sherry of all kinds, and con- 
 fine the whiskey to those specimens not colored with caramel. 
 In fever, if self -limiting and of moderate severity, alcoholic 
 stimulants are not indicated until convalescence has been 
 established, when they may be given with advantage. You 
 may regard it as an indication for alcohol when the fever is 
 very high from the outset, and the heart appears embar- 
 rassed, as shown by a weak or absent second sound. Chronic 
 alcoholism, in nearly all instances, may be successfully treated 
 without liquor. When it is required, it should be given in 
 the form of spirits, and in large doses. In liver disease alco- 
 hol is usually contraindicated. If demanded, claret or brandy, 
 well diluted with aerated water, should be chosen. Insomnia 
 is often relieved by mulled wine or by whiskey and hot water. 
 Beer is also of service in this connection. I need hardly say 
 there is danger of the formation of the habit under these cir- 
 cumstances, nor need I remind you that whiskey is best for 
 the old. In consumption the malt liquors are of service early, 
 and the spirituous liquors later in the disease. Remembering 
 that here, more than in almost any other disease, the diges- 
 tion is of the greatest importance, you will be governed en- 
 tirely by the effect produced on the digestion. In chronic 
 rheumatism and renal disease they may only be given when 
 the demand is greater than the contraindication, and all the 
 while the effect must be noted. Well-diluted spirits are best 
 here. In scurvy, malt liquors are especially serviceable, yet 
 some do better on claret or spirits and water. 
 
 " Now, while certain suggestions can be made quite posi- 
 tively and on well-founded reasons, there must remain many 
 instances where your individual judgment must come into 
 play. Whenever you prescribe an alcoholic, whether to man 
 or to woman, whether to the young or to the old, remember 
 well and ponder well on the terrible weapon you are using 
 both for good and evil. I beg of you not to use it therapeu- 
 tically in a reckless manner, and I pray God to especially 
 guide you in prescribing it to the young and susceptible." 
 
 302 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 
 5 per cent 
 
 15 per cent 
 
 40 per cent. . 
 
 50 per cent 
 
 60 ner rent 
 
 Wine, Liquor, or Beverage added. 
 
 
 135 min. 
 
 180 min. 
 
 Embar- 
 rassed. 
 300 min. 
 
 Almost no 
 digestion. 
 
 3 3. 
 
 ? ?' 
 
 Proof Spirit, 
 Brandy, Gin, 
 or Whiskey. 
 
 
 
 
 115 min. 
 150 min. 
 200 min. 
 200 min. 
 
 Embar- 
 rassed. 
 
 Almost no 
 digestion. 
 
 J 
 
 
 
 
 180 min. 
 
 200 min. 
 
 Embar- 
 rassed. 
 
 3 <-" 
 
 3 3 
 
 8 
 
 7 
 
 9§ 
 
 
 <^ 
 
 S g. 
 
 3 p 
 
 8 
 
 5' 
 
 
 
 
 
 140 min. 
 180 min. 
 
 8 
 
 3. 
 
 
 
 
 p" 
 n 
 
 00 
 
 o 
 
 3. 
 3 
 
 
 100 min. 
 130 min. 
 
 3. 
 5 
 
 Cham- 
 pagne. 
 
 si" 
 
 
 140 min. 
 200 min. 
 
 3. 
 3 
 
 
 Burton 
 Ale. 
 
 
 3 
 5' 
 
 
 3 3. 
 
 3' 3' 
 
 
 8 
 3. 
 
 
 Lager 
 Beer. 
 
 c 
 o 
 
 O 
 
 303 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 TABLE SHOWING THE EFFECT OF SHERRY AND HOCK UPON 
 SALIVARY DIGESTION.i (ROBERTS.) 
 
 Proportion of Sherry or Hock contained in 
 the Digesting Mixture. 
 
 Sherry. 
 
 Hock. 
 
 
 8 minutes. 
 30 minutes. 
 No action beyond 
 
 soluble starch. 
 No action. 
 4 minutes. 
 
 16 minutes. 
 
 0. 5 per cent 
 
 1. per cent. 
 
 80 minutes. 
 No action beyond 
 soluble starch. . 
 No action. 
 
 
 40. per cent., neutralized 
 
 4 minutes. 
 
 1 Time normally required equals four minutes. 
 
 TABLE SHOWING THE EFFECT OF ALCOHOL, BRANDY, AND 
 WHISKEY ON SALIVARY DIGESTION. ^ (ROBERTS.) 
 
 Proportion of Proof Spirit, 
 
 Brandy, or Whiskey 
 in the Digesting Mixture. 
 
 Proof Spirit. 
 
 French Brandy. 
 
 Scotch Whiskey. 
 
 5 per cent 
 
 10 per cent 
 
 20 per cent 
 
 40 per cent 
 
 60 per cent 
 
 70 per cent 
 
 90 per cent 
 
 4 minutes. 
 
 4 minutes. 
 
 4 minutes. 
 
 8 minutes. 
 14 minutes. 
 20 minutes. 
 Very slow action. 
 
 4 minutes. 
 Very slow action. 
 No action. 
 No action. 
 No action. 
 No action. 
 No action. 
 
 4 minutes. 
 30 minutes. 
 Very slow action. 
 No action. 
 No action. 
 No action. 
 No action. 
 
 2 Time normally required, four minutes. 
 
 Fruits and Nuts as Articles of Diet. — There are few things 
 of more importance for the physician to know and under- 
 stand than the composition of foods, their effects upon the 
 system, and the philosophy of the physiology of metabolism, 
 including katabolism and anabolism. There is great defect 
 in the teachings of the day in our medical schools in regard to 
 these matters, and whilst they have advanced considerably 
 in recent years, there is yet great room for betterment and 
 improvement. 
 
 304 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 A j^lcince at the accompanying tables will show the value 
 of fruit as food from the economic stand-point. 
 
 VARIOUS SUBSTANCES. 
 
 Waste 
 
 from loo 
 
 pounds as 
 
 purchased. 
 
 Edible Dry 
 
 Matter in loo 
 
 pounds as 
 
 purchased. 
 
 Cost of one 
 pound of 
 
 Edible Dry 
 Matter. 
 
 Fuel value 
 
 of one 
 pound as 
 purchased. 
 
 Potatoes 
 
 Wheat flour 
 
 Corn-meal (bolted) . . 
 
 Oatmeal 
 
 Milk 
 
 Fresh codfish .... 
 Hind-quarter of fat beef 
 
 Fowl 
 
 Oysters 
 
 Pounds. 
 
 15- 
 
 29.9 
 14. 1 
 30. 
 
 Pounds. 
 17.9 
 
 87.5 
 87.1 
 92.8 
 
 13- 
 
 11. 6 
 
 35-9 
 24.4 
 
 11. 7 
 
 2.8 
 3-5 
 
 2-3 
 
 6.7 
 17.7 
 34-5 
 33-3 
 61.5 
 150. 
 
 325 
 1640 
 
 165s 
 i860 
 
 325 
 205 
 
 "35 
 680 
 
 23s 
 
 FRUITS. 
 
 Waste 
 
 from 100 
 
 pounds as 
 
 purchased. 
 
 Edible Dry 
 
 Matter in 100 
 
 pounds as 
 
 purchased. 
 
 Cost of one Fuel value 
 
 pound of I of one 
 
 Edible Dr>' ' pound as 
 Matter. purchased. 
 
 Apples . . . 
 
 Apricots . . 
 
 Blackberries . 
 
 Grapes . . . 
 
 Pears . . . . 
 
 Plums . . . 
 
 Raspbenies . 
 
 Strawberries . 
 
 Averagre 
 
 Pounds. 
 25. 
 
 6. 
 
 25- 
 25- 
 
 4.8 
 
 Pounds. 
 
 13-5 
 14. 1 
 10.5 
 
 15-9 
 12. 1 
 20.6 
 14.2 
 8.2 
 
 8.4 
 21.4 
 76. 
 19. 
 
 12.5 
 20.2 
 
 49-3 
 98.3 
 
 225 
 225 
 245 
 320 
 
 235 
 370 
 255 
 155 
 
 12.4 
 
 :!8.I 
 
 256 
 
 30 = 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 VEGETABLES. 
 
 Beets 
 
 Cabbage . . . 
 Carrots .... 
 Lettuce .... 
 Onions .... 
 Parsnips . . . 
 Green peas . . 
 Pumpkin . . . 
 Rutabaga turnips 
 Squash .... 
 Tomatoes . . . 
 
 Average . 
 
 Waste 
 
 from loo 
 
 pounds as 
 
 purchased. 
 
 Pounds. 
 20. 
 
 15- 
 20. 
 18. 
 10. 
 20. 
 
 SO- 
 SO- 
 SO. 
 
 Edible Drj' 
 
 Matter in 100 
 
 pounds as 
 
 purchased. 
 
 Pounds. 
 10. 
 
 Copt of one 
 pound of 
 
 Edible Dry 
 Matter. 
 
 6.6 
 18.3 
 
 9- 
 102. 
 
 19- 
 9- 
 
 72.8 
 
 30. 
 
 7.8 
 
 37-3 
 22.3 
 
 Fuel value 
 
 of one 
 pound as 
 purchased. 
 
 170 
 140 
 170 
 
 8S 
 210 
 285 
 200 
 
 60 
 
 13s 
 125 
 
 loS 
 
 25-7 
 
 30.3 
 
 ^53 
 
 These are Professor W. H. Jordan's tables, and are valu- 
 able from the stand-point of the chemist and of the economist. 
 The tables show that fruits cost about ten times as much 
 as flour, corn-meal, and such articles, taking into considera- 
 tion their food values; therefore there must be found other 
 considerations than that of food value for prescribing and 
 eating fruits. Fruits have long been a great part of the diet 
 of the older races, and of the semi-civilized and savage tribes. 
 The latter, especially those of the tropics and temperate lati- 
 tudes, live on fruits, fish, and starchy vegetables, and these 
 people are usually healthy, strong, and vigorous, and were 
 more so until their more civilized and enlightened brothers 
 introduced among them the various seductive poisons of a 
 higher civilization. As a rule, with fruit we take much bulk 
 that is not nutritious, and this very bulk is useful because it 
 prevents us eating too much of the stronger articles of diet. 
 Given fruit as the first course at breakfast, and we will not 
 be so apt to overload our stomachs with buckwheat cakes 
 and sausages, and the fruit taken will in many ways help us 
 
 306 
 
FORTY YEARS IN THE MEDICAT. PROFESSION 
 
 to get Cfjnifortably rid of the grentcr burden, the sugars and 
 acids of the fruit course being the factors here. The aroma 
 of the fruits is ])leasing to the senses, and thus aids secretion 
 in various forms, especially of the digestive juices. 
 
 Taking this view of the matter, fruit is better taken with 
 the meal, and before the meal rather than after the meal. 
 During the meal especially we crave condiments or some- 
 thing to cater to our taste and bring out a j^-oper secretion of 
 the digestive juices and ferments, and to accomplish this we 
 eat cranberry with our turkey, currant jelly with our roast 
 mutton, capers with our boiled mutton, roast apple with our 
 goose, and apple-sauce with our roast pork. A good scien- 
 tific reason for eating these fruits is that the fats of the meats 
 with which they are eaten are, as a rule, neutral fats ; that is 
 to say, they have not sufficient acid in them to cause the alka- 
 line bile and pancreatic fluid to emulsify these fats, and the 
 fruit acids here make up the deficiency in nature. What a 
 teacher nature is, anyhow ! 
 
 Fruits contain much water, and the general make-up is 
 finished with sugars, starches, the gelatinous substance called 
 pectin, acids, and cellulose, the cellular tissue, composed of 
 carbon, hydrogen, and oxygen. When fresh they are mark- 
 edly antiscorbutic and appetizing. Pectin is a carbohydrate, 
 and the quince contains a large amount of it, making it espe- 
 cially good for jelly. The acids of fruits are the citric, the 
 tartaric, especially in the grape, and the malic, which exists 
 largely in the apple particularly. The organic acids are in 
 union with alkalies, and these form salts, and these salts are 
 split up in the system and leave the alkalies free, which usu- 
 ally combine and form carbonates or phosphates with acids 
 found in the body. 
 
 Again, this is a fact of great importance both practically 
 and scientifically. Why do we give lemon- juice and expect 
 benefit, in rheumatic fever for instance, when the blood is so 
 acid already that the profuse perspirations change litmus blue 
 to red almost by their fumes before contact? A\'e can answer, 
 in giving lemon- juice in such cases, or any other fruit- juice, 
 
 307 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 we do not give it as an acid to increase the already over-acid 
 condition of the blood. We give it, paradoxical as it may 
 appear, as an alkali to increase the alkalinity of the blood, 
 bringing this about by the citric acid of the lemon being 
 combined with salts, and these salts splitting up and reappear- 
 ing as carbonates and phosphates, and these reducing the 
 acidity of the blood, and thus aiding the return to health of 
 the rheumatic condition. Even if the citric acid of the lemon 
 is free, it meets salts in the system, and does the same good 
 in a more direct way. This matter is all important. 
 
 Dr. Hoy has launched a tirade against fruit as an article of 
 diet, simply because it is an acid diet, as he claims, and de- 
 stroys the alkalinity of the blood. Hoy claims that fruits are 
 mostly sugar and water, and this mixture ferments easily and 
 destroys digestion. He claims that digestion, especially diges- 
 tion below the stomach, is accomplished in alkaline surround- 
 ings and in alkaline media, and the acid in fruits eaten de- 
 stroys this alkalinity and thus interferes with digestion, and 
 therefore that fruit is improper diet in most instances. I 
 think we have shown that it does no such thing, and that the 
 fruit acids, both combined and free, are, by the time they reach 
 the point of intestinal digestion, in a condition not of acidity 
 to render the surroundings acid, but are neutral or alkaline, 
 and in this way help digestion, as they undoubtedly do even 
 if they do not contain a special digestive ferment, like the 
 pine-apple, called bromelin, which has the property of convert- 
 ing albuminoids into peptones. The juice of the papaw has 
 the same power, even in a greater degree than the pine-apple, 
 and doubtless many more fruits have juices with this power, 
 if, indeed, all fresh fruit-juice does not have it to some degree 
 greater or less. The prune and the fig and such fruits he 
 condemns as causing by their coarse skins and seeds bowel 
 irritations. More likely nature has provided just such fruits 
 for these special purposes for man, and instead of condemning 
 them it is our duty to learn all about them and use them in 
 the proper cases. The fig, the date, the prune, and such fruits 
 are, indeed, most useful fruits. 
 
 308 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Hoy says aj^ain, in his opposition to fruits as food for man, 
 that the intestinal juices do not act on starch, albuminoids, 
 and fats, but act on tlie maltose marlc frmn the starch by the 
 saliva and pancreatic juice, and on all forms of sugar, which 
 may have been taken with the food. They convert these into 
 glucose. The media in which this conversion occurs must be 
 alkaline. Acid destroys this action, therefore acid in fruit 
 eaten stops it. Yes, it would if it was present as free acid, 
 but it is not present as free acid, but is combined with bases 
 in the form of salts, and has an alkaline effect. Again, the 
 small intestines transfer the digested matters in them into the 
 blood. By their epithelial cells they change peptone into 
 serum albumin and glol)ulin, and as these they enter the 
 blood, and here the media must be alkaline, and therefore 
 fruit-eating is against this process. I say again, fruit rather 
 helps along the alkaline surroundings, does not either check 
 them or stop them, and is therefore beneficial. There is one 
 condition where it is wrong to eat much fruit, especially 
 wrong, such a fruit as apples, for example. If such be eaten 
 after a hearty dinner, where much starchy matter like rice 
 and potatoes has been eaten, acid indigestion will surely fol- 
 low, because the fermentation has been hurried by the combi- 
 nation of the fruit- juice and the excess of starch. A little 
 soda or potash will soon correct this temporary trouble. That 
 " fruit is gold in the morning, silver at noon, and lead at 
 night" is not altogether true, but will serve somewhat as a 
 guide in our eating it. 
 
 Hoy gives the following as definitions of fruits and vege- 
 tables. " All succulent fruits produced by annual plants, as 
 well as the stalks, roots, leaves, and tubers of any plant used 
 by man as food, are vegetables. All succulent fruits produced 
 by perennial or biennial plants, and used as food, are fruits. 
 The ripened edible seeds of leguminous and graminaceous 
 plants are vegetable food, as are also nuts, which are the dry, 
 oleaginous, or starchy fruits of perennial plants, in which the 
 epicarp is liquefied." He speaks of fruit as acid and of vege- 
 tables as not acid. ]\Iany vegetables contain acid, as the 
 
 309 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 spinach with its oxalic acid, the cabbage with a Httle of the 
 same,' and the rhubarb with a great deal. The tomato has 
 acid, much of it at times, but by its continued evolution from 
 the realm of the vegetable to that of the fruit, it may be well 
 to pause in classifying it, so rapid is its transformation to the 
 fruit list approaching. Fruits contain, some of them, a little 
 fat and waxy matter, as the olive, but, as a rule, sugars and 
 starches predominate, with a very little nitrogen in the shape 
 of vegetable albumin. Their aroma and flavor are given by 
 various essential oils and compound ethers inherent in them 
 and generated in the ripening of the fruit. The mangosteen 
 of Borneo and the durian of Java are said to hold these above 
 all others and to be the most luscious of all fruits. From the 
 latitude in which they are raised, they are evidently sweet 
 fruits. The cultivation of sour fruits, whether in a temper- 
 ate or a hot climate, reduces the acid in them and improves 
 their aroma and flavor. There is one thing always to remem- 
 ber in eating fruit of any and all kinds, — they are invariably 
 an inviting host for all pathogenic and other germs, and 
 should never be eaten until the outer skin has been removed 
 or until they have been thoroughly washed and cleansed. The 
 boys' green-apple bellyache comes as often from the patho- 
 genic germs that go down with his apples as from any indi- 
 gestible properties pertaining to the fruit he has eaten. 
 
 A good anecdote is told of the great Pasteur, who above all 
 other men probably knew of the risks we run from taking in 
 pathogenic germs with our food. Pasteur was dining, and 
 among other things cherries were served with the fruit. Pas- 
 teur was very careful to thoroughly wash his cherries before 
 eating them, and delivered quite a lecture on pathogenic 
 germs and their dangers, to those about the table, among 
 whom were several children. The dinner finished, Pasteur, 
 wanting water, in the absent-minded way often attributed 
 to great men, quaffed off the water in which he had washed 
 his cherries, and the children chaffed him in great glee. Here 
 were two object-lessons in nature study, one on absent-mind- 
 edness, and one on pathogenic germs. 
 
 310 
 
FORTY YEARS IN THI-: MJ-.DICAL PROFESSION 
 
 Fruits arc iisiially classified as stone fruits, pomes, f>r the 
 fleshy fruits, Hkc tlic ;ii)|)lc or pear, berries, ca])sules, or C(jv- 
 ered fruits, and the pepos, or melon family. Some, like 
 the banana and the date, will support life for a \on^ time on 
 account of the great amount of sugar in them ; others, like 
 the pear and the api)lc, are hcl])S in the general diet; and 
 others again have less nutritive value than these, but have 
 their uses as appetizers and digesters, as the papavv and the 
 pine-apple. Thompson sums up the uses of fruits in the ani- 
 mal economy as follows : 
 
 To furnish nutriment. 
 
 To convey water to the system and relieve thirst. 
 
 To introduce various salts and organic acids, which im- 
 prove the quality of the blood and react favorably upon the 
 secretions. 
 
 As antiscorbutics. 
 
 As diuretics, and to lessen the acidity of the urine. They 
 do this owing to the decomposition of various alkaline salts 
 in the blood or tissues, which are reformed into alkaline car- 
 bonates, and as such are excreted. For this reason fruit is 
 good for gout and the gouty diathesis, because it prevents the 
 accumulation of acid urates. 
 
 As laxatives and cathartics. 
 
 To stimulate the appetite, improve digestion, and give vari- 
 ety in the diet. 
 
 As special cures for certain diseases, like the grape-cure, 
 although their specific action is very doubtful. 
 
 The apple, lime, lemon, and orange have much potash, lime, 
 and magnesia in their composition, and are the antiscorbutic 
 fruits par excellence. Peaches may be added to these. The 
 most nutritious fruits are the sweet and starchy fruits, and 
 are the banana, the fig, the date, the plum, and the grape. 
 The most watery of fruits are the melons, the citrus fruits, 
 as oranges, limes, lemons, and shaddocks, together with 
 grapes. 
 
 The ripening of fruit is an interesting process. The ab- 
 sorption of oxygen by the fruit has much to do with it. The 
 
 311 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 contained acids and the tannin are altered by this as time 
 goes on and the astringency and acidity of the fruit decrease, 
 the starch going into levulose or ghicose, and the gelatinous 
 pectin is formed. Now, with these the volatile ethers and oils 
 appear, and the fruit is ripe, or fit to eat, and this holds and 
 this ripe condition increases until the fermentations of decay 
 start up and the fruit returns again to its original elements, 
 just as do all other organic bodies. 
 
 Thompson gives the most digestible fruits as grapes, or- 
 anges, lemons, cooked apples, figs, peaches, strawberries, and 
 raspberries. I look upon strawberries and raspberries as 
 rather gouty, from the less tendency of their acids to com- 
 bine with bases during digestion, and thus leaving more free 
 acid than other fruits to disturb the alkalinity of the blood. 
 Not so digestible as the other fruits in the list given are 
 melons, prunes, plums, raw apples, pears, apricots, bananas, 
 and fresh currants. Of course, in all this much depends upon 
 the condition of the fruit as to ripeness, etc., and the idiosyn- 
 crasy of the individual. The most useful fruits for invalids 
 are oranges, lemons, baked apples and pears, stewed prunes, 
 grapes, and the meal made from the banana, but not the fresh 
 banana ; it is too sweet and too starchy. 
 
 Fruit-juices I have spoken of, and of fruit-syrups, which 
 are much used, and are made either from the fresh fruit or 
 from the prepared fruit- juices; both are equally good when 
 the materials are in proper condition. Lemonade, orange- 
 ade, raspberryade, raspberry vinegar, and such compounds 
 are much used, and should be made from the juices of the 
 fresh fruit, when obtainable, especially lemonade. Circus 
 lemonade is made from citric and tartaric acid and colored 
 with probably some aniline dye to make it pretty. Such a 
 drink has no call for either the sick or the well. For the sick, 
 lemonade and orangeade made from the effervescing waters 
 are among the best and most invigorating, and such drinks 
 should not be overlooked. 
 
 Dried fruits are fruits from which the water has been ex- 
 pelled either by the sun or by artificial heat, and are preserved 
 
 312 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 l)y their own sugar or glucose. Most of these are bleached 
 by sul])hur fumes. Whilst this may do no great harm to 
 them as articles of food, it surely can do no goofl, and is a 
 trick of the trade that should be stopped. 
 
 Preserves we are all familiar with. They are, .as a rule, 
 indigestible, containing a large excess of sugar, and are more 
 and more being superseded by canned, tinned, or bottled 
 fruits. Here the fruits are heated to destroy the bacteria 
 present in them and then are hermetically sealed, and will 
 keep in this condition just so long as no fresh air enters to 
 bring new bacteria among them to set up fermentation. Re- 
 member one point : after a tin can has been opened, imme- 
 diately empty it and keep the contents until used in a china 
 or glass bowl. If left in the can the contents soon become 
 poisonous and unfit for food. 
 
 The very finest and best of the fruits, and, in fact, all other 
 articles of food preserved in this way, are those done up in 
 glass. They are probably more expensive, but are in every 
 way safer, for there are many reasons why metal cans and 
 metal soldering, together with the acids of the contents, may 
 react on the consumers and produce metallic poisoning, espe- 
 cially lead poisoning. The competition in trade causes many 
 of the canners to use low-grade tin, the tern plate, which is 
 little more than iron with a coating of lead ; indeed, in this 
 quality of metal there is little or no tin, and if the cans are 
 recklessly soldered so the solder may enter and mingle with 
 the contents, then doubly unfortunate are those who con- 
 sume it. Remember, as to all preserved, canned, or other- 
 wise treated fruits, they lack the elements of freshness, and 
 for some unexplained reason they are not nearly so useful as 
 antiscorbutics as are the fresh fruits or vegetables. 
 
 To show the importance of fruit to the American people 
 as a part of their diet, let me give a short review, the facts 
 for which I obtain from government publications and my own 
 experience. The early colonists found here many wild fruits, 
 berries, grapes, and nuts. From these selections were made, 
 and these were cultivated and improved, and foreign slips and 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 cuttings were planted and grafted. In 1821 about three mil- 
 lions of pounds of dried fruits were imported. Apples were 
 the first fruit we exported successfully. John Bartram, of 
 Philadelphia, the well-known originator of Bartram's Garden 
 in that city, a part of which is the Eastwick property at Gray's 
 Ferry, and I think is now a public park, grew on these grounds 
 the well-known Newtown pippin apple, which he successfully 
 exported to England by sailing vessels, the trip consuming, 
 on an average for the eastern voyage, forty days. In 1821 
 we imported over two millions of pounds of raisins. In 1894 
 California alone exported one hundred and three millions of 
 pounds. 
 
 It is not generally known that the dried currant as im- 
 ported is not a true currant, but is a small seedless raisin from 
 Greece. They can be grown and cured in California, but 
 the business is not very profitable. Plums are growing to be 
 a large item of fruits in this country, and prunes are already 
 a very large item, and are rapidly driving out the foreign 
 product. In 1896 California produced over fifty-five million 
 pounds. Figs are now being raised and cured in this country 
 in quite large quantities. In Mississippi and in Louisiana 
 cjuite a number are packed, and in California the original old 
 Black Mission fig, grown there as such for over one hundred 
 years, is being replaced by trees of the Smyrna and Italy 
 varieties, and the fig industry is prospering. California pro- 
 duces now over a million dollars' worth per year. Dates are 
 not as yet grown commercially in this country, nor are tama- 
 rinds. 
 
 The citrus fruits are grown very largely in Florida, Cali- 
 fornia, and Arizona, and some in Louisiana. Previous to 
 the serious damage to the trees in Florida in 1894 and 1895, 
 the Americans controlled the market in the United States. 
 In 1894 Florida grew five million boxes, and in 1900 they 
 hope to again have a large crop, barring accidents from frost. 
 The Florida oranges, considering the care and attention given 
 to them in selection and cultivation, are doubtless the finest 
 of any in the world. The California oranges are chiefly of 
 
 314 
 
FORTY YEARS IN TIN': MIOUICAL PROFESSION 
 
 the Bahia variety, or, as otherwise called, the Washington 
 navels and Riverside navels. California can ship nov^ four 
 million boxes of orang'es annually. This is indeed a won- 
 derful State. I have been on the summit of the Sierra 
 Nevada Mountains and could have jumped into a snow- 
 bank that would have buried me many times over my head. 
 In two hours by rail you could land and i)ick oranges and 
 lemons from the trees and see the palms flourishing in the 
 open air. 
 
 Australia is a great fruit country. The pine-apple, the 
 grape, and the banana are grown in Queensland. The grape, 
 the orange, the apple, and the peach are grown to perfection 
 in New South Wales and South Australia. Western Austra- 
 lia is a great grape country. In Tasmania they raise among 
 the finest apples and pears of the world, and ship them to 
 Europe in cold storage successfully. The strawberries, rasp- 
 berries, currants, and gooseberries of Tasmania are also noted. 
 My friend. Dr. H. Benjafield, of Hobart, Tasmania, is one of 
 the great Australian authorities on fruit, and is an accom- 
 plished gentleman. If we reflect, we see that when the trees 
 of Australia are in bloom, our trees here are about maturing 
 their crop, and vice versa, they being about as far south of 
 the equator as we are north of it. When their fruit arrives 
 in Europe or in the United States most of our crop of the 
 year has been consumed. In the Australian countries fruit 
 is so abundant that, in the season, pine-apples can be pur- 
 chased at three cents apiece. United States money, grapes for 
 from five to six cents per pound. Mandarin oranges for one 
 cent per dozen, and bananas for from two to four cents per 
 dozen. 
 
 In Australia the consumption of fruits by all classes of 
 people is enormous, and thoroughly explodes the idea that 
 fruit causes general intestinal disturbances and is unhealthy. 
 The death-rate in these countries is very low. There are 
 luncheon shops in all of the towns of Australia, Tasmania, 
 and New South Wales where fruit is given, all one can eat, 
 with a cup of tea, coffee, or milk, for from ten to twelve 
 
 31S 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 cents. These shops are used by all classes for the mid-day 
 meal, and the people patronizing them are usually strong and 
 healthy. In summer the weather is very hot, and fruit ices 
 are used to a large extent. There are many of what are 
 called tea-rooms, for women exclusively; the attendants are 
 women, who in their black dresses, white aprons, and white 
 caps have a neat and attractive look. In these rooms six 
 cents is paid for a cup of tea or coffee, with bread and butter 
 and all the fruit they can eat. I mention these matters here 
 because I think physicians should encourage such arrange- 
 ments for both men and women in this country, for the Aus- 
 tralian people are a strong, vigorous, sober, intelligent, and 
 progressive race, and this strength and vigor comes, very 
 much of it, from their environment and from the great quan- 
 tities of fruits and meats they so notably consume. In giving 
 fruit with bread and butter and cereals, use the sweeter and 
 subacid fruits to the exclusion of the very acid or sour fruits. 
 The very acid fruits may affect digestion of the starch in the 
 bread and cereals, as they may not be sufficiently combined 
 with bases, but contain too much free acid. When the sys- 
 tem appears to crave acids, eat sour fruit, do not drink vine- 
 gar and such. 
 
 As to the peculiar medicinal properties of some nuts and 
 fruits, almonds are credited with giving brain-power, juicy 
 fruits give the higher brain- and nerve-power, apples give the 
 brain rest, prunes are nerve sedatives. There are fruit-cures, 
 and several centuries ago medical men became enthusiastic 
 over their medicinal virtues, and grapes and strawberries to 
 the amount of many pounds a day were recommended to be 
 eaten. Here certainly was an opportunity for nettle-rash to 
 get in its work, and for the vasomotor system to become em- 
 barrassed. 
 
 The grape-cure, not only for the indigestions, but for va- 
 rious other ailments, is carried on at the present time to a 
 considerable extent. Many persons flock every season to 
 the Rhine vineyards, or to Italy and the south of France, to 
 take the grape-cure for from six weeks to two months, and 
 
 316 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 are expected for that Icii^^li of time to eat from five to ten 
 pounds of grapes daily. Grapes are fattening, and hence are 
 good for tlic tuberculous and dyspeptics, and they are also of 
 service to the neurastiienics. The gra[ies must be thoroughly 
 ripe and of the best (quality. Sour gravies are said to have 
 the opposite effect. " The fathers have eaten sour grapes, and 
 the children's teeth are set on edge." 
 
 The various pathogenic and other germs of the alimentary 
 canal are said not to thrive at all in fruit-juices, and this is 
 given as the secret of the success of the various fruit-cures. 
 There is another way to look at it. Those who take these 
 cures are generally high livers, are from among the Carlsbad 
 people, and the fruit-cure to them is semistarvation, and semi- 
 starvation to them is just what they need for restoration to 
 health. A course at Carlsbad is about one and the same thing 
 with grape-cure. 
 
 The physician should never tire of nature study, and before 
 I pass to special fruits let me give some views of Dr. Boiling 
 W. Barton, of Johns Hopkins, on " Why the leaves turn color 
 and fall." 
 
 Dr. Barton says the leaves of most of our trees fall in the 
 autumn because it would be poor economy on the part of the 
 tree to retain them. They would catch the snows and ices of 
 winter and thus break the limbs of the trees by this extra 
 accumulated weight. The evergreens hold their leaves in 
 winter; such are tough and leathery or reduced to needles 
 like the pines. Most trees shed their leaves by an act of am- 
 putation, or sloughing, and cover the scar with a layer of 
 cork, which stops bleeding and excludes germs. In the fall 
 they assume the splendid colors of autumn foliage. This 
 change in color has, so far as is known, no special biological 
 significance; it is a mere incident in the later life and death 
 of the leaves. Color in flowers makes of them organs of al- 
 lurement to insects, birds, etc., which visit them for their 
 honey, and in return render service in pollination. Color in 
 fruit makes it conspicuous, and secures free transportation by 
 sundry animals, which thus scatter the seed. The hues of au- 
 
 317 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 tumn foliage mean little more in the lives of the plants than 
 does the color of precipitates in the test-tubes of the chemist. 
 
 To understand these color changes in the dying leaf we 
 must know something of the purpose and functions of healthy- 
 active leaves. This function is not, as is often said, to give 
 shade, whether to the plant itself or to man or beast. If they 
 shade the roots and so economize water, this is only by the 
 way, and not the important role they play in the life of the 
 plant. The plant gets its food from the earth and the air. 
 These are the raw materials, salts of the soil dissolved in 
 water, and oxygen and carbonic acid gas free in the atmos- 
 phere. These simple substances are received in the leaves 
 and spread out with the green substances of the leaf-cells to 
 the action of the sun's rays, and are thus converted into the 
 complex organic products upon which the plant depends for 
 its growth and upon which animals can live. The leaf-green 
 or chlorophyll is the substance upon which all this compli- 
 cated chemistry depends, and has therefore been spoken of 
 as the most important of all known compounds, for life, as 
 we know it, could not exist without it. Without light and a 
 certain high temperature the chlorophyll would avail nothing. 
 
 Leaves may be likened not inaptly to a factory operating 
 only in summer time, when the sun is bright and the air warm. 
 Then it is that a number of definite products are manufac- 
 tured and transported back through leaf-stalk and stem to 
 parts where they may be immediately needed for growth, else 
 to be stored for future use. As autumn comes on the nights 
 grow chill and conditions become unfavorable; preparations 
 are set on foot to stop work and to destroy the factory. At 
 this period the factory is more or less filled with manufactured 
 goods and of waste or accidental products, the more impor- 
 tant ones of which are to be removed and saved before the 
 factory goes. The most expensive of all these is the chloro- 
 phyll. This, with starch, sugars, etc., is to be carried into the 
 body of the plant. But they are not transmissible in their 
 present form ; they must be changed into soluble if not sim- 
 pler substances, and so removed to the storage-places. In 
 
 318 
 
FORTY YEARS IN TlfE MEDICAL PROFESSION 
 
 this breaking up of the chlorophyll especially, new proflucts 
 arise, such as microsco])ic oil-clrf)])S and certain fine granular 
 bodies. These refract the light and arc the cause of the color 
 in the leaves, together with other coifM-ing-mattcrs dissolved 
 in the cell sap. In a word, we may say that the color of au- 
 tumn foliage is due to waste products at the time the leaves 
 are being emptied of valuable material preparatory to being 
 cast off as dead tissue. The better the crop of leaves, the 
 more brilliant fall colorings we may expect. Frost is not 
 necessary to start it, only chilly nights. The changes may 
 occur in July even, if wounds or disease come to the tree. 
 In the northern part of the United States and in Canada the 
 colorings are brighter than in the Middle States or farther 
 south. The reason is, the maple abounds in the North and 
 has brilliant coloring, and, moreover, in the North they are 
 not subject to droughts so much as farther south, and conse- 
 quently the cool autumn catches the leaves with richer con- 
 tents, more color-forming material. 
 
 SPECIAL FRUITS. 
 
 The Apple. — Chemically the apple is composed of vegeta- 
 ble fibre, albumin, sugar, gum, chlorophyll, malic acid, gallic 
 acid, lime, and much water. It also contains more prosphorus 
 than any of the other fruits or vegetables. This is useful in 
 forming the nervous matter of the brain and spinal cord and 
 the general nervous system. What I have said of fruits in 
 general will apply to apples and all fruits to follow, and I wish 
 merely to call attention to the best of the species for all pur- 
 poses, and especially for purposes of diet for the sick. A phy- 
 sician should know wdiich apple, which pear, which grape, 
 etc., is the best, their season, and all about them. The apple 
 grows in most of the States of the Union, and is generally 
 distributed over the world. Some varieties, of course, are 
 better in some districts than others, and some are known only 
 in certain localities. Of the hundreds of varieties of fruits. I 
 only propose to mention and describe those which have merits 
 sufiticient to warrant them a place. 
 
 319 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 SUMMER APPLES. 
 
 SniJtincr Queen. — This is the best of our early summer 
 apples for eating out of hand or for cooking. It is striped 
 with red on a yellow ground, and is of medium size, some- 
 what acid, spicy and rich flavor. 
 
 Szveet Bough. — Next comes the Sweet Bough, a greenish- 
 yellow apple, sweet and pleasant for eating, but does not cook 
 well. 
 
 Red Astrachaii. — Large, striped, red apple, very beautiful, 
 and one of the best of the summer apples to eat raw or to 
 cook. It came to us from Russia. 
 
 Yellow Transparent. — Also a Russian apple, of a light- 
 yellow color, and one of the best of its season. 
 
 Summer Permain. — One of the very best and handsomest 
 of the late summer apples. This is a beautiful red apple and 
 very choice in every way. 
 
 There are other summer apples, but they are not much 
 used anyhow, especially now, as we can keep over the winter 
 varieties so late by cold storage, and those I have given are 
 the best. 
 
 FALL APPLES. 
 
 Maiden's Blush. — This is the handsomest and among the 
 best of the early fall apples. It is yellow, with a distinct blush, 
 and very good for eating and cooking and for decoration ; it 
 is very handsome. 
 
 Fallawater or Tulpehocken. — This is a large, yellowish- 
 green apple, and very good for eating or cooking. 
 
 TJie King Apple. — This is a large red apple, and in every 
 way a very desirable one. 
 
 Smith's Cider. — We see a great many of these apples in 
 market in the early autumn. It is a red apple, very good to 
 cook, not very good to eat raw. 
 
 Grimes's Golden Pippin. — Yellow with russet dots. A de- 
 sirable fall apple in every way. 
 
 Yellozv Bell-Flozuer — Belle Fleur. — Beyond a doubt, when 
 you can get this apple, raised in Pennsylvania, New Jersey, 
 
 320 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Delaware, or Maryland, it is of all apples facile princeps of its 
 own season, from October to Christmas. There are many in 
 the market coming' from the West, but they do not compare 
 in flavor with those raised in the States mentioned. The sur- 
 face is pale yellow, with a beautiful blush in the better speci- 
 mens. The apple is juicy and crisp, with a spicy aroma and 
 flavor altog-ether its own. 
 
 WINTER APPLES. 
 
 Baldzviii. — This is a red apple, and probably the most com- 
 mon apple in the market in early winter. It is one of the 
 best of the all-round apples, being tasty and pleasant, both to 
 eat out of hand and to cook. 
 
 Ben Davis. — Of late this is the apple we see most of in the 
 winter market, especially late in winter and in the spring. It 
 is a beautiful red apple, but there its good traits end. It is 
 mealy, soft, and tasteless, and has not one redeeming merit to 
 recommend it, except its looks and keeping qualities. The 
 latter especially is unfortunate, for the sooner it rots the better 
 for lovers of good fruit. For the grower it is unfortunately 
 a profitable apple. 
 
 Spitzcjihcrg. — This is a solid, not very attractive-looking 
 red apple, known among the market men as "Spitz;" but 
 taste it, and you will say there is a spiciness, a flavor, that 
 attracts you ; and eat another, and you will say, " Surely, 
 this is the best apple by odds I have ever eaten." It is the 
 best apple / have ever eaten. No other apple compares with 
 it, not even the Newtown pippin or Bell-Flower. It is very 
 scarce in the market. New York is the chief source of supply. 
 There the trees are not doing well, and this makes the apple 
 scarce and high. Never mind that; buy it at any price if 
 you w^ant a delicious fruit to eat out of hand or to cook. 
 
 Nezvtozvn Pippin — Albemarle Pippin. — This is a grand 
 apple, and the best specimens grow in the Shenandoah Valley, 
 in Virginia, and its neighborhood, and in our market it is the 
 most expensive apple, bringing nearly double the price of 
 other apples. Her ^Majesty the Queen of England is said 
 21 321 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 to import a supply of them yearly, although, as a rule, the 
 Englishman will take none but red apples. The Newtown 
 pippin is a large, yellowish-green apple when ripe. The stalk 
 is short and deep-set, and surrounded by light-russet rays. 
 As a rule, to get the finer specimens now, we must spray the 
 trees with fungicides, as we must all apple-trees at the present 
 day. 
 
 When buying apples of any kind, always look for smooth, 
 regular-shaped specimens. The irregular knotty ones have 
 been prey to insects. Those with black and other dark spots 
 have been prey to fungi, and, as a rule, are what are called 
 scabby, and have been raised by careless growers and are not 
 first class. 
 
 Rome Beauty is an apple from Ohio we see frequently in 
 the market. It is of medium size, verging on dark red in 
 color, and is in every way desirable. 
 
 Cart House and its seedling Nero are lovely apples; in- 
 deed, are among the most desirable for all purposes. There 
 are two species of Cart House, — the yellow and the white 
 flesh. The skins of both are deep red, and every specimen 
 will without an exception show one or more little warty ex- 
 crescences. The yellow-fleshed variety is by far the best, 
 and we in Delaware never take any other when we have the 
 choice. 
 
 Stayman's Wine-Sap (its parent, the Old Wine-Sap). — 
 Always buy Stayman's. This species originated with Dr. 
 Stayman, of Kansas. It is large, of a bright-red color, keeps 
 well, and is in all respects a desirable apple. 
 
 Lady Apple. — This is a most beautiful little apple for deco- 
 rating purposes, and has a lovely aroma and spicy, attractive 
 flavor. It is of a yellowish waxen color, with deep crimson 
 cheeks where it greets the rising sun. This is the proper 
 apple to treat as the French do for table and other decora- 
 tions. Just before the coloring sets on the apple they apply 
 with an adhesive material a cut of any figure they wish to 
 show on the apple, — a bird, a fish, or any mythological or 
 other figure. This remains until the apple is gathered, and 
 
 322 
 
FORTY YEARS IN TllIC MI'.DICAL PROFESSION 
 
 if still adhering-, it is removed and the figure shows on the 
 apple. In Paris apples so treated bring from one to two 
 francs each. 
 
 The Morvcn is a very beautiful apple and of very high 
 flavor. It is a seedling of the Lady apple but somewhat larger, 
 and originated on " Morven," one of my fruit-farms at New 
 Castle, Delaware. 
 
 Northern Spy. — This is a large red apple, with much green 
 in its tinges, and is one of the first-class fruits found in our 
 winter market. 
 
 There are several native Delaware and Eastern Shore of 
 Maryland apples whose cultivation is increasing. If you ever 
 come across them, buy them and you will not regret it. They 
 are: Late Delaware Winter, which resembles Lawver, a red 
 apple; Jackson, a red apple resembling the old Grindstone, 
 of which it is supposed to be a seedling; Lankford, a red 
 apple w^ith green tinges ; and the Lily of Kent. 
 
 Smokehouse is a red apple, a very good one, but scarce 
 after November. 
 
 Roxhury Russet. — This is an apple of beautiful russet color, 
 of medium size, and shading off in places to a light green in 
 many specimens. It keeps late, and is a most toothsome apple 
 in the spring, probably the best obtainable after February. 
 Golden Russet and English Russet do not differ greatly from 
 Roxbury Russet. Grindstone is a good apple at this season 
 also. 
 
 Szvaar. — A greenish yellow. If you can buy Swaar you 
 will make no mistake, especially in the early v^inter. 
 
 York Imperial. — A light-crimson apple, shaded with dark; 
 subacid and very desirable. 
 
 Stark. — You will often find Stark in the market. It is a 
 greenish yellow. I cannot recommend it highly. 
 
 Now and again you must allow an apple to your diabetic 
 patients, and you want them as free from sugar as possible. 
 The best for such a purpose are Red Astrachan, Summer 
 Permain. Smith's Cider, Bell-Flower, King, Rome Beauty, 
 Spitzenberg (this is the apple par excellence for the diabetic), 
 
 323 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Northern Spy, Stark, York Imperial. Apples in the spring 
 have more sugar, and should then be avoided by the diabetic. 
 The foregoing list comprises the best obtainable, and is suffi- 
 cient to suppl)^ apples of the best varieties all through the 
 apple year. Oregon and some of the far Western States are 
 beginning to ship us apples. They come in boxes like ordi- 
 nary orange-boxes in shape and holding about a half-bushel 
 of fruit. They are handsome, but are by no means equal in 
 flavor to the apples east of the Rockies. 
 
 Peaches. — The chemical composition of the edible parts 
 of the peach is as follows: Water, 93.7; protein, .5; fat, .2; 
 carbohydrate, 5.3; ash, .3. Fuel value per pound, 115. I 
 give here a list of the peaches found in our markets during 
 the season, and as nearly as possible in the order of their 
 ripening, beginning with the earliest, which usually come 
 from Georgia, beginning the latter part of June, and ending 
 with those coming from- California as late as the Christmas 
 holidays. 
 
 Alexander. — This is about the earliest peach, but we rarely 
 see it except when it is grown near home, as it is too delicate 
 to carry far. It is a white peach, of good flavor, and usually 
 a freestone. 
 
 Amsden. — This closely resembles Alexander in every way. 
 
 Early Rivers. — Freestone. This is the best of the early 
 peaches, and comes ten days after Alexander. It is a hand- 
 some white peach. 
 
 Troth. — This is a beautiful little white-flesh peach with 
 deep blush. It is a dry, sweet, mealy peach, and is a free- 
 stone. Some years peaches cling to the stone more than 
 they do other years. Of course, there are some peaches 
 always clingstone. 
 
 Mountain Rose. — Freestone, white flesh, one of the best 
 peaches, and much like the old Early York, whose place it 
 has taken. 
 
 St. John. — The best large, early, yellow peach, with a red 
 cheek. 
 
 Foster. — A very good orange-red peach with yellow flesh. 
 
 324 
 
FORTY YEARS IN THE Ml'JJlCAL PROFESSION 
 
 Crawford's Early. — This is much like T'oster, but it is not 
 holding its own as a variety; it is freestone. 
 
 Old Mixon. — This is the queen of peaches as to flavor. No 
 other peach equals a perfect Old Mixon in flavor, I care not 
 where it is grown; and those grown on the i^elaware and 
 Chesapeake Peninsula are the most luscious of all the peaches 
 of the world. It is a freestone. The skin is of a yellowish 
 white with a deep-red cheek; the flesh is white, red at the 
 stone, and both tender and rich. 
 
 Moore's Favorite. — Almost exactly like Old Mixon. 
 
 Reeves's Favorite. — A very large and handsome peach with 
 yellow flesh, among the very handsomest and best of the yel- 
 low peaches ; freestone. 
 
 Stump. — A superb peach with white flesh and a bright-red 
 cheek, and is free from the stone. 
 
 TJi'urber. — A good peach, supposed to be a seedling of the 
 Chinese cling, but it is a freestone. 
 
 Old Mixon Cling. — Like its sister, the freestone Old 
 Mixon, it exceeds in flavor all other cling peaches, but is a 
 very rare peach in the market. 
 
 Mary's Choice. — Resembles Crawford's Early, but is su- 
 perior to it in every way as found to-day ; freestone. 
 
 Susquehanna. — A rare peach in the market, but it is a 
 magnificent one of yellow flesh and red cheek, and is usually 
 very large ; freestone. 
 
 Elhcrta. — A truly grand peach, and the show peach of 
 Georgia. It is a seedling of the Chinese cling. Yellow flesh, 
 with beautiful deep-red cheek, and is elliptical in shape and 
 freestone. Its only fault is, some specimens have some bit- 
 terness of flavor. 
 
 Georgia Bell. — A very fine peach, something like Elberta. 
 but is white fleshed and comes from Georgia. 
 
 Dr. R. P. Harris told me the finest peach ever in the United 
 States was the " Robinson Crusoe.'' a seedling grown in Dr. 
 Cox's yard at Ninth and Spruce Streets. Philadelphia. Dr. 
 Cox's son brought the stone from Juan Fernandez and 
 planted it. 
 
 325 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 . Crazi'ford's Late. — A superb peach ; yellow flesh, red cheek ; 
 very large, handsome, and luscious; subacid flavor; free- 
 stone. 
 
 Lemon Cling. — Elegant, large, and handsome cling peach. 
 
 Ward's Late. — A freestone, white-flesh peach, with a beau- 
 tiful red cheek and delicious flavor. It is scarce in market. 
 
 Chair's Choice. — A very good late yellow-flesh peach, with 
 red cheek; freestone. 
 
 Fox's Seedling. — One of the best of the late white free- 
 stone peaches, with red cheek. It is rather oval in shape, with 
 an unguiform projection at its apex end. 
 
 Smock and Beer's Smock. — Late, yellow flesh, very dry 
 and mealy peaches, much used in canning and preserving. 
 For those who like a dry, mealy peach they are very fine. 
 
 Doctor Black. — A very late, very large, lemon flesh color, 
 luscious freestone peach. The finest peach of its time of 
 ripening, coming after the other desirable peaches have gone. 
 Very few are on the market, but Mr. Charles Wright, of 
 Seaford, Delaware, is propagating the tree commercially. 
 
 Geary. — A very late freestone, yellow peach, which has the 
 peach flavor somewhat, but never ripens. This is our latest 
 peach. 
 
 White Heath Cling. — This is a grand peach, is very scarce, 
 and is the proper peach to brandy. 
 
 Salway. — Not very good in the East, as a rule, but is the 
 best peach we get from California, and can be bought on the 
 fruit-stands usually up to Christmas. It is mealy as we get 
 it, and, like all California peaches we get in the East, is in- 
 sipid. The other peaches coming from California are, chiefly, 
 Early and Late Crawfords. 
 
 In order that one may know when to go to the markets for 
 certain peaches, I give a table of the time of ripening of the 
 better varieties of the Delaware and Chesapeake fruits. A 
 week to ten days later will give the time for finding the New 
 Jersey, Western Maryland, and Pennsylvania peaches, and 
 four to six weeks earlier will find the same varieties from 
 Georgia and the South and Southwest: Alexander, July i 
 
 326 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 to 7; Amsdcn, July i to 7; Early Rivers, July 20 to 25; 
 Troth, Au^c^ust 15 to 20; Mountain Rose, August 23; Fos- 
 ter, August 15 to 18; Crawford's Early, August 15 to 20; 
 Reeves, August 20; Moore's Favorite, August 23; Old 
 Mixon, August 25 ; Ward's Late Free, September i to 2 ; 
 Sus(iuchanna, August 31; Mary's Choice, August 20; 
 Stump, September i; Crawford's Late, August 30; Fox's 
 Seedling, September 5 to 7; Smock and Beer's Smock, Sep- 
 tember 15; Salway, yellow, freestone, September 25; White 
 Heath Cling, for brandied peaches, October i to 15; Doctor 
 Black, October 10 to 15; Bilyeu, October i to 12. 
 
 If a diabetic should eat peaches at all, and he surely may 
 now and again, the proper ones for him are the subacid varie- 
 ties, the best of which are Foster, Early and Late Crawford, 
 Reeves, Susquehanna, Smock, Salway, Elberta, Doctor Black, 
 and Bilyeu. I look upon the peach particularly, but all fruits 
 more or less, as very important articles of diet. The acids 
 of the peach are very prone to break up the compounds of the 
 waste substances, particularly of nitrogenous waste, and thus 
 they are enabled to pass off through the kidneys, and an ex- 
 cess of water drunk helps this passing off. These tissue- 
 wastes may be largely in the form of uric acid, and thus 
 peaches particularly may help sufferers from rheumatism, 
 gout, and allied disorders, by breaking up these compounds 
 and placing them in a condition to be eliminated from the 
 system, and thus relieving the toxaemia, for toxaemia it 
 really is. 
 
 Pears. — These I give in the order of their ripening. The 
 summer pears are usually perishable, but the late pears hold, 
 many of them, up to Christmas, and by the use of cold storage 
 can be held indefinitely, and are found in our markets up to 
 warm weather in the spring. I may say here that pears are 
 grown on the natural grafted or budded pear-tree, — that is, 
 pear on pear, — but many are grown on quince stock. This 
 dwarfs the tree, and hence we have standard pears and dwarf 
 pears. The dwarf trees are shorter lived, but undoubtedly 
 produce the best specimens of fruit in every wa3^ Some varie- 
 
 327 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 ties dwarf better than others. Some pear-trees require to 
 be double worked to get good results; that is to say, you 
 graft one variety on a stock, and then next year to this you 
 graft a variety that grows well only on this last stock. There 
 are half -standard trees, that is to say, trees that have been 
 planted as dwarfs, — pears on quince-roots, — and these planted 
 deep enough to throw out roots from the pear stock as well 
 as from the quince. These trees live longer than pure dwarf 
 trees. Early pears ripen better in a cool room or shaded spot, 
 after they have been picked. Late pears should be left on the 
 trees as long as possible, then kept as nearly as possible in a 
 temperature of 40° F., and then moved to a warmer apart- 
 ment as we wish to ripen them. Wilder and Koonce are two 
 early pears, whose status is not yet exactly known. Man- 
 ning's Elizabeth is the best of our early summer pears for 
 eating out of hand, and is due in mid-summer. Its flesh is 
 melting, sweet, and perfumed, with plenty of juice. It is 
 rather a small red pear, with some russet on the crown half. 
 
 Lazvson. — One of the most beautiful pears grown, but not 
 of high quality to eat. It comes in July. It very much re- 
 sembles the German pear, Forelle, the most highly colored of 
 all pears when properly grown. The only place I have ever 
 seen the Forelle in market in this country was in Baltimore. 
 These pears, the Lawson and Forelle, are very valuable for 
 decorative purposes, and for the sick-room are equal to the 
 rose, violet, or carnation; and what is more comforting to 
 the sick than fruit and flowers and the subdued tones of sweet 
 music, and what a touching object-lesson has Dumas given 
 us in " La Dame aux Camelias" ! 
 
 Bartlett. — Among the grandest of pears in every point of 
 view. The best come from Pennsylvania, New York, Dela- 
 ware, and Maryland, the handsomest from California, but 
 these lack flavor. When will people learn to buy fruit for 
 eating purposes, not by its color, but by its taste? A dealer 
 in choice fruits some time ago asked me if I had any highly 
 colored pears to send him; he said it made no difference 
 about flavor, he wanted high color, to make it sell. Califor- 
 
 328 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 nia sends the clearest, cleanest, highest colored fruits, be- 
 cause her climate is so dry and free from fungi, which do 
 so much to harmlessly discolor fruit. Jt all lacks flavor here, 
 for it is pulled too green. In California it is better, but not 
 equal to Eastern fruit. 
 
 Clapp's Favorite is a handsome i)car, but a[)t to be found 
 unsound at the core. 
 
 Doyenne d'Ete is a small summer pear, as its name indi- 
 cates ; of good flavor. 
 
 Buifum is a very nice russet pear coming in the early au- 
 tumn. 
 
 DucJiesse d'Angoidcuic. — One of the largest and grandest 
 of pears, and w^hen properly ripened is superb for eating. It 
 has a thick skin and not always high color, but these do not 
 hurt it. No one should eat the skin of any fruit; the rind 
 carries germs, pathogenic and otherwise, in abundance. If 
 you cannot pare the fruit, at least wash it thoroughly. 
 
 Anjon. — One of the very best of pears, and comes to us 
 late in the season ; and from California it comes late into the 
 winter and spring. The Anjou is one of the great pears, and 
 you will make no mistake in buying them when able. 
 
 Clairgcau. — A beautiful pear, but not often found in our 
 market, except from California ; nor is Flemish Beauty. 
 
 Hozuell. — This is a lovely pear, much like the Bartlett. It 
 is the whitest in flesh of all pears, and this makes it a beau- 
 tiful pear to seal in glass. 
 
 Seckel. — We all know Seckel. that lovely little pear which 
 comes to us in the early autumn, and is only excelled in flavor 
 by one pear, and that pear is Dana's Hovey. This looks 
 something like Seckel, with some cinnamon russet on it. It 
 is melting, buttery, juicy, with a honeyed sweetness and ex- 
 quisite aroma. It is undoubtedly the highest flavored of all 
 pears. Seckel is second to it. Dana's Hovey comes very 
 late. We ought to find it in the market in November, De- 
 cember, and January. I think it is more easily obtained in 
 Washington and Boston than in other places. 
 
 Lazvroice. — I want to recommend the Lawrence pear. It 
 
 329 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 is a lovely pear, and few are better for eating or packing". 
 Its merits are not generally known. It is not a showy pear, 
 and seldom has any color except yellow and green. You 
 might sell to the passing crowd one barrel of the beautifully 
 colored California Bartletts while you were selling a handful 
 of Lawrence. The handful of Lawrence, however, is worth 
 the barrel of Bartletts for eating purposes. 
 
 Bosc. — A long, slim, russet pear, so good a pear that some 
 pronounce it not excelled b}^ any pear that grows. 
 
 Sheldon. — A large, yellow, russet pear, nearly of the aver- 
 age apple shape. If the Sheldon pear should be offered you, 
 buy it ; you will seldom get a better one. 
 
 Kieffer. — The modern wonder among pears. It is a hy- 
 brid, and supposed to come from the union of the Japanese 
 sand pear and the Bartlett, and was found growing in a gar- 
 den in the city of Philadelphia. It is a most wonderful pear 
 to produce fruit, and will keep to mid-winter or later, if prop- 
 erly cared for, without cold storage, and, if well ripened, has 
 a fair flavor and a beautiful blush for decorative purposes. 
 It is a great winter pear, and many barrels are yearly sent to 
 Europe. Next to the Bartlett and Howell, it is the best pear 
 to can. It is white and clear, but if too much sugar is added 
 it takes on a pink tinge. This does not hurt it at all, but 
 dealers object to it as off color. It is probably the most 
 profitable pear to raise in the East; at least my own experi- 
 ence tells me so, as I have hundreds of trees on my fruit 
 farms. The proper way to handle it is to allow it to remain 
 on the tree as long as possible, then gather it and lay in long 
 rows under the trees in the orchard, and only remove to the 
 house when freezing weather threatens. Keep them at about 
 40° F. until you want to ripen them up, when a warmer tem- 
 perature soon makes them fit to eat or to can. They are bet- 
 ter canned when ripe and not too green. To ship them to 
 Europe they usually reduce the temperature by a month's 
 cold storage before starting them. 
 
 The pears that come to us from California are the Clair- 
 geau, the Easter, the Bartlett, the Winter Nelis, the Anjou, 
 
 330 
 
FORTY YEARS IN TJIK MEDICAL I'KOFESSION 
 
 and the Doyenne du Corniclie. They are all fairly good, but 
 the best is Winter Nelis, so far as I am able to judge. As 
 to pears in general, they are among the best and most luscious 
 of our fruits, and to pick out the best is a difficult under- 
 taking. In my opinion, the three highest flavored pears are 
 the Dana's Hovey, the Seckel, and the Bosc, in the order here 
 given. For an invalid, such as a diabetic, the Kieffer is the 
 best for him, and may be allowed now and again. The chemi- 
 cal composition of the pear is as follows: Water, 83.9; pro- 
 tein, .6; fat, .8; carbohydrates, 14.2; ash, .5. Fuel value 
 per pound, 310. Recollect this is an analysis of the edible 
 portion only. Pears are stronger food than peaches, but not 
 so strong as apples. 
 
 Grapes. — The chemical composition of grapes is as fol- 
 lows : Edible portion, water, 78.8; protein, 1.3; fat, 1.7; 
 carbohydrates, 17.7; ash, .5. Fuel value per pound, 425. 
 Probably a little stronger than apples. The best grapes 
 grown in the East, for eating purposes, are as follows : 
 
 Moore's Early. — This is the best of the early grapes. It is 
 a large black grape with a blue bloom. 
 
 Warden. — A fine grape, and as an eating grape is superior 
 to Concord, and has a thin skin and a large berry. 
 
 Concord. — A large purplish-black grape. It comprises a 
 large portion of the grapes we see on sale in the market. It 
 has not a very high flavor, but is useful for all purposes that 
 grapes are put to. 
 
 Delazvare. — A small red grape, and probably the best fla- 
 vored of all the grapes we buy of the American type. 
 
 Catazvha. — Next to the Delaware in flavor is the Catawba. 
 It is a larger grape, and is a very common one in the market. 
 
 Martha. — A white grape, and one of very high flavor. 
 
 Lady is about as good as IMartha, and is white. 
 
 Niagara is the white grape we see most of in the general 
 market. It is a very good grape, with a little of the fox}' 
 flavor. 
 
 Empire State is a grape much like the Niagara, but possi- 
 bly not quite so good. 
 
 331 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Pockliiigtoii is another white grape, and probably has a 
 better -flavor than either Niagara or Empire State. 
 
 Clint 0)1 is the great wine grape for domestic wine, and 
 Salem is another, but the juice of any of them makes a fair 
 wine. For unfermented grape-juice, the Concord is most 
 used, because it is plentiful and cheap. 
 
 The before-mentioned grapes are all of the American va- 
 riety and are distinguished from the European varieties by 
 the fact that the skins are thick, the pulp holds the seeds inter- 
 woven with it, and the pulp comes out of the skins holding 
 the seeds, and when eaten we usually swallow seeds and pulp 
 and discard only the skin. In the European varieties of 
 grapes the seeds are merely set in the pulp unattached, and 
 can be picked out like the kernels of a nut, and we eat skin 
 and pulp, discarding only the seeds. Most of the California 
 grapes we get in the market are of the European variety, and 
 far excel any we can raise in the open air east of the Rocky 
 Mountains. 
 
 Tokay. — This is the beautiful large red grape we see so 
 many of in baskets holding from five to eight pounds. It 
 is an elegant grape, of delicious flavor and aroma, and is 
 more eaten here than any of the Pacific coast grapes. 
 
 Muscat. — This is by far the highest flavored of the Cali- 
 fornia grapes we get in the East. It is a white grape, with 
 the true Muscat flavor and aroma, and is a revelation to 
 grape-eaters. The Muscatelle is a smaller grape of the same 
 flavor as the Muscat. 
 
 Emperor. — This is a red grape from California, but not so 
 often seen as the before-mentioned varieties. 
 
 Morocco. — This is a black, round grape, and, like all the 
 grapes from the Pacific coast, is attractive and pleasant. 
 
 Ferdel is a white grape which has been mentioned to me, 
 but I am not familiar with it. 
 
 Cornichon is a black grape, large, egg-shaped, and quite 
 plenty in the market, especially late in the season. It has 
 good flavor, but is the most unsatisfactory of the California 
 grapes, as it is of the American type, where the pulp and 
 
 332 
 
FORTY YEARS IN Till-: MEDICAL PROFESSION 
 
 seeds intcrniinL;ic or tangle up; the skin is thick, and un- 
 pleasant if eaten. 
 
 Raisins. — The CaHfornia raisins are pro1)ably now the best 
 in the world. The cHmate is most suitable, and the grapes 
 from which they are made are in every way satisfactory. 
 
 Coleman Grape. — This is the great black grape, with stems 
 half an inch in diameter, which we see in the fancy fruit- 
 stores, the bunches weighing pounds, and selling for fabulous 
 prices. These grapes are imported from Englanfl, where 
 they are grown under glass as one of the luxuries. 
 
 The English and French fruits, including peaches, plums, 
 apricots, and such, grown under glass or protected in some 
 way, are magnificent; they are perishable, and of course we 
 never see them here ; even there they are only luxuries those 
 in affluent circumstances can enjoy. We grow here under 
 glass very fine grapes of the European type which are of 
 exquisite flavor and full aroma. Among the best are Black 
 Hamburg, a very large black grape; Sw^eet Water, a white 
 grape of good flavor; and the Muscat, always fragrant and 
 always acceptable to sick or well. The white Almeria grapes 
 come to us from Spain, on the borders of the Mediterranean, 
 and, although rather insipid, fill a void when no other grape 
 is in the market. 
 
 Apricots. — The apricot is a delicious fruit, coming as it 
 does very early in the season, between cherries and peaches, 
 and from California we get them quite early in the spring. 
 The California apricots hold the Eastern market because so 
 few are raised here owing to the attacks of the curculio and 
 worms at the collar of the tree. These are matters now wdiich 
 we know all about, and the remedies are at hand, and it is 
 the fault of the grower in omitting attention to details if he 
 does not succeed in raising apricots as well in the East as they 
 do in California. The Russian varieties do best with us, 
 probably, and the best of these is Harris Hardy, with a flavor 
 exceeding any of those brought from the Pacific coast. 
 Others we grow in the East are Early Golden, Acme, Moor- 
 park, and Roman. Gibbs is an extra early, ripening in June, 
 
 333 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 and Budd is a late one of good quality. Apricots are raised 
 on peach stocks, on almond stocks, on apricot stocks, and on 
 Myrobolan plum stocks. Among the best of the California 
 apricots are the New Castle, Russian, Moorpark, Blenheim, 
 and Royal. There are many other varieties. The apricot is 
 naturally more nearly allied to the plum than to the peach, 
 having the broad leaf and the smooth stone of the plum, but 
 having down on its skin like the peach. 
 
 Nectarines. — On the other hand, the nectarine is a 
 peach, with a smooth glossy skin like the plum. The nec- 
 tarine is inferior in every way to the peach and to the apricot 
 as a fruit. It has more of the noyau flavor than has the peach. 
 Among the good varieties are the Downton, Boston, New 
 White, Old White, Lord Napier, Elruge, and Golden. 
 
 Plums. — The plum is a popular fruit, and we may look 
 for a great increase in its cultivation in the East and a 
 great increase in the fruit in the markets. They have been 
 arranged in two divisions, — Division I., red, purple, blue; 
 Division II., green, white, yellow. There are varieties of 
 plums without end. J. W. Kerr, of Denton, Caroline County, 
 Maryland, is one of the great American authorities on plums. 
 He is a large nurseryman and propagator of these and other 
 trees, and a large plum-grower for market. In his American 
 group, native plums, he gives over one hundred and twenty- 
 five varieties, among the names being American Eagle, Cali- 
 fornia, Etta Holt, Kieth, Louisa Smith, Stella, Winnebago, 
 Yellow Sweet, Sloe. We will begin to find a constantly in- 
 creasing supply of native plums in our markets, and they are 
 bound to become an important part of the fruit supply for the 
 masses. The Nigra group is for the far-off cold Northwest, 
 and we will probably see few of them here, but they will give 
 those people a hardy fruit for their inhospitable climate. The 
 Miner group of plums are grown in the East and are late in 
 ripening. The Wayland group are hardy, and grow in all 
 parts of the country except the extreme Northwest. The 
 Wild Goose group is the profitable group for the country 
 south of New York in the East, and Wisconsin in the West, 
 
 334 
 
FORTY YEARS IN 'JJII-: MEDICAL PROFESSION 
 
 and are the ones we are most a])t to encounter in the markets 
 of New York, Philadelphia, Baltimore, anrl Washington. 
 Among the hest varieties are Choptank, Clifford, Freeman, 
 Kroh, Ohio, Osage, Smiley, Sophie Whitaker, Red Cling, 
 Wild Goose, Wooten. The Chickasaw group of native plums 
 is for the country south of Mason and Dixon's line. Among 
 the best are Munson, Newman, Piram, and Yellow Trans- 
 parent. 
 
 Besides the l)efore-mentioned groups of native plums, we 
 have the Watsoni group, the Marianna group, the Maritima 
 group, the Primus bcsseyi (the sand cherry), the mongrels, 
 and others, not yet classified. Truly, a great class of fruits, 
 and one destined to do great good as it goes on in its evolu- 
 tion to perfect types. 
 
 The next type of plums is the Triflora group, or the Japan 
 plums. Much of this fruit comes to us now from Califor- 
 nia, and the beautiful large plums we see in the fruit-stores 
 are mostly from this source. Delaware and Maryland are 
 growing them now in perfection, and our supply of the future 
 will be much of it from these States. The Abundance is the 
 variety we see most of, — large, oblong, mottled, lemon-yellow, 
 sometimes much red, cling. Another is Berckman's, a cling, 
 and another, Burbank, which rots badly. Hale is a good one, 
 greenish yellow, with streaks and shadings of red, cling. Kel- 
 se}^, greenish yellow with red, or all red. Kerr, very early, 
 cling, conical, bright yellow. Red June, very early and good. 
 White Kelsey, large, conical, greenish white. Yosebe, ear- 
 liest of all Japan plums, small, red, freestone. Chabot. one 
 of the best, red on yellow ground, cling. 
 
 I give here the chemical analysis of the average apricots, 
 nectarines, plums, and prunes. Plums, edible portion : Water, 
 78.4; protein, i ; carbohydrates, 20.1 ; ash, .5. Fresh prunes, 
 edible portion: Water, 80.2; protein. .8; carbohydrates, 18.5; 
 ash, .5. Dried prunes, edible portion: Water, 26.4; protein, 
 2.4; fat, .8; carbohydrates, 68.9; ash, 1.5. Nectarines, edi- 
 ble portion: Water, 82.9; protein, .6; carbohydrates, 15.9; 
 ash, .6. Apricots, edible portion: Water, 85; protein, i.i; 
 
 335 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 carbohydrates, 13.4; ash, .5. Fuel value per pound of plums, 
 390; of fresh prunes, 360; of dried prunes, 1360; of necta- 
 rines, 305 ; of apricots, 270. 
 
 Many of the old plums under the old names may still be 
 found in market, and among the best are the Lombard, the 
 red gage, Smith's Orleans, Washington, green gage. Impe- 
 rial gage. Damson, and others. 
 
 Fresh Prunes. — If we get fresh prunes here in the East, 
 they probably come from California. Prunes are plums, that 
 is the long and the short of it. A fresh prune is a plum of a 
 variety which, when dried in a peculiar way, makes the dried 
 prunes, or prunes of our market. The names of the chief 
 varieties of the French prune plums are the St. Catharine and 
 the Brignolles, with a number of others. The chief Califor- 
 nia varieties are the Brignolles, Bulgarian, Datte de Hongrie, 
 German Golden, Hungarian, Silver, St. Catherine, St. Mar- 
 tin's, Tragedy, Wangenheim, Giant, and Imperiale Epineuse. 
 The fruit is picked after the dew is dried off. California has 
 an advantage here over France, — the climate is so dry. The 
 fruit is then ripened in shallow baskets. When ripe it is shut 
 up in spent ovens for twenty-four hours. It is then removed 
 and the ovens reheated. Then the prunes are replaced in the 
 ovens. In twenty-four hours they are again removed, turned 
 over, and laid on the leaves in the bottoms of the baskets. A 
 third time the ovens are heated and the prunes are returned, 
 and in twenty-four hours are taken out and allowed to cool. 
 They are again heated from one to three times more, and 
 then they are packed and ready for market. Nearly all of 
 the prune output of California is sun-dried, and no artificial 
 heat is required. There is a plum there called the Hungarian 
 prune, yellow egg, much of which is cured by heat in evapo- 
 rators. There is a large prune product in Oregon, Washing- 
 ton, and Idaho, nearly all of which is cured by artificial heat 
 in evaporators. 
 
 The prunellos are plums, sometimes called prunelles. They 
 are dried and packed in regular masses like dates, and come 
 in boxes or mats. They are quite acid, and not very easily 
 
 336 
 
FORTY YI'ARS JN TllJi AIKDICAL PROFESSION 
 
 digested. Remember, always, in Ijuying plums of any kind 
 fresh, to see that they are just ripe and not over-ripe. After 
 fermentations of decay have started in them they become 
 very hospitable hosts for many germs, pathogenic and other- 
 wise, and are apt to produce what the boys call " green-apple 
 bellyache," or something worse. 
 
 Date Pliiiii. — Some species of this tree produce ebony, and 
 are valuable trees. They are of the genus Diospyros, belong- 
 ing to the natural order Ebcnacecc. The chief species from 
 which the fruit comes is the Diospyros kaki, or Chinese date 
 plum. Our common persimmon is of this genus, the Dios- 
 pyros virginiana, and is quite a good fruit after it has been 
 well frosted and developed its sugar. We are all familiar 
 with dates, how they come in mats. They have a good flavor, 
 and are a useful fruit for many purposes. The Diospyros 
 kaki gives us the Japanese persimmon. We see them in mar- 
 ket now, fresh from California and near by. Few of them 
 thrive in the open air in the East above the Carolinas. Fine 
 ones come from Florida. The Tane Nashi is a yellow seed- 
 less one, and thrives in the open air on the lower part of the 
 Delaware and Chesapeake peninsula. 
 
 The chemical composition of dates and persimmons is as 
 follows: Edible portion, water, 20.8; protein, 2.2; fat, 5.1; 
 carbohydrates, 70.4; ash, 1.5. Fuel value per pound, 1565. 
 
 Tamarinds come to us chiefly from the West Indies. The 
 tamarind-tree also grows in the East Indies. I never thought 
 much of tamarinds. They are said to be laxative and cool- 
 ing. The tree furnishing the fruit is the Tamarindus indica. 
 The fruit is a pod from two to six inches long, containing 
 seeds or beans, with a pulp something like our common locust 
 bean. The pulp, put up with sugar, gives us tamarinds as we 
 get it. 
 
 The mango, of the species j\[augifera, we get green, as 
 a pickle, or put up with sugar as a preserve; neither is of 
 much account. The mangosteen we never see in the United 
 States, but will probably see them frequently when we run 
 over to Manila to shake hands with our fellow-citizens of the 
 22 3Z7 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Philippines. When those islands become States of the Union, 
 we may get them from there in cold storage. \Vhen we do 
 get them, and get them in prime condition, they will be of 
 about the shape and size of an orange, and have a broad, pel- 
 tate, lobed stigma. The rind is like that of the pomegranate ; 
 it is also something like the pomegranate in structure. It is 
 at first green, and changes to dark brown. It is said to be 
 the most luscious of fruits, the pulp and juice a mingling of 
 the strawberry and grape. It is absolutely healthy, and can 
 be eaten with safety in the tropics in great quantities by sick 
 or well. 
 
 The Durian. — Here is another East Indian fruit. The 
 expansionists probably had eaten it, and know what they are 
 going for. It is a most delicious fruit, which undoubtedly 
 those of our people who oppose expansion to the East have not 
 yet tasted. The name of the tree bearing the fruit is the Durio, 
 of the family Sterculiaceco, the only known species of its genus, 
 Durio zibethinus. The fruit is round or oval and nearly a 
 foot long. It has a hard rind, with prickles. It has five cells, 
 each with several seeds. The pulp is of a light yellow, with a 
 delicious flavor, and an odor not at all inviting. The seeds 
 are cooked and eaten like nuts. 
 
 The papaw is the fruit of the Carica papaya. It is some- 
 thing like a fig, and is eaten like it. The taste grows on one. 
 It is coming into use as a digester of albuminoids. I have 
 the trees growing, having raised them from the seed. They 
 grow wild in Delaware, especially around mill-ponds, but are 
 difficult to transplant. In the southwestern part of the United 
 States they grow wild luxuriantly. 
 
 Pomegranate. — The many-seeded fruit, botanically. The 
 tree bearing this fruit is Punica granatum. There are two 
 kinds, the sweet and the sour, of a yellow color tinged with 
 red. The pulp is the edible portion. It is hardy, even in the 
 Middle States, if trained on the southern side of walls or 
 other protector. I have eaten them in California and Mexico, 
 where they thrive admirably. They are a poor fruit where 
 we have so many better ones, but may be grateful in hot 
 
 338 
 
FORTY YKAKS IN TIHC MICDICAL PROFESSION 
 
 weather to one craving acid. The l)ark contains much tannin, 
 and is used mech'cinally where an astrinj:^cnt is neerlcd. 
 
 Figs. — Tlie fruit of tlie Ficus carica. Chemical analysis: 
 Water, 79.1; protein, 1.5; carbohydrates, 18.8; ash, .6. 
 Fuel value per pound, 380. Figs thrive in the c^pen air, on 
 the lower part of the Delaware and Chesapeake Peninsula, 
 and from there south and on the Pacific coast. The fresh 
 fig is very sweet, to some insipid, and to others very grateful. 
 Great quantities of them can be eaten at once when just ripe, 
 as they are very digestible. They are cured by artificial heat, 
 and in California in the open air. They have a reputation 
 as an aperient; this is probably on account of the peristalsis 
 produced by the physical action of the seeds. 
 
 GuAVA. — From the fruit of the Psidium guaiava. The 
 fruit is bright yellow, and very fragrant; indeed, so fra- 
 grant is it that the taste appears insipid after the delightful 
 odor. It comes to us chiefly from the West Indies and Flor- 
 ida. The jelly made from it is delightful. 
 
 Alligator Pear (Persea Gratissima) . — This fruit is a 
 native of the West Indies and of tropical America. The 
 leaves and the bark have some reputation as an antiperiodic. 
 I have eaten them on the western coast of Mexico, where 
 they are highly esteemed as a breakfast course. 
 
 Alligator Apple. — Fruit of the West Indian tree, 
 Anona palustris. I give it here merely to distinguish it from 
 the alligator pear. It is used medicinally as an astringent 
 chiefly in Mexico. It is known as the Custard Apple. 
 
 The Cocoanut. — Fruit of the Cocos nucifcra, one of the 
 best known of the palm-trees, and which always greets us as 
 we approach the shore of any of the tropical islands. It 
 flourishes only near the sea, but will grow inland in hot 
 countries, but is unfruitful there. The blossoms are very 
 beautiful. The clusters of blossoms are produced every six 
 weeks during the wet season, and each cluster produces a 
 number of nuts. In planting nuts, the three black spots, or 
 monkey eves, are set upward, and from one of these eyes the 
 stem emerges. In the tropics the trees live one hundred 
 
 339 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 years; in greenhouses, from ten to twelve years only. In 
 the tropics the wood is known as porcupine wood. Here 
 the large leaves are used for clothing and to build huts. They 
 are also used for writing on and for fans, fences, nets, sieves, 
 combs, etc. Of the husks, scrubbing-brushes, ropes, and such 
 utensils are made. The juice extracted from the flowers 
 makes a drink. Fermented, it makes palm wine; distilled, 
 it yields arrack, like that obtained from rice. The nuts when 
 green contain quite a quantity of fluid. This is much used as 
 a cooling drink, and the gelatinous mass lining the shells is 
 eaten alone or flavored to suit the taste. If too much of the 
 juice is taken, it irritates the urinary organs. It contains 
 sugar, water, gum, oils, and soluble and insoluble salts. What 
 we know as cocoa-nut is the albumin, etc., deposited on the 
 inside of the shell. It is dried and prepared as we see it in 
 the market, and used for various purposes by both the sick 
 and the well. The chemical analysis is as follows : Water, 
 3.5; protein, 6.3; fat, 57.4; carbohydrates, 31.5; ash, 1.3. 
 Fuel value per pound, 3125. Quite a strong combination, 
 truly. There is much oil extracted from the cocoa-nut, which 
 makes the finest soaps, candles, and such, and for body lubri- 
 cation it is unsurpassed. The cocoa-nut is a digester of albu- 
 moses, and an active one, from a proteolytic ferment which 
 it contains. 
 
 Banana. — A plant of the genus Musa. The banana is 
 Mitsa sapientiim, the plantain is Musa paradisiaca. We buy 
 in our markets bananas for plantains, and we buy plantains 
 for bananas. For food there is not much difference. They 
 come yellow and red. The red are usually larger. The 
 chemical analysis of each is about as follows: Water, 74.1; 
 protein, 1.2; fat, .8; carbohydrates, 22.9; ash, i. Fuel 
 value per pound, 480. Compare this with boiled white 
 potatoes, and see how nearly they approach. The potato 
 has most of its carbohydrates in starch, and the banana in 
 sugar and starch. The sweet potato has both sugar and 
 starch. Boiled white potato: Water, y^^.y; protein, 2.7; 
 fat, .2; carbohydrates, 22.3; ash, i.i. Boiled sweet potato: 
 
 340 
 
FORTY YJ':ARS in TIJI-: MEDICAL PROFESSION 
 
 Water, 69.3; protein, 1.8; fat, 7; carbohydrates, 27.1 ; ash, 
 I.I. Fuel vahie per pound: White potatoes, 475; sweet po- 
 tatoes, 565. Here we read the vahies as food of the three 
 great staples, — the banana, the white potato, and the sweet 
 potato. The banana grows from the slip; that is to say, they 
 cut the plant off at the ground and transplant it. I have seen 
 them l)rought from the West India Islands and planted in 
 Florida in this way, and they thrive in the southern part. The 
 fruit is very green when cut to ship to our Northern cities, 
 and suffers in flavor compared to that cut and ripened in the 
 tropics. Formerly much was lost in shipping, but now fast 
 steamers bring it in three or four days from Jamaica, Cuba, 
 and the nearer islands, and we are getting the fruit in good 
 shape compared with the earlier days. Fifty years ago a 
 banana was almost a curiosity in Philadelphia; now it is a 
 staple article of diet, and a very wholesome one. In the 
 tropics the banana is the eating variety, and the plantain 
 usually the variety they cook in various ways. They are 
 fried, baked, and made into pies and puddings. Bananas 
 are dressed with wine, with sugar and cream, and with wine 
 and orange and other juices. I think the devil is the author 
 of some of these mixtures, by which he hopes to inveigle 
 some foolish mortals he has set his keen eyes upon. The 
 natives cut bananas into strips and dry them, and mash this 
 up and eat it. We are getting now into our markets a banana- 
 meal. This, I think, will prove a good thing for both sick and 
 well. It may be eaten in any way after cooking, as we eat 
 porridge of any kind ; with milk or cream and a little sugar 
 added, it is most palatable and invigorating. In eating the 
 banana out of hand, it should be very ripe, and it is not very 
 ripe until the skin has softened and turned well black. Fer- 
 mentation has not commenced on the inside when the skin 
 is quite dark. 
 
 The Pine-Apple. — This is another of the tropical fruits 
 rapid transit is putting in our markets in prime condition. In 
 the parlance of trade they are called *' Pines." It takes its 
 name from its resemblance to the pine-cone. Botanically it 
 
 341 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 is Aiiaiiassa sativa. It belongs to the family BronicUacccE. 
 From this its active principle, bromelin, takes its name. We 
 formerly looked upon pine-apple as a most unwholesome fruit 
 in every way, as a breeder of all sorts of diseases, especially 
 of cholera. How little we knew then of the origin of such 
 troubles, and the merits and demerits of things to be eaten! 
 If prepared properly, pine-apple is a most digestible fruit, 
 and is a digester itself of albuminoids, from the ferment bro- 
 melin it contains, as before spoken of. The wrong way to 
 eat pine-apple is to shred it and throw away the core and the 
 skin, for in the core and fibre and skin resides the bromelin. 
 The proper way to eat pine-apple is to shred it and then 
 squeeze all the juice out of the fibre and core and skin, spread 
 it over the pine-apple, and eat it thus, plain or sweetened, and 
 after eating — not before eating — other things. The proper 
 time to eat pine-apple is after dinner, or after a " dejeuner a 
 la fourchette." Then the bromelin assists the digestion of all 
 the albuminoids consumed at the meal. So powerful is this 
 bromelin that if persons eat the skin, the core, or the fibre, 
 particularly, the tender skin and mucous membrane of the 
 lips and tongue and inside of the mouth goes through a 
 process of digestion in spots, and pine-apple sore mouth is 
 developed. Here is a scientific explanation of what every 
 one knows comes now and again from eating pine-apple. The 
 best preventive is to cleanse the mouth and lips with water, 
 or better, mint water, or some of the essential-oil waters, 
 after having eaten this fruit. I frequently prescribe, with 
 very good results, pine-apple juice for the dyspepsia arising 
 from the indigestion of the nitrogenous foods. This juice, 
 to be effective, should be made from the fresh fruit, using 
 the skin, core, fibre, and all, and then straining it. A wine- 
 glassful or more may be taken after eating. If you cannot 
 get the fresh juice, you may use the juice of the shops, with 
 more or less effect, but the fresh juice is the best, as it is of 
 all fruits for all purposes. The best and finest pine-apples I 
 ever saw were grown on the island of Toboga, in Panama 
 Bay. The chemical analysis of the pine-apple, edible por- 
 
 342 
 
FORTY YKAKS IN THE MEIJICAL PROFESSION 
 
 tion, is as follows: Water. '^9.3 ; ])rotein, .4; fal, .3; car- 
 bohydrates, 9.7; asli, .3. i'"uel value i)ei' ])oiiiul, 200. 
 
 The Orangic. — The (|ueen of the citrus fruits, Citrus au- 
 rantium and other varieties. The other citrus fruits are the 
 lime, the lemon, the citron, the bergamot, and the shaddock. 
 The orange needs a favorable soil and climate. In Europe 
 the orange grows as far north as 42°. It will not do it in 
 our country east of the Rocky Mountains. They grow the 
 best in the world in Florida ; they are also grown in Louisiana 
 and Mississii:)pi, and a few in Texas, Georgia, and Alabama, 
 In Arizona they grow to perfection, and in California they 
 are a staple crop, being chiefly of the seedless navel, so called; 
 they are a Bahia orange. Our Consul there found that they 
 grew wild in the surrounding jungles. He sent a few cut- 
 tings to the Agricultural Department at Washington, and Mr. 
 Saunders succeeded in growing a few of them, and gave a 
 few to Mrs. Luther C. Tibbetts, of California, who took them 
 to her husband, Luther C. Tibbetts, at Riverside, California. 
 He succeeded with them, and to him is due the honor of in- 
 troducing the navel orange from Bahia, Brazil, into Cali- 
 fornia. 
 
 The orange is a native of India, and grows wild along the 
 southern slopes of the Himalaya Mountains among the tribu- 
 taries of the Ganges. They were brought to the United 
 States from Europe. The seedling orange-tree is known to 
 exist over six hundred years old. The seedling trees live 
 much better and longer than the grafted trees ; in fact, graft- 
 ing is a devitalizing process as far as the orange goes, if it 
 does not apply to all grafted trees. The grafted orange-trees 
 give us better fruit and commence to bear earlier, but their 
 limit of useful life is about twenty-live years. The chemical 
 analysis of the orange is as follows: Water, 88.3: protein, 
 .8; fat. .6; carbohydrates, 9.7; ash, .6. Fuel value per 
 pound, 220. 
 
 Real!}' the best oranges I ever tasted I bought in Acapulco, 
 on the western coast of Mexico. They were a very small 
 yellow orange, grown on the mountain-slopes, and were prob- 
 
 343 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 ably seedlings, as the Mexicans did not give much care to 
 improying the natural character of their fruits. The sweet 
 orange is the Citrus aurantiuui, as before stated. The bitter 
 orange is the Citrus vulgaris. We have no use for it except 
 for its bitter peel now and then, and to send it to the Scotch- 
 man with which to flavor his Dundee jam or marmalade. We 
 all know of the uses of orange-blossoms for their lovely per- 
 fume, for the adornment of the bride where they are classic, 
 and for the making of orange-flower water. In the orange 
 countries we see the blossoms on the tree and the fruit of the 
 last season still hanging, truly an enchanting scene, and the 
 melting odors from the bloom render the surroundings ravisse- 
 ment. The best oranges we get, as I have said before, come 
 from Florida. The Indian Rivers are the best of these. They 
 also send us some very fine navels. The special oranges are 
 the Mandarins and the Tangerines, the Chinese types, those 
 little oranges which slip from their skins like walnuts from 
 their hulls, and in doing so do not soil your kid glove; they 
 have a flavor and odor of their own, and to some they are very 
 palatable. There is another little curiosity of the Citrus type, 
 the cute little Comquot, or Chinese orange. They are a con- 
 densation of lusciousness and full of aroma. You eat them 
 skin and all, and to the sick and weary invalid they are often 
 a revelation, and- help his lagging digestion. They come to 
 us from Florida. Jamaica sends us good oranges, and mani- 
 fest destiny, it appears, will soon literally smother us with 
 such luxuries from our new colonial possessions. 
 
 Shaddock. — The fruit of the Citrus decumana, the word 
 decumana referring to its size, — immense. It is supposed to 
 be the " forbidden fruit," and was introduced into the West 
 Indies from China by an English sea-captain. Shaddock by 
 name. It comes to us now from the West Indies and Florida 
 chiefly as grape fruit. The quality of the fruit is inferior: 
 it is at once sour, bitter, and unpleasant, but has become pop- 
 ular to eat before breakfast as a peristaltic persuader, and is 
 also used at ladies' luncheons, but is here dressed with sugar 
 and sherry and other wines, to make it palatable. The devil, 
 
 344 
 
FORTY YEARS IN THE MI':DICAL PROFESSION 
 
 I am sure, Ii.'ul something to flo willi llic invention of this last 
 concoction, and women are still nsin^ it to lemjjt their own 
 sex, if not to tempt man. 
 
 Olivks. — The fruit of the Olca ciirofxvd, or common olive. 
 The lilac and the ash, among our well-known trees, come 
 under the same order as the olive. They furnish us with 
 olive oil and the fruit. The oil we are all familiar with, or, 
 rather, we suppose we are, but much of what we get in the 
 shops for pure olive oil is expressed from cotton seed and 
 peanuts, both of which, by the way, when properly handled, 
 make fair table oils. True olive oil, as we find it in Italy, 
 would not suit our tastes in America at all. It is dark and 
 heavy, with strong taste and odor peculiarly its own. It is 
 remarkable how one gets accustomed to it and comes to like 
 it. It is like leaving France and her sweet saltless butter and 
 going to England and eating her salted butter. At first the 
 difference is marked, but we soon become accustomed to it. 
 The oil is gotten from the fruit by expression, and as fine as 
 I ever tasted was at the home of my late friend, Tiburcio 
 Parrott, in the Napa Valley, California. He paid great atten- 
 tion to the getting of a good quality of oil, and California 
 and her olive interests lost a good and progressive helper 
 when he died. For eating, the olive goes through a prepara- 
 tion peculiarly its own, to get it rid of its bitterness and un- 
 pleasant flavor. The fruit is gathered green, but full grown, 
 varying in size from a filbert to a pigeon's egg, and is then 
 put into strong h^e, and after a while in water, which is re- 
 newed often for several days. They are then bottled and a 
 liquor poured over them one-half water and one-half satu- 
 rated brine, with a number of aromatics added, this brine 
 being first boiled. We find ripe olives, with the stones re- 
 moved, treated in the same way. They are far the best for 
 eating, I think, and add zest to the post-prandial wine and 
 nuts. The olive farcie is a toothsome but rich morsel. They 
 are the piece de resistance of olives, and are made by extract- 
 ing the stone and stuffing with anchovy, etc. 
 
 Lemons. — The fruit of the Citrus limonium. and one I 
 
 345 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 almost overlooked, yet one of the most important and grate- 
 ful medicinally. Its juice, its rind, and its oil are equally 
 useful. It came originally from India with the orange. The 
 lemon- and orange-trees are much alike and grown under the 
 same conditions of soil and climate. Lemon- juice contains 
 two per cent, of citric acid, with mucilage and a bitter ex- 
 tractive. There is one peculiarity about the oil, as about most 
 of the essential oils, — it does not keep long, but becomes to 
 all intents and purposes turpentine and utterly unfit for its 
 special uses. We should insist always on having such oils 
 fresh or properly preserved from this change. Mixing with 
 alcohol is the proper way to preserve them. 
 
 The Mulberry. — The red mulberry. Morns rubra, is a 
 common one, and one of the best, having a pleasant, very 
 sweet flavor. Being very perishable, it is only found in the 
 market a short time. The same may be said of the white and 
 the black mulberry. They are closely related to the fig fam- 
 ily of fruits. The white mulberry, the Morns alba multicau- 
 lis, is the favorite tree for the silkworms to feed upon, and 
 doubtless most of us remember the stories of our grandfathers 
 of the excitement produced by the silkworm craze years ago. 
 Downing's Ever-Bearing is probably the best producer of the 
 best berries, and goes on producing day after day during a 
 long season. Few ever appear in the market. They are a 
 healthy fruit. 
 
 The Cantaloupe. — The best and most delicate fruit of 
 the melon tribe, and so named from the Villa Canteluppi^ 
 near Rome, where the fruit abounds. It comes from the Cii- 
 curbitacece, or gourd family, and is botanically the Cucuniis 
 melo. It grows almost anywhere in America. The best 
 come from Delaware, Maryland, New Jersey, and Colorado. 
 The skin is roughened with a cork-like net-work, and the 
 better the specimen the more developed is this net-work. The 
 small round or oval, dark greenish-yellow specimens are the 
 best, although some of the large elliptic-shaped ones are of 
 good flavor. There is a mean-looking melon of small size, 
 with the net-work well developed, with dark-green coloring, 
 
 346 
 
FORTY YEARS JN THE MEDICAL PROFESSION 
 
 and a snout at one cxlrcniily, usually of a lighter color, 
 on the order of a wart. This melon usually comes from 
 Gloucester and Salem Counties, in New Jersey. It is with- 
 out doubt the best and most luscious of all specimens yet in- 
 troduced, possibly barrinfj^ the new melon, Kocky Ford, from 
 Colorado. Look at it (jnly, and ycni would ]jass it by as for 
 the pigs; taste it, and you will never cease to praise it. Jenny 
 Lind is its name. The market men call them " Ginnys." Just 
 as I am writing this I received the following note with seeds 
 from my friend, Dr. Robert P. Harris, of Philadelphia : 
 
 " I send you a new citron melon from Greece. There were 
 four kinds of seeds, and their testing in Florida showed that 
 these were the best, produced the largest citrons and the most 
 distinctive. Fruit yellow fieshed, ten by thirteen inches, semi- 
 translucent, superior to known varieties. Try them. They 
 are in the shape of a truncated cone, as to form of melon." I 
 zuill try them, and the " Harris," I have no doubt, will excel. 
 A few days after I received the seeds Dr. Harris died, and all 
 good work lost a devoted follower. 
 
 The Watermelon. — The delight of our fellow-citizens 
 of African descent and the pride of the small boy. Botani- 
 cally, the Citndlus vulgaris. It grows almost anywdiere and 
 under almost any conditions. Thousands come to our mar- 
 kets yearly, starting in June or earlier from Florida, and 
 ending with those from New Jersey up to the appearance of 
 the Frost King in September. They are of various colors 
 externally, the Southern melons being generally striped with 
 light and dark green lengthwise, with the forbidding name 
 of rattlesnake. Thoroughly chilled with ice, they are a lus- 
 cious delicac}'- on hot days, are very healthy, somewhat diu- 
 retic, and altogether desirable for the well, and often for the 
 sick. The seeds are without doubt valuable in some cases as a 
 diuretic. 
 
 The chemical composition of the cantaloupe is as follows : 
 Edible portion, water, 89.5; protein, .6; carbohydrates, 9.3; 
 ash, .6. Fuel value per pound, 185. That of the watermelon 
 is as follows : Edible portion, water, 92.9 ; protein, .3 ; fat, 
 
 347 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 .i; carbohydrates, 6.5; ash, .2. Fuel value per pound, 130. 
 There is a citron melon, a true watermelon. It is spherical 
 and marked with stripes and shades of green. It is hard and 
 tough, and is used only for preserves. It makes a handsome, 
 clean preserve, and so does the rind of the edible watermelon. 
 Its chemical composition, dried and sugared, is as follows : 
 Water, 25.6; protein, .4; fat, .6; carbohydrates, 72.5; ash, .9. 
 Fuel value per pound, 1380. The carbohvdrates here are 
 doubtless mostly sugar. 
 
 Partridge Berry. — Here we have a very interesting berry 
 for the physician, often called the teaberry, the flavor of which 
 is familiar to every child in his candy-stick. Botanically it 
 is Gaultheria procumbens, and I believe is the same as the 
 Mitchella repens of Gray, which is also called checkerberry, 
 winter clover, and w4ntergreen. It is a beautiful little red 
 berry, of a sprightly pungent, aromatic taste, in market 
 throughout the winter. Its flowers are very fragrant. It is 
 an evergreen trailing plant, creeping around the roots of trees 
 in moist places in the woods and swamps. The fruit is often 
 grateful to invalids, and especially is useful in lithsemic cases. 
 This berry is one of the sources of oil of wintergreen, and 
 much of it is prepared in New Jersey according to the United 
 States Dispensatory. Professor Proctor has also obtained 
 it from the sweet birch. It is supposed to exist in the roots 
 of Poly gala paucifolia and in the roots and stems of Spircoa 
 ulmaria, Spircua lohata, and Gaultheria hispidula. This is all 
 of great importance to the physician on account of the free 
 use now^ made of salicylic acid and its salts, especially in the 
 treatment of rheumatism and gout. The question here arises. 
 Is there any advantage arising from the use of it, as it exists 
 in nature in these plants, over that produced synthetically by 
 chemical process? This is done by the method of Kolbe, by 
 treating a solution of carbolic acid in caustic soda with car- 
 bon dioxide at a moderate heat. Horatio Wood lays down 
 the chemical difference very clearly. Thus, oil of winter- 
 green contains ninety per cent, of methyl salicylate, a substi- 
 tution compound in which one atom of the hydrogen of sali- 
 
 348 
 
FORTY YiiARS IN 'I'lll-: MI-:i)]CAI. J'KOl'ICSSION 
 
 cylic acid has been replaced hy a molecule of melhyl, Cll..,. 
 The formula of salicylic acid is CtHoO.-j. The formula of 
 methyl salicylate is Cj ( ^jj^'j j O.,. VVhen oil of wintergreen 
 
 is taken into the animal system, one atom of carbon anrl two 
 atoms of hydrogen in the methyl are removed by oxidation 
 
 and C^ ( q^^ j O.j becomes CyHnO.}. C7 ( ^f^ ) O3 has an 
 
 atomic weight of 152, while the atomic weight of C^HuOg is 
 138. The administration of one hundred and fifty-two grains 
 of methyl salicylate ought to be equivalent to the administra- 
 tion of one hundred and thirty-eight grains of salicylic acid. 
 Now, as one hundred and sixty-nine grains of oil of gaul- 
 theria contain one hundred and fifty-two grains of methyl 
 salicylate, they should be equivalent to one hundred and 
 thirty-eight grains of salicylic acid. Now, the important 
 question comes up. Does the use of the natural salicylic acid 
 in these different vegetable sources, as from the partridge 
 berry, birch, and such, have any advantage over the use of the 
 synthetic compound made artificially by using carbolic acid, 
 caustic soda, and carbonic acid? Stokvis has investigated 
 the subject closely, according to Horatio Wood, and concludes 
 that there is a marked quantitative difference, the natural 
 acid being distinctly less poisonous than the synthetic product. 
 This he believes to be due to the superior osmotic action of 
 the natural acid. There is a general impression abroad that 
 the artificial product is much more irritating to the kidneys 
 than the natural, and therefore it is, I think, better to use 
 the oil of wintergreen as our source of salic3dic acid than to 
 use the artificial salicylate or its salts, as the sodium salicy- 
 late; although I am not inclined to believe one much more 
 injurious than the other, especially if we use the salt and not 
 the pure acid, which I believe is now rarely done. I am 
 particularly well pleased with the combination of colchicine 
 and methyl salicylate in acute gout. I have given this par- 
 ticular notice to the partridge berry to show what great im- 
 portance in medicine may attach to an insignificant little 
 fruit, and to impress upon my readers the importance of accu- 
 
 349 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 rate investigation into such now universally used remedies as 
 salicylic acid and its salts, and methyl salicylate as it exists 
 in nature. 
 
 Pigeon Berry or Poke Berry. — The beautiful lake-col- 
 ored berry of the common poke, Phytolacca decandra, should 
 receive mention here, if merely to warn persons that it is not 
 free from danger if used as food, and has some of the prop- 
 erties ascribed to it as a cure for rheumatism. Pigeons are 
 very fond of the berries, and when eating them abundantly 
 their flesh may be poisonous, as pheasants may be from eating 
 the laurel. Poke-root is emetic. Another poke is the Indian 
 poke growing wild around us. This is the American helle- 
 bore, and produces the well-known remedy, formerly used 
 more than at present, Veratrmn viride. White hellebore is 
 the European hellebore, the Veratriim album. 
 
 Haw. — The hawberry, or at least one of them, of a dark- 
 blue color when ripe, is a very toothsome one, but the species 
 which bears it is a very rare one; indeed, I am in doubt as 
 to its identity and whether it comes under the hawthorns or 
 the stone fruits. The buckthorns, as a rule, have purgative 
 qualities, and we get the valuable cascara sagrada from the 
 California buckthorn, the Rhainnus piirshiana. 
 
 Wine Berry. — A new berry of the raspberry order, and 
 said to be different from any other berry. It is juicy, and its 
 flavor is sweet, and may be used for eating, wine, preserving, 
 or canning. 
 
 Logan Berry. — Another new berry among the fruit men. 
 It grows or trails on the ground like the dewberry. Its fruit 
 is often over an inch long, dark red in color, with the shape 
 of a blackberry and the color of a red raspberry, with a com- 
 bination of the flavor of both. 
 
 Gooseberries. — The gooseberry is a very common fruit, 
 and with cultivation and proper ripening it is very toothsome, 
 especially the large English varieties introduced here. These 
 are at the same time very delicate, from the tendency of the 
 berries to mildew {erysiphe mors uvcc). It comes botanically 
 under the type Rihes grossiilaria. There are many species in 
 
 350 
 
FORTY yjOARS IN 'II ll', MI'.DICAL PROFESSION 
 
 America. 'Hicy niak'c .'imonj^- the Iiest of jams, and analyze 
 as follows: Refuse, 3.5; water, 85.7; protein, .5; carbo- 
 hydrates, 9.8, which includes 1.4 per cent, acid; ash, .4. 
 
 The Currant. — There are two species of the Rihcs tribe. 
 The Rihcs rubrum, the red currant, is the one we generally 
 see in this country, and the best varieties are the Red Dutch 
 and Fay. The fruit is (juite acid, yet a few of them are 
 pleasant to eat, and are healthy. There are also some white 
 varieties, or, rather, some light-colored varieties. The black 
 currant is the one most used in England, and has a heavy 
 odor and flavor of its own. The red currant makes a sprightly 
 jelly for mutton, venison, and wild ducks, giving zest to the 
 flesh and acidifying, as it were, their fats, which are more or 
 less neutral, and do not emulsify properly with the bile and 
 pancreatic juice until acidulated somewhat. The black cur- 
 rant, Rihcs nigruui, is quite astringent, and is a favorite in- 
 gredient in throat lozenges and such remedies. The English- 
 man loves its jelly. The currant analyzes about as follows in 
 the dried state: Water, 27.9; protein, 1.2; fat, 3; carbo- 
 hydrates, 65.7; ash, 2.2. Fuel value per pound, 1370. 
 
 The Cranberry. — The cranberry we all know of from the 
 delicious sauce it makes and which serves the same purpose 
 in digestion as currant jelly and other sauces. It comes with 
 many varieties from the Vaccininin inacvocavpon and other 
 shrubs which grow wild in boggy places in the temperate 
 zone throughout the world. In the bogs the organic decay 
 aromid it gives it its organic acid ; cultivation improves the 
 berry greatly, and the finest I ever saw were sent me by a 
 friend from his bogs on Cape Cod. Cranberries ship best 
 over the seas packed in water ; they analyze as follows : 
 Water, 88.5; protein, .5; fat, .7; carbohydrates. 10. i ; ash. .2. 
 Fuel value per pound, 225. 
 
 The Cherry. — This fruit especially delights the small boy. 
 and gives him many a bad turn, not so much because the fruit 
 is innately bad as that the small boy is innately reckless in 
 his eating of it. Here is the analysis of the edible portions : 
 Water, 86.1: protein, i.i; fat, .8: carbohydrates, 11.4; 
 
 351 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 ash, .6. Fuel value per pound, 265. Not a bad showing for 
 health. The bad reputation of the cherry as an article of 
 food is doubtless caused by the habit of eating it out of con- 
 dition as to ripeness, and as to its fermenting or rotting state, 
 and because it is a most hospitable host to pathogenic and other 
 germs. Before it is eaten it should be thoroughly washed 
 and cleansed. Botanically it is the Primus cerasus, or Prunus 
 vulgaris, and is said to be of Asiatic origin. The wild cherry- 
 tree is the Prunus virginiana, or the Cerasus virginiana. 
 There is much prussic acid in the cherry-wood, particularly 
 in the bark of the wild cherry, which is taken advantage of 
 for medicinal purposes. Our finest cherries for eating come 
 undoubtedly from California, where the soil and climate suit 
 them exactly. They come to us of the black and white varie- 
 ties, the finer specimens being the Governor Wood, Black 
 Tartarian, Cleveland Bigarreau, Reine Hortense, Llewel- 
 ling. Napoleon Bigarreau, and others. These are all mag- 
 nificent fruits, and give us good healthy luxuries of the 
 fruit kind. In the country east of the Rockies, including our 
 own near-by neighborhoods, these grand cherries of the 
 French and other types do not do so well as young trees. 
 They appear to be weak, and yield to sun scald and other 
 destructive diseases. I have planted a number of them, and 
 very few live, while, on the other hand, on the same fruit- 
 farm there are trees vigorous and hardy of the best of the 
 old heart cherries approaching a century old. I cannot help 
 but think there is some inherent weakness in our young trees 
 brought about by improper propagation and by the devital- 
 izing processes of grafting and budding. We grow fine sour 
 cherries where we cannot grow the sweet ones, the best of 
 the sour cherries being the Early Richmond and May Duke. 
 The Quince. — This fruit is useful only for preserves and 
 for its many medicinal qualities. Its seeds produce an emol- 
 lient much used by oculists as quince-seed mucilage. In treat- 
 ing it, the fruit requires parboiling to set the albumin as a 
 preliminary to sugaring it. The best varieties are the Or- 
 ange, the Champion, the Meech, and the Rea. 
 
 352 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 The Blackberry. — This comes under the genus Rubus. 
 The wild blackberry is the Rubus villosus. It is cultivated, 
 and the evolution to the higher types has been rapid. It is 
 used medicinally for its astringency, the fruit, the leaves, 
 and the roots. The best varieties we find in the market are 
 the cultivated Wilsons, Wilson, Jr., and the Early Harvest. 
 The common wild blackberry has a fine flavor, more delicate 
 than the cultivated. All the berries, both wild and culti- 
 vated, are much used for jams, wine, and brandy, each being 
 more or less astringent. The analysis is as follows : Water, 
 89.9, protein, .9; fat, 2.1; carbohydrates, 7,5; ash, .6. Fuel 
 value per pound, 245. 
 
 Dewberry. — This is about the same berry in analysis as 
 the blackberry, but it is perhaps a little sweeter and larger 
 in the wild state, and trails along the ground, whilst the 
 blackberry-canes grow upright. The Lucretia is the chief 
 variety in the market. They are both known among coun- 
 trymen as brambles. Botanically the dewberry is the Rubus 
 trivialis, or Rubus canadensis. 
 
 The Raspberry. — This comes under the same genus as 
 the blackberry, the Rubus. The raspberry is the Rubus idcous. 
 The red wild raspberry is the Rubus strigosus, and the 
 black wild raspberry is the Rubus occidentalis. The fine speci- 
 mens we see in the cultivated reds and black caps doubtless 
 come from these as the result of selection and cultivation. 
 They are too familiar to all to need any description, and I 
 need only say that the flavor of the raspberry is among the 
 most delicate and delicious of all berries. They analyze as 
 follows: Water, 85.8; protein, i; carbohydrates, 12.6; 
 ash, .6. Fuel value per pound, 255. The best red varie- 
 ties are Miller, Marlboro, Brandywine, Turner, Cuthbert, 
 or Queen of the Market, a very large and beautiful berry, 
 but apt to be soft if carried far. Shaffer's Colossal is the 
 largest; Hansell is the earliest. Of the black caps, the best 
 are probably Souhegan and Gregg. You will occasionally 
 see a yellow or amber raspberry in the market; they are 
 sports. The Golden Queen is a fine one, and is a sport of 
 23 353 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 the Ciithbert. It is a luscious berry, and an odd one for dec- 
 orative purposes. Raspberry vinegar, raspberry syrup, rasp- 
 berry wine, and raspberry jam are products of the raspberry. 
 The Strawberry. — The strawberry is a luscious and in 
 every way an interesting berry. Let me say, as a matter of 
 precaution in regard to the strawberry, the raspberry, the 
 blackberry, and all such berries, care should be exercised as 
 to eating large quantities of them, and particularly of rasp- 
 berries and blackberries. Children and elderly people should 
 be particularly cautioned, as the large bowels are liable to 
 become packed with the seeds and cause inconvenience and 
 trouble. They also cause urticaria in many, probably from 
 some idiosyncrasy of the individual, or from something they 
 may accidentally meet in the bowel, and set up a ptomaine 
 poisoning on a limited scale, evincing itself by the indigestion 
 and the rash accompanying it. Let us return to the straw- 
 berry. Its chemical composition is as follows : Water, 90.9 ; 
 protein, i; fat, .7; carbohydrates, 6.8; ash, .6. Fuel value 
 per pound, 175. The various species belong to the genus 
 Fragaria, and are of the rose family. The fruit as we eat it 
 is not really the true fruit of the vine. The pistils are placed 
 tipon a convex receptacle, and this, when the ovaries are ripe, 
 is much enlarged, and this is the fruit as we eat it or call it. 
 The true fruit is the little ripened ovaries which look like 
 seeds scattered all over what we eat as the fruit. Under cul- 
 tivation the stamens of some varieties abort, and the blossom 
 is thus not self-fertile; that plant is dioecious, and in raising 
 the berries practically, it is necessary with these dioecious plants 
 to set a fertile or some monoecious kind about every third or 
 fourth row. This makes the plant an interesting study, as 
 the Indian-corn plant is an interesting study. Here the silk 
 is the pistils, and these must be impregnated by the pollen 
 -of the antlers at the top of the stalk, or no grains of corn will 
 be produced. Here the stamens and pistils are in different flow- 
 ers or different parts of the same plant. The best varieties of 
 strawberries are named below, and to appreciate the great con- 
 sumption of the berries it is only necessary to watch the line of 
 
 354 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 travel on the railroads leading from the Delaware and Chesa- 
 peake Peninsula or from South Jersey. Thousands of car- 
 loads pass every season for the markets of the great cities. The 
 Michel is the first of the early berries, and is an all-round good 
 berry. It has a perfect blossom. The Ideal is one of J. W. 
 Kerr's new berries, with a perfect blossom. Oriole is another, 
 with imperfect blossoms. The Sharpless is an old, very large, 
 and well-tried variety. The Bubach No. 5 is, I believe, the 
 largest and, taking everything into consideration, the finest 
 berry yet introduced. It is imperfect as to blossom. The 
 Gandy is the best berry we see late in the market, and has a 
 perfect blossom. The Kentucky is the firmest late berry, and 
 has a pistillate bloom. Warfield No. 2 is a good berry, pis- 
 tillate. Wilson Albany is one of the very oldest varieties and 
 a very firm berry, and carries a long distance well ; stam- 
 inate. The Haverland is a fine berry of the lady-finger order ; 
 pistillate. The Lady Thompson, staminate, is a good berry 
 from North Carolina early in the season, but not good raised 
 in the Middle States. These early berries, some coming from 
 Florida in January, must be firm to have carrying capacity. 
 Warfield No. 2, I think, comes from Florida in January and 
 February. The Crescent is probably the most productive 
 berry for the grower; it is small, a good berry, but not at- 
 tractive ; it is pistillate. The Hovey is the oldest of the large 
 varieties, very dark red, and very large and luscious. It is 
 rare now. Lovett, a good berry from New Jersey. Van 
 Deman, named for Professor Van Deman, late United States 
 Pomologist; staminate. The best new strawberries in our 
 markets are the Bismarck, Tennessee Prolific, and Johnson's 
 Early. All these have perfect bloom. The largest and finest 
 strawberries I ever saw were in California fortv vears ago. 
 They were a light cream-color, nearly white, and immensely 
 large, with a delicious flavor. I have never seen berries like 
 them in any other country. Whether they were sports or 
 originals I do not know. California is a great State for all 
 fruits, and I believe you can purchase strawberries in the San 
 Francisco markets every month in the year. 
 
 355 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 How and why Fruits decay. — Dr. G. C. Caldwell, of the 
 Cornell Experiment Station, has given us some good points 
 on this head. The changes which take place in the ripening 
 of fruit are in some respects similar to the changes of rotting. 
 In ripening, the abundant starch of the green fruit is changed 
 to cane-sugar; later a great part of the cane-sugar becomes 
 glucose. These changes may go on whilst the fruit is still 
 on the tree, or in the storage-room after it has been picked. 
 This change of cane-sugar to glucose does not help the fruit 
 in flavor, for glucose is less sweet than cane-sugar. The 
 riper fruit gets, short of decay, the sweeter it gets, not be- 
 cause the cane-sugar changes to glucose, but because so much 
 of the starch, which is tasteless, becomes sugar and some of 
 the acids of the fruit are decomposed. As fruit goes on to 
 rot, what cane-sugar there is goes to glucose, and then this 
 glucose is decomposed. The proteids and the tannin also are 
 decomposed, and new chemical compounds are produced which 
 cause the brown color and the unpleasant taste of the decay 
 which has now set in. Different species of fungi cause this 
 rotting of the fruit, and the three important ones are Pencil- 
 Hum glaucum, Botrytis vulgaris, and Oilium fructigenum. 
 This last-mentioned one exists even on the fruit-trees, and 
 attacks both the ripe and the green fruit, and is even found 
 on the blossoms. It goes in at the stem of the fruit, into the 
 twig and the leaves, and kills both, producing the twig blight 
 and leaf blight so common. Flies and wasps and other in- 
 sects carry this fungus from tree to tree. The more wasps 
 and flies there are about, the more decayed fruit there is. 
 These fungi of decay produce a poison which kills the cells 
 of the leaves and of the twigs and of the fruit. Now, as to 
 spraying for these fungi with copper and arsenic, even if we 
 spray late, when the fruit is grown, there is little trace of the 
 poisons on the fruit, and they are safe to eat. I have sev- 
 eral years since experimented with fungicides sprayed on 
 apples in winter storage in Delaware, and at the time I 
 thought the results were good. The great increase in these 
 fungi over the times of fifty years ago, together with the 
 
 356 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 higher temperatures of our cellars where our fruit is often 
 stored, are the great reasons why our fruit does not keep now 
 Hke it did in the cellars of our grandfathers. General cold 
 storage is coming in to remedy all this and to decrease, I 
 trust, the development of the fungi of decays. 
 
 MUSHROOMS. 
 
 The Edible and the Poisonous Fungi. — Mushrooms are so 
 universally used for food that it is of the greatest importance 
 that not only physicians but laymen should know at least 
 sufficient about them to avoid those growing wild which are 
 poisonous, and to distinguish those which are edible. Bulle- 
 tin No. 15, Department of Agriculture, by Dr. W. G. Farlow, 
 gives the best resume of the subject I am acquainted with, 
 and to him I am indebted for assistance. Mushrooms are 
 toadstools, and therefore the names do not distinguish them. 
 The best known and edible of the toadstools are what we 
 know as mushrooms, so called in the markets. There are 
 many other toadstools not known in market as mushrooms, 
 which are edible, and many more of them are not poisonous, 
 even if not very palatable. How do you tell the edible from 
 the poisonous fungi ? We do not exactly know scientifically, 
 but we know in regard to many of them empirically, because 
 some one has eaten this one and lived to tell the story, and 
 another person has eaten that one and died from the effects. 
 The number tried empirically is small in comparison to the 
 whole number of species of toadstools. As to this great num- 
 ber of unknowns, we might say that this one is not poisonous 
 because it resembles that one we know to be harmless, and 
 this one is poisonous because it resembles one we know to 
 be poisonous. This reasoning may not always be practically 
 safe. Mushrooms and toadstools (I use the word mushroom 
 to apply to the edible fungi, or, rather, the ones we are fa- 
 miliar with in market or on our tables, and the word toadstool 
 to apply to those not generally used as food, whether edible 
 or not edible) belong to the group of fungi known as Hyme- 
 nomycctes. They grow in the ground or on the bark of trees. 
 
 357 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 There is first a ball, which gradually enlarges and shoots up 
 into a stem bearing at the top the umbrella, or pileus. This 
 gradually expands, in some species largely, and in others 
 keeps more of a ball shape. The mushroom, or toadstool 
 comes from fine threads. These threads are the spawn, or 
 the mycelia, the spores of fungi. Each thread is called a 
 hypha. 
 
 The word mushroom is almost universally used to ex- 
 press an upstart of any kind, whether in real life or other- 
 wise. This would seem to indicate that we all think of 
 the mushroom as springing up in a night. This is not the 
 case. The button developing from the mycelia takes often 
 a long time, even weeks, months, or years, before it comes 
 from the mycelia or spawn in the ground to the top. True, 
 the mycelia, or spawn, are the whole plant, and the mush- 
 rooms are the fruit only, the reproductive bodies like the 
 apples of the apple-tree. The spores, the mycelia, the spawn, 
 reside in the mushrooms or fruit of the fungus. The buttons, 
 in the parlance of trade, are these young non-expanded mush- 
 rooms, and mushrooms are the expanded buttons. In Europe 
 buttons are most used. In this country we use mostly the 
 expanded fruit. In the toadstool family the under side of 
 the umbrella, or the pileus, bears the spores or seeds. In 
 some species these are like the spokes of a wheel, and radiate 
 to the circumference from the top of the stalk. In others they 
 are packed in and together like tubes in a boiler, in others 
 like teeth, whilst in still others the surface is only set in 
 wrinkles. The wheel-spoke or gill group are called Agari- 
 cini, or the agarics; the tube group are the Polyporei, the 
 teeth group the Hydnei, and the wrinkle the Thelephorei. 
 
 There are some toadstools with no stalk at all, yet even 
 some of these mere balls are edible, but no one but an expert 
 should even think of eating them. Nearly all of the edible 
 mushrooms belong to the agarics and the polyporei. No one 
 when beginning, and not yet an expert, should gather buttons 
 for food, for it is then so difficult to distinguish the species. 
 Of course, this does not apply to cultivated mushrooms, for 
 
 358 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 the species is known and raised only for food. Again, do not 
 eat old decayed mushrooms, as even the edible ones when 
 old may develop poisons. 
 
 The common mushroom, Agaricus campestris, is really the 
 only species cultivated and sold in our markets during win- 
 ter. In summer it grows wild, is most plentiful in June, 
 July, August, and September, and is found more frequently 
 in old pasture-fields than in other places. As a rule, it does 
 not grow in the woods. The stalk and umbrella are white 
 or cream-color, and the gills are pink, going on to dark brown 
 or purplish brown as the mushroom gets older. This pink or 
 brown color is due to the spores on the gills. The stalk is 
 cylindrical and solid, and near the umbrella is a membranous 
 ring, and below this there is no membrane or scales. Re- 
 member this. They grow singly or in clusters of several. 
 Before the umbrella opens the gills are covered by the veil; 
 when the mushroom expands, the veil ruptures and the red 
 gills are exposed. What is left of the veil clings around the 
 stalk and forms, a little below the umbrella, the ring before 
 spoken of. Some fragments of the veil also remain attached 
 to the margin of the umbrella, giving it a slightly fringed 
 appearance. When looking for this mushroom see that the 
 gills are pink or dark brown and not white, that the stalk 
 is round and solid and has the ring below the umbrella, and 
 that it has no bulb at the ground end and no scales or bag 
 of a membranous material. It never grows on old logs or 
 trees. 
 
 The two poisonous toadstools in danger of being mistaken 
 for the common mushroom are the Amanita phaUoides, the 
 deadly agaric, and the Amanita muscaria, the fly agaric. The 
 former is the worst, and the latter is the most common. The 
 fly agaric is quite common; it grows on roadsides, on the 
 borders of fields, but not often in pastures, and not usually 
 with the common mushroom. It grows very often among 
 pine-trees and under evergreens. It grows singly and is often 
 very large. Its gills are ivhite, not pink. Its stem is hollow, 
 not solid like the common mushroom stem, there is ahvays a 
 
 359 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 bulb at the ground end, and scales on it. The color of the 
 umbrella is brilliant yellow to orange, and a deep red, espe- 
 cially orange. The surface of the umbrella is polished with 
 a number of warty scales, which cannot be rubbed off. There 
 is a large membranous collar hanging down from the upper 
 part of the stem. This is the mushroom most frequently 
 causing poison, but surely no one having the least experi- 
 ence in gathering mushrooms could mistake it for the com- 
 mon edible mushroom. Pick it up, and it is light, and the 
 stem has no strength, and bends like a piece of cooked maca- 
 roni. The common mushroom has a firm, solid stem. This 
 fly agaric strongly resembles the Amanita ruhescens, one of 
 the most delicious of mushrooms, with a flesh of red tinge. 
 None but an expert should gather this; they may pick the 
 poisonous fly agaric for it. 
 
 There is another delicious mushroom not common in the 
 North, but often found in the South, — the Amanita ccesarea, 
 or royal agaric. Here the gills, ring, and stalk are yellow, 
 not white, no scales on the stalk, but a bag-like membrane 
 through which the stalk runs. The deadly agaric has the 
 umbrella without warts, the gills white, the stalk hollow, with 
 a large ring and a bulb at the ground end, with a bag-like 
 upper margin, and a hollow stalk long and slender. No one 
 can mistake this hollow stalk in any mushroom for the solid 
 stalk of the edible common mushroom after once he has felt 
 and compared them. There are no scales or warts on the 
 common mushroom; then the color of the gills, the general 
 appearance, its standing with head erect, whilst the hollow- 
 stem ones have a mean, leaning, cast-down look, showing 
 them the villains they are. The common mushroom often 
 has the umbrella four inches broad ; the stalk is stout, round, 
 and smooth below the ring, and not usually as long as the 
 umbrella is broad. The common mushroom has an odor of 
 its own, a woody odor, a raw odor, and so has the deadly 
 agaric. The fly agaric has little or no odor. All these three 
 — the fly agaric, the deadly agaric, and the common mush- 
 room — have a taste not unpleasant in the raw state, and un- 
 
 360 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 fortunately, when cooked each has good flavor and not dis- 
 tinctive. 
 
 The Horse Mnsliroom, Agaricus arvensis, lool<s like the 
 common mushroom, the Agaricus campestris, but is larger, 
 and is often taken for and eaten for the common mushroom. 
 It is edible and safe. It grows along hedges and in cultivated 
 fields. The umbrella is shining white and the stem is a little 
 hollow. The gills are at first white, a very suspicious quality, 
 but they brown up as it gets older. The ring is double, not 
 single, as in the common mushrooms. 
 
 There is another common mushroom, an edible one, the 
 Hypholoma appendiculatnm. It grows in clusters around 
 stumps in grass fields. The color is transparent white, with 
 a purple or a brownish tinge when wet. The umbrella is 
 thin and bell-shaped, and the edges roll up somewhat. The 
 gills are a purple-brown; it has no ring, and the stalk is 
 hollow. 
 
 The Horsetail Fungus, the maned agaric, Coprimis coma- 
 tus, is edible, and grows along the roadside in grass in dense 
 clusters. The umbrella in this species remains closed, not 
 open, and when commencing to decay it rolls outward, and 
 the fungus liquefies in a dark fluid. This is the way it de- 
 cays. The umbrella is white, with fringy scales. The gills 
 are broad, close to the stalk, and, like the common mushroom, 
 turn from pink to dark. The stalk is long and hollow, and 
 has a ring which can be moved up and down. A few appear 
 in early summer, but it is most plentiful in the fall. Two other 
 specimens of Coprimis are found, and mostly around walls 
 and houses, — Coprimis afranientarius. The stalk is short and 
 stout, and it is edible. The color is ashy and dark, and it has 
 no scales, but is furrowed. Coprimis micaceous is a small one 
 and is edible, with the umbrella light brown or darker. These 
 species are quite common and grow around houses, but I do 
 not think they are so palatable as to entail the certain risk the 
 amateur runs in eating such. 
 
 I think ninety-nine-one-hundredths of the wild mushrooms 
 we eat are the Agaricus cauipcstris, the common mushroom, 
 
 361 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 and any one can tell them after a very little practice. Before 
 eating any other kind I want them passed upon by an expert 
 who has very frequent practice. Our most poisonous species 
 of toadstools have a wrapper, as it were, around the base of 
 the stalk, called a volva; if in addition they have white gills 
 and spores and a bulbous base, with scales, they should not be 
 eaten. 
 
 The Parasol Fungus, Lepiota procera, is large and tall, and 
 grows in grass ; it is not poisonous, but is tough and not de- 
 sirable. It is white or brown. The umbrella is scaly, and 
 the ring is free on the stalk. 
 
 The Chanterelle, the Cantharellus ciharius, grows in the 
 woods in summer. It is yellow and has a crumpled margin. 
 The upper surface is depressed and the gills run down over 
 the stalk. It is not good enough to risk eating it, if gathered 
 by the average hunter. 
 
 The Fairy Fungus, Marasmius oreades, grows in the grassy 
 lawns in rings, which are called fairy rings. It is tough and 
 not good, though edible. The stalk is tubular, and the um- 
 brella or pileus is thin. It is of a drab color ; the spores are 
 white. To determine the color of the spores of a mushroom 
 press it on a piece of white paper and allow it to remain a 
 while, and the color of the spore will be shown. 
 
 Fungi with Milky Juice. — These are of the genus Lacta- 
 rius. The milk is usually white, but may be red or blue. In 
 some species it is very acrid. They are safe, but not good. 
 There is one specimen said to be good, — the Lactarius deli- 
 cosus. It is a mountain fungus. The milk is red and after- 
 wards turns to green. The fungus is red. The Russules are 
 mostly small and grow in swamps and woods. The gills are 
 yellowish. Some are edible, and some are poisonous. The 
 Oyster Fungus, Pleurotus ostreatus, has no central stalk, but 
 grows to trees attached by a short stalk at the side. They 
 grow in clusters attached to a tree, like oysters attached to 
 rocks. They are yellowish in color, and the clusters are often 
 a foot or more wide. The gills are long. It is edible, but not 
 very palatable, and not worth any risk. The Polyporei, or 
 
 362 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 tube-bearing fungi, as distinguished from tiic fungi with 
 gills, have central stalks and some only lateral, like the oyster 
 fungi. Most of the species are not palatable if edi1>le. The 
 edible species belong to the genus Boletus. They are soft 
 and fleshy, and grow on the ground in woods and fields. 
 Some are edible and some are poisonous. They are not 
 worth risking as an article of diet. Boletus subluteus is edible, 
 but not very palatable, not worth eating. 
 
 The Steinpilz of the Germans is very large. The stalk is 
 stout. The tubes are two inches long; they are white, and 
 then become yellow. It is edible, but not worth eating. This 
 is the true Cepe. In the boleti, if the mouths of the tubes are 
 red, do not eat it. The boleti, as a rule, are rather dangerous. 
 
 The Beefsteak Fungus, Fistulina hepatica, grows on 
 stumps, particularly on oak and chestnut stumps. When 
 young the upper side is of a peach-color, growing to a deep 
 red with age. The tubes are flesh-color and are on the under 
 side. The surface looks like a cooked tongue or like a beef- 
 steak. It is safe to eat. 
 
 Teeth-bearing fungi, Hydnei, hedgehog fungi, are some of 
 them edible, but not palatable. Their color is white to brown 
 and red and yellow. The two most common are Hydniim 
 imbricatum and Hydnum repandmn. They are found in 
 swamps. The coral-shaped fungi of the family, Thelephorei, 
 are not poisonous. I do not think them worth eating, but 
 some experts say many of them are good. 
 
 Morels and Truffles. — The morels are among the best 
 of fungi to eat. Botanically they are not close to the toad- 
 stools. They may be called the tripe-like fungus, and the 
 honey-comb runs into the covering. Hunt for them in the 
 spring and early summer in woodland that has been burned 
 over. The stalk is white and granular. Truffles, the great 
 delicacy of Europe of the fungi, are not found in the United 
 States, at least not the prized ones. They are like small pota- 
 toes, and are hunted by trained dogs and pigs, and dug out 
 of the ground. If found with us, it will probably be on cal- 
 careous soil, among hills covered with oak-trees. 
 
 363 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Puff-Balls. — Gasteromycetes, or puff-balls, as a rule, 
 have -no stalk ; they lie on the ground. The powder comes 
 with age and is chiefly composed of mycelia or spores. The 
 largest is the Lycoperdon giganteum, and grows to a circum- 
 ference of forty inches. The flesh is white or yellowish and 
 firm, and edible before it becomes powder. Another puff-ball, 
 edible, as most of them are before the powder forms, is Lyco- 
 perdon cyafhiforme. There is one species of puff-balls poi- 
 sonous, and it grows around houses, the Scleroderma vulgare. 
 The exterior is yellow and warty, and the inside is purple or 
 black, with white. None of these puff-balls are sufficiently 
 attractive as food, unless one is starving, to cause one to run 
 a risk of eating Scleroderma vulgare for Lycoperdon cyafhi- 
 forme. Dr. Farlow well says, " When you are in doubt, never 
 eat a fungus." This is the only rule needed. Truly they are 
 only a luxury anyhow, not a staple food. There is no danger 
 in eating cultivated ones, for then there can be no mistake: 
 no poisonous ones are cultivated. The cultivated common 
 mushroom, the Agaricus campestris, is as finely flavored when 
 cultivated as when grown in its wild state. 
 
 The tests to distinguish poisonous from non-poisonous 
 mushrooms or toadstools in common vogue, as of cooking a 
 silver spoon with them, the blackening of the spoon being a 
 sign of poison, are utterly unreliable. Cooking in milk or vine- 
 gar may do more harm than good if the fungi be poisonous. 
 There are two classes of poisonous fungi, the irritant and the 
 narcotic. The narcotic are the most dangerous. The irri- 
 tant may work their own cure by causing vomiting soon after 
 they have been eaten. The narcotic may cause serious symp- 
 toms after ten or twelve hours through the nerve-centres. 
 The irritant fungi, as a rule, have a pungent, disagreeable 
 taste, the narcotic a rather pleasant taste. Muscarin is the 
 chief poisonous active principle of the Amanita muscaria. 
 Muscarin is a colorless alkaloid, which forms salts with acids. 
 Muscarin is not poisonous to flies, but this mushroom con- 
 tains another poison which is volatile and kills flies. Mus- 
 carin can be made synthetically by treating cholin with nitric 
 
 364 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 acid. Poisoning by the fly mushroom comes on in from a 
 half-hour to two hours, up to ten hours. First come colic, 
 vomiting, and diarrhoea, then contracted pupils and saliva- 
 tion; then the patient becomes drunk, as from alcohol, the 
 vision is disturbed, and convulsions may supervene; stupor 
 comes on with apoplectic symptoms, and either symptoms of 
 collapse and death follow or the patient gradually recovers 
 from his stupor and recovery takes place. The fatal result 
 is often postponed until the second or third day. 
 
 As to treatment, evacuate the stomach by emetics or apo- 
 morphine hypodermically ; if free vomiting does not take 
 place, use the stomach-pump and give croton oil to evacuate 
 the bowels. Atropia is the antidote to muscarin; give it 
 hypodermically. Combat tendency to heart failure with digi- 
 talis, strychnine, etc. Atropia is only a physiological anti- 
 dote ; there is no known chemical antidote to muscarin. The 
 poison in the Amanita phalloides, the death cup, is phallin. 
 Phallin is a toxalbumin, and boiling fortunately makes it less 
 dangerous. Phallin kills, not by causing collapse, but by de- 
 stroying the red blood-corpuscles, setting free the haemoglo- 
 bin. Poisoning sets in after from twelve to fifteen hours. 
 The patient acts like one in collapse of cholera, but death 
 comes not from heart paralysis, as in poisoning from the fly 
 amanita, but from the blood breaking down, causing exhaus- 
 tion. Evacuate the stomach and treat on general principles. 
 Be sure and use injections of normal salt solution into the 
 veins or the tissues. There is no known antidote to phallin. 
 It is supposed to arrest the heart's action in diastole. The 
 proper treatment is to evacuate the stomach by proper meth- 
 ods, even washing it out with oceans of aseptic warm water. 
 Digitalis is probably antagonistic to muscarin. Give twenty 
 drops of tincture of digitalis hypodermically, and then digi- 
 talis, whiskey, ammonia, and such remedies as the case may 
 require. In digitalis poisoning the heart is usually arrested 
 in systole. 
 
 Farlow's rules for beginners gathering mushrooms are as 
 follows : 
 
 365 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 1. Avoid fungi in the button state, and in the decayed state 
 if the decay is only slight. 
 
 2. Avoid all fungi which have stalks with a swollen base 
 surrounded by a sac-like or scaly envelope, especially if the 
 gills are white. 
 
 3. Avoid fungi having a milky juice, unless the milk is 
 reddish. 
 
 4. Avoid fungi in which the umbrella or pileus is thin in 
 proportion to the gills, and in which the gills are nearly all 
 of equal length, especially if the umbrella is bright colored. 
 
 5. Avoid all tube-bearing fungi in which the flesh changes 
 color when cut or broken or where the mouths of the tubes 
 are reddish, and in the case of other tube-bearing fungi ex- 
 periment with great caution. 
 
 6. Fungi which have a sort of spider-web or flocculent 
 ring around the upper part of the stalk should in general be 
 avoided. 
 
 Rules I, 2, and 5 may for the beginner be regarded as abso- 
 lute, with the exception to Rule 2 of Amanita ccesarea, the gills 
 of which are yellow. 
 
 Rules 3, 4, and 6 have more numerous exceptions, but 
 these rules should be followed in all cases unless the collector 
 is content to experiment first with very small quantities, 
 and learn the practical result. As to mushrooms, they have 
 been supposed to be highly nitrogenous and hence strong 
 food. I have seen this recently denied, and they were put 
 down as wishy-washy diet. They give up much water on 
 cooking. 
 
 The following analysis shows just what they are as food. 
 Fresh mushrooms: Water, 91.11; non-nitrogenous sub- 
 stances, 2.57; fat, .13; grape-sugar mannite, 1.05; other 
 non-nitrogenous substances, 3.71; woody fibre, .67; ash, 
 -76. Fresh truffles: Water, 72.08; non-nitrogenous sub- 
 stances, 8.91; fat, .62; other non-nitrogenous substances, 
 7.54; woody fibre, 7.92; ash, 2.21. Fresh common morel: 
 Water, 90; non-nitrogenous matter, 3.48; fat, .24; grape- 
 sugar mannite, .72; other non-nitrogenous substances, 3.95; 
 
 366 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 woody fibre, .67; ash, .94. This is not a strong showing, 
 and does not make them the highly nitrogenous diet we have 
 been taught that they are. Remember, though, in cooking 
 most of the bulk goes off in water, and what remains is quite 
 concentrated. 
 
 There is something unexplained attaching to mushrooms. 
 In Italy the common mushroom, Agaricus campestris, is not 
 only rejected as an edible variety, but it is feared as poi- 
 sonous. The climate, soil, and environment must make a 
 difference surely. The mushroom for spontaneous reproduc- 
 tion probably depends on animals, especially the horse and 
 the horned cattle. The mycelia are taken in with the grass 
 they eat, then passed through during digestion, and come forth 
 in the manure of the animal. Animal droppings are the proper 
 material in which to sprinkle the mycelia when artificial culti- 
 vation is to be carried on. They grow in caves, in casks, or 
 in benches placed in flower forcing-houses or in cellars. Some 
 grow them in the cellars of dwelling-houses, where the heat- 
 ing apparatus of the house is utilized to give proper heat for 
 developing the mushrooms from the spores. This is a very 
 dangerous custom, as many pathogenic germs may be culti- 
 vated at the same time, and that much-dreaded germ of teta- 
 nus or lockjaw, the bacillus tetani, is especially at home in 
 stable droppings. Mushroom spawn or spores come in so- 
 called bricks, from their shape and resemblance to common 
 bricks, and can be purchased from the general seed dealers. 
 This is really the proper way to get mushrooms. Raise or 
 buy the cultivated ones. You always then get the common 
 mushroom, a perfectly safe one, and the best of all, taking all 
 things into consideration, and you do not depend on the Toms, 
 Dicks, and Harrys who gather the w'ild ones and hawk them 
 from door to door, and who know nothing whatever about 
 discriminate selection. 
 
 NUTS. 
 
 Nuts in the United States are not a staple article of diet. 
 and the chief ones eaten and containing nourishment are the 
 cocoa-nut, the almond, the chestnut, the English and black 
 
 2>^7 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 walnuts, peanuts, shellbarks, and pecans. There are many of 
 good -flavor which are appetizing and attractive, and as one 
 lingers over a good dry sherry they give a softness and a 
 mellowness to the wine and bring out its good qualities, as it 
 enlivens and brightens the post-prandial conversation. 
 
 In Europe, especially in France and Italy, nuts enter largely 
 into the diet of the poorer classes. In the United States, In- 
 dian corn is so plentiful and so cheap, and is so much in every 
 way the better food, there is no need of even the poorest of 
 our people taking to nuts as food. Of late years wheat has 
 become so reduced in price as to make it available for food 
 to all of our people, and the poorer classes are now even turn- 
 ing up their noses at Indian corn. 
 
 In France the laboring classes eat freely of chestnuts. 
 They remove the outside shell and blanch them by throwing 
 them into boiling hot water ; then rubbing off the inside skin, 
 they place a cloth wet with hot water in an earthen pot, and 
 nearly fill it with chestnuts. These they cover with another 
 wet cloth, and put the pot on the fire and steam them. They 
 usually eat them with salt, like roasted potatoes, or with 
 milk. Thus eaten, they are a palatable and useful article of 
 diet. We must remember that none of the European chest- 
 nuts are as palatable as our American sweet chestnuts. They 
 are much larger, but have much less sugar. Raw, they usu- 
 ally are not palatable. In Europe they eat their chestnuts 
 boiled and roasted, and in soups and as dressings for meats 
 and poultry. In the mountainous regions they make a bread 
 out of chestnut-meal, which is palatable, and they use the 
 nuts for food for animals. For such purposes they do not 
 shell them. In Europe they are cheap, selling for about one 
 cent per pound at retail. Chestnuts may be served as a puree, 
 with chops, boiled tongue, and such dishes, instead of mashed 
 potatoes, and if made from the American chestnuts it will be 
 found delightful. The marron glace is a luscious confection, 
 and is made from the meal and sugar properly flavored. 
 
 Chestnut soup : Hull and blanch a pound of chestnuts, the 
 best obtainable ; put them in cold water, then dry them, and 
 
 368 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 cover them with one quart of good stock; stew them for 
 three-quarters of an hour, then rulj them to a paste and pass 
 them through a fine wire sieve; Ijoil this and add milk suffi- 
 cient to make three pints of soup, and season to the taste with 
 salt and pepper. 
 
 The chestnut botanical ly is the Castanca vcsca or Castanea 
 vulgaris. It has an oblong, lanceolate leaf, serrated mark- 
 edly. The blossoms are peculiar looking, and come quite late 
 in the spring or early summer. There are sterile clusters in 
 long catkins, and fertile blossoms, two or three together, in 
 a round prickly involucre at the base of the catkins. There 
 is no corolla. The calyx is on the summit of the ovary, and 
 encloses the stamens and stigmas. The nut is familiar to all. 
 The chestnut-tree lives to a great age, and attains an enor- 
 mous size. They analyze thus (the fresh edible portion) : 
 Water, 44.9; protein, 8; fat, 10.8; carbohydrates, 54; ash, 
 1.8. Fuel value per pound, 1480. Dried: Water, 5.8; pro- 
 tein, 10.6; fat, 10; carbohydrates, 70.9 ; ash, 2.7. Fuel value 
 per pound, 1940. Here is a food value nearly equal to wheat 
 flour or corn-meal, and also showing that the chestnut is not 
 fit food for the diabetic. 
 
 The chief enemies to the chestnut are the larvae of the 
 chestnut weevils, the larger ones from the Balaniiius caryatry- 
 pcs and the smaller ones from the Balaniiiiis rectus. The 
 grubs, of a light cream-color, are often found in the nuts. 
 When the trees are in bloom the beetle appears, just about 
 the time the staminate catkins drop. They have long, slen- 
 der snouts, and bore through the rough sticky burs and 
 through the shells of the nuts within the burs. The female 
 lays her eggs in the nut, and the hole heals. The eggs hatch, 
 and the larvae work within the nut and mature with the chest- 
 nuts. The w^orm, now grown, eats through the shell and 
 ruins the nut. It goes to the ground, where it changes to a 
 pupa, and the next season appears as a beetle again, and again 
 goes through his transformation. The remedies for the 
 worms are not satisfactory. Spraying does not reach them. 
 The best we can do is to kill those in the gathered nuts by 
 24 369 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 smoke or hot water and other methods, so as to prevent the 
 larva from entering the ground and changing into its pupa 
 state, and becoming a beetle again. 
 
 I ask no concessions for this digression into this little na- 
 ture study. Physicians should know all about such things, 
 and such studies are a relief to one exhausted with the over- 
 work of practical medicine. Physicians, lawyers, clergymen, 
 school-teachers, and others should all take up some form of 
 nature study. They would be happier and better in every 
 way. It should in many ways be taught in the schools, and 
 I am glad to say efforts in its behalf in that direction are suc- 
 ceeding. 
 
 Our chestnuts in this country are the native sweet seedling 
 chestnuts, the native grafted chestnuts, the European chest- 
 nuts, and the Japan chestnuts. Leaf fungi, the Marsonia 
 ochroleuca and the Cryptosporium epiphyllum, attack the Eu- 
 ropean and the natives, and rarely the Japan. Spraying with 
 the Bordeaux mixture used for grapes, etc., being lime and 
 copper sulphate in water, is effectual in controlling it. 
 
 Professor G. Harold Powell, entomologist and horticul- 
 turist of the Delaware College Agricultural Experiment Sta- 
 tion at Newark, Delaware, is one of our best authorities on 
 the chestnut, as is J. W. Killen, of Felton, Delaware, one of 
 our best practical authorities. Powell holds that the Japan 
 flora better suits the United States than the flora of the chest- 
 nuts from Western Europe, and thinks the Japans will im- 
 prove greatly by selection, etc., in our country, and also by 
 the infusion into them of our native stock. 
 
 To my own taste our native chestnut and our native chin- 
 quapin, Castanea pumila, are by far the best of all in flavor, 
 whether raw or cooked. Next come the European varieties 
 native in the United States, as the Ridgely, Paragon, Numbo, 
 and the du Pont. Next come the Japans grafted, which are 
 ■dwarfish in their nature and very early and prolific bearers. 
 The best of them are Kerr, Martin, Biddle, Doctor Black (for 
 an early one), Kent, Killen, Hale, and Parry. Last I place 
 the European seedlings, generally known as Italian chestnuts 
 
 370 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 with us. I have a number of trees a quarter of a century old, 
 which bear large crops. The weevil is hard on them. Most 
 of my trees fortunately bear good large nuts, but in buying 
 these seedling trees, of course it is a lottery as to what quality 
 of nut you get. The leaves of the chestnut have antispas- 
 modic properties, and the fluid extract is a remedy in per- 
 tussis and such troubles. 
 
 Peanut. — The peanut is a legume, the Arachis hypogcoa. 
 The French call it the pistache dc terrc. It comes to us either 
 from Africa or Brazil. Its chemical composition is : Edible 
 portion, water, 9.2; protein, 25.8; fat, 38.6; carbohydrates, 
 24.4; ash, 2. Fuel value per pound, 2560. Here is a very 
 strong food, high in protein and fat particularly, and too 
 strong in carbohydrates for diabetics. It is the poor man's 
 nut for food beyond all others. They are too strong in fat 
 for many stomachs, but a little fruit or subacid jams eaten 
 after them will help out in their digestion by assisting to emul- 
 sify the peanut oil. Vast quantities of these nuts are raised 
 in the United States, and they are of very great commercial 
 importance, furnishing a staple article of diet in the nuts, and 
 much oil useful for many purposes, even making a very good 
 salad oil, and with our cotton-seed oil often sold for the best 
 olive oil. 
 
 Almonds — Amygdalus. — The plum, peach, cherry, and 
 nectarine are of the same genus. The peach is the Amygda- 
 lus persica. There are the bitter and sw'eet almonds. The 
 bitter almond has less oil than the sweet, but contains more 
 hydrocyanic acid. The leaves of both contain much hydro- 
 cyanic acid. The sweet almond is a toothsome nut, but in- 
 digestible, as a rule. Sweet almond oil is much used, and 
 valuable in its way. The chemical analysis of sweet almonds 
 is as follows: Water, 6; protein, 23.5; fat, 53; carbohy- 
 drates, 14.3; ash, 3.1. A gouty and fat- forming food, it 
 should be used only moderately, to bring out the flavor of 
 sherry, Madeira, or port. 
 
 Filberts or Hazel Nuts. — Genus, Corylus. Two species 
 are native of the United States. They flower very early in 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 the spring and are attractive. They are bushes rather than 
 trees. ■ The Corylus colurna grows to a tree in Asia, and yields 
 a fine oil. The chemical analysis is as follows: Water, 7.1; 
 protein, 17.4; fat, 62.6; carbohydrates, 10.4; ash, 2.5. Like 
 almonds, they are low in carbohydrates and high in fat. Dia- 
 betics may eat them moderately, as they may eat almonds. 
 
 Pecans. — The Carya olivcBformis, or hicoria pecan, is a 
 species of hickory. This nut is very common in the South, 
 and especially in the Southwestern United States. It thrives 
 in the Middle States, especially on the Delaware and Chesa- 
 peake Peninsula. It has been proposed to graft it on the 
 English walnut to hurry its growth and to improve the nuts. 
 It will take on all of the hickories. Dr. John Le Conte, of 
 Philadelphia, well known for his scientific attainments, 
 brought, in 1853, a unique pecan from Texas. He named 
 it Hicoria tcxana. It has been cultivated in Georgia. The 
 tree only attains a height of from ten to twelve feet. The 
 ordinary pecan-tree grows to a height of one hundred feet. 
 Pecans are becoming very plentiful, as large orchards of them 
 are being planted commercially in different parts of the coun- 
 try. They analyze not much differently from the filbert or 
 shellbark, or the common hickories. The membrane covering 
 the kernel is bitter, and should be avoided in eating them. 
 They are high in oil. The kernel will burn and make a good 
 light. Pounded up or ground, shells and all, they make good 
 hog-feed. Corsa thinks the mast fed to cows would give a 
 good flavor to butter if the shell were excluded. 
 
 Shellbark or Shagbark. — William P. Corsa gives this 
 as Hicoria laciniosa (Sargent) or Carya sulcata (Nuttall). 
 This is undoubtedly the best flavored of all the nuts that 
 grow. The best are so soft of shell that they may be cracked 
 with the teeth, although I am free to admit that an inorganic 
 nut-cracker or hammer of some kind would be safer so far as 
 the teeth are concerned. The nut is oily, fairly high in pro- 
 tein, and sufficiently low in carbohydrates for the diabetic to 
 eat. There are many other species of the hickory-nut, all of 
 which have been noted by Corsa in his work on Nuts and 
 
 372 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Nut Culture in the United States. There arc the Mocker 
 Nut, Hicoria alba, known as the bull nut, etc. ; the Pignut, 
 Hicoria glabra, or Bitter Hickory; the Nutmeg Hickory, 
 Hicoria myristiccofornis; the Bitter Nut, Hicoria minima; 
 the Water Hickory, Hicoria aquatica. 
 
 Cream Nut, Brazil Nut — Bertholletia Excelsa. — It be- 
 longs to the order Lectythidacca. The natives call it Juvia. 
 It is too tender as to frost for the United States, even for 
 Southern Florida, commercially. This nut is a curiosity. 
 They are, as we see them in the stores, in the form of a trian- 
 gular prism; a number of these are contained in a round 
 case or box, fitted in, the case being often as large as a child's 
 head. Crack the case, and out fall the nuts. The meat is in 
 one piece, like an almond, and of the triangular shape of the 
 hull. When fresh they have a fine flavor. As they grow old 
 they become rancid. In this country we do not often get 
 good fresh Brazil nuts. The oil from the nuts makes good 
 lamp oil. 
 
 Chilean Nut. — A most beautiful tree, and is growing 
 successfully in California, Guevina avellana. The fruit has 
 an agreeable nut-like taste, but in its raw state is poisonous, 
 like the Brabejum. 
 
 Queensland Nut — Macadamia Ternifolia. — Corsa re- 
 ports this fruit like a drupe, round and smooth, with a shell 
 like a walnut ; it is like the filbert, but superior in flavor. 
 
 Betel Nut — Arcca Catechu. — This is only one of the areca 
 nuts. The fruit is the size of a hen's tgg, and the seed or 
 nut is the size of a nutmeg. The people of India chew it as 
 the Americans chew tobacco, calling it betel. This is made by 
 mixing it with the leaves of the piper betel and lime. The nut 
 is used mostly with us by reducing it to charcoal and then 
 making a tooth-powder from it. This charcoal is so hard it 
 pohshes the enamel of the teeth. From four to six drachms 
 of the nut is said to be effectual in tapeworm. One of the 
 various catechus comes from the Arcca catechu, official U.S. P. 
 
 Pistachio Nut — Pistach — Pistacia Vera. — The tree is 
 dioecious. The nuts are borne on the female tree in clusters. 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 and are covered with a light-green husk. The tree is a native 
 of Syria, but has been introduced into the United States and 
 grows successfully in the South and in California. It is 
 used for flavoring medicines and confectionery, and also for 
 coloring them light green. The French use it to flavor sau- 
 sages and such foods. 
 
 Kola Nut — Sterculia Acuminata, Cola Acuminata. — This 
 nut is a native of Africa. It commences to bear when four 
 years old. The tree, like the orange, has the flowers and 
 fruit on it at the same time. The ripe nut is a brownish 
 yellow capsule, inclosing both red and white seed, varying in 
 number from five to twenty. They are collected and assorted 
 with care. The sound seeds are placed in dark baskets lined 
 with leaves, and are thus transported. If not well cared for, 
 they are liable to ferment. According to Dr. Neish, the nut 
 is rich in caffeine and theobromine. Kola nuts contain more 
 caffeine than coffee, and in them it is free and uncombined 
 and easy to obtain pure. It lessens mental and bodily fatigue, 
 and is safer than beer as a beverage. The natives of Africa 
 esteem it highly as a help in fatigue. It may be harmless, but 
 surely all such remedies need care and watching in pre- 
 scribing, and kola and coca are among those needing most 
 to be watched. 
 
 GuARANA. — The fruit and leaves of the Paullinia sorbilis; 
 these also furnish caffeine, and also are astringent. 
 
 Butternut — Juglans Cinerea — White Walnut. — This 
 nut is very generally distributed in the United States. In 
 Delaware it is common along the banks of the White Clay 
 Creek. The soft half-grown nuts make a very good pickle. 
 The quality of the nut is put down as good. Personally, I 
 do not like it. It is difficult to remove from the shell, and is 
 strong in oil. 
 
 Black Walnut — Juglans Nigra. — Every one knows this 
 nut, it is so widely distributed. It is more planted for 
 its timber than for its nuts. It bears a strong oily nut, but 
 has a flavor of its own. Its analysis is as follows : Water, 
 2.5; protein, 24.9; fat, 54.7; carbohydrates, 16.3; ash, 1.7. 
 
 374 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 It is quite a strong food, very oily, with a little too much car- 
 bohydrates for diabetics to eat of freely. A few will do them 
 no harm. My friend. Dr. Robert P. Harris, of Philadelphia, 
 recently deceased, has called my attention to the effect of 
 washing with soap and water a black walnut just taken from 
 its green hull. It makes it of a beautiful light cream-color, 
 and renders it quite attractive for market. 
 
 California Walnut — Juglans Californica. — This is a 
 California black walnut. Its fruit is smaller than the Eastern 
 walnut. It makes a good stock for the Persian walnut. Ju- 
 glans rupestris is another black walnut common to Texas. 
 
 English Walnut, Madeira Nut, Persian Walnut, 
 Grenoble Walnut — Juglans Regia. — This tree is a native 
 of Asia. It is widely distributed. It grows in Delaware to 
 perfection, and I have never seen it cut down by frost. It 
 bears abundantly. The anguillula does not affect it here. In 
 the city of New Castle there are trees probably a century old, 
 which bear bushels of the best nuts annually. The houses 
 screen them and doubtless prevent sun scald. In exposed 
 places this can be prevented by screens. I have fine thrifty 
 trees growing on my fruit farms in Delaware and Maryland 
 over twenty-five years old. As yet they have borne few nuts. 
 In my experience the tree does not commence to bear in or- 
 chard culture in the Middle States under sixteen to twenty 
 years of age. The chemical analysis is as follows : Water, 
 2.5; protein, 17.1; fat, 60; carbohydrates, 19.1; ash, 1.4. 
 They are quite rich in fat, and almost too strong in carbohy- 
 drates for diabetics to eat freely. There are many varieties, 
 with no great difference between them, some having softer 
 shells than others. The finest seedling I have seen was from 
 a tree in Merchantville, New Jersey, and sent to me by the 
 late Dr. Robert P. Harris. 
 
 Japan Walnut — Juglans Sieholdiana, Juglans Cordifor- 
 mis, Juglans Mandshurica. — The Mandshurica is much like 
 our butternut, but has a very much harder shell. The meat 
 is a little on the butternut flavor. The Sieboldiana does not 
 differ much from the Mandshurica; probably the shell is a 
 
 375 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 little more like the English walnut shell, but very much 
 harder; indeed, it is very hard and dense. Cordiformis is 
 smaller than the other two, and has a somewhat softer shell. 
 The trees all look alike. The nut may be a valuable addition 
 to our list, but as a shade-tree I regard the Japan walnut as 
 a very great addition and a great boon. The trees have beau- 
 tiful foliage, beautiful blossoms at the tips of the branches, 
 bear their fruit in clusters, and grow more rapidly than the 
 Carolina poplar; in fact, they are hardier, and will produce 
 good effect and good shade quicker than any other tree I 
 know of. The Persian walnut is also a beautiful lawn tree, 
 and grows fairly rapidly. The Eucalyptus globulus grows as 
 fast as the Japan walnut, but is not hardy generally in the 
 United States, and absorbs so much water that it robs other 
 trees and plants near it. 
 
 SouARi Nut. — This is a new nut just introduced into this 
 country from the Indian River country of Venezuela. This 
 nut consists of a single nut in a very hard shell, like the Brazil 
 nut, except that the Brazil nut is multiple in its larger shell, 
 not single. The outer shell of the souari nut is very hard, 
 and is clam-shaped and of a snuff-color. It has a creamy 
 taste, but is inferior to the Brazil nut in flavor. It has some- 
 thing of a raw mushroom odor and flavor. It may be eaten 
 plain, or with pepper and salt, or with cheese, or may be 
 roasted or boiled. 
 
 v^J 
 
CHAPTER XL 
 
 George B. Wood and S. D. Gross on Tubercle — Koch's Discovery of the 
 Bacillus TuI)erculosis — Present Definition of Tubercle — Physical Attri- 
 butes of Tubercle — Tubercle Bacillus in Man and the Lower Animals — 
 Pulmonary Tuberculosis in Man — The Physician and Tuberculosis — 
 Early Diagnosis Important — The Bacillus and Diagnosis — Case of 
 Chronic Interstitial Pneumonia and Tuberculocidin — Tuberculins and 
 their Therapeutic Principles and Uses — Toxines and Antitoxins — 
 Koch's Tuberculins A, O, and R — Maragliano's Serum — Virchow's Ob- 
 jections to Koch's Tuberculin A — Mulford's Serum — The Economics of 
 Tuberculin — Tuberculous Cattle in Europe and America — Necessity for 
 Action — Prevention and Treatment of Tuberculosis — Surgical Tubercu- 
 losis — Treatment of Haemoptysis — Murphy's Method of treating Pul- 
 monary Tuberculosis — Secondary Infection — Cures — What Factors 
 hold Tuberculosis Latent — Climate and Environment — Pulmonary 
 Hemorrhage and Altitude — The Indians as an Object-Lesson — Re- 
 lieving Crov^'ded Centres — Sanitaria and Sanatoria and Treatment — 
 Common Colds — Consumption in Hotels — Solitary Life Best — Altitude 
 — The Heart and Altitude — Diabetics and Altitude — The Climate of the 
 United States East and West — Sanatoria and Climate in Europe — 
 Serum Treatment in the Adirondacks — Inhalations as Remedies. 
 
 Without discussing- its cause at the opening of this chap- 
 ter, we may well say that tuberculosis is the greatest of all 
 factors in hurrying mankind to death; not only mankind, 
 but the lower animals as well, descending to as yet unknown 
 depths in the scale of life, and carrying destruction to an ex- 
 tent that we are only just beginning to realize and under- 
 stand. Forty years ago Professor George B. \\^ood was a 
 close observer and a high authority on medical subjects. His 
 distinction between tubercle and cancer was that tubercle 
 tended to health, and cancer tended to death. His definition 
 of tubercle was : A solid extravasated matter, which, in cer- 
 tain states of the system, is deposited in various parts of the 
 body, and from its shape, ordinarily assumed, is called tu- 
 bercle. The state of the system leading to this deposit was 
 
 Z77 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 called in those days, as it is to-day, the tuberculous diathesis. 
 He recognized the gray and translucent and the yellow and 
 opaque tubercles, that they underwent softening, acted as 
 foreign bodies, and sometimes the cavities left by them healed, 
 or the whole mass became protected by organized fibrin and 
 isolated from doing harm. He recognized heredity as a 
 cause of tuberculosis. To his idea, tubercles were not a 
 product of inflammation, but were a cause themselves of in- 
 flammation. At this time they were cutting quite close to 
 the cause of tubercle, or rather tuberculosis, by microscopic 
 investigation, and the one thing lacking was the advent of 
 some genius to add staining of the specimens to the resources 
 of the microscopist. 
 
 Compound corpuscles were noticed by Virchow as early 
 as 1 85 1. Pus was not inherent in tuberculous masses, but, 
 when present, came from the surrounding inflamed tissues. 
 As tubercle softened, fatty matter was generated, and a fatty 
 degeneration took place. The true tuberculous liquid was 
 sometimes absorbed, and left in the place of the tubercle only 
 a calcareous mass. That is a physical fact true to-day. 
 
 To sum up, here is Wood's definition of tubercle, and the 
 accepted definition among a great majority of pathologists 
 of that day : A formless fibrinous matter is first extravasated, 
 having a low and feeble vitality; that, as the result of an 
 imperfect attempt at organization, coagulation takes place 
 with the production of granules and peculiar corpuscles, and 
 that the tubercle thus formed grows by accretion of similar 
 matter to its surface, and then, as a result of the law of its 
 constitution, undergoes a series of changes, ending in its 
 complete disintegration. Light at this time was just com- 
 mencing to dawn upon the profession as to the zymotic nature 
 of so many diseases. Two theories as to contagion were then 
 in vogue, and advanced thinkers were becoming less and less 
 conservative. The first theory of contagion was fermenta- 
 tive, the ferments entering the blood and causing chemical 
 changes that result in a further production of similar conta- 
 gious matter. Thus the reproduction of the morbific agent 
 
 37S 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 is explained. The contagions existing in the system are ex- 
 hausted by these fermentations, and thus second attacks of 
 such diseases are prevented. 
 
 The second explanation of contagion is on the germ theory, 
 " invisible organic agents, animal or vegetable, which, fully 
 developed or in the state of germs, enter the blood-vessels 
 and there live and propagate to the no little disturbance of 
 the system, which is at length excited into desperate efforts 
 and throws off the intruders and their whole brood, or per- 
 ishes in the attempt." This doctrine was not exactly accepted 
 by Wood and his contemporaries, but they were beginning to 
 see visions of the true causes of disease. 
 
 In 1864 Professor S. D. Gross made no distinction between 
 tuberculosis and scrofula. To him phthisis and scrofula were 
 the same. A tubercle in the lung was the same disease as a 
 tubercle in a bone or in a lymphatic gland^ having the same 
 origin, running the same course, and producing the same 
 results. He intimated that he considered syphilis as the great 
 parent of tubercle and its parasitic existence. The old gentle- 
 man had a way about him of looking ahead, and getting about 
 as near the truth without the use of modern helps as any of 
 his contemporaries. He denied that tubercle was an unor- 
 ganizable product like colloid and melanosis. Gross was one 
 of the best pathologists of his day. The blood-vessels demon- 
 strated to be in it clearly show there is something \vithin it 
 to be nourished and protected. Tubercle is an organic sub- 
 stance, he repeats, because it often begins to soften at its 
 centre. He looked upon tubercle as a morbid deposit pro- 
 voked by anything causing the system to run down, from 
 heredity to syphilis. Local inflammation of the part sets the 
 seat of the tuberculous deposit. Gross denied the contagious- 
 ness of scrofula or tuberculosis. 
 
 Less than twenty years ago these vie\vs of forty years ago 
 which I have quoted were held and defended by the average 
 pathologists and thinking men of the medical profession, and 
 it was only as far back as 1881 that Robert Koch gave to the 
 scientific world his famous and far-reaching discovery of the 
 
 379 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Bacillus tuberculosis, and demonstrated it beyond peradven- 
 ture. to be the cause of all forms of tuberculosis, thus clearing 
 up many questions which had been clouded by the mists of 
 ages, and giving to suffering man a scientific basis upon which 
 to work and, I trust, to effectually eliminate the greatest 
 enemy to his future existence and continued happiness. Since 
 Koch's discovery we know enough to define tuberculosis as an 
 infectious disease, the cause of the infection to be the bacillus 
 tuberculosis. We know now the cause of the tubercles to be 
 the setting up of a specific inflammation by the tubercle bacilli, 
 and the cause of general tuberculosis to be the same micro- 
 organism. We know the end of these inflammations may be 
 caseation or hardening, and these may end in ulceration, 
 chronic ulcerative consumption, or calcareous degeneration, 
 which is a method of cure, the calcareous masses being ex- 
 pectorated or remain in the lungs, surrounded by a ring of 
 hyperplastic connective tissue. As to the tubercle bacillus, 
 this is not the place to discuss it, for it is as well known to 
 bacteriologists as the cattle are to farmers. 
 
 There is one question yet probably not clearly settled. Is 
 the bacillus tuberculosis of man identically the same as the 
 tubercle bacillus of the lower animals? As to the onset of 
 pulmonary tuberculosis particularly, I propose to give the 
 result merely of my own personal experience. If the practice 
 of medicine was properly appreciated by the world, and was 
 not, even at this enlightened era of its existence, looked 
 upon by the average man as a mere business of pill-giving, 
 empirically at that, the family physician in his watching over 
 his clients, if he were an intelligent and careful man, would 
 probably see, on account of his training, some youthful mem- 
 ber of the family, not sick, yet not well. A close scrutiny of 
 the individual, having gone over the family history, which he 
 would know anyhow, for that would be a part of his business, 
 would show that probably after three o'clock p.m. almost 
 daily the bodily temperature of his ward would be one or two 
 degrees above normal, and the cheeks would flush slightly; 
 and further investigation would show at this time that there 
 
 380 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 was a slight fulness at the top of the sternum and a tendency 
 to hack a little; all these symptoms passing off with a slight 
 moisture of the skin and a little debilitated feeling towards 
 midnight. To the practised car some change in the physical 
 signs in the lungs would be found, if in a space never so small, 
 and possibly, by proper examination, the dreaded micro- 
 organism of consumption would be found in the sputum. 
 The diagnosis thus early assured, what innumerable chances 
 of recovery that patient would have over those coming for 
 help late with the disease well established. Should no trouble 
 be found in the lungs, it would be the duty of the physician 
 to institute a thorough examination of every part and organ 
 of the body where tubercle might invade, and weigh all the 
 symptoms. 
 
 See the other side of the picture : a happy family, with no 
 medical supervision, with a bad family history as to tuber- 
 culosis, if you choose; a favorite son or daughter just bud- 
 ding into maturity, all these symptoms appearing as enumer- 
 ated : the high evening temperature, — oh, only the crimson 
 cheek of health; the cough, — only a little cold; the pro- 
 gressive weakness — nothing, the appetite is so good, only a 
 little rest required ; and so the case goes on, — cough, sweats, 
 expectoration, hemorrhage perhaps, and then the doctor called 
 in haste. An examination shows the helplessness of all 
 human aid, and another is added to the death-rate of con- 
 sumption, already appalling, and much of this owing to faulty 
 methods in the organization of society. The only remedy for 
 this state of affairs is for society to recognize the necessity of 
 constant medical supervision over each and all of its mem- 
 bers. To-day it clings to the old couplet philosophy : 
 
 When the devil was sick, the devil a monk would be ; 
 When the devil was well, the devil a monk was he. 
 
 Moral : The devil does not know when lie is sick, but should 
 have an expert at hand to tell him. The chances of cure in 
 consumption, or of checking its progress, all depend upon an 
 early diagnosis. I think this is a law, surely; that it is the 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 experience of every thoughtful practitioner of medicine, I 
 doubt not. 
 
 The finding of the bacillus tuberculosis in the sputa con- 
 firms the diagnosis of pulmonary consumption. Does the 
 failure to find it declare the case not to be one of pulmonary 
 consumption? I must confess that in my experience it ex- 
 cludes it. I have had some most interesting cases, and where 
 the bacillus was not found they all came out right. I had 
 one most remarkable case : this man had all the rational signs 
 of consumption; for a year his cough disturbed the neigh- 
 borhood, his expectoration was profuse, his emaciation ex- 
 treme, and with his coughing spells he vomited his food. He 
 had evening rise of temperature, and it was never normal, 
 and hectic and night sweats were marked. In this condition 
 he came to me. He had numerous moist bronchial rales with 
 puerile respiration, except in the lower lobe of the left lung, 
 which was flat. The apices, with the exception of the respi- 
 ration, were normal. His family history was not first class. 
 There was no fluid in the pleural cavities ; there was dyspnoea, 
 the chest was retracted, its circumference was diminished, and 
 its movements were restricted ; there was even amphoric res- 
 onance over the diseased lung. The man was the picture of 
 a case in the last stages of consumption, with secondary infec- 
 tion of the system; and such was my fear, although there 
 were some hopeful signs, as sound apices, etc., left to comfort 
 me. I am never willing to give an opinion, even in such a 
 case, until after one or more examinations of the sputa. I felt 
 sure those of this man were reeking with the micro-organism. 
 Repeated examinations by one of the ablest bacteriologists 
 in this country. Professor F. D. Chester, of the Delaware 
 College Agricultural Experiment Station and the Delaware 
 State Bacteriological Station at Newark, Delaware, failed to 
 find a single specimen. I began to have hope that the man 
 would get well, but it seemed like hoping against hope. With 
 bacteriological examinations frequently, the man went on for 
 months without much improvement, although everything ap- 
 parently possible was done for him. 
 
 382 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 After these repeated investigations for the bacillus tuber- 
 culosis, with nej2^ative results, I made the diagnosis of chronic 
 interstitial pneumonia, with a possil^le chance of improvement, 
 but not of cure. I then commenced the use of tubercu- 
 locidin, which came from Germany, and which I obtained 
 through the courtesy of Dr. Arthur T. Neale, Director of the 
 Delaware Experiment Station. The result was wonderful. 
 The other treatment was kept up. Normal vesicular murmur 
 gradually appeared in the diseased lung, and the man, from 
 having given up, began to regain his spirits. In six months 
 he was apparently well, went into business, and now for sev- 
 eral years has been an active, successful citizen, and keeps up 
 with the boys, too. The tuberculocidin, I believe, had some 
 effect. There was reaction after each injection at first, and 
 he had a great number, extending over months. It must 
 have had some effect on the fibrous structure, and allowed the 
 restoration of the alveolar structure of the lung. 
 
 Klebs prepared tuberculocidin by separating it from the 
 original tuberculin by chemical reagents. It is supposed to 
 contain germicidal agents specific to the pathogenic organ- 
 ism, which germicidal agents are produced by the pathogenic 
 organism in the culture medium. The books give chronic 
 interstitial pneumonia as a lingering, but incurable disease. 
 Since this case, I have had no case in which to repeat the 
 treatment. Should I get a similar one, I should use tubercu- 
 locidin, or one of the tuberculins. If my diagnosis was cor- 
 rect, and I think it was, this case surely got well. As to the 
 tuberculins and kindred products, I have used them all or 
 most of them, or seen the result of their use in conjunction 
 with medical friends. I do not like to give up hope for the 
 hopeless in this direction, but oh, what a cruel fate was that 
 which dashed the hopes first held out to these poor sufferers 
 by Koch's first eft'orts! I hope still, even if it is against the 
 laws of true science as we see them to-day, to look for hope 
 and relief in this direction. I brush aside all such doubts, 
 and still I hope, and hope, and hope, and trust, and trust, and 
 trust, and to-day I almost believe succor will at last come 
 
 383 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 from some such source, for do we not know that in nature 
 every Hving thing generates its own poison, why not this king 
 of httle microbes ? 
 
 Professor Samuel O. L. Potter, of San Francisco, the well- 
 known author, has given us clear views as to the different 
 tuberculins and what they are. He says, in strict usage the 
 term serum therapy would include only the employment of 
 blood-serum from an animal other than the patient, the serum 
 carrying an antitoxin specific to the disease from which the 
 patient may be suffering. As generally used, it embraces also 
 the use of toxines and modified toxines, produced in media 
 other than the blood-serum. The therapeutic principle is the 
 same in all, — the employment of an agent produced by the 
 life action of a pathogenic organism for the purpose of effect- 
 ing an artificial immunity against the disease to which the 
 said organism is specific. If we use a toxine, the organic cells 
 of the patient's body are supposed to be excited to produce an 
 antitoxin in the patient's own blood-serum. If we use an 
 antitoxin, the organic cells of another animal are relied upon 
 for the manufacture of the antitoxin, the patient being saved 
 from the strain of doing it. In treatment by modified toxines, 
 an effort is made, first, to partially destroy the toxine by oxi- 
 dation, thereby attenuating its power and so lessening its ex- 
 citant action without wholly destroying said action. Sec- 
 ondly, to separate the toxic material by chemical precipitation 
 from a supposed curative ingredient, retaining the latter for 
 therapeutic use. In each method the existence of an antitoxin 
 is inferred. In the last, this is supposed to be developed in the 
 culture medium, together with the toxine, by the action of the 
 pathogenic organism, while in the others it is presumed to be 
 produced by the organic cells of an individual animal organ- 
 ism excited by the toxine to such production. 
 
 As to Koch's tuberculins, the original was a purely toxine 
 treatment, by which he sought to produce an artificial immu- 
 nity against the disease in the patient by exciting the natural 
 reaction of his own organic cells to produce a specific anti- 
 toxin in his blood. This is Koch's tuberculin A, and is made 
 
 384 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 from tubercle bacilli by extraction with a one-tenth normal 
 soda solution. I take this to be Koch's original tuberculin. 
 
 Tuberculin O he obtains by oxidizing cultures of tubercle 
 bacilli by drying them, pounding them in a mortar, anrl then 
 forcing them through hydrogen moncjxide, FLO, in a cen- 
 trifuge. 
 
 We have recently heard much of tuberculin R. This is 
 what is left after tuberculin O has been taken off as the upper 
 layer. In making tuberculin O, what is left is treated again 
 with HoO, and thus again and again subjected to the action 
 of oxygen, until no residue is left, the conversion into oxi- 
 dized tuberculin constantly going on. If pursued too far, the 
 resulting tuberculin would be inert. This oxidation attenu- 
 ates the tuberculin as Pasteur attenuated his hydrophobia 
 virus, by drying and pounding the spinal cords of rabbits. 
 The more the attenuation, the less the reaction. Now, as to 
 all tuberculins and such remedies, the attenuation is produced 
 by oxidation, either by Koch's and Pasteur's plans, as given, 
 or by heat. 
 
 Maragliano's serum is an antitoxin, and is made by sub- 
 jecting the blood-serum of another animal to the action of 
 toxine, and thus forcing the animal to manufacture the anti- 
 toxin at its own expense, and saving the individual upon which 
 it is used that strain upon his organization. The ass is nearer 
 immune to the tubercle bacillus than most animals, and I 
 think Mulford's tubercle antitoxin comes through the ass. 
 Having seen exactly what these toxines and antitoxins are, 
 it is easier to analyze them and see what we might expect 
 of them as to curing tuberculosis. Virchow's objections to 
 Koch's tuberculin A were that the severe reaction — that is, 
 the elevation of temperature — attending its use was often dan- 
 gerous. The actual results of using it were the softening and 
 disintegration of passive tuberculous deposits, and thus from 
 these disseminating the bacilli in abundance and lighting up 
 new foci of infection wherever these lodged. It is easy to be 
 seen that, if used at all, it should be used only in the very first 
 stages, and if secondary infection had come, it might be quite 
 25 38s 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 dangerous. Koch claims these dangers are eliminated by oxi- 
 dation of the tuberculin, and thus its attenuation, and that 
 tuberculin R can be used with impunity. 
 
 Let us hope on until hope has been realized. Neither Hora- 
 tio Wood nor Joseph McFarland are hopeful. Wood says, 
 as all can see, when the tubercle bacillus grows in the human 
 lung, the toxine which it forms slowly kills the tissues and 
 produces ulceration. At the same time it finds its way into 
 the blood and produces hectic fever and other symptoms we 
 so often see. Now, if Koch's tuberculin (tuberculin A, I sup- 
 pose he refers to) is injected into the individual in small quan- 
 tities, no reaction is seen, but when this is aided by the toxine 
 which has been produced by the system (remember, tubercu- 
 lin A is a toxine), and which is already in the blood, the two 
 toxines together — the injected and that already in the blood 
 — will produce reaction and hectic fever. At the same time,^ 
 the injected toxine will reinforce that in the blood, and the 
 two will bring about rapid ulceration of the lung and dis- 
 charge of the tubercle. Even if this ended in the discharge 
 •of every tubercle bacillus, it would not cure the patient. It 
 ■does not help the primary weakness of the patient, his inabil- 
 ity to resist the onset of the tubercle bacilli ; it does not even 
 prevent the reinfection of the loosened tubercle. Indeed, the 
 very loosening of the tubercle bacillus favors its entrance 
 into the lymphatics and the blood-vessels, and its consequent 
 dissemination throughout the body. 
 
 Virchow soon found out that a general tuberculosis often 
 followed immediately upon the treatment of a local tubercu- 
 losis by injection of tuberculin A. This is all undoubtedly 
 true, as we see it to-day, but let us " hope on, hope ever." 
 We have made great progress : we have the cause of the 
 disease; we know it is an infectious disease; we know the 
 natural history of the cause ; we know that we can in a great 
 measure limit the production of that cause by proper methods, 
 by proper laws, and by proper hygienic rules. The protec- 
 tion of the individual will compel the enforcement of such 
 methods, of such rules, and of such laws. 
 
 386 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 The bacillus itself is a parasite, and lives on the animal 
 body. The problem before us is to destroy it and its toxine 
 developed by it in the animal body, and yet not destroy that 
 animal body. Let us work and hope, and hope and work. I 
 trust we shall yet triumph. When it comes, and may God 
 hasten the day, the serum treatment will not be a toxine 
 serum, as the tuberculins, but an antitoxin serum, like diph- 
 theria antitoxin. Some animal will be rendered immune to 
 the toxine, and its serum will be the antitoxin to the tubercle 
 bacillus toxine, and if also to the bacillus itself, then we will 
 have it. McFarland, Maragliano, and Panquin are working 
 on these lines, as well as many others. 
 
 I will merely mention here that epidemic influenza, com- 
 monly called " grip," a word which has been engrafted on 
 our language from the French, has its bacillus, the bacillus 
 of PfeifTer. It comes in the form of rods, single or in chains, 
 and stains well in methylene-blue. 
 
 As a preliminary to consumption, we spoke of the rise of 
 temperature, etc., in the evening as one of the first symptoms. 
 When watching this symptom, always think of the possibility 
 of syphilitic fever ; it acts almost in the same way and needs 
 far dififerent treatment. In consumption, mark the dry hack 
 when the patient first lies down. Gravitation from the apex 
 of the lungs when standing, and the return when first lying 
 down, causes this. It is a mere physical symptom. Keep up 
 examinations for tubercle bacilli ; they are not always found 
 at once. Watch the apices of the lungs, especially the left, 
 for dulness and changed rales; have the patient frequently 
 weighed, and watch for loss of weight. Always examine the 
 urine for sugar and other irregularities; your patient, if 
 under forty, may be diabetic and need attention to diet. Ex- 
 amine the blood for anaemia, and remember there are latent 
 cases, and these may have other foci than the lungs. If pos- 
 sible, have infecting foci, as enlarged lymphatics, etc., re- 
 moved. In my experience, hemorrhagic cases of consumption 
 are more chronic than non-hemorrhagic cases. The local 
 depletion retards the toxsemia and the secondary infection. 
 
 387 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Dyspnoea is a sad complication, and laryngeal complications 
 are among the most distressing. Pain is chiefly pleuritic, 
 and can usually be alleviated. 
 
 Acute miliary consumption is a sad complication; here we 
 have the shad-roe lung, as Dr. William Pepper, Sr., called it. 
 Look well here for foci of general infection in all parts of the 
 body, and you will probably find one or more ; and watch for 
 bacilli in the supta, the blood, even in the faeces and in the 
 eye. Do not mistake it for typhoid fever, for malarial fever, 
 or for asthma. Be careful you do not mistake any case of 
 tuberculosis for malarial fever. This ought not to happen 
 now, with a proper use of bacteriology. Tuberculosis of any 
 kind may follow typhoid fever; here the system is in good 
 shape for the successful reception and attack of the bacillus. 
 Keep your wits about you; remember the family history, 
 the environment of your patient; watch the rational signs 
 carefully, one and all, and take in all of the physical signs, 
 with the aid of auscultation, percussion, and bacteriology, not 
 forgetting the heart and large arteries. Do not let the brassy 
 cough of an aortic aneurism pressing on the recurrent laryn- 
 geal deceive you as to its origin, or whooping-cough or ma- 
 lignant troubles about the chest throw you off the track ; and 
 remember that malignant and septic troubles, other than those 
 of tuberculous origin, may affect the organs of the chest, as 
 well as of other parts of the body. Senn says he believes 
 many cases of supposed carcinoma are nothing more than 
 cases of some form of tuberculosis. Senn is a great surgeon, 
 and good authority. Do not forget to hold this matter in 
 mind. If such mistakes have been made in the past, they 
 should not be made in the future. It is well to remember 
 that the insane, the feeble-minded, and weaklings generally 
 are especially prone to tuberculosis. 
 
 As to the use of tuberculin for diagnostic purposes in man, 
 it is scarcely proper to use tuberculin A in case the patient 
 has tuberculosis. As to tuberculin R, if one wishes, he may 
 use it as an additional help to diagnosis. I do not think it 
 would do harm. Tuberculin A is used a very great deal 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 among cattle, and the reaction here after its introduction 
 never fails to take place if the animal is tuberculous. 
 
 In the work done in the matter of tuberculosis among cattle 
 by Dr. Neale and his coworkers of the Delaware Agricultu- 
 ral Station, I had an opportunity of investigating whether 
 or not there was any antagonism between the bacillus of tu- 
 bercle and the bacillus of anthrax. I had hoped there might 
 be, and at first there was evidence of some antagonism, but 
 it did not bear closer investigation, and the results of the 
 work were negative. To lessen tuberculosis among human 
 beings, it is our duty, first, to lessen the number of tubercle 
 bacilli abroad in the world. To do this, we must get rid of 
 the great causes producing them. In the second place, it is 
 necessary to endeavor to raise up the human race to a point 
 of health where susceptibility will decrease and place them 
 under conditions where they will not be so prone to the at- 
 tacks of the bacilli. I believe syphilis to be one of the greatest 
 factors in rendering the human race vulnerable to the tubercle 
 bacillus, and this factor reaches from generation to genera- 
 tion, " the sins of the fathers" being visited upon the chil- 
 dren. 
 
 Our greatest hope to-day, in dealing with human tubercu- 
 losis, is in its prevention. Personally, I believe the State 
 should go to extremes in this matter, and at the same time 
 the unfortunate owner of infected and infecting animals 
 should receive some compensation. There is no manner of 
 doubt that the milk of a tuberculous cow, especially if she 
 have tuberculosis of the udder, will infect man with tuber- 
 culosis. I believe the milk will infect if the udder is sound. 
 I believe the meat of an infected animal, if eaten by man, 
 will produce tuberculosis in man unless it has been sterilized 
 by heat or in some other way. Then what? \Miy should 
 man allow such a menace to his health? Why not eradicate 
 it as far as possible ? Why dilly-dally ? We are doing better, 
 but are not yet radical enough. Whilst statesmen and poli- 
 ticians and poor, weak humanity falter, the brightest and best 
 among us are the constant victims of a cruel and cowardly 
 
 3S9 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 hesitancy. In France and Germany the inspection of beef 
 animals is the most advanced. All animals are rigidly in- 
 spected after they have been killed. If tuberculous, certain 
 parts are allowed to be sold and are marked as tuberculous, 
 and full directions are given how to cook it to make it safe 
 for human food. Go to our cattle-yards and you can pick out 
 the tuberculous cattle, and most of them are cows. They are 
 often — not always — thin of flesh, and they cough. " Cough- 
 ers" is the name the dealers give them. Another name is 
 '' Boulogneys." 
 
 Not to take up time and space, I will give a few statistics 
 showing the fearful presence of tubercle among our food 
 animals. In Copenhagen, out of 132,294 bullocks and cows 
 slaughtered for food, 23,305 showed evidence of tubercle. 
 Out of 8292 pigs, 1272 were tuberculous. Even 369 calves 
 out of 185,765 showed evidences. Only one sheep out of 
 337,014 showed evidence. Here is a practical point and an 
 object-lesson. In Berlin, out of 142,874 cattle slaughtered, 
 21,603 showed evidence. Of 518,073 hogs, there were 7055 
 showing evidence of the tubercle. Of 108,348 calves, 125 
 were tuberculous. Of 355,949 sheep, only 15 were con- 
 demned. In Edinburgh a number of cows were killed on 
 account of the appearance of pleuropneumonia there. Forty 
 per cent, of these were tuberculous. Here is an object-lesson 
 in city-kept cows with generally bad environment. 
 
 The tubercle bacillus is of general distribution. It is in all 
 expectorations of the tuberculous ; it is on their persons and 
 hands; it is in the houses, in cars, in boats, in the dust of 
 houses, and in the dust of the streets, and the more it is blown 
 about and distributed the worse it is. They love to be dried 
 and remoistened; they revel in such treatment. In our 
 houses brooms should be abolished; heavy hangings and 
 heavy carpets should be much curtailed; also upholstered 
 furniture. Carpet-sweepers and moist cloths should take the 
 place of brooms and dusters. The aseptic house will come 
 after a while, and cars and all such places of congregation 
 and resort will be, in a measure, aseptic, Man will be more 
 
 390 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 careful in his herding. Individual bedsteads will take the 
 place of the present abomination, — particularly of the United 
 States, — the double bedstead. No two persons should occupy 
 one bed as a rule of domestic life, and, if possible, every indi- 
 vidual would be the better of a separate room or apartment. 
 All these reforms accomplished, we will then ai)proach the 
 condition where the aseptic individual is possible. 
 
 In my own State, Delaware, from what I can learn from 
 having been active in starting the work of investigation, and 
 from information gathered from my friends and coworkers, 
 I am sure twenty per cent, is a small estimate of the number 
 of our milch cows tuberculous. In New Jersey there are 
 probably as many, and in Pennsylvania, from the investiga- 
 tions of Professor Leonard Pearson, there are probably more; 
 but active interference there has of late reduced the percent- 
 age. All herds should be tested with tuberculin; it is sure, 
 and Dr. James Law, the expert of Cornell, says, from a large 
 series of experiments, it does no injury whatever to the sound 
 cow. It is the gilt-edged herds that need watching most. 
 Choice breeding and selection, the environments of the palace 
 stables, and want of out-door life are active causes in breed- 
 ing the bacilli and rendering such cow^s fit subjects for their 
 attack. So, again, are the cows kept w^ith bad environment 
 in towns and cities. It is equally important that no attendant 
 on dairy cows should be tuberculous, and every effort should 
 be made, by spraying water around the stables, to keep down 
 all dust whilst men or animals might be subject to its influ- 
 ences, for by dust the bacilli are most frequently spread 
 around. The natural life of the cow is in the free and open 
 country. West of the Mississippi River horned and other 
 animals are the most robust. They have a more natural en- 
 vironment, and the bacillus tuberculosis does not thrive so 
 well in the pure dry air of that region. 
 
 Again let me say, I look upon this question of tubercle ba- 
 cilli, in our meat and milk supply particularly, as a burning 
 one. This source throttled, and the mortality of tuberculous 
 diseases would diminish greatly, and instead of being our 
 
 391 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 greatest foe, would become a minor evil. To-day it is through 
 milk that a great many of our so-called summer diseases 
 among children are tuberculous. As it is, we must sterilize 
 or Pasteurize these foods, watching that we do not go too 
 far in removing all their freshness and causing scorbutic 
 troubles. Men who appreciate the horrors of the situation 
 must take these matters up and educate the people, who for 
 their self-preservation must act; surely they will act. To 
 bring about proper legislation will take money, for I do not 
 believe in taking the private property of the individual, even 
 for the public good, without some proper compensation. Pur- 
 suing this matter, by the light thrown out on the way by 
 science and scientific men, we will in the end see mankind 
 immeasurably benefited, and the human race saved from the 
 horrors and sufferings now so relentlessly imposed upon it 
 by many or all of the so-called zymotic diseases. 
 
 Here let me say. Lupus vulgaris is a very interesting affec- 
 tion, and its tuberculous origin, owing to the work of Henry 
 W. Stelwagon, Duhring, and others, is now well known. The 
 great point is to distinguish it from syphilitic lupus and from 
 rodent ulcer, and to cure it. It comes to little children from 
 being fondled often by tuberculous parents or nurses. I 
 would not hesitate to use tuberculin R here, and study its 
 action, watching it closely. Everything should be done to 
 prevent autoinfection and the infection of others. It is my 
 rule always to impress this on my tuberculous patients. The 
 spitting habit, always vulgar anyhow, should especially be 
 avoided. Persons are beginning to appreciate this, and the 
 authorities are becoming active. Houses cannot be kept too 
 clean, and especially dishes, knives and forks, spoons, and 
 such used by the invalid. The temporary spit-cup should be 
 used, or cloths or porous paper, and these frequently burned 
 up. All clothing or bedclothing used by the invalid — better, 
 the clothing of all in the house — should be frequently boiled 
 one hour, or roasted at a high heat in ovens, or disinfected by 
 formaldehyde fumes, and all apartments should be frequently 
 fumigated with formaldehyde. If there is hereditary tendency 
 
 392 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 in one or more of your families, watch them closely from 
 infancy to forty years of age. Especially watch mothers and 
 nursing babies. Do not allow a tuberculous woman to nurse 
 a child, or even care for a child, nor, above all, to sleep in 
 the same apartment with it. 
 
 The very serious question comes up, Shall we isolate con- 
 sumptives? " Blood is thicker than water." We cannot do 
 it until by isolation we can promise cure or hope of cure. 
 Then we can talk of isolation absolute, not before. 
 
 As to the medical treatment of tuberculosis, find, first, the 
 focus or foci of infection. Call in the surgeon, if any of these 
 can be removed. Pulmonary tuberculosis is the common trou- 
 ble, of course. If the digestion is good, use the stomach for 
 the strongest nourishment in every possible form, both direct 
 and indirect nourishment, and this is all it is necessary to. say. 
 I differ from most physicians. If the patient is a user of 
 tobacco, let him continue it to the full extent of his enjoy- 
 ment. It is as good a germicide as creosote and all such 
 stuff that is given, and has just as good a chance of reaching 
 the pathogenic germ or its toxine, and the smoke inhaled is 
 worth all the other inhalations so universally used, and gives 
 the otiuiii cum dignitate without the accompanying opium aim 
 digitale. Of course, if your patient's circulation is weak- 
 ened by the tobacco, curtail it; for we want no points of 
 stasis as a starting-point for new foci of infection. 
 
 Through the lungs is one of the most available channels 
 to reach the bacilli, for, as external causes of infection go, 
 they reach the general system as frequently through the lungs 
 as they do through the ingestion of tuberculous substances. 
 In children I believe the bacilli enter with the milk and en- 
 throne themselves in the delicate intestinal epithelium as the 
 most, to them, available method of reaching the system. The 
 stronger intestinal epithelium of the adult is not so available 
 as the resting-place of the pathogenic germ, and here the lung 
 becomes the most available, and thus we reach more of them 
 through the lungs. Never give nauseating expectorants to 
 your consumptive patients, nor opium if it upsets them. Chlo- 
 
 393 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 ral and such remedies are far better. Upset the digestion, 
 and you do great injury, irreparable injury, indeed. Give 
 cod-Hver oil, if it can be taken with advantage, and emulsions 
 only if the crude oil cannot be assimilated. Alcohol is a 
 sheet-anchor in checking retrograde tissue change, and has 
 doubtless some germicidal action. Man is the only fool who 
 takes alcohol as a beverage. Counterirritations, as a rule, I 
 have abandoned, and have relegated them, with the moxa 
 and the actual cautery, to the realm of the barbarous ages, 
 where they belong and always did belong. 
 
 We have learned much about tuberculosis of the bones, and 
 these the surgeon deals with. There is only one point here, 
 and a very practical one, and we should study it, each from 
 his own experience. Does the cure of a tuberculous ailment 
 not of a serious character change the focus of distribution of 
 the pathogenic germs, and thus more speedily infect vital 
 organs like the lungs? The same question we may put to 
 ourselves in gynaecological tuberculosis. There is one thing 
 the gynaecologists have taught us : we can cure tuberculous 
 peritonitis by laparotomy as a preliminary treatment. In the 
 treatment of pulmonary hemorrhage it is a mistake to use 
 ergot, a remedy so much and so erroneously used. It only 
 increases the trouble by its action on the vasomotor system. 
 The proper remedies are trinitrin and such remedies as de- 
 crease the blood-pressure. The older physicians used blood- 
 letting to produce the same effect. It was effective, but the 
 result was obtained by the long way around. I have had no 
 experience with the method, but I cannot help referring to 
 Dr. Murphy's proposed method of treating pulmonary tuber- 
 culosis. 
 
 Murphy claims that nature cures consumption by a deposit 
 of connective tissue around the focus of infection. Anything 
 favoring this will cure the disease. He illustrates by a tuber- 
 culous knee-joint. Set it at rest, and new tissue forms and 
 the cure comes. Rest is necessary. We have ninety square 
 metres of respiratory surface in the lungs ; we can live with 
 half of that surface, or much less for mere existence without 
 
 394 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 exertion. The lung has great capacity to repair itself should 
 there he solution of its continuity. We coffer-dam the dis- 
 eased spot, and nature makes the cure. There are three ways 
 to do this. First, remove a rih, or ribs, and allow the chest 
 to contract over the diseased region. Secondly, open the 
 chest and inject some non-poisonous substance into the pleu- 
 ral cavity, a substance that will remain a long time unab- 
 sorbed. This method is similar to allowing the chest wall to 
 collapse by the removal of the ribs. He recommends nitrogen 
 gas for this purpose. The gas remains for months unab- 
 sorbed, and the cure goes on. There may be slight dyspncea 
 after the injection, but this soon passes off. The operation 
 is simple, with little pain or discomfort. Murphy thinks the 
 dangers of compressing the lung too suddenly and of the 
 gas entering the veins are possible, but not probable. I see 
 the instrument-makers already have out the whole apparatus 
 for the purpose as devised by Dr. Murphy. Murphy's third 
 method is much like his first: open the chest and allow the 
 wall to sink over the seat of the disease. 
 
 The philosophy of cure in consumption is to check the 
 ravages of the cause, the tubercle bacillus. If checking the 
 ulceration caused by the toxine generated by the pathogenic 
 germ will cure consumption, Dr. Murphy is on the right 
 track. If his method leaves the author of this ulceration and 
 toxaemia to go free, and to come time after time and repeat 
 his work. Dr. Murphy's methods will not cure consumption. 
 The difficulty in consumption is, the disease is usually local, 
 and does not produce immunity after infection. Again, we 
 have the secondary or mixed infection to contend with as the 
 case advances, and, so far as we know of remedies at present, 
 this makes the case hopeless. Murphy is right, the forma- 
 tion of fibrous tissue around the foci of infection is the only 
 cure, so far as we know, but this is the spontaneous method, 
 nature's method. The logical plan, then, is to spur on nature 
 to effect the cure, and to curtail the evolution of the tubercle 
 bacilli, the great first cause. The number of spontaneous 
 cures of consumption is greater than we dream of, and the 
 
 395 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 number of cases of surgical and other cases of tuberculosis 
 recovering is very large. More than half of the human race 
 are tuberculous, and more than half of these die of tuberculo- 
 sis in one form or another, and in those vi^ho do not die of it 
 it generally becomes latent or is cured, and they die from some 
 other cause. 
 
 The question presenting itself to us now is, What is the 
 great factor in holding tuberculosis latent, or in curing it? 
 So far as we know, it is climate and environment ; and could 
 all the unfortunate victims of tuberculosis avail themselves 
 of such resources we would see a great diminution in the 
 number of victims. As we go north and west, in our own 
 country particularly, we find such atmospheric conditions and 
 such altitudes as conduce to the comfort and well-being of 
 the tuberculous, because, by the altitudes and state of the 
 atmosphere, the almost constant presence of sunlight in day- 
 time, the conditions are sterilized, immunized, and strength- 
 ened. The almost entire absence of humidity, the low tem- 
 perature, the altitude, the pure air, cause increased respiration, 
 and hence the number of red corpuscles in the blood is in- 
 creased, and the oxygenizing power of the blood is of course 
 enlarged. In these high altitudes persons going there at first 
 suffer from embarrassed respiration to a greater or less de- 
 gree. This is caused by the diminution of the atmospheric 
 pressure causing increased action of the heart. These symp- 
 toms usually subside in a few days, and a tolerance of the 
 environment is established. Epistaxis may come on, from 
 vasomotor activity. You will say hemorrhage from the lungs 
 will probably come on, and may be an element of danger. As 
 a rule, persons with unsound lungs will not suffer from pul- 
 monary hemorrhage in high altitudes ; they may suffer more 
 than those with sound lungs from embarrassed respiration, on 
 account of encroachments of disease upon their normal lung 
 space, but they will not be apt to bleed from the lungs, for 
 the reason that the excessive vasomotor activity will drive the 
 blood out of the deep viscera, such as the lungs, and thus 
 deplete them and render them less liable to bleed. Thus, then, 
 
 396 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 we have the two explanations : the nose bleeds because vaso- 
 motor activity renders it, a superficial organ, plethoric, and 
 the lungs, the deeper organs, depleted. 
 
 Reasoning from what we have said in regard to the blood- 
 cells, etc., why would not blood be a remedy to check the on- 
 ward course of tuberculosis? I have tried it faithfully in a 
 number of cases, the patients going to the slaughter-houses 
 and drinking it hot from the animals. I have seen refined, 
 delicate women drink it thus without the least repugnance. 
 I never saw it do any real good, after considerable observa- 
 tion. The patients were always enthusiastic, and expressed 
 and argued themselves better, but each went to the common 
 melancholy end of the great majority of consumptives. I 
 have travelled extensively through our Western country, both 
 recently and in the early days. There is a prevailing impres- 
 sion in all of the high altitudes that the tubercle bacillus, from 
 a lack of moisture, will not live, or at least will not thrive, at 
 an altitude of over five thousand feet, and some say even four 
 thousand feet. I believe there is much truth in this as far as 
 the open air is concerned. Now, at five thousand feet build 
 a town, or at ten thousand feet, the altitude of Leadville, 
 Colorado, erect your modern houses, furnish them with mod- 
 ern furnishings, and heat them up to the modern standard 
 of 75° F. Here you have builded a palace and an elysium 
 for the king of pathogenic germs, and from this we can draw 
 our moral of the treatment of consumption : High altitude, 
 dry air, sunlight, little or no artificial heat, and, whenever 
 possible, in the open air, and in a tent rather than in a house, 
 at any time. 
 
 The Indian is an object-lesson. Turn him out wild, and 
 he is vigorous, hale, and hearty, if only he can be held aloof 
 from the selfish designs of the white man. Bring him into 
 civilization, give him houses and lands and all modern com- 
 forts, what is the result? The deadly tubercle bacillus finds 
 in him a victim after his own heart, and the poor Indian soon 
 yields to his relentless charges. A few years ago the United 
 States army had recruited for it some companies of Indians. 
 
 397. 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Great care was taken to choose only the best of a very large 
 number offering. The result was melancholy. As soon as 
 they were brought under army discipline in barracks they 
 began to fail, and consumption made such inroads upon them 
 that the authorities were compelled to abandon the effort for 
 Indian soldiers. I saw the last company in barracks at Fort 
 Douglass, Utah, in 1894. They were a fine-looking set of 
 men, but nearly all of them showed incipient signs of con- 
 sumption, and in a few days all were discharged and returned 
 to their natural environment. Fortunate men, that they could 
 so easily regain conditions where nature might restore them, 
 or at least check their rapid march to the grave. 
 
 Thousands living in the parts of the world where consump- 
 tion runs rife, unrestrained by any natural influences, must 
 bear and suffer unless they have pecuniary means with which 
 to seek more congenial climates. Can this large class be 
 helped at home? Can we do anything for them as they pass 
 on through all of the stages to the last, the secondary infec- 
 tions? Can the antistreptococci, the normal, immunized, or 
 other serums avail them here? Can pneumotherapy, can 
 pneumatic differentiation, help them over the thorny path? 
 If people could only be scattered, scattered in their residences, 
 scattered in their towns; and this can only be done by scat- 
 tering the towns. Have no slums. The dwellers of cities, 
 owing to the increased facilities for near-by travel offered 
 both by steam and electricity, are scattering more and more 
 into suburban homes, thus relieving the crowded centres. 
 This will surely have a good effect on the tuberculous and on 
 those with tuberculous tendencies. Take the world over, I 
 do not care whether it be in the dry high altitudes or on the 
 moist and level plains of the seaboard, the cases of tuberculo- 
 sis, the deaths from tuberculosis, vary as the density of the 
 population varies, — the denser the population the greater the 
 number of victims. In the city of New York, with 81,828 
 dwellings, there were during the last five years deaths from 
 tuberculosis in 18,771 houses. In the fourth ward, in 248 
 houses, there were 541 cases of tuberculosis in three years. 
 
 398 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 In many houses the continued recurrence of tuberculosis is 
 reported. Here is a good object-lesson and its sad story, 
 from which we may gather ins])iration for rcff>rm, which 
 leads us t(j infer that to check tubercuUjsis entirely we must 
 discard towns except for business, discard houses and their 
 surroundings for tents, destroy all infected animals, give up 
 our modern luxuries in travel, and go back to primitive times, 
 in order to drive out the modern monster, the bane of our 
 civilization. Society will not do this, but modern methods 
 and modern ideas, guided by the ever-spreading and expand- 
 ing light of science, will take hold of this scourge and will 
 in the end conquer it, so far as nature allows her methods to 
 be interfered with by man. 
 
 As to climatic treatment, we can make the ideal climate at 
 or near our homes, provided our homes are not in favored 
 regions; this we can do by placing our patients in sanitaria 
 and sanatoria now rapidly coming into vogue for the pur- 
 pose. There are many in this country, and many in Europe. 
 Insurance societies in Germany are establishing them for the 
 treatment of their clients, and such societies, I think, will 
 come sooner or later in this country, and thus solve a problem 
 for the man of limited means. For the opulent we have many 
 already. They are only a make-shift. When possible, the 
 patient should move, bag and baggage, to the proper climate, 
 and make it his home. Years ago, consumptives went to mild 
 winter climates only. The only reason was to avoid taking 
 cold. This did good, saving the onset of cold through the 
 extremities by chilling the nerve extremities, causing conges- 
 tions reaching to the lungs themselves, and establishing new 
 foci of infection. This was all, the surroundings were reek- 
 ing with the pathogenic germs, and were in every way unde- 
 sirable. 
 
 When the great Northwest began to expand, forty years 
 or more ago, experience showed that consumptives, if in the 
 preliminary stages, did well there. St. Paul. Minnesota, be- 
 came quite a resort. Experience was right, although we then 
 knew nothing of the cause of the disease. St. Paul had a dry, 
 
 399 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 bright, sunny atmosphere and many other desirable quaHties 
 as a residence for the tuberculous. The altitude was not suffi- 
 cient, and the thermometer went too low at times, and the 
 mid-winter thaw was against it. For sanitarium treatment 
 in place of special climate and altitude treatment, we may 
 make the case conform to the surroundings, and it need not 
 be necessary to take into consideration the age, condition of 
 the heart, the stage of the disease, etc., all of which must be 
 thoroughly looked into before we order our patients away for 
 climatic or altitude treatment. 
 
 Now, as to the sanatorium treatment of tuberculosis. First, 
 as to the two words as they are used, sanatorium and sanita- 
 rium. The former is really the proper word, and both are 
 of rather recent coinage, rendered necessary, like other new 
 words, by the world's progress. They are both derived from 
 the Latin verb sanare, to heal, whence we have sanitas, health, 
 and sanus, sound, — sound health. Sanatory is derived from 
 sanator, one who heals. Sanitary is derived from sanitas, 
 health. Sanitary refers to a condition. Sanatory refers more 
 to action towards the condition. I should incline to speak of 
 a large resort for invalids, without special methods of treat- 
 ment, or where treatment and pleasure were combined, as a 
 " sanitarium," A private hospital, or an institution not ex- 
 actly a hospital, but at the same time devoted altogether to 
 the care and treatment of invalids, whether general or spe- 
 cial, I would call a " sanatorium." The Century Dictionary 
 gives sanatorium as the proper word, and the word sanitarium 
 as an improper use of the word sanatorium. I rather incline 
 to the definitions I have given. 
 
 Treated at home, consumptives, or patients having any 
 form of tuberculosis, should, first of all, live as near as pos- 
 sible out of doors, and dress for the weather. They should 
 exercise absolute personal cleanliness, and care for the expec- 
 torations, etc., so as to burn them up. They should have a 
 room to themselves, if in the house, and exercise all means 
 to prevent infection of friends or premises. This is the gist 
 of home sanatorium treatment. 
 
 400 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 General hospital treatment is nf)w becoming more and more 
 an open-air treatment, even if the patients are bedridden. 
 This helps the patient, and lessens the liability of infection 
 to others and to the premises. 
 
 The popular sanatorium rest-cure is about the same in all, 
 and is about as follows : Selecting the spot in the proper loca- 
 tion, at a proper elevation, and with the proper atmosphere, 
 sunlight, and surroundings, the sanatorium is established. 
 First, there must be absolute cleanliness of buildings and sur- 
 roundings, and the patients must be examined before admis- 
 sion, to see that the case is a proper one, so far as the heart, 
 etc., are concerned, for the environment. The altitude should 
 not be less than four thousand five hundred feet. Disinfection 
 must be thorough and continuous, to protect both the sick 
 and the well who are compelled to live in the sanatorium to 
 care for them. The expectoration of patients must be burned, 
 every drop of it. Rooms and floors must be washed daily. 
 All dust must be burned, and all utensils must be boiled, par- 
 ticularly napkins and towels, after each using. For the " rest- 
 cure," a gallery is built opening to the south. Here absolute 
 rest is taken all day in chairs and beds. After three or four 
 months of this treatment, short walks are indulged in around 
 the grounds, where are arranged seats and sun-boxes. The 
 head and eyes must be protected from the sun. The surround- 
 ing air, if the sanatorium is properly located, is perfectly dry, 
 and on this account the doors and windows of the sleeping- 
 rooms are always open, the patient avoiding drafts as much 
 as possible. If the least chilly, the patient must always sum- 
 mon an attendant with hot-water bags and wraps. If the tem- 
 perature of the patient runs above normal, a cold-air bath in 
 the sun is used to check it, much as we use cold water for 
 typhoid and other fevers. Food, rest, open air, and sunlight 
 are the remedies used, without much medicine. This method, 
 closely followed, is affecting cures in from six months to 
 three years, or even longer. 
 
 These methods are particularly applicable to the weak 
 and delicate cases and those too far advanced or too much 
 26 401 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 complicated with secondary infection for rough-and-tumble 
 life. , 
 
 There are some favored spots in the world where the in- 
 habitants never take cold, and instances are given which show 
 that colds are surely infectious diseases, the infection being 
 carried by human beings ; that it runs a definite course ; and 
 that one attack for a certain length of time confers immunity, 
 thus showing a pathogenic germ to be the cause. In my own 
 case I have an object-lesson. I have made a number of sea- 
 voyages ; nearly every time I have come ashore and mingled 
 with the busy world; in about from forty-eight to seventy- 
 two hours I have taken a cold, which has run the usual course 
 of colds. It is said of Nansen and his men that during their 
 three years' residence in the Arctic regions not one of them 
 ever took a cold, yet they were constantly exposed to cold, 
 wet, and fatigue. So, of the members of an expedition for 
 three years in Franz Josef Land, none ever took a cold. As 
 soon as these people returned to the civilization of the Tem- 
 perate Zone they took colds. Men living in Spitzbergen, away 
 from the centres, keep well. As soon as they go to the coast 
 settlements they take cold. On the island of St. Kilda, away 
 beyond the western Hebrides, about one hundred people re- 
 side. The coast is inhospitable, and only for about four 
 months in the year can vessels approach it. The people are 
 always well, and never have colds during the eight months 
 of non-intercourse with the outside world. So soon as a 
 vessel arrives, then, in a few days, every man woman and 
 child on the island has a cold. 
 
 These are wonderful object-lessons, and cause us to think 
 deeply. We will probably utilize such places, but we must 
 do it with certain restrictions as to intercourse with the 
 outer world, and bar the luxuries of our advanced civiliza- 
 tion, and thus bar out the pathogenic germs of consump- 
 tion, pneumonia, influenza, and all zymotic diseases. Thus 
 by prevention, through fresh air and sunshine, we can 
 really do much more for our patients than by saturating 
 them with creosote, guaiacol, and such remedies, which have 
 
 402 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 a vaunted germicidal power, yet a])|)car to be in little or no 
 way specific remedies. 
 
 The sanatoria are all very well, and ^ome of the rigid rules, 
 as to antisepsis, of these institutif)ns should be carried to our 
 homes, our hotels, our steamships, our sleeping-cars, our 
 places of amusement, and particularly our churches and our 
 schools. Our boarding-schools and colleges should come 
 imder rigid inspection, and sanitary schools in aseptic regions 
 will in the future be a proper safeguard for boys and girls 
 who may be delicate, with bad family histories. 
 
 As to the general resorts for consumptives, carried on com- 
 mercially in the western part of our country, such as large 
 hotels and the so-called sanitaria and boarding-houses, my 
 advice to invalids is to give them a wide berth. I have trav- 
 elled through a great deal of that country, and been in a 
 number of them, and among the saddest of sights is to see a 
 large roomful of consumptives comparing notes, coughing 
 and spitting during the whole time, the atmosphere and fur- 
 nishings and the company themselves reeking with tubercle 
 bacilli, and deluded with the idea that they are doing what 
 is best for them to do to regain health, which never under 
 such conditions can be regained, but all going faster, under 
 the circumstances, to their sad and inevitable end, and, worse 
 than all, laying the foundation for just such horrors in those 
 around them not yet infected. Those who go away for health 
 want to avoid the crowd; they need to live as nearly alone 
 as possible, and they want to be well enough and strong 
 enough to take active exercise, to live in the open air almost 
 entirely. Ranch life is the ideal life, and the nearer com- 
 panionship is reduced to the horse and the blanket, the better 
 chance will the patient have of cure. The ''one Jungers," as 
 the natives call them, patients with a cavity, or honey-combed 
 or solid apex, can enjoy this life and improve greatly and. 
 prolong life indefinitely if only secondary infection has not 
 set in. After that has come, the unfortunate consumptive 
 should not, as a rule, leave home, especially if diarrhoea and 
 other weakening troubles accompany it. 
 
 403 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 As to altitude, it is best to ascend gradually. Do not go 
 to ten thousand feet at once. Probably four thousand to six 
 thousand feet is best. Individual peculiarities may assert 
 themselves, and compel changes from time to time. If the 
 case is one of fibroid consumption, be very careful of too high 
 elevation, as well as in cases of laryngeal tuberculosis. As 
 to this last, the great desideratum is to be within reach of a 
 good physician, and to get a place absolutely free from dust ; 
 and increase the altitude slowly, at least. Always examine 
 the heart of your consumptive patients before you send them 
 away, and note any deviation from the normal. Do not send 
 your cases with hypertrophy of the heart suddenly to high 
 altitudes, and cases of weak dilated heart, never. Diabetics 
 do not do well in high altitudes; the heart is very irritable, 
 and the blood-pressure increases the urine outflow. 
 
 So far as I can determine, the United States and Mexico 
 have the best climates in the world for the tuberculous, and 
 the best of these are in Colorado, Arizona, New Mexico, and 
 old Mexico. In our Adirondack region many find a congenial 
 home, but I think the good care and treatment they receive 
 there has as much or more to do with it than the climate. The 
 elevation is only about two thousand feet, and there is, as a 
 rule, too much moisture. This applies to all of our country 
 in the East of two thousand feet elevation or less. The North 
 Carolina, South Carolina, and Georgia climates are fair, and 
 have some places with good accommodations at about two 
 thousand feet, but there is too much moisture, and too many 
 invalids are crowded together to make such places desirable, 
 unless one can have a cottage of his own. Florida is too 
 moist, and the temperature varies considerably. Here the 
 crowds of sick and delicate people are an objection, if in hotel 
 life. I do not like southern California, especially on the coast, 
 yet it is a delightful place to spend a winter; but it is too 
 hospitable a home for the pathogenic germ. Minnesota, Ne- 
 braska, and Dakota have an elevation of about one thousand 
 feet, and are in places fairly dry and pleasant. In Colorado 
 the climate is very dry, and at times very cold, and is, as a 
 
 404 
 
FORTY YEARS IN Till-: MICUICAL PROFESSION 
 
 rule, mOvSt desirable for those aljle to take exercise anrl live 
 out of doors. Much the same may be said of parts of Wyo- 
 ming and Montana, and parts of New Mexico and Arizona. 
 Here we can get elevations of from four thousand to as high 
 as fourteen thousand feet, if we choose to go to the top of 
 Pike's Peak in Colorado. The ideal climate, I think, is the 
 warm and dry climate of southern New Mexico and southern 
 Arizona, with an elevation anywhere from three thousand to 
 five thousand feet. At the Las Vegas Hot Springs, New 
 Mexico, there is a sanitarium well cared for, where both sick 
 and well can spend a pleasant winter or make a pleasant home. 
 This is not fclr from Santa Fe and Albuquerque, and in a 
 very pleasant part of the country. Silver City, New Mexico, 
 is in a good location, one of the best, indeed, and the sur- 
 rounding country gives opportunities for persons who can 
 rough it. The town itself is not overrun with invalids. In 
 Arizona, Phcenix is a desirable place, and, taking it as a 
 centre, one may choose widely and establish a home in some 
 available locality. Those who go to such places should go 
 with a view of taking up a permanent residence and estab- 
 lishing a home. If they get well, it will not be safe to leave 
 for five years, at least, and in that time they make new friends 
 and the old homes change, often so much as to make the 
 return a sad one, and the disease may light up again in the 
 moist climate. 
 
 There is one thing to remember in choosing a climate for 
 the tuberculous. — the individual is the important factor. 
 Study and observe well the individual. The idiosyncrasies 
 of one person may make a place in every way improper, 
 which would suit another exactly. Remember what those 
 persons seek who migrate searching for health : as far as the 
 tuberculous are concerned, they seek a place, first, where the 
 pathogenic germ does not thrive; secondly, where they may 
 best maintain the natural immunity inherent in all ; and 
 thirdly, where they may best establish and hold an artificial 
 immunity to the germ. The surroundings are important, and 
 very important matters are occupation and amusement, and 
 
 405 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 proper food and clothing. I have advised many patients to 
 change their residences on account of tuberculosis, and I have 
 watched many who have changed who were not under my 
 personal care. Those going to Europe for travel, and then 
 locating on the Mediterranean and in other genial climates, 
 have, as a rule, not done well. The life generally is tiresome, 
 and not suited to an invalid unless a home is established. 
 
 There are many sanatoria (especially in Germany), as at 
 Goibersdorf, Falkenstein, Hohenhonnef, Nordach, and Rei- 
 boldsgriine. These may suit the Germans. We have them 
 just as good at home, and in a much better climate. Besides, 
 I do not believe in crowding the tuberculous either in houses, 
 in districts, or in communities. We want to separate them. 
 If crowded, asepsis as to the individual, his belongings, his 
 food, his surroundings, in fact in all conceivable ways, must 
 be perfect, for both his own protection and for the protection 
 of others. Those persons I have sent away who have done 
 best are young men and women of moderate means, who, 
 after their location, were compelled to take up some employ- 
 ment for a livelihood. Those who went into the country, or 
 roughed it on ranches and in such employments, did best. A 
 number have located in Denver, Colorado. They generally, 
 at my advice, took employment where they could get plenty 
 of outside air. They made friends, they have done well in a 
 business way, they have established homes, some have fami- 
 lies, and most of them are prospering in mind, body, and es- 
 tate. The secret was, the necessities of existence drove them 
 to work, they became interested and separated from their 
 fears and evil forebodings as to their condition of health, and 
 the result was in every way good. On the other hand, I have 
 known a number who had everything in this world, in a 
 pecuniary way, to make them happy. They went for long 
 visits, and generally in the winters; of course, they put up 
 at the best hotels, crowded as they were with brothers and 
 sisters in suffering. The result was always bad, and, as a 
 rule, they would have been better and safer, and perhaps lived 
 longer, in their own comfortable homes in the East. 
 
 406 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Another class, yoimi;- iiicii of means, in the incipient stajjes 
 of piihnonary tiiherculosis, start to travel, and spcnrl a season 
 in the Riviera. They hve luxuriously at the hotels and clubs, 
 and a society life in general. Of course, they deteriorate; 
 they come home and go West for a home ; they settle, per- 
 haps in the city or town, where they meet the Ijest society 
 and have the best time. They live at the club usually, and 
 live an idle, listless life. They suffer from ennui, of course, 
 and nothing can shake them up to activity of any kind. The 
 result is bad, and the remorseless disease completes its work 
 in about the average time of the average case. Had such 
 men gone West and at once started out on the trails, away 
 from the civilization of the towns, taken up ranch life of some 
 sort, and lived with their horses and blankets, their chances 
 of recovery, or of lives greatly prolonged, would have been 
 excellent. In such cases lies the moral of the whole treatment 
 of tuberculosis by climatic conditions. It depends as much 
 upon the individual and his actions as it does upon the climate 
 and the environment in general. 
 
 Before I close, let me return once more to the captivating 
 and hope-inspiring subject of serotherapy in tuberculosis, and 
 give the experience of Dr. J. Edward Stubbert, of the Loomis 
 Sanatorium for Consumptives, at Liberty, Sullivan County, 
 New York. The matter is from his report for the six months 
 ending May i, 1898. The altitude at Liberty is tw'o thousand 
 three hundred feet. Patients do better there in winter than 
 in summer, although the year round they do w^ell. The at- 
 mosphere is dry and the sunlight is abundant. The cold 
 northwest winds do the patients good and not harm. They 
 walk through snow two feet deep, and improve by such work. 
 He allows all patients whose evening temperature does not 
 go above 100° F, to w'alk moderately, and if the temperature 
 does not go over 99°, no restriction whatever in regard to 
 exercise is placed over them, even up to or exceeding walking 
 ten miles or more a day. We try, he says, to improve the 
 general nutrition of the patients, in order to enable them to 
 
 overcome a specific poison. As to medicines, he uses creosote, 
 
 407 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 oil of cinnamon, ichthyol, and guaiacol valerianate. Ichthyol 
 in keratin-coated pills is best, especially if there are intestinal 
 complications. I suppose Dr. Stubbert looks upon it as exer- 
 cising a local germicidal action here, as, no doubt, this is the 
 great field for creosote and all such remedies. Hot air inhala- 
 tions were used in about thirty-five per cent, of the cases, with 
 encouraging results. 
 
 Now, as to the serum. I agree with Dr. Stubbert in the 
 following statement, when he says, " I am not ready to pin 
 my faith to serotherapy in tuberculosis, but in view of the 
 fact that, so far as bad results are concerned, it has proved 
 negative, and that a comparatively fair number of cases have 
 apparently improved under its administration, I believe it to 
 be the duty of the profession to continue clinical investigations 
 along this line." He says the cases treated in New York City 
 in private practice by Dr. Loomis and himself as yet give rise 
 to no positive conclusions. Loomis's experience in hospital 
 patients in New York City gave entirely negative results as 
 to improvement. Stubbert says the good effects appear to 
 be reduction of temperature, decrease of tubercle bacilli, and 
 probable immunity conferred upon patients after returning 
 to their homes. He says he has discarded its use in the sana- 
 torium except in incipient cases. The serum he used in his 
 cases reported was the United States government serum of 
 de Schweinitz. Now, I take it this serum is a tuberculin, 
 the tuberculin A of Koch, without attenuation by oxidation. 
 Therefore it is a toxine, and not an antitoxin. Let me give 
 here his recapitulation of the number of cases treated : 
 
 Whole number of cases treated 82. 
 
 Expectoration decreased in 82 per cent. 
 
 Appetite improved in 81 per cent; 
 
 Weight gained in 78 per cent. 
 
 Physical signs improved in 82 per cent. 
 
 Temperature decreased in 49 per cent. 
 
 Bacilli disappeared in 13 per cent. 
 
 Apparent immunity established in 21 per cent. 
 
 Bacilli decreased in 35 per cent. 
 
 Cough decreased in 79 P^i" cent. 
 
 Generally improved 85 per cent. 
 
 r 408 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 This surely is not a discouraging showing, coming from a 
 reliable source. The use of tuberculin is contraindicated in 
 cases showing" much softening or cavities, in incipient cases 
 with marked hereditary taint, in those in whom vital capacity 
 is much below normal, in those showing rapid heart action, 
 and in most cases of mixed infection. In any case, it is not 
 dangerous to inject the serum; occasionally a slight reaction 
 occurs in the first few treatments. It does not interfere with 
 digestion ; where the bacilli have disappeared they have done 
 so while the sputa were still present. No report of any relapse 
 of patients cured has been given, although they may have 
 returned to their former environment. 
 
 The most encouraging report from Dr. Stubbert was in 
 regard to his use of the Pasteur antistreptococcic serum in 
 six cases of mixed infection, showing, of course, the presence 
 of streptococci in the serum. The idea was to neutralize the 
 secondary infection, and give thus a clear field for the action 
 of the antitubercle serum. The injection used was about ten 
 cubic centimetres each time. In the first case expectoration 
 ceased almost immediately for a number of days and then 
 returned in diminished quantity. On examination, the strep- 
 tococci were found to be far less numerous and smaller in 
 size. The next case had had bronchitis for four years. Then 
 tuberculosis developed. This disappeared under antitubercle 
 serum, but bronchitis remained. The sputa were muco-puru- 
 lent and contained streptococci. After one injection of anti- 
 streptococci serum cough and expectoration increased materi- 
 ally. After a few wrecks the patient began to improve, and 
 the expectoration became very markedly less purulent. This 
 patient still lives. The next case had a dry cavity at one 
 apex. The streptococci disappeared after four injections of 
 antistreptococci serum, and the sputa, after a considerable 
 time, still contained tubercle bacilli. In the fifth case, the 
 antistreptococci serum had no effect. The sixth case was one 
 of tuberculous meningitis. Eight injections of antistrepto- 
 cocci serum had no effect. If the cause of failure of anti- 
 tubercle serum is in many cases mixed infection, then see 
 
 409 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 how important the report of the action of antistreptococci 
 serum in these cases becomes, and how encouraging to go on 
 with its use, and how very encouraging to these cases which 
 we have always had to look upon as so hopeless heretofore. 
 The antistreptococci serum acts very much more slowly in 
 these cases of chronic infection than it does in cases of acute 
 infection. 
 
 It will be remembered by the reader, that when, a few pages 
 back, I spoke of the work done in order to test the relation- 
 ship of the bacillus of tuberculosis and the bacillus of anthrax 
 by Dr. Neale and his assistants at the Delaware College Agri- 
 cultural Experiment Station at Newark, I was compelled to 
 record my great disappointment at the negative character of 
 the results of the experiments. I have now by me the Quar- 
 terly Bulletin of the Pasteur Institute of New York City for 
 December, 1897. In it I find an article by its Director, Dr. 
 Paul Gibier, " Do Laboratory Researches allow us to hope for 
 the Early Discovery of a Specific Remedy for Tuberculosis ?" 
 Gibier was working- on microbic symbiosis in general, with 
 the object of investigating whether, by some kind of vital 
 competition between the bacillus tuberculosis and the various 
 other bacteria, it would be possible to cause the latter to de- 
 velop a soluble ferment giving the cells of the animal organ- 
 ism the power of digesting the bacillus. He inoculated suc- 
 cessfully a number of guinea-pigs with the tubercle bacilli. 
 He kept four animals as tests ; that is to say, he allowed them 
 to go without any treatment after they had developed tuber- 
 culosis. The others he inoculated with a liquid obtained by 
 filtering through clay the cultures of a number of bacteria 
 which had thrived in company — symbiositic bacteria they 
 might be called — with the tubercle bacillus. Injections were 
 made every other day, the quantity of fluid being gradually 
 increased to two cubic centimetres. The test pigs died in two 
 and one-half months, three months, and three and one-half 
 months. Those treated with the filtered liquids of the cul- 
 tures of tubercle bacilli and streptococci, tubercle bacilli and 
 staphylococci, tubercle bacilli and subtiles and others, were 
 
 410 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 not helped as to tlicir tiil)crcnlosi.s, and died before the test 
 ])ijn"s. He took twf) of the tuberculous pigs and treated them 
 with a li(|uid of a culture of tubercle bacilli and anthrax. 
 After receiving five or six injections, the ulcerations at the 
 points of their tubercle injections began to heal, and their 
 inguinal glands, before enlarged, began to decrease in size. 
 One of the two tubercle and anthrax pigs died accidentally. 
 The other continued to receive the combined tubercle anrl an- 
 thrax injections, at first every two or three days, then twice 
 a week, and then once a week, for two months. At the end 
 of the two months, the ulcers had healed and the glands had 
 gone down to natural size. It was well, and at the end of 
 two years, when it was killed accidentally, it had thrived and 
 doubled its size. Other experiments in the same line by Gibier 
 did not turn out so encouragingly, but he rightly argues, 
 " Experiment in this line is worth while, and in the end we 
 will by some such means be able to arrest the development of 
 the tubercle bacillus," and thus cure tuberculosis in man and 
 the lower animals. God speed the day. 
 
 Another method of attacking the pathogenic germ is by in- 
 halation, and an account of some experiments given by Mur- 
 rell in the Philadelphia Medical Journal for February i8, 
 1899, shows how men are working on all sides to overcome 
 this arch enemy of animal existences. He took twenty pa- 
 tients suffering from pulmonary tuberculosis in various stages, 
 none of whom were confined to bed. He arranged for them 
 to inhale once or twice a day, and some of them continuously 
 night and day, air impregnated with either oil of cinnamon 
 or oil of peppermint. The details were well carried out, and 
 the results were uniformly ^unfavorable. In the bacteriologi- 
 cal examinations neither of the oils showed any deleterious 
 influence on the growth of the tubercle bacillus. Experi- 
 ments were made with formaldeh3^de in forty per cent, 
 aqueous solutions, the patients inhaling a spray containing 
 one part of this solution in sixteen of water ; at the same time, 
 bacteriologic examinations were undertaken with a six per 
 cent, solution of formaldehyde, and the results proved most 
 
 411 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 satisfactory as regards its action on the bacillus tuberculosis. 
 No contaminations occurred in any of the tubes. All the 
 controls grew "well except in one agar-agar tube sealed with 
 paraffin in a jar, which failed by an accident. No tube kept 
 under the influence of formaldehyde vapor for forty hours, 
 ninety-six hours, or ten days showed any growth whatever. 
 Subcultures were made from several tubes of the solid media, 
 and from all the tubes of the fluid media. All of these failed 
 except one of glycerin and beef-broth exposed for forty-eight 
 hours, which, reinoculated on blood-serum, began to grow 
 feebly after three weeks. A repetition of these experiments 
 gave the same result. 
 
 All this shows that even a weak solution of formaldehyde 
 shows a marked inhibitory influence on the growth of the 
 tubercle bacillus, and prolonged for forty-eight hours en- 
 tirely prevents their growth and future development. The 
 clinical results are quite up to the bacteriologic experience. 
 The six per cent, solution was usually employed, increased or 
 diminished according to the idiosyncrasy of the patient. The 
 drug was inhaled once or twice a day, compressed air by a 
 simple mechanical arrangement being made to bubble through 
 the solution. Coughing in some cases was annoying during 
 the inhalation. Out of twenty cases treated, six were incon- 
 clusive, because not persisted in, or other treatment was used 
 with the inhalation. The other fourteen cases did well, only 
 the inhalation treatment being used. Twelve were decidedly 
 benefited, and two were slightly improved. These cases were 
 in all stages of the disease. 
 
 Murrell recommends, as the best method of treating pul- 
 monary tuberculosis, to obtain bacilli from the expectoration, 
 cultivate them, pass over them various volatile substances 
 until one is found which will arrest their growth, and then 
 administer it by inhalation. 
 
 I have not said much of drugs in connection with tubercu- 
 losis, but the new South American remedy, kalagua, must not 
 be passed over, for it really, on so good an authority as the 
 
 Loomis Sanatorium physicians, shows great antiseptic prop- 
 
 412 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 erties, in closes of three grains three times a clay. Attention 
 was first attracted to it in South America by the effect the 
 eating of the leaves had on tuberculous cattle. It apparently 
 cured them. The remedy produces no ill effects. The analy- 
 sis is given as follows: Water, 8.51 ; extract of ether, 3.01 ; 
 albuminoids, 22.19; ashes, 16.79; cellular and extract mat- 
 ter not ozote, 49.43. The Loom is report gave five per cent, 
 apparently cured, sixty-two per cent, improved, fourteen per 
 cent, stationary, nineteen per cent, worse. In septic cases 
 ichthyol is highly recommended from the same source, and 
 good authority it is, too. It is almost a specific in changing 
 purulent sputum in doses of from twenty to thirty grains a 
 day. The Sanatorium also, in its last report, gives more hope 
 from antitubercle serum than do most other clinicians at the 
 present time. 
 
 One word more. We have considered tuberculosis of the 
 lungs, bones, joints, glands, and other parts, but have not 
 spoken of the circulatory system. Tuberculosis is a protean 
 disease, the more we study it. In cases of heart disease, espe- 
 cially in the young and delicate, whether of the myocardium, 
 the pericardium, or the endocardium, before you relegate the 
 case to the domain of rheumatism or to the class of cases re- 
 garded as idiopathic from cold or wet, consider them well. 
 Cardio-vascular disease surely predisposes to tuberculosis of 
 some form. Either the tuberculous trouble or the cardiac 
 trouble may be primary. The tubercle bacilli and its toxines 
 and other pathogenic germs may produce the heart trouble. 
 The toxines are active in producing the sclerotic forms. The 
 bacilli produce nutritive changes in the tissues. Tuberculous 
 lesions of the valves of the heart are often found ; so it is well 
 to remember the possibility of this in all cases. Tuberculous 
 pericarditis is probably far more common than is usually sup- 
 posed, and doubtless the cause of the condition is far more 
 commonly overlooked than diagnosed. There is another trou- 
 ble which is very frequently of tuberculous origin, — acute 
 pleurisy. Remember this in diagnosis, in treatment, and, 
 above all, in prognosis. 
 
 413 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Before I close this chapter let me add a note on a practical 
 point in hay-fever. Having been a lifelong sufferer myself 
 from a form of hay-fever, — the June cold, commonly called 
 the rose cold, — I naturally take interest in any matter per- 
 taining thereto. We know it comes in other forms besides 
 the June cold, the chief other forms being the autumnal ca- 
 tarrh, coming on about August 20, or when the rag-weed or 
 bitter weed (Ambrosia artemisicEfolia) blooms, and the peren- 
 nial form which pesters its victims during the whole part of 
 the year when all vegetation is not dormant. I believe all 
 of these forms have a common cause, and that cause is bac- 
 terial. Plant pollen is given as a cause. Vibrios in the nasal 
 chambers have been given as a cause, and vibrios are bacteria. 
 Some claim it is a neurosis pure and simple. I know all suf- 
 ferers from hay-fever are neurotic at the time they are under 
 the morbific influences, and during this time there is occlu- 
 sion of the nostrils and tender spots on the nasal mucous 
 membrane ; but there is really no essential diseased condition 
 of the nasal mucous membrane as a cause, and the neurotic 
 condition is an effect rather than a cause. As I said before, 
 I believe the cause is from pathogenic germs, and these enter 
 with the dust of the air and cause the trouble. There is an 
 individual sensitiveness to their action, just as some indi- 
 viduals are sensitive at times or always to other pathogenic 
 germs. I believe the pollen of plants do their part, but more 
 as a host for the pathogenic germs, and by their natural irri- 
 tating qualities, than in any other way. 
 
 Now, as to the practical point. In investigating some mat- 
 ters in connection with electric lighting, I met a young man 
 who had been a sorry sufferer from hay-fever since he was 
 four years of age. His residence is Wilmington, Delaware. 
 From August 20 to the first heavy frosts of each year he has 
 been unfit for any work, from asthma and other troubles. 
 Three years ago he went to Oakland, Maryland, high up in 
 the Allegheny Mountains, and worked in an electric-light 
 plant, which merely generated the current, but had no storage- 
 battery plant. He received no benefit there, either from ex- 
 
 414 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 postire ill tlic works or from tlic climatic conditions. Since 
 •last spring he has worked in llic plant at Wilmington, Dela- 
 ware, much of the time in the storage-battery room. This 
 year he has been absolutely well in every way throughout the 
 hay-fever season, and he attributes his freedom from trouble 
 to something he breathes when in tlie storage-battery room. 
 
 I examined this young man during the time he should have 
 been suffering. I found him well and strong, twenty-three 
 years of age, weight one hundred and thirty-five pounds, five 
 feet six inches high, with a good family history, and not a 
 hay- fever subject by inheritance. There were a few dry and 
 moist rales over the chest, such as we might find in any one 
 who might have been at times more or less asthmatic. He 
 told me he was cured. I asked him by what means? He 
 said by inhaling the fumes in the storage-battery room. " I 
 am especially benefited," he said. " when we are over- 
 charging to bring up low cells and when the booster is on." 
 The question now was to find what these fumes were. I 
 found upon questioning the very intelligent gentlemen con- 
 nected with the plant that their idea was that the fumes were 
 hydrogen peroxide, hydrogen dioxide. Here was an expla- 
 nation consistent with my belief of the cause of the disease, 
 the cause being bacterial and hydrogen dioxide a destroyer 
 of bacteria; and probably this patient was benefited in the 
 storage-battery room just as whooping-cough patients are ben- 
 efited in the gas-houses where illuminating gas, carburetted 
 hydrogen, is made, the carbolic acid fumes here acting as a 
 germicide to the now pretty well established cause of per- 
 tussis. 
 
 In order to more fully investigate what these fumes of the 
 storage-battery room might be. I consulted my friend. Pro- 
 fessor C. L. Penny, Professor of Chemistry in the Delaware 
 College Agricultural Experiment Station. Newark, Delaware. 
 In giving me notes of his examination. Professor Penny 
 alludes to the young gentleman, the victim of the hay-fever, 
 as saying that the curative agent in his case was hydrogen 
 dioxide, and that it had to him an unpleasant odor, yet hydro- 
 
 415 
 
FORTY YEARS IN THE MEDICAL PROFESSIO^r 
 
 gen dioxide has no odor. "If the hydrogen dioxide is the 
 curative agent, it must be largely as carried into the air by 
 the spray from the bubbling of the battery, and in that case 
 with some of the dilute sulphuric acid. Whether it would be 
 abundant enough and far-reaching enough, carried in that 
 way, to do any good, I do not know. In view of everything, 
 it would seem to me that ozone is the one probable explana- 
 tion of the case. Ozone has long been known to be evolved 
 from electrolytic action, such as that of battery-charging. 
 Where such enormous electrolysis is going on as in the Wil- 
 mington power-house, and in so small a confined space as the 
 battery-room, the air must be very highly charged with ozone. 
 The electrolysis of less than an ounce of acidulated water, 
 with a weak battery current, will emit an odor very percep- 
 tible in a room for some feet around. Now, the amotmt of 
 action must be multiplied by many thousands to make it com- 
 parable with that in the power-house at Wilmington. Then I 
 do not see anything improbable in supposing that there is, at 
 certain hours, enough of ozone in the air of the battery-room 
 to have an unquestionable effect on floating organic matter, 
 or miasms, and prove disastrous to them. We do not know 
 certainly of any other volatile emanation from electrolysis 
 than ozone, common oxygen, and hydrogen. So far as I 
 know, no one suspects any other such emanation; hence I 
 would say, with the information available, that if a curative 
 effect in the battery-room, peculiar to that place and not no- 
 ticed elsewhere, is unquestionable, and if, as I understand to 
 be the case, the curative effect is noticed only or chiefly when 
 the liquid in the batteries is boiling, with evolution of gas, 
 then I would not hesitate to attribute the curative effect to 
 ozone as the only body certainly known to be present and 
 capable of such effect." 
 
 I know one case is little upon which to base inference in 
 clinical medicine, but this case opens up an interesting subject, 
 and may point the means to relief and cure in many cases now 
 only relieved by changes in climate and residence, so incon- 
 venient to all and so impossible to the many. 
 
 416 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Dr. Douglass, of New York, recommends for all forms of 
 hay-fever the dried suprarenal glands. I have no doubt he 
 argues for this remedy on account of its well-known property 
 of depleting the nasal mucous membrane. It thus restores 
 the over-distended condition of the nasal erectile tissue. He 
 uses it both locally and as a spray, and by tablets internally 
 every two hours until until some prostration is manifest. 
 
 27 417 
 
CHAPTER XII. 
 
 Rheumatism an Infectious Disease — The Bacillus of Rheumatism — 
 Thyroid Extract in Rheumatism — Uric Acid in Rheumatism — Nuclein 
 — The White Blood-Corpuscles — Diagnosis — Treatment — Rheumatic 
 Gout — Multiple Arthritis Deformans — Gout — Arteriosclerosis — Meta- 
 bolism — Anabolism — Katabolism — Theories of Gout — Origin of Uric 
 Acid — Causes of Gout — Gout of the Intestines — Treatment of Gout — 
 Water — Lithia — Diet in Gout — Intermitting Heart — Alcohol in Gout — 
 Cider Cure for Gout — Vegetables in Gout — Contracted Kidney — Medi- 
 cines in Gout — Piperazine and Pichi in Gout — Thyroid Extract causing 
 Gout — Menstrual Gout — Carlsbad — An American Carlsbad — Diabetes 
 Mellitus — Glucose — Starches — Dextrose — Glycogenic Matter — Tubercu- 
 losis and Diabetes — Pancreatic Lesions — Carl von Noorden — The Liver 
 and Glycogen — Fat — Hyperglycemia — Causes of Diabetes Mellitus — 
 Mayer's Theory — McCaskay's Suggestions — Relationship between Dia- 
 betes and Obesity and Gout and Diabetes — Gluten — Diagnosis — Tests 
 for Sugar — Pregnancy and Diabetes Mellitus — Alcohol — Recoveries — ■ 
 Diabetes and Gouty Kidney — How to watch a Diabetic — Diabetic 
 Coma — Diabetics Vulnerable — Diabetics and Tuberculosis — Thyroid 
 Treatment — Prognosis — Diet and Treatment — Jambul and Piperazine 
 — Substitutes for Cane-Sugar — Wines and Spirits — Waters — Fruits — 
 Nuts — Allowable Articles of Diet — Terrapin — Rest Treatment — Gluten 
 Flours and other Diabetic Flours and Foods — Analysis of Macaroni, 
 Flours, etc. — The Soja Bean — Aleuronat Flour — Adulterations. 
 
 Forty years ago Dr. George B. Wood defined rheumatism, 
 meaning rheumatic fever, to be a constitutional affection, at- 
 tended with a pecuHar irritation or inflammation, to which all 
 parts of the system are liable. The general definition to-day 
 is, an infectious disease, with fever and arthritis, more or less 
 general. Some yet believe it to be due to a disturbed metabo- 
 lism, the nitrogenous products being converted into lactic and 
 uric acids and alloxuric products, instead of being carried off 
 as urea. Hence we get the highly acid perspiration and high 
 fever. Probably a few yet class it among the neuroses, like 
 the neuralgias. Every day the number grows who class it 
 with the specific infections, as they do typhoid fever, dysen- 
 
 418 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 tery, erysipelas, and pneumonia. Personally, I believe here 
 is where it belongs. 
 
 A French bacteriologist claims to have isolated the patho- 
 genic germ, an anaerobic bacillus resembling the bacillus of 
 anthrax. It is said to elaborate negative chemotaxic sub- 
 stances, and also products which produce necrosis in animal 
 tissues, thus accounting for the heart lesions so often seen 
 in rheumatic fever. Salicylic acid is said to affect adversely 
 this bacillus, and the germ is not usually found in the blood. 
 This might explain why the giving of thyroid extract pro- 
 duces rheumatism, as has been the experience with some, be- 
 cause it acts not specifically as thyroid extract, but only by the 
 pathogenic germs it introduces into the system. 
 
 Whatever may be the cause, it looks at present very plau- 
 sible to me that it is caused by a specific pathogenic germ 
 which is destroyed by the exhibition of salicylic acid, acting 
 as a germicide. How germs may act in producing the disease 
 is for the future to determine. They may check the breaking 
 up of the many compound waste substances in the system, 
 which when broken up pass off harmlessly through the kid- 
 neys and other organs. These tissue wastes may be in the 
 form of uric acid and allied substances. Again, as claimed 
 by Bouchard, rheumatism may be a toxaemia resulting from 
 the decomposition of food-stuffs in the stomach endowed with 
 conditions favoring such decomposition, such decomposition 
 favoring the generation of the peculiar germs; not only in 
 the stomach, but throughout the whole intestinal tract may 
 these conditions be present. 
 
 What part uric acid may play in causing rheumatism is an 
 interesting question. If rheumatism is an infectious disease 
 of bacterial origin, uric acid can only play a secondary part 
 in the causation. It is either produced by or increased by 
 this bacterial action, or its elimination from the system is 
 checked by it. The same may be true of lactic acid. As to 
 the source of uric acid, Vaughan says nuclein is broken up, 
 alloxuric bodies are formed, and uric acid, the most highly 
 oxidized of these substances, is the chief representative in the 
 
 419 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 urine of the nuclear metabolism resulting, as here indicated, 
 in the body. Here we come back to the cell, " omnis cellula 
 e cellula," and in their life and death we look for the origin 
 not only of life, but of death. Every cell at some period of 
 its life has a nucleus. The nucleus of a cell is the part con- 
 cerned in the transmission of its life to another cell. Nuclein 
 is the material of which the nuclei are composed. In health, 
 the nucleus of the red blood-corpuscle perfects it to carry the 
 oxygen and disappears. From Kossel's experiments we know 
 that nucleated cells contain, in addition to nucleinic acid, ger- 
 micidal basic substances, protecting them against bacterial 
 invasion. Here we approach the claims of those who insist 
 that we have in nuclein a germicide. Inject it into the sys- 
 tem, and we increase the number of white blood-corpuscles, 
 these being the natural scavengers of the body, which check 
 or prevent entirely the multiplication of the pathogenic germs 
 in the body. These polynuclear white blood-corpuscles do 
 not eat up, as it were, the germs, but destroy them by some 
 chemical action peculiar to themselves. What germicidal 
 properties blood-serum may have, inherent or acquired, come 
 through the polynuclear white blood-corpuscles. Increase 
 these and you fortify the body against the attacks of all path- 
 ogenic germs. 
 
 I mention these somewhat intricate facts and suppositions 
 to show that in some part of it we may sooner or later locate 
 such diseases, not only as rheumatism, but gout too, and all 
 may arise from a vicious metabolism in all the name implies, 
 and the cause of this vicious metabolism may be a bacterio- 
 logical one and a controllable one. This theory is more plau- 
 sible because of Vaughan's adherence to the theory of Hor- 
 baczewski as to the formation of uric acid in the economy. 
 We have long been taught that uric acid is the result of the 
 imperfect oxidation of urea, or rather uric acid should have 
 gone to urea had its completed oxidation gone on. Horbac- 
 zewski showed that the amount of uric acid and other xanthin 
 substances formed in the body is a measure of nuclein meta- 
 "bolism, the more there is in the body, the more nucleated cells 
 
 420 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 we know are undergoing disintegration. In such a disease 
 as rheumatic fever there must be enormous disintegration of 
 nucleated cells, and here the excess of uric acid may be a result 
 and not a cause of the disease. Compare rheumatism with 
 the so-called gonorrhoeal rheumatism, and we can reconcile 
 ourselves more and more to ordinary rheumatism being a 
 germ disease. Gonorrhoeal rheumatism is undoubtedly caused 
 by the gonococcus, this protean germ even attacking the heart, 
 as in mycotic endocarditis, and thus showing its similarity to 
 rheumatic fever. 
 
 So far as my experience goes, rheumatic fever is a much 
 more rare disease than it was formerly, say forty years ago. 
 Like all zymotic diseases, — if it is a zymotic disease, — it is 
 becoming, indeed, quite a rare disease. The reason for this 
 undoubtedly is the great improvement in drainage and the 
 general improved environment of homes, whether in town or 
 country. People are much better clothed and much better 
 shod than they were some years ago, and the means of travel 
 are so much more comfortable and expeditious, and hence less 
 conducive to colds and illness coming from them. When the 
 germ theory as to rheumatism is settled, and afifirmatively, 
 there will be little trouble in the diagnosis. To-day our meth- 
 ods of distinguishing the disease are about as they were years 
 ago. It is a disease rather of the poor than of the rich, al- 
 though this applies rather more to the chronic forms than to 
 the acute. The prognosis is much improved, on account of 
 the improved and more successful methods of treatment, and 
 heart, brain, and spinal complications are more rare. Keep 
 your wits about you, and you will rarely mistake it for an- 
 other disease in its ordinary forms, but be very careful when 
 you come to its concealed forms. 
 
 Years ago the cure for rheumatic fever was given as six 
 weeks in bed. To-day most of the cases we can control by 
 salicylic acid and its salts within seventy-two hours. We 
 may use them in any form, by the mouth, by the skin as in 
 ointments, and by the rectum. Healthy surroundings should 
 by all means be given the patient; indeed, surroundings as 
 
 421 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 near aseptic as possible, and he should never be allowed to 
 have cotton or linen come next his skin. There is nothine 
 new in diet, except it is more liberal than that of our fathers. 
 I oppose all animal broths, such as beef-tea and the like, in 
 most of the zymotic diseases, because they make good culture 
 media and model hosts for pathogenic germs, and for this 
 reason I oppose them in rheumatism in any form, for, if it is 
 a germ disease, the digestive tract is a place to grow them par 
 excellence. Should the treatment by salicylates not be toler- 
 ated, we have salol and such drugs, really much the same, as 
 salol breaks up into salicylic acid and carbolic acid in the in- 
 testines. These not agreeing, or failing, use intestinal anti- 
 sepsis of different kinds, both direct and indirect, using 
 freely of alkalies, with opiates to subdue the pain. Make all 
 affected joints as nearly immovable as possible. This method 
 gives great comfort. Subacute and chronic forms now and 
 again will yield to salicylates and germicides generally. It 
 is most important in these cases to make their surroundings 
 comfortable and give them wool next to the skin and plenty 
 of it. Intestinal lavage does good here, keeping in mind 
 the greatly increased possibilities of auto-intoxication. 
 
 These rules apply to cases of muscular rheumatism also, 
 particularly the intercostal and lumbar types. See that your 
 cases of chronic rheumatism are well fed with proper food, 
 especially of milk and bread and fish and eggs, and do not 
 forget massage and electricity; they increase oxidation, and 
 thus carry off the waste products. Cod-liver oil is good food. 
 These are generally alkaline foods, and, reasoning from the 
 general acid condition of the blood in all rheumatic cases, 
 should be proper food. If such patients waste away and lose 
 flesh, give them, freely even, of starchy food. Starches are 
 really diluted fats, and fat in diet checks the waste of albumin 
 in the tissues and subserves the strength. 
 
 Arthritis Deformans, Rheumatoid Arthritis, or Rheumatic 
 Gout. — I have seen this much more frequently in women than 
 in men, and most of the women have borne children. This 
 makes me think there may be something in the neurotrophic 
 
 422 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 theory of the disease first put fortli Ijy I Jr. Jolin K. Mitchell, 
 the elder. Behind all this there may he a pathogenic germ 
 working in some mysterious way, a veritahle polyp. Cod- 
 liver oil and strychnine are the hest remedies I know of, with 
 wool clothing, good food, and an environment as nearly asep- 
 tic as possible. 
 
 Multiple Arthritis Deformans. — I see these much more fre- 
 quently in women. They are supposed not to be true gout. 
 I am sure most women who have them, under favorable con- 
 ditions of life, live to be old. I am sure heredity plays a great 
 part in their production, and they appear to me to nearly ap- 
 proach some forms of gout or rheumatic gout. If they ulcer- 
 ate, suppurative arthritis is apt to follow. The chronic pro- 
 gressive form may affect nearly every joint of the body, and 
 the patient be helpless and in a condition not differing much 
 from ultra cases of rheumatic gout. Whether or not uric 
 acid is present in the blood in these diseases, as it is in gout, 
 or absent, as it is in rheumatism, I do not know. In the treat- 
 ment of acute articular rheumatism, and in all forms where 
 pain is the prominent symptom. I believe the hot-air treatment 
 will prove to be of great value. 
 
 GOUT. 
 
 It has been truly said, " A man is as old as his arteries," 
 and the great factor of all in causing their loss of elasticity 
 and the lessening of their caliber, thus producing a true arte- 
 riosclerosis, is undoubtedly syphilis ; the next factor is the 
 abuse of alcohol, and the next is gout, followed by other less 
 important causes, such as luxurious living, with a want of 
 exercise, the play of the emotions, and the zymotic diseases. 
 Coming on after this hardening of the arteries, we have en- 
 largement of the left ventricle of the heart, a compensatory 
 enlargement, for the arteries are really peripheral assistants 
 to the heart, and when they lose their elasticity the central 
 heart must beat more lustily to drive the column of blood 
 through the system, and hence we get increase of blood- 
 pressure, followed, if not by renal changes, which really often 
 
 4-23 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 coexist with these troubles in the form of contracted kidney, 
 then by ohguresia, the condition of the heart and arteries 
 rendering them incompetent to pump the full blood-stream 
 through the kidneys, and hence, even with sound kidneys, we 
 have albuminuria. Given renal casts, we may know the kid- 
 neys are yielding. Such as these are the exaggerated cases 
 of arteriosclerosis, and with them a man has reached old age, 
 whether he be forty years old or ninety. If forty or under, 
 to bring on the condition he has violated some one or more of 
 nature's inexorable laws. If he has reached old age, his con- 
 dition is a normal one, his sands of life have about run 
 out, and the rupturing of his hardened arteries brings him a 
 timely and natural passing to the regions of the silent ma- 
 jority. Such a case is apparent to the trained diagnostician, 
 but arteriosclerosis reaches to much more refined and to finer 
 lesions of the economy than these. So much so, indeed, that 
 it has been said more than once that a majority of mankind 
 really die of arteriosclerosis, either of the grosser or finer 
 kinds. Such being the case, and gout being one of its great 
 factors, we should study and investigate most thoroughly 
 such an arbiter of human happiness and human existence. 
 
 Before taking up the study of the causation of gout, it will 
 be well to pass in review some matters pertaining to food and 
 its action on the economy, including such processes as meta- 
 bolism and its congeners, katabolism and anabolism. I think 
 I have before given the definitions of metabolism, katabolism, 
 and anabolism, but it will do no harm to repeat them, for, if 
 we do not know them, we surely cannot appreciate or under- 
 stand the supposed causes of gout. Metabolism signifies 
 change as applied to tissues, tissue change in nutrition and 
 secretion. Katabolism is the process of forming products of 
 secretion — which, according to Virchow, are metabolic prod- 
 ucts — by protoplasm. This is retrograde metamorphosis. 
 Anabolism is a building-up process, forming living proto- 
 plasm from dead nutrient material. This is assimilation. 
 
 Professor W. O. Atwater has given us, in speaking of the 
 uses of food in the body, a very good idea of metabolism, and 
 
 424 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 I will make use of it in speaking of these matters. He thinks 
 Liebig's assertion, that chemical changes in the vegetable world 
 are synthetic and in the animal analytic, is true; but there 
 are many exceptions in both. Atwater thinks the physical 
 processes in the plant are chiefly the transformation of kinetic 
 or motor energy into potential energy. Those in the animal 
 are just the opposite, — the transformation of potential into 
 kinetic or motor. Now, this is normal metabolism. Normal 
 metabolism is of two kinds, the metabolism of matter and the 
 metabolism of energy. These two processes conform, the for- 
 mer to the conservation of matter, and the latter to the conser- 
 vation of energy. This brings these complex processes into 
 line with the two fundamental laws of the conservation of 
 matter and the conservation of energy, and thus the doctrine 
 of nutrition is set on a firm basis. Atwater says the terms 
 " flesh formers" and " fuel values" are plainer terms than 
 protein, fats, and carbohydrates. 
 
 Food has two chief uses, — to form the tissues and to act 
 as fuel. In tissue-building we have the metabolism of matter. 
 In fuel we get the heat and muscular power, and thus deal 
 with the metabolism of energy. The proteins, as we have 
 before stated when considering diet, are the tissue-builders 
 chiefly, but also serve in a measure as fuel, the fats and the 
 carbohydrates being the chief fuel factors. As fuel, the nu- 
 trients replace each other as to their potential energy. In food 
 we must have sufficient of protein to form tissue and sufficient 
 energy from the fuel foods to give heat and strength. In the 
 body fat we have stored fuel. The fuel value of fat is double 
 that of protein and carbohydrates. Fat in the food is stored 
 in the body as fat. This is important. The fuel part of the 
 proteins and the carbohydrates must be transformed into the 
 body fat. The fuel value of food is its fat-forming value. 
 To get at the amount of matter metabolized we take into ac- 
 count the food and the drink taken and the oxygen inhaled 
 by the lungs. Much of this goes to form blood, muscle, body 
 fat, bone, etc. What is left is outgo, and consists of the resi- 
 due after having made the blood, the bone, the muscle, the 
 
 425 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 fat, etc., the worn-out materials of the body which undergo 
 chemical changes and go off as gases through the lungs and 
 skin, the excreted urine, being composed of both liquid and 
 solids, the fecal matters, and the other excretions from the 
 digestive tract. All these processes going on normally in the 
 healthy individual constitute normal or healthy metabolism, 
 and such an individual will not suffer from gout. So far as 
 we know, the gouty individual is gouty because the different 
 metabolic processes going on in his system are abnormal, and 
 the victim of gout is the victim of abnormal metabolism. 
 
 What causes this abnormal metabolism is the problem to 
 solve. Does it come through the food primarily, owing to 
 its unbalanced condition as a ration for the individual, — that 
 is to say, owing, for instance, to an excess of nitrogen, now 
 so generally claimed, — or could it possibly be an infection, a 
 zymotic infection, the food eaten making the digestive tract 
 an acceptable host to the pathogenic germ, this germ being 
 the author of the abnormal metabolism in devious and remote 
 ways, and hence in the end causing the excessive formation 
 of uric acid or its defective elimination, acknowledging for 
 the time that the pathological factor in gout is uric acid? I 
 am not inclined to acknowledge anything as proven irrevoca- 
 bly as the pathological factor in gout, and, such being the 
 case, I see no objection to theorizing, or guessing, if you 
 prefer to call it so. To-day, I think the chances of gout being 
 an infectious disease caused by a pathogenic germ or germs 
 are just as great as that uric acid in the blood or system causes 
 it, or if uric acid in the blood or system does cause it, there is 
 good reason to believe that a pathogenic germ or germs may 
 be a direct or indirect cause of the excess of uric acid. It 
 may be asked here what part do intestinal microbes play in 
 digestion? Their ferments may be factors in digestion, as 
 are the enzymes and unorganized ferments. Bacteria may 
 be necessary to the physiological decomposition of albumi- 
 noids in the digestive process, and hence by their absence or 
 greater or less number may influence their digestion and the 
 
 formation of uric acid. 
 
 426 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Again, taking this infectious view of the origin of gout, we 
 know bile is the great intestinal antiseptic and the natural peri- 
 staltic persuader. Practically, we find in gouty attacks and in 
 lithremic conditions a more or less deficiency of bile, and hence 
 a clear intestinal field for the workings of intestinal microbes, 
 as we might suppose them to work, if a pathological factor in 
 gout. In gouty persons there is this condition, it appears to 
 me from clinical experience only, generally existing, accom- 
 panied by constipation and all the conditions going to make 
 up what we might call an hepatic insufficiency, which insuffi- 
 ciency might rest on the liver anatomically or upon some 
 defect inherent in it as a producer of bile up to the proper 
 standard for its work in the animal economy. 
 
 Haig claims that calomel drives the uric acid out of the 
 blood and into the tissues, and that this causes an attack of 
 gout, for he looks to uric acid as the one cause of gout. On 
 the other hand, the calomel should stimulate the liver to send 
 out an excess of bile and render the surroundings antimicro- 
 bic and check the gouty attack sooner or later. The two sup- 
 positions are not so opposite to each other as one might think 
 on first examination, and may be easily reconciled. Haig be- 
 lieves all colds to be caused by an excess of uric acid in the 
 blood, uricacidsemia plus a microbe. I trust that some day 
 he may find out all gout to be uric acid plus a microbe, or a 
 microbe plus uric acid. 
 
 Haig writes entertainingly and delightfully, his style is 
 charming, resembling that of Sir Thomas Watson more than 
 any writer I know of. His work on uric acid in the causation 
 of disease reads like a romance. Sometimes I think his en- 
 thusiasm runs away with his judgment; again he resembles 
 a book-keeper who forces his balances to meet the conditions 
 present. I say this without any feeling of disrespect. I ad- 
 mire his enthusiasm and his perseverance, and only good can 
 in the end come from his honest intentions and zealous indus- 
 try. Haig believes gout to be rheumatism, and rheumatism 
 to be gout, age only varying the clinical aspect, and the cause 
 of all to be uric acid. Indeed, the presence of uric acid in man 
 
 4^7 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 is a protean factor in disease, and the cause not only of rheu- 
 matism and gout, but of many and various ailments and con- 
 ditions harassing mankind, the latter diseases being caused by 
 the effect of the uric acid on arterial tension. Haig appears 
 to have absolute faith in his ability to handle uric acid as a 
 pathological factor in man. He claims to be able to produce 
 artificially an arthritis in man. Salicylates, he says, clear the 
 blood of uric acid by removing it from the body, whilst acids, 
 sulphates, opium, mercury, the iodides, iron, lead, and lithia 
 remove it by holding it in the joints, liver, spleen, and other 
 tissues. By giving an alkali, he claims he will produce head- 
 ache, mental depression, slow pulse, etc., by increasing the 
 excretion of uric acid. By giving an acid he claims to cure 
 the headache by decreasing the excretion of uric acid, and, as 
 it is not excreted, it must go somewhere, and it goes into the 
 tissues and joints and causes gout. This, I believe, is Haig's 
 theory of the action of uric acid as a pathological factor in 
 gout. 
 
 As far as our present knowledge extends, we are, I think, 
 compelled to admit that uric acid is a pathological factor in 
 gout, possibly the great pathological factor, for Garrod has 
 shown us that in an acute attack the blood is loaded with it. 
 Why these metabolic changes? Why these secretory prod- 
 ucts? Can there be an infection? If an infection, is it di- 
 rectly from the living parasite or from its poisonous secretion, 
 for in diseases either the one or the other may be a cause ? 
 
 Metabolism begins with assimilation and ends with excre- 
 tion, and between these boundaries any of these troubles may 
 arise. Then, again, what influences may be at work here for 
 good or for evil? What are the functions of the ductless 
 glands, now being so faithfully studied? What effect has 
 .normal cell action, and what may be the effect of abnormal cell 
 action, are questions constantly presenting themselves when 
 we come to study disease with the ever-increasing light of 
 the present day. Accepting uric acid as the prime factor in 
 the causation of gout, what theory of its formation shall we 
 accept ? Shall we take Garrod's theory, that it is the result of 
 
 42S 
 
FORTY YFiARS IN THIi MEDICAL PROFESSION 
 
 nitrogenous waste, that it represents a lower degree of oxida- 
 tion than urea, and thus, being more or less insoluble, it is 
 not carried off but accumulates in the system and produces 
 Haig's uricacidoimia? This accumulation in the system is 
 an incomplete waste product, and it is here because it is not 
 urea as it sliould be ; and it is so because of some defect in the 
 liver interfering with its urea-making powers. The fault in 
 the liver is probably its faulty action on the peptones in diges- 
 tion. Its action on the peptones, if normal, causes the proper 
 formation of urea; if abnormal, it is only uric acid, much 
 lower in oxidation than urea, that is formed. In order to 
 check this formation of uric acid we withhold the nitrogenous 
 foods and thus reduce the amount of peptones for this unfa- 
 vorable action of the liver. 
 
 This is a beautiful theory, and really the theory to-day 
 upon which most of our ablest clinicians base their theory of 
 the treatment of gout. I believe it is about to be pulled down, 
 yet practically the dietetic part of the treatment may not be 
 greatly changed. The prudent gouty man must semi-starve 
 himself still. After all, this is not unnatural, for a life of' 
 luxury will always have its penalties, for, as far as man's ani- 
 mal existence is concerned, it is an unnatural life. 
 
 Now, as to the other origin of uric acid, brought out by 
 the work of Vaughan and others, which we spoke of at length 
 when treating of rheumatism. Here its origin is given as the 
 result of the oxidation of the nuclein of the blood-corpuscles. 
 In addition to uric acid, we must also look to the uric acid 
 group of leukomaines as a factor in the causation of gout. 
 Here is a more complex cause, and a better opening still for 
 the workings of pathogenic germs as a near or remote cause 
 too. Here comes in the nervous factor. We must look on 
 tliis uric acid and these leukomaines, if not normally formed, 
 as victims of a faulty metabolism, or of some faulty secretory 
 functions, or may be of germ origin so far as the leukomaines 
 are concerned, and these faults lie in the nervous system, and 
 here we have gout among the neuroses. What becomes of 
 the methods of treatment of our best clinicians of to-day 
 
 429 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 under these circumstances? They must change their rigid 
 and fixed rules as to diet, especially as to the absolute elimi- 
 nation of the nitrogenous foods. Now, if gout may come 
 under any suspicion of the infections, there may still be a 
 good reason for withholding the proteids to a greater or a 
 less degree. 
 
 I spoke in the treatment of typhoid fever of the advisability 
 of withholding animal broths in that disease, as they were 
 available culture media for the pathogenic germ. The same 
 advice may in a measure hold good in gout and many other 
 diseases, and thus w^e may with propriety withhold in a great 
 degree all foods serving to produce or increase an auto-intoxi- 
 cation, rendered more possible from the presence of such foods 
 in the digestive tract. 
 
 In the treatment of gout my experience leads me more 
 than in any other disease, excepting diabetes mellitus, to study 
 well the individual, and to become familiar with his idiosyn- 
 crasies, both mental and physical, and this, whether the case 
 be chronic or acute. Above all things, study your patient as 
 to his tolerance of nitrogenous food, — carbohydrates and fats. 
 All persons differ as to their tolerance of these substances, 
 and particularly the gouty so differ. One gouty person may 
 eat roast beef and get a colic, and another may get a colic 
 from starchy food, or from sugar, or from fats. These are 
 most important points to remember in practice, and to disre- 
 gard them is empiricism. The great factors in treatment are, 
 first, water and plenty of it; second, semi-starvation, — not 
 really semi-starvation, but semi-starvation only as compared 
 with the inordinate eating and drinking habits of the average 
 man; third, salicylic acid and its salts, colchicum and aperi- 
 ents; fourth, exercise and dress, and proper environment, 
 with a life regulated to bring about and keep up the alkalinity 
 of the blood, for we know by experience that our gouty pa- 
 tients only do well under this condition, be the causes what 
 they may. 
 
 Now, as to the acute attack. If local, heat applied, even the 
 hot air, is most grateful. Local applications are not usually 
 
 430 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 in favor, Init logically, I think oil of gaultheria might be 
 painted upon the affected joint. If the disease is general, 
 push the salicylates and colchicuni and ojjium if necessary to 
 stop the suffering as soon as possible. I say opium, although 
 Haig says it increases the arthritis by driving the uric acid 
 from the blood into the joints. The patient should drink 
 water to his utmost capacity, to get rid of the nitrogenous 
 waste through the kidneys; and after the pain subsides, so as 
 to let up on the salicylates and colchicum, salol may be sub- 
 stituted as more of a germicide to the digestive tract, where 
 it breaks up into salicylic acid and carbolic acid. 
 
 Whilst it is necessary to watch the patient closely, espe- 
 cially if at all inclined to be feeble, rigid low diet is the rule, 
 and milk is best, and not too rich at that. Watch for retro- 
 cessions, for they may come suddenly and bring disaster. 
 The gouty patient is a vulnerable patient, whether his case 
 be acute or chronic. The disease is a protean disease, and I 
 know of no organ of the body, of no function of the body, of 
 no sense of the body, whether special or general, it may not 
 involve. 
 
 Allow me to speak of a matter here. Is gout increasing as 
 a disease in the United States? Undoubtedly it is, just as 
 rheumatism appears to be diminishing. The causes undoubt- 
 edly are the spread of luxury from the vast increase of wealth 
 accumulated in private hands, the great increase of the use of 
 malt liquors and wines as beverages, and another factor not 
 often taken into account, — the absorption of lead into the 
 system, this coming in the old forms of drinking water 
 through lead pipes and the various other forms unseen and 
 unheard of, as through the enamelled inside bands of our 
 first-quality hats, especially the English hats. The great fac- 
 tors in lead entering the system to-day are the general uses 
 of the metal in water-pipes, in beer-pumps and pipes, in soda- 
 water apparatus, in tinned or canned food products, and in 
 the free use of lead foils in tobacco products as at present mar- 
 keted. These outrages on the health of mankind are prevent- 
 able, and should be stopped by law without delay. Haig 
 
 431 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 thinks lead diminishes the alkahnity of the blood and hence 
 causes gout. I believe plumbism is a neurosis, and the pres- 
 ence of lead in the system undoubtedly causes this neurosis, 
 and it so affects tissue metabolism as to produce gout, going 
 back for its cause, if you choose, to the formation of the uric 
 acid and leukomaines from the nuclein of the blood-corpuscles. 
 In gout of the intestines particularly, or supposed gout of the 
 intestines, be very careful to differentiate it from lead colic, 
 and remember that they may and do often coexist. In your 
 differentiation do not fail to bear in mind the various symp- 
 toms of appendicitis. 
 
 The interesting, points in the treatment of gout are, after 
 all, how shall we advise the victims of chronic gout and the 
 victims of the so-called lithsemic condition to live, in order 
 that they may have the most comfort and get the most out 
 of life, not only in its enjoyments, but in its prolongation to 
 a green and happy old age. You may tell your patients at 
 once, there is one way not to do it, and that is " to eat, drink, 
 and be merry," and to endeavor to do away with all untoward 
 consequences by taking the so-called anti-gout remedies, 
 whether they come from their regular medical attendants 
 or come from the long list of proprietary remedies seen in 
 every drug-store. Among men of the world whom gout is 
 pinching, it is common to see them taking Blair's pills, an 
 English preparation of reputation. Colchicum and opium 
 probably are ingredients, and give temporary relief. Laville 
 is another popular remedy, which undoubtedly owes its virtue 
 to colchicum. I do not care what such remedies contain, and 
 how effective they may be, the method does great harm, and 
 invites in the end much suffering and premature death. 
 
 Now, as to water. Judiciously used, I believe it to be our 
 greatest weapon in fighting gout, particularly chronic gout. 
 It should be used freely, both per rectum and per orem and in 
 bathing. Intestinal lavage I look upon as of the greatest 
 benefit in the treatment of the lithsemic or gouty condition. 
 The water should be sterilized, and chloride of sodium, one 
 of the best intestinal antiseptics, should be added at the rate 
 
 432 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 of a heaped teaspoonful to n pint. This may be given on re- 
 tiring, as much as the large bowel will tolerate, and heUl as 
 long as possible. If preferable, during an hour before retiring, 
 drink a quart, more or less of water, and with it take thirty 
 grains of sodium bicarbonate should there be a tendency to 
 acifl eructations. I particularly recommend sodium here and 
 not the potassium salt, for in gout the kidneys are, we kncnv, 
 very vulnerable, and potassium is more irritating to the kid- 
 neys than sodium. If there be no need for the sodium on 
 this account, take from five to ten grains of salol with the 
 water. This breaks up into salicylic acid and phenol in the 
 upper intestinal tract, and is antiseptic and increases nitroge- 
 nous elimination. The gouty patient, as a rule, is not a 
 thirsty person, and few drink enough water. They should 
 drink all that it is possible for them to take and be comforta- 
 ble. It is the great weapon in the fight against the gouty 
 condition. Where it is possible to obtain them, the natural 
 alkaline waters are most useful, and of these the Vichys are 
 the best. Wherever we can get a good alkaline water in our 
 own country, or get to the springs to use them, they will 
 prove useful if taken in large quantities. 
 
 The lithium salts have long been recommended by Garrod 
 and others as solvents for uric acid and the urates. In my 
 hands they have never shown any practical effect as lithium. 
 The " lithia" waters on the market are usually good, pure 
 waters, with a suspicion of lithium in them, a mere suspi- 
 cion, and if lithium was really of any use in the treatment 
 of gout it would take bottles of most of them for a single 
 dose. They come nicely put up, and do good by encouraging 
 patients to drink w^ater; beyond this they amount practically 
 to nothing. Carbonated, they are aiders of digestion and 
 very acceptable. There are many waters of other brands on 
 the market, both plain and carbonated, some of them very 
 pure. Here is their mission : they give good pure water and 
 encourage the drinking of it, and are handy for travellers 
 who become ill by constantly changing the water supply ; and 
 they carry off, as do most fluids taken, the excess of nitroge- 
 28 433 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 nous waste, which retained becomes a source of pabulum for 
 microbes and a prominent factor in auto-infection and auto- 
 intoxication. This use of water in gout applies most particu- 
 larly to women, who are great sufferers from lithsemia, and 
 who very rarely drink water sufficient for their common 
 needs, much less as a remedial measure. 
 
 There is another important measure, in addition to this 
 water treatment of gout. Now and again, say once a week 
 or once a fortnight, give a small dose of calomel, sufficient 
 to stimulate the liver, for such it probably does, causing it 
 to throw out an extra amount of bile and thus antisepticize 
 the bowel. There is generally constipation in the gouty, 
 which is best relieved by the aperient waters before the morn- 
 ing meal, and may be taken daily if needed. Any of the 
 saline purgatives may be used if preferred. 
 
 Now, as to food. For reasons before given, we must avoid 
 in a great measure foods rich in nitrogen, for if on this score 
 our reasoning is not yet on a firm foundation, experience 
 comes to our aid and tells us much. Do not forget to study 
 your patient. Is he strong and vigorous, or is he weak and 
 failing, and what idiosyncrasies has he as to certain articles 
 of diet? Horatio Wood is one of our best authorities on 
 diet, as he is on many other matters. He says there is no 
 diet for gout; it is diet for the individual. Sydenham first 
 warned the gouty against red meats, and red meats may give 
 one person gout and cure another; that is to say, the latter 
 case may be weak and puny and absolutely in need of the 
 strength only to be derived from nitrogenous food. For the 
 same reasons one may require starch and sugar to a greater 
 or less degree, and one may go to pieces on them as part of 
 the diet. A milk diet may be necessary for some cases for a 
 longer or shorter time, and even reduced milk or skim-milk 
 or other milk preparations, as koumiss and the like. As to 
 meats, there is little difference really in the amount of pro- 
 teids in the red and white meats. A reference to the article 
 ■on diet in a former chapter will show all of this matter in a 
 hv'iei space. Roast chicken is nearly as strong as roast beef, 
 
 434 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 and roast turkey is well up to roast chicken, whilst roast 
 goose is very fat and a little lighter in nitrogen than either 
 of the others. The gouty patient must eat less in (juantity, 
 and thus cut down his nitrogen. Semi-starvation must be his 
 rule. Overeating is a habit anyhow, and a very bad habit, 
 too. Accustom yourself to leaving the table comparatively 
 hungry a few times, and the inconvenience soon passes away. 
 We all eat too much. 
 
 Now as to fish as the lighter flesh diet. It is lighter diet 
 than animal flesh, but it depends on what kind of fish. Salmon 
 is nearly as strong as roast beef. In fact, all fish are com- 
 paratively strong in nitrogen. The shellfish are weaker and 
 better food for the gouty. A reference to the article on diet 
 will tell the fish story. As I have said before, whilst fish, or 
 at least many of them, are high in nitrogen, they are lighter 
 food than animal flesh, for they do not overload the blood 
 with waste products as the animal foods do, and the blood 
 sooner clears itself of the waste products from fish than of 
 those from animal food. 
 
 Let us go to a clinical study, and by this I think we can 
 show a difference in the efifect of animal flesh and fish diet. 
 Intermitting heart, not the more serious irregular heart, is. 
 as we all know, so common among the sufiferers from chronic 
 gout and the gouty condition, and is serious, not because it 
 is in itself a serious condition, but only as to the ill effect it 
 may have on the patient. Some never know they have it. 
 Avhilst others are very unhappy over their condition. Brady- 
 cardia and tachycardia come under the same head. Here an 
 excess of nitrogen in the food and the overloading of the 
 blood with waste products are, I think, the prime factors of 
 causation. Fish diet causes much less of this overloading of 
 the blood with waste products, and hence is not nearly so apt 
 to cause arrhythmia as the animal flesh diet, for the alkalinity 
 of the blood is not so much lessened by it. Toxines are more 
 apt to develop from such food, and these in the intestines 
 cause such functional heart troubles. They overload the 
 stomach usually, or rather cause the stomach hard, quick 
 
 435 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 work to get rid of them, and, the blood-vessels being over- 
 loaded-, arrhythmia occurs. Excess of blood-pressure is also 
 a factor, and this we usually have in the gouty, hence the 
 gouty man is more apt than the healthy man to suffer from 
 functional heart disturbances after eating and drinking, and 
 particularly after the use of tobacco. These troubles can be 
 classed among the neuroses pure and simple. Again we may 
 ask the question, Is gout a neurosis? 
 
 Some teachers have condemned a diet composed chiefly of 
 carbohydrates as of more injury to the gouty than a diet 
 chiefly of nitrongenous food. The reasoning is that too much 
 carbohydrates may take so much oxygen for their oxidation 
 that there will be a deficiency for the changing of the uric 
 acid into urea, and thus leave the uric acid in the blood. Too 
 much fat may do the same thing in the same way. Thus the 
 accumulation of winter fat is apt to give us spring gout, a 
 favorite reason for it. 
 
 Now let us take up alcohol and its effect on the gouty. 
 Alcohol, nicotine, and morphine all diminish temperature^ 
 the first two by relaxing the blood-vessels and increasing per- 
 spiration, and the later by preventing all glandular and molec- 
 ular activity. Alcohol in any form, ether, chloroform, and 
 the like, all reduce the alkalinity of the blood, and are innately 
 bad in gout. Alcohol also undoubtedly reduces the bacteri- 
 cidal action of the blood, and is bad for that reason in gout. A 
 sober guinea-pig will withstand six times the dose of toxines 
 that a drunken guinea-pig will. Alcohol's affinity for oxygen, 
 of which it robs the blood, causes the loading of the blood with 
 toxines, which result from imperfect oxidation of the tissues, 
 and thus we see hw the drunken guinea-pig succumbed before 
 the sober guinea-pig. An excesss of alcohol is particularly 
 bad for the gouty. It bloats and gives a false look of health. 
 This bloat is an abnormal tissue, an unbalanced tissue, which 
 should have been consumed by the vital processes in health 
 by oxidation, but the alcohol has used up this oxygen and 
 the normal oxidation of the fat did not go on, and hence it is 
 stored up as useless, harmful, unbalanced tissue, and the vic- 
 
 436 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 tim is an unhealthy fat person, his car-marks being plainly 
 visible, for he carries his own sign. He is a bloat. 
 
 Alcohol goes to acid in its digestion, and thus reduces the 
 alkalinity of the blood. Sugar with alcohol increases its 
 power of reducing the alkalinity of the blood ; so beware ! 
 take your whiskey straight, not as a cocktail. The sugar in 
 wines makes them more objectionable, for it starts all sorts 
 of intestinal fermentations and decreases the alkalinity of the 
 blood. The best drink for the gouty is water or milk. Of 
 spirits, a pure California brandy, with no coloring-rnatter, 
 is best, and next to this is Scotch whiskey, because it is free 
 from sugar. American whiskey is a good drink, except that 
 the sugar coloring-matter is objectionable. Of wines, I should 
 object to all but a good, sound claret, and that well diluted. 
 Sugar in claret is a horror in any form, and those using it 
 not only spoil a good wine, but deserve the horrors of diges- 
 tive nightmare. If one must have a sparkling wine, use the 
 Moselles rather than the champagnes, unless the latter are 
 inky dry. The malt liquors are poison to the gouty, and 
 should under no consideration be indulged in. Lager beer 
 has only three per cent, of alcohol, but it will not do. In these 
 malt drinks we have alcohol and sugar mixed, and they are 
 highly acid. That is all there is about it. They will not do 
 for the gouty man or woman. Sweet cider and sweet perry 
 (pear cider) are not particularly gouty, but when fermenta- 
 tion has passed to the acid stage they are objectionable. 
 The basis of the cider cure of gout, often used in France, 
 is just this : the juice contains much potash, and this acts 
 by reducing the acid state of the blood, just as the potash 
 in lemon- juice does in the lemon- juice rheumatism treat- 
 ment. 
 
 Shall we avoid the carbohydrates in gout? That depends 
 upon the individual. It is nonsense to lay down absolute 
 rules for numerous patients. One living on carbohydrates 
 to a greater or less extent may have constant acid dyspepsia 
 and auto-intoxication, particularly if sugar be associated with 
 them. If either disagree, avoid them as much as possible. 
 
 437 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 For sugar, saccharin or diabetin may be substituted now and 
 again.- Saccharin is antiseptic, and may thus interfere with 
 digestion and cause dyspepsia. It renders the urine acid. As 
 a rule, gouty people who have not ruined their digestion can 
 take carbohydrates with impunity, and they agree with them. 
 If they do not agree, they probably interfere with the com- 
 plete metabolism of the albuminoids, and one or the other 
 must be cut off to a certain extent, or altogether ; and so with 
 fats. If they agree, they can be taken in moderation, provided 
 there are no other contraindications. If the kidneys are in- 
 volved and albuminuria appears, use fats as a rule. They 
 check the waste of the albumin, and so do the carbohydrates, 
 for they are only diluted fats. The kidney troubles in gout 
 are a common and serious complication, and when the pa- 
 tient can endure it for a time, milk diet may be called for, 
 and even skim-milk diet, or buttermilk, a by-product of cream. 
 Remember, one patient may thrive on such diet, another may 
 endure it, whilst a third may sink under it. Milk is a normal 
 alkaline complete food. Fresh breads are microbic food, 
 and usually disagree in gout. Toasted and stale breads are 
 better. Avoid all foods causing fermentative dyspepsia and 
 those that may cause indigestion of any kind, or any that 
 might cause ptomaine poisoning; they each probably have 
 their specific pathogenic germ. Now and then a patient may 
 thrive best on the diet for diabetes mellitus, one of the conge- 
 ners of gout, but such cases are rare. 
 
 Now, an important question comes up : what about the 
 acid vegetables and fruits? I think, as a rule, they may be 
 used, watching the effect on the individual. Strawberries are 
 forbidden in gout by most physicians on account of their acid- 
 ity. Linnaeus, who suffered from gout most of the time, 
 said he was only well in strawberry time, when he ate largely 
 of them. Like the lemon, their acidity may be only apparent, 
 not real, and they may render the blood alkaline, not acid. 
 Their juice is probably germicidal, like that of many other 
 fruits. It is not impossible they may have an effect of pro- 
 ducing hippuric and benzoic acids, thus rendering the uric 
 
 438 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 acid soluble. Wc take caljljag'c, liriissels sprouts, turnips, 
 celery, tomatoes, s])iiiach, asparagus, and such vegetables, 
 not forgetting rhubarlj, so grateful in the early spring. It 
 is doubtful if rhubarb has any effect on the formation or the 
 elimination of uric acid, although it contains some oxalic 
 acid. Its mineral matter in some way, I doubt not, is useful, 
 and I do not believe it ever caused a serious fleposit of oxa- 
 lates in the urine or tissues. The same may be said of spin- 
 ach, tomatoes, asparagus, cabbage, and such vegetables ; they 
 probably all contain oxalic acid. According to recent inves- 
 tigations the mineral matters of all of these vegetables act 
 chemically and prevent the deposition of gouty matter in the 
 tissues, and are the best remedies to prevent such deposits. 
 I believe this to be true; this is the way in which nature 
 solves such problems, and for such uses they have been given 
 to man. 
 
 I know of no vegetable which the gouty person can use 
 freely equal to green corn. The small amount of maizenic 
 acid it contains has a good effect and does not excite meta- 
 bolic activity of tissues, nor does the corn as a vegetable to 
 a large degree, and by its bulk it leads to a healthy condition 
 of the bowels where obstinate constipation is so often an 
 unpleasant factor. In soup with milk it may be used every 
 day in the year, and this makes an ideal dish for the lithaemic 
 sufferer. Do not use much salt with the corn, as the syno- 
 vial fluids have great affinity for salt, and you thus may 
 check the formation of the soluble sodium biurate. Zea, 
 corn-silk, acts as a diuretic, and I believe is useful in chronic 
 gout, especially in cases where the bladder is irritable. It 
 is a diuretic, increasing arterial pressure, and should be given 
 in large quantities of hot water every few hours. 
 
 Cheese is highly nitrogenous and must be used with cau- 
 tion, but I see no reason why a gouty man cannot take a 
 morsel now and again to give zest to a cracker or possibly a 
 mild salad. Eggs are a common and useful article of diet, 
 for, if fresh, they are absolutely sterile food and perfectly 
 safe as far as germ infection goes. They are said to be of 
 
 439 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 an alkaline tendency and to set the urinary secretion alka- 
 line. If a gouty patient is weak and needs proteid diet, eggs 
 are most useful. If the patient be strong and vigorous, use 
 the yolks freely, and discard the white, as it is too strong, 
 being typical albumin. If you know your gouty patient to 
 be the victim of contracted kidney, interstitial nephritis, be 
 very careful of concentrated nitrogenous food, especially those 
 like red meats, and the white of eggs, which leave more or 
 less waste products, which require much oxygen to eliminate 
 them from the blood. 
 
 Ursemic convulsions may be looked for in such cases, and 
 I sometimes think the cause is more the toxines developed 
 from such food than from the other causes usually assigned. 
 Such cases may be infantile convulsions over again. In these 
 renal cases use the amount of urine flowing as the barometer. 
 If you are ordering your patient a large quantity of water, 
 of course it goes off rapidly by the kidneys. If the excess 
 of the normal amount is still too high, check the blood- 
 pressure by nitroglycerin, and possibly save your patient from 
 cerebral hemorrhage or some" accident always pending from 
 the impaired condition of the arteries of such patients. Under 
 these conditions asthmatic troubles are apt to show them- 
 selves, and may be purely of a neurotic origin connected with 
 the gouty condition, and so may sore throat, generally of an 
 erythematous nature, although this latter trouble I think is 
 common in both acute and chronic gout, as are skin affec- 
 tions generally of an eczematous nature. 
 
 Gouty headache is common, and usually alternates with 
 the before-mentioned annoyances. It usually is most annoy- 
 ing on first waking in the morning, and is usually a hot, 
 burning pain through and back of the eyes. Those who have 
 been victims of migraine, or sick headache, up to the age of 
 forty-five usually are the sufferers from gouty headache after 
 that age. High blood-pressure is a factor in gouty headache, 
 and the remedy is plain, — lower it. This headache usually 
 passes off after a cold bath and a rub to the head and shoul- 
 ders, if the patient is robust and reacts well. A light break- 
 
 440 
 
FORTY YEARS IN THE MEDICAL PROEESSION 
 
 fast and a walk in the fresh air complete the cure. Sick 
 headache, as a rule, passes off only with the setting sun. In 
 chronic gout medicinal remedies should only be used in acute 
 attacks, or subacute attacks, marked with pain. I believe the 
 best remedy is the salicylates of sodium or strontium, in 
 connection with colchicum ; they both do better when used 
 together. The salicylates are antipyretic and possibly anti- 
 periodic and germicidal. They possibly control pain through 
 their influence on the vasomotor system and by causing the 
 elimination of urea and uric acid. If the patient have albu- 
 minuria, be careful with the salicylates; better use colchicum 
 alone most of the time or with the iodides. Colchicum may 
 increase the elimination of both urea and uric acid, and may 
 do this probably through its cholagogue effect on the liver 
 and thence through the peptones from the food. Iodide of 
 potassium may he given with colchicum. With kidney lesions, 
 strontium is to be preferred with colchicum. This is against 
 Haig's reasoning, if we wish to keep down the arthritis, but 
 in practice it acts well, especially in the feeble, with marked 
 arteriosclerosis in any form. As I have before stated, I 
 usually prefer a capsule containing methyl salicylate and col- 
 chicin, and I especially prefer this combination if I have to 
 use salicylic acid when the patient has albuminuria, for if 
 there is any difference in their irritating action on the kidneys, 
 I think the methyl salicylate the least irritating as between it 
 and the synthetic compounds. 
 
 Professor James Tyson, one of our best authorities, prefers 
 the salicylates in the treatment of gout. I think a Turkish 
 bath at frequent intervals is one of the best eliminators in 
 the treatment. The best plan, after all has been said, is semi- 
 starvation, whether direct, by cutting down the amount of 
 food, or indirect, by active exercise, adding to this semi- 
 starvation the free use of water; and the Turkish bath is 
 one of the best ways by which to use the water. By these 
 means we best guard the kidneys from degeneration and save 
 the arteries from the inroads of arteriosclerosis. By such 
 means, with proper clothing, proper environment, and changes 
 
 441 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 of climate when possible, leading a quiet, sober, and active 
 life, the activit)^ being ganged by the physical condition, the 
 gouty individual may keep his Nemesis at bay and reach a 
 green old age. 
 
 Ointments of the salicylates are undoubtedly useful for 
 anointing the joints, and the same may be said of the oil of 
 gaultheria, used as a paint and frequently applied. 
 
 As yet there is little favorable to report in regard to the 
 use of piperazine in gout. I am sure of one thing: it is of 
 great use in those cases where there is a tendency to the de- 
 posit of the urates in the kidneys, producing frequent attacks 
 of renal colic. I would always give it in these cases for its 
 effect on the diathesis, for its local effect on the stone in the 
 kidney, and after it has reached the bladder. I am satisfied 
 that a five-grain dose three times a day is the best remedy 
 in all forms of muscular rheumatism or gout. It is sup- 
 posed to act as a solvent to uric acid. Do not give acids in 
 food or medicine whilst the patient is taking piperazine. 
 
 Pichi is a shrub found growing in Chile and Peru. It has 
 greenish-blue leaves and a balsamic odor. Its active principle 
 is in its balsamic resin. Dr. Hervey W. Whitaker, of Colum- 
 bus, Ohio, says it is a strong cholagogue and has a stimu- 
 lating effect on all mucous membranes. It is a valuable 
 remedy in gall-stones. In the uric acid diathesis, gout, 
 chronic rheumatism, sciatica, muscular rheumatism, and 
 gouty headache it is of great value. Its remedial action far 
 excels that of the salicylates in such troubles. Uric acid for- 
 mations rapidly disappear from the urine under its use, and 
 the general condition improves. It acts through the liver, 
 being, I suppose, a strong cholagogue. Whittaker thinks its 
 active principle effects some combination in the circulation 
 favorable to the solution, excretion, and elimination of the 
 products of metabolism, which a sluggish liver would other- 
 wise be incapable of transforming. It is the best bitter tonic 
 in chronic alcoholism, and is most useful in the cystitis of 
 enlarged prostate, and in gout of the intestines it is said to 
 be superior to the salicylates. It is useful in jaundice and 
 
 44-2 
 
FORTY YEARS JN TMK MF^DICAL PROFESSION 
 
 cirrhosis of the hver. The iluid extract is tlie best prepara- 
 tion. It will not mix with water, owing to its resinous prop- 
 erties, except yon add a small f|uaiitity of an alkali, say, twenty 
 to thirty grains sodium bicai^honate to the ounce. The dose 
 is a half-teas{)oonful every four hours, more or less. A good 
 mixture is glycerin one ounce and fluid extract pichi one- 
 half ounce. A teaspoonful and a half in water is a dose. It 
 may also be given in powder, in a capsule or a tablet. 
 
 Thyroid extract and gout and rheumatism, from clinical 
 experience now accumulating, give opportunity for interest- 
 ing study. Horatio Wood reports four cases in which gout 
 or rheumatism followed the administration of thyroid ex- 
 tract. He has as yet drawn no conclusions from these cases 
 for publication. Dr. B. K. Rachford, of Cincinnati, Ohio, 
 has also called attention to the action of thyroid extract in 
 producing gout. Rachford sums up as follows : 
 
 1. Attacks of arthritic gout are associated with the excre- 
 tion of an excess of the alloxuric bodies in the urine. 
 
 2. Thyroid feeding will increase the excretion of the allox- 
 uric bodies in the urine, and will produce an acute arthritis 
 in a patient suiTering from chronic rheumatic gout. 
 
 A third fact he adds : The menstrual period in \vomen often 
 precipitates an attack of gouty inflammation, and may be 
 called menstrual gout. Now^ at the menstrual period there is 
 a hyperacidity of the thyroid gland, and thus we may be led 
 to suppose that the thyroid secretion has something to do 
 wath the abnormal body chemistry which is coincident with 
 these gouty attacks. 
 
 These are valuable and interesting facts, and may in the 
 end give some clue to the true pathology of gout. In giving 
 thyroid we produce a decided loss of weight, due in part to a 
 destruction of the nitrogenous tissues, but chiefly to the 
 wasting of the fats. One-sixth loss is from the former and 
 five-sixths from the latter. The eftect here is to interfere 
 wath the tissue balance and to lower the fuel values much 
 more than the flesh-formers. Somewhere between these com- 
 plex processes having to do with tissue-building and fuel 
 
 443 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 values must be the cause of gout, and this is where it is now 
 generally located, and is expressed by a faulty metabolism. 
 As age comes over us we grow decrepit, day by day and more 
 and more the victims of disarranged and abnormal meta- 
 bolism, and so we do in gout, and after all, what is gout but 
 old age, premature if in the young, fully ripened if we have 
 reached the time of the " sere and yellow leaf"? This being 
 the case, the remedy would appear to be, not thyroid extract, 
 which pulls down and destroys, but the extracts probably of 
 those glands which are rather builders up, and the flesh and 
 extracts not of old animals, but of the younger, wherein we 
 might hope to find that of which old age has deprived us, and 
 the taking of which might in some degree or another rein- 
 vigorate us. Such was the notion, probably, of the late illus- 
 trious Brown-Sequard. 
 
 In Europe the good livers, as they reach the age when gout 
 begins to nag them, are accustomed to take the cure, as they 
 designate it, yearly. The cure is nothing more than a rest 
 of the digestive and other organs, with copious washings out 
 of the system with water, to carry off the accumulated ni- 
 trogenous wastes of the system. The cure generally con- 
 sumes a period of six weeks, and is a rational way of letting 
 up, whether the taker is a high roller or merely a good fellow, 
 or a hard worker in professional or business life, or a woman 
 temporarily blase from the exactions of the social whirl. 
 Carlsbad is the typical resort for the cure. Would we had a 
 Carlsbad in the United States! We should have; we have 
 the making of such at Saratoga or in the Virginia mountains, 
 and many other places where we have the waters. The trouble 
 is, that in this country people look upon all such resorts as 
 a place in which to dissipate, rather than to rest. We are 
 improving in this respect, and soon, I have no doubt, we shall 
 have an American Carlsbad, where the free American citizen 
 will allow himself, under surveillance, at least long enough 
 to wash away his gout along with his other grievous sins. 
 At the same time, the hotel men and boarding-house keepers 
 must be absolutely restricted in their rapacity, for the serving 
 
 444 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 of improper food and drink must be made impossible at tlie 
 American Carlsbad, as it is at the German Carlsbad. The 
 best we can do to-day is to visit the various sanatoria. There 
 are many well-appointed ones in the country, but, as a rule, 
 they are expensive and are not by any means the Carlsbad we 
 are hoping for and looking for. 
 
 Should you go to Carlsbad fairly well and strong, wishing 
 to reduce your weight and get rid of gouty aches and pains, 
 3^ou would visit a local physician of reputation and present 
 your letter from your regular professional adviser. Under 
 the care of the local physician you would probably take a 
 course about as follows : In the morning get up at half -past 
 five o'clock and be at the proper spring at six o'clock. Take 
 one glass of water and move about quietly for fifteen minutes, 
 at the end of which time take another glass and keep in mo- 
 tion. Continue this course until you have taken in all five 
 glasses of water. After the last glass has been taken, continue 
 to walk quietly for one hour. Now go to breakfast, which 
 will probably be composed of three pieces of German zwieback, 
 one portion of boiled ham entirely lean, a cup of tea with 
 milk, but with no sugar. After this the kidneys and bowels 
 will probably act freely. Until eleven o'clock walk briskly 
 over the hills. Hill-climbing will be strongly urged upon 
 you by the doctor ; and after this, say, from eleven to twelve 
 o'clock, Swedish gymnastics, and frequently after this a Turk- 
 ish bath and massage. One o'clock is the mid-day hour for 
 dinner, which is frugal and plain : No soup ; boiled fish only, 
 with lemon-juice; your choice of lamb, veal, or chicken, 
 roasted, with little or no fat; no potatoes, carrots, or peas 
 are allowed, but you may eat string-beans or lettuce with 
 lemon- juice only, no vinegar nor oil. For dessert a compote 
 without sugar. The only drink allowed is a half-bottle of 
 sound red wine. After dinner, walk until four o'clock p.m., 
 the walking to be done rather quietly and slowly, with little 
 or no hill-climbing. You }]iust keep moving constantly until 
 six o'clock, when tea or supper is ready. The idea is not to 
 sit down and rest at all if you have the strength to continue 
 
 445 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 moving. Keep in the open air. The supper will consist of 
 either cold lamb, cold mutton, chicken, or ham, with as little 
 of fat as possible. With this you will be served with three 
 pieces of German zwieback and a half -bottle of some of the 
 effervescing waters. Go to bed not later than nine o'clock 
 P.M., having smoked not more than one mild cigar, should 
 3^ou happen to be a smoker. You are constantly enjoined to 
 drink plenty of water. The shortest cure is three weeks at 
 Carlsbad, and the keeping up of the diet and exercise rigidly 
 for three weeks longer, should you leave the Spa. For the 
 gouty, for the high liver, for the gourmand, this is a rational 
 treatment once in a year surely, and doubtless prolongs life 
 and the comfort of living. For six weeks they do penance 
 and eat only to live; for the remainder of the year they enjoy 
 themselves, more rationally, at least, by this abstinence, in 
 the blissful occupation of living to eat. 
 
 DIABETES MELLITUS. 
 
 Diabetes mellitus is a condition where there is an excessive 
 secretion and discharge of urine, where there must be at least 
 three parts, and maybe as high as ten parts, in a thousand 
 of saccharine matter in the blood, and secondarily in all the 
 organs, secretions, and excretions of the body, and is due to 
 some derangement of the glycogenic function of the liver; 
 or defect in the assimilative processes may overload the blood 
 with sugar and cause it to appear in the urine. Over-stimu- 
 lation of the system by eating and drinking and other ex- 
 cesses may cause it temporarily; irritation of the floor of 
 the fourth ventricle and some other parts of the brain and 
 nervous system may cause it, coming probably through a dis- 
 turbed vasomotor action. Defective assimilation may cause 
 it by failing to properly use the sugar of the system as pro- 
 duced, and thus send it off by the urine. Remember that 
 cane-sugar, called sometimes saccharose, or sucrose, must be 
 converted into glucose, or grape-sugar, before it can be ab- 
 sorbed or assimilated, and hence glucose is a predigested 
 sugar, a predigested carbohydrate. 
 
 446 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Sugars are crystalHzablc carlxjhydrates, in which oxyj^en 
 and hych^ogen are present in the proper proportions to ff^rm 
 water. As food they have the same use as starches, and 
 starches to be assimilated are first converted into dextrin, 
 which is a gummy mass obtained by heating starch to about 
 400° F., or into glucose and some alcohol. Glycogenic mat- 
 ter, called so by its discoverer, the great French physiologist, 
 Claude Bernard, is that substance in the system which is con- 
 sumed in muscular contraction, and this is its use, or one of 
 its chief uses. The carbohydrates furnish this chiefly, al- 
 though some may come from the nitrogenous foods. The 
 more the muscles are used the larger they become, a familiar 
 illustration of which are the muscles of the trained athlete, 
 and there must be plenty of nitrogen in the system to feed 
 them, and plenty of glycogen to furnish the fuel, the residue 
 going off as urea. Now, observing diabetics, we see them 
 sometimes going rapidly to a decline, because in such cases 
 the glycogenic matter runs out, runs away by the urine, and 
 they are compelled to get too much of their fuel from their 
 nitrogenous tissues, and are burned up to furnish the fuel 
 to the muscles the glycogen should have furnished. The 
 sorry victim of this condition must soon succumb. He is 
 starving to death. It is in these cases we are accustomed 
 to find in the urine acetone, diacetic acid, beta-oxybutyric 
 acid, and such substances, being formed from the decompo- 
 sition of the albumin of the body, and not from the albumin 
 taken as food. The invalid is existing by consuming his 
 owai nitrogenous tissues, supplying force to his muscles by 
 burning them for fuel. 
 
 The lamented and genial W^illiam R. Travers was in the 
 last years of his life a diabetic. Near the end he rapidly failed 
 from this consuming of the nitrogenous tissues, and. as he 
 expressed it, he was " burning the candle at both ends, and 
 was devilish near the middle." 
 
 The pathogenic germ of tuberculosis is particularly prone 
 to attack diabetics under thirty years of age, and my experi- 
 ence leads me to believe they rapidly consume their nitroge- 
 
 447 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 nous tissues from a lack of gl3'X0genic matter so necessary to 
 robust health. An interesting point here is, do the tubercle 
 bacilli have any effect, direct or indirect, on the formation 
 or improvident destruction of the glycogenic matter? An- 
 other point : the treatment of such cases, whether tubercu- 
 lous or not, demands the strongest nitrogenous and fatty 
 diet, carefully watching the effect, and the question comes in 
 to vex us, whether or not we must give a liberal amount 
 of carbohydrates too, as they furnish most of the glycogen 
 to the system. We must surely at least test their tolerance 
 of the carbohydrates and alcohol. I have here given the 
 modus operandi of the devastation even unto death produced 
 by this loss of glycogen, which at the temperature of the body 
 is converted into glucose and passes off by the urine, pro- 
 ducing nothing more nor less than the disease we call diabetes 
 mellitus. There is probably in the system a glycogenic fer- 
 ment which causes this change of the glycogen into glucose. 
 What it is we do not know. Pancreatic lesions are found in 
 many cases of diabetes mellitus, but no conclusions have yet 
 been drawn from such lesions. In some cases the nervous 
 element may predominate; in others there are disarrange- 
 ments of the digestive organs, caused possibly by hepatic or 
 pancreatic lesions ; and again, we see cases where we can set 
 our seal on no lesion or important function of any organ. 
 
 We have shown the uses of glycogen in the system ; it may 
 be well to see how it gets into the system, in order to under- 
 stand at least something about the disease we are consider- 
 ing. Carl von Noorden has probably given us the best article 
 on Diabetes Mellitus up to this present time, and what I am 
 about to say concerning the causes, physiology, etc., is largely 
 taken from his article, the use of which I beg leave to ac- 
 knowledge. After all, much of it is mere conjecture, but it 
 looks to me as though in many particulars he was getting 
 near the truth. Glycogen is a polysaccharid, and must be 
 converted into a soluble carbohydrate before it can be ab- 
 sorbed. Diastase is the ferment to cause this conversion, 
 and gives us from starch, amidulin, erythrodextrin, achro- 
 
 448 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 odextrin, isomaltose, and maltose. Now, as these pass into 
 the intestinal wall and portal vein, they are almost entirely 
 converted into grape-sugar. Dextrin and maltose are also 
 converted into glucose when taken in food or drink. Cane- 
 sugar is a disaccharid. In the alimentary canal it is split up 
 by the action of acids, ferments, and bacteria (see the impor- 
 tant action of germs here) into grape-sugar and fruit-sugar. 
 If eaten in large quantities, some of it must pass into the blood 
 unconverted into glucose or fruit-sugar (levulose). Fruit- 
 sugar and milk-sugar enter the blood unchanged. Here is a 
 practical point : diabetics may eat them sparingly, and the 
 same applies to saccharin. Cellulose from wood-pulp, of 
 which cotton is a typical example, is isomeric with starch. 
 If eaten it is never absorbed. In the intestinal canal it is 
 fermented and changed by bacteria into methane, carbonic 
 acid, acetic acid, and butyric acid. From the intestinal wall 
 the carbohydrate stream flows through the portal vein to the 
 liver. Various forms of carbohydrates are in this stream, 
 according to the food taken. There may be glucose, levulose, 
 lactose, saccharose, milk-sugar, with some dextrin and mal- 
 tose. Whatever the form of the carbohydrate, the liver at 
 once takes hold of it and converts it into glycogen, which is 
 deposited in flakes in the hepatic cells, and probably in loose 
 combination with albumin. The liver closely guards the 
 amount of the sugar in its blood leaving it. The sugar in 
 the blood is grape-sugar. There may be a very little glyco- 
 gen. The liver always keeps a certain percentage of grape- 
 sugar in the blood. It excretes a little glycogen, but first 
 converts it into grape-sugar, and in health the percentage is 
 always about the same. There is some glycogen in the 
 muscles. The muscles get their glycogen from their own 
 store of grape-sugar. The liver collects the carbohydrates 
 from the blood of the portal vein, fixes them as grape-sugar, 
 and gives them up to the general blood when needed. Gly- 
 cosren is formed from albumin as well as from carbohydrates. 
 This is of practical importance, and tells us why diabetics 
 sometimes consume their own tissues to support life. 
 
 29 449 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 The carbohydrates are always present, coming from the 
 carbohydrates and proteids of the food. The muscle-cells are 
 always consuming them, and furnish force and heat from 
 their combustion. So long as grape-sugar is in the blood in 
 physiological quantity, none goes out with the urine. When 
 a muscle is worked, it consumes sugar by oxidation. A 
 muscle can work by consuming albumin, but not long. It 
 will then seize fat as most available. For the muscle to use 
 it, the liver converts it into sugar. The liver only does this 
 when there are no carbohydrates or albumin for it to use for 
 the purpose. Now we see why the diabetic so often loses his 
 fat rapidly: the liver takes it to make sugar for fuel when 
 the normal formation of fuel sugar is running off by the kid- 
 neys, possibly. 
 
 What happens if the carbohydrates are in excessive supply 
 in the system? Three hundred grammes of glycogen is the 
 normal amount in the system. When this has been made by 
 the carbohydrates, any excess of carbohydrates is deposited 
 as fat. If there be still too much carbohydrates, the indi- 
 vidual gets hyperglycsemia, — too much sugar in the blood. 
 If the percentage of sugar in the red blood exceeds 0.2, ali- 
 mentary glycosuria results, which is not diabetes mellitus. 
 If a man eat 1 50 to 200 grammes of cane-sugar, he will prob- 
 ably, in an hour, have alimentary glycosuria, which will last 
 for three hours. The same thing will happen if he eat 120 
 grammes of milk-sugar, 250 grammes of glucose, or 200 
 grammes of levulose, or fruit-sugar. 
 
 A healthy man does not have diabetes, because his glyco- 
 gen reservoirs can hold all of his sugar. In the diabetic prob- 
 ably these reservoirs overflow and flood the blood with sugar. 
 A temporary glycosuria may be caused by hepatic disturb- 
 ances, muscular disturbances, nerve disturbances, apoplexy, 
 poisonings, passage of gall-stones, exophthalmic goitre, and 
 some other conditions. The liver, the muscles, and the glands 
 all store up glycogen. We may eat an excess of carbohy- 
 ■drates, and at the same time be suffering from a diseased 
 liver of the most consuming nature, yet not have even a tem- 
 
 450 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 porary glycosuria. Therefore, we may reason, the cause of 
 diabetes melHtus does not reside in the liver. 
 
 There is a temporary diabetes caused by ];hloridzin poison- 
 ing. Phloridzin is a glucoside from the roots of the apple 
 and cherry. It acts on the renal epithelium to cause it to lose 
 its power of holding back the sugar when filtering out the 
 urine. It is a toxic glycosuria, in which unfler-consumption 
 is joined to over-production. This fact seems to impress von 
 Noorden with the fact that possibly, after all, the kidneys 
 themselves may be a pathological factor in diabetes mellitus. 
 Extirpate the pancreas of a dog, and so long as he lives he is a 
 diabetic. Lepine says the pancreas produces a ferment which 
 enters the circulation and causes a breaking up of the grape- 
 sugar molecules within the blood. This is a pretty theory, 
 and may be a true one to explain cases of pancreatic diabetes. 
 
 Does the over-production of glucose in the system cause 
 diabetes? Von Noorden does not think so. He does not 
 think there is an incapacity of storage for the glycogen, thus 
 letting out the sugar into the blood. Glycogen is really ani- 
 mal starch, and resembles inulin. Is insufficient consumption 
 of the sugar in the tissues a cause? If the insufficient con- 
 sumption of the sugar in the cells were a factor, this sugar 
 could still be converted into fat and stop the diabetes, but it 
 is not, for, as a rule, diabetics lose their fat. Von Noorden 
 rather assumes as factors parts of several theories, chiefly 
 insufficiency of glycogen reservoirs and insufficient sugar con- 
 sumption. The latter may include inadequate distribution 
 of carbohydrates, diminution of the property residing in the 
 tissues of seizing and breaking up the sugar molecule, diminu- 
 tion of the property residing in the tissues of compressing 
 the sugar molecule into a fat molecule. Glycosuria resulting 
 from an over-production of sugar from albumin and fat is 
 not known to occur, he says. Over-production plays no part 
 in diabetes mellitus in man, says von Noorden, but diabetes 
 due to diminished consumption of carbohydrates is an estab- 
 lished fact. It is immaterial what may be regarded as the 
 causative factor of this diminished consumption, it stands 
 
 451 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 in the foreground in experimental pancreatic diabetes, and 
 probably also in the great majority of cases of diabetes mel- 
 litus in man. 
 
 These are the views of probably our foremost thinker on 
 the subject, and, although an improvement on those of men 
 before him, still lack the precision and requirements of abso- 
 lute scientific truth founded on absolute scientific fact. All 
 we can do at present is to adhere to the theories advanced, 
 and undoubtedly most cases of diabetes mellitus can be ex- 
 plained quite satisfactorily in one of these ways. In the 
 dietetic form more sugar is taken into the economy than the 
 liver can work up. In the nervous forms there is a vasomotor 
 disturbance which interferes with the blood-supply of the 
 liver, and also with its glycogenic functions. In the pan- 
 creatic forms the pancreas may fail to secrete its sugar-de- 
 stroying ferment, and thus the blood may become surcharged 
 with glucose. The fluid of the pancreas contains at least 
 three enzymic bodies which play important parts in diges- 
 tion. One of these is diastatic, is capable of converting starch 
 into sugar, and is supposed to be identical with the ptyalin of 
 the saliva. One gramme of the pancreatic juice of a dog 
 containing only .014 gramme of organic solids will convert 
 4.672 grammes of starch into sugar in a half-hour. Impair- 
 ment of this function surely must have a great effect on the 
 sugar of the economy. 
 
 Now we come to another theory as to the origin of dia- 
 betes mellitus in man, and although it is a startling one, it 
 is by no means an erratic one. Dr. Abraham Mayer, of New 
 York, advances the theory that it is the result of the perni- 
 cious influence of a specific bacterium or its ptomaine in the 
 organism, acting centrally on certain brain-centres, or periph- 
 erally on the glycogenic reservoirs. The nervous system con- 
 trols the normal production of sugar in the body. If from 
 accident, neoplasm, worry or mental strain, poisons, etc., this 
 influence is impaired or abolished, the bacteria and their pto- 
 maines exert their influence for harm. The bacteria invade 
 
 452 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 the organism ; in health the normal resistance of the economy 
 hokis them in check, or perhaps some ferment physiokjgically 
 produced by metaboHc changes in certain organs acts as an 
 antitoxin to them. Granting this, we will cure the diabetes 
 produced by the bacteria by exhibiting a bactericide. Dr. 
 Mayer reports bichloride of mercury as the remedy to do 
 this. His treatment is as follows : A history of the case is 
 obtained, and the patient is weighed. The quantity of urine 
 passed in twenty-four hours is noted, the specific gravity is 
 taken, the quantity of sugar is estimated, and other abnormal 
 characteristics are noted. If the urine fails to react to Ger- 
 hardt's test, the patient is put on an antidiabetic diet for 
 two weeks, during which time bichloride is taken, beginning 
 with one-twelfth of a grain three times a day, and in three 
 days increase to one-tenth of a grain. In a w'eek's time one- 
 sixth of a grain is given after each meal, well diluted with 
 water. It acts at first on the bowels and does not salivate. 
 In three weeks the sugar has been greatly reduced, and the 
 patient has improved in every way. Now the dose of bichlo- 
 ride is reduced to one-sixteenth of a grain three times a day. 
 The diet is now^ increased a little, or rather is not so severely 
 restricted. The urine is examined every day, and the even- 
 ing urine tested. From time to time the drug is suspended, 
 but, even if the sugar entirely disappears, the bichloride is 
 given in small doses. 
 
 These cases he treated were not syphilitic cases. Cases 
 with a history of lues (congenital syphilis, probably meant) 
 showed marked improvement. Dr. ]\Iayer claims the drug 
 as a specific in diabetes, and recommends its general trial by 
 the profession. Dr. G. W. McCaskey also says it will be well 
 to investigate closely the bacteria of the stomach and intes- 
 tines in cases of diabetes mellitus, not wath the expectation 
 of supplanting dietetic treatment, but with the view of aiding 
 with suitable treatment for possibly existing virulent bacte- 
 rial protozoa or parasitic growths. These in some way may 
 afifect the ferments, checking or increasing the normal sugar 
 
 453 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 supply of the system, thus acting, whether it be in over-supply 
 or under-supply. 
 
 Von Noorden gives some interesting points in regard to 
 obesity and diabetes and the form called by some lipogenous 
 diabetes. In all cases of diabetes the oxidation of carbohy- 
 drates is restricted. Glycosuria and hyperglycccmia can only 
 follow when the fat-forming as well as the oxidizing cells 
 have lost their power of arresting the sugar molecule. He 
 thinks it is possible that both consumption (oxidation) and 
 storage (fat conversion) of the materials are interfered with 
 by a common cause, as, for example, the resistance of the 
 diabetic tissue to glycogen formation. You may conceive a 
 case in which the ability to burn up sugar in the organism is 
 alone interfered with, whilst the carbohydrate conversion to 
 fat continues. Here the cells are bathed in a rich sugar so- 
 lution, yet they starve, because they cannot seize the sugar 
 molecule. Hence follows a tissue hunger, which by reflex 
 action starts a sharper appetite, and hence more food is taken, 
 and from this more fat is deposited. This person is really 
 diabetic, yet he does not excrete sugar externally, but in the 
 fatty tissues, and in the end almost always becomes a true 
 diabetic. Here is a relationship between obesity and diabetes, 
 and there may be some such relationship between gout and 
 diabetes. Some cases are at first gouty and then become 
 diabetic, and there are cases the reverse. Then there are cases 
 in which the two diseases coexist. The diabetes coming first 
 gives the worst prognosis. The cases in which there is coex- 
 istence are usually not severe cases. I have seen such cases 
 in men of middle age who violated every hygienic law appli- 
 cable to their condition, and yet they did well and appeared 
 to prosper, until suddenly they yielded to some intercurrent 
 attack, like apoplexy or diabetic coma, to which their condi- 
 tion rendered them continually liable. 
 
 Von Noorden appears to think diabetes mellitus is not com- 
 mon among the insane. My own experience leads me to be- 
 lieve there is quite a percentage of the insane diabetic, and 
 alimentary diabetes is quite common if they are not well regu- 
 
 454 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 lated as to their diet, but allowed to give way to their animal 
 instincts. There are no chronic medical cases which 1 ap- 
 proach with more sense of responsibility than T do those of 
 diabetes mcllitiis. No man has any right to take them unless 
 he has made himself familiar with the subject, and it is not 
 right to dismiss them with a placebo and tell them to live on 
 nitrogenous diet. Every case requires profound and deep 
 study, and demands ever-watchful and anxious care. In very 
 many cases life may be prolonged indefinitely under proper 
 surveillance, without which the end may come, and in many 
 cases does come, prematurely. Remember, one cannot live on 
 nitrogenous foods indefinitely. Such foods are of easy diges- 
 tion, and are not prone to putrefaction, but they are deficient 
 in nucleo-albumin, which is essential to the building up of the 
 red blood-corpuscles and for supplying energy to the nervous 
 system. Living a long time on such diet produces anaemia 
 and debility, whether the person be healthy or diabetic. 
 
 Let us look at gluten, so much spoken of as diet for the 
 diabetic. It is the nitrogenous element of the food cereals. 
 It has been said that gluten and water constitute all that is 
 necessary for food and drink. Gluten really is not a single 
 food element. There are four substances in it, — vegetable 
 albumin, vegetable casein, vegetable fibrin, and vegetable gel- 
 atin, the latter being considered an albumin-saving food, and 
 there is a possibility of forming fat from the albuminates. 
 If we could get a pure gluten food, and add fat to it by butter 
 and milk and such methods, we could get a more desirable 
 food for those unable to use the carbohydrates. Diabetic pa- 
 tients are often difficult to manage. Early in the case get 
 yourself en rapport with him, get his confidence, and have 
 him consult you as frequently as possible. 
 
 Diabetes is doubtless increasing in frequency in this coun- 
 try. Wear and tear is greater every day, over-consumption 
 of the carbohydrates is increasing, and the nature of our foods 
 is causing us to be more and more the subjects of unfavorable 
 bacterial action. Americans are among the great carbohy- 
 drate consumers of the world. It is not necessary to say 
 
 455 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 much of the diagnosis, which is not difficuh usuah}'. Keep 
 your eyes open, for there are doubtless intermittent forms. 
 Tuberculosis of some form may mask it, and a word or an 
 action may give us a hint. The first hint may come from 
 the eye, from a tendency to stupor or coma, from a sexual 
 neurosis, from a vaginal pruritis in the female, from a neu- 
 ritis of the arrn or lower extremity, especially a sciatica, 
 the diminution of the tendon reflexes, a loss of flesh, ex- 
 haustion, spongy gums, dry skin, great thirst or strong 
 appetite, constipation of the bowels, polyuria, a sticky drop 
 of urine, possibly on the shoe, whitish in color after evapo- 
 ration, glucose in the urine by test. As to the tests for 
 sugar, the fermentation test with yeast is a sure one, and 
 one b}'- which we can tell the comparative amount of sugar 
 in the urine. I like Moore's test as an easy one. There must 
 be five per cent, of sugar present to make it available. If you 
 see the specific gravity over 1025, look out for sugar. Tyson 
 has seen sugar as low as loio. The low proportion of other 
 ingredients caused this, perhaps, or fermentation. Do not 
 examine your specimens after fermentation and the sugar has 
 gone off. Fehling's solution affords a good test, and by it 
 you can calculate the quantity of sugar present. It may be 
 purchased in tablet form, and is handy. It does not keep long 
 made up, nor does Pavy's. Trommer's test is a fair test, and 
 will show under favorable conditions as low as one per cent, 
 of sugar. You must get an orange-red. After it cools, and 
 the precipitate is only light yellow, you may only have re- 
 duced uric acid, creatinin, etc., and thus make a grave mis- 
 take. Nylander's test is von Noorden's favorite : Take four 
 grammes of sodium tartrate and dissolve it in one hundred 
 cubic centimetres of a ten per cent, solution of caustic soda, 
 to which two grammes of bismuth subnitrate have been added. 
 Heat this to 122° F. Cool and filter. Boil ten cubic centi- 
 metres of urine in one cubic centimetre of the solution two 
 minutes. If sugar is present, metallic bismuth is thrown 
 down. This is black, and the fluid is dark or even black. If 
 there is no black, there is no sugar. This test will show sugar 
 
 456 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 if it exists only to tlic amount f)f one per cent. It is neces- 
 sary often to test for acetone, aceto-acetic acifl, beta-oxybu- 
 tyric acid, or oxyl)Utyric acid. The latter is important, for 
 when present, diabetic coma ]irobal)ly soon will follow. For 
 tests for these the reader is referred to text-books. 
 
 The pathological and bacteriological laboratories which 
 are, or should be, established in every community, in which 
 such investigation can be made, are a great advantage and 
 help to practitioners of medicine, and of untold benefit to 
 sufferers from disease. If your patient be pregnant, there 
 may be more thorough investigation needed. Before preg- 
 nancy, menstruation is usually very much diminished. In 
 about two-thirds of the cases pregnancy goes on to the end. 
 In about one-third of the cases miscarriage takes place late 
 in the pregnancy. For her ov^ai sake and the baby's sake 
 the diabetic mother should not nurse her child. 
 
 Pruritus vulvae is very common in the pregnant woman, 
 and so are boils and carbuncles, and much sugar goes off by 
 the urine. Some one has said diabetic women are more apt 
 to produce female children, because for the perfect ripening 
 of the ovum oxidation must be perfect; that is to say, no 
 sugar must be left unburnt. When any is left, the ovum be- 
 comes less ripe and less well nourished ; hence the properties 
 of its protoplasm are less well developed, and by the theory of 
 crossed inheritance it is more than likely to produce a female 
 child. When you commence with your patient you want his 
 family history and his own history from the time he noticed 
 illness. Record his weight and note it from time to time. 
 This is of great importance, as may be well seen. Now you 
 want to find out his condition as to sugar. Put him on his 
 usual diet for several days, and measure and take account of 
 the glucose in the urine. For the same length of time let the 
 patient take an absolute diet, say of rare beef and tea with- 
 out cream or sugar, and then take an account of the 
 sugar, and you will see where you are. From this you 
 will learn much. vSome people bear carbohydrates well, and 
 some do not; so take this into account with a new patient, 
 
 457 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 and go on and study his tolerance for carbohydrates. You 
 can soon fix his hmit with careful watching. Remember, the 
 diabetic probably does not burn sufficient of his carbohydrates 
 for fuel and strength, he may not store sufficient as glycogen, 
 and he may not convert sufficient into fat. One day he may 
 do worse in these physiological duties than he may the next 
 day. Now, suppose he only eats the rare beef and drinks the 
 tea, and you find considerable sugar, what then? It argues 
 badly. He must be making the sugar from his albumin and 
 letting it gradually into the circulation, and not even con- 
 •suming this. His glycogen storage must be seriously dis- 
 abled. The splitting up of the sugar molecule in the tissues 
 and its compression into fat must be seriously disturbed. 
 Here the beef is possibly a dangerous diet, for the patient 
 will get too much sugar even from it. Yet if we do not give 
 it, will he not use too much of his own albuminous tissues to 
 produce it ? Your patient is in great danger here. It is your 
 duty to watch him and test him on different diets until you 
 get what suits him best. 
 
 In testing the urine in these cases, indeed in all cases, it 
 is best to take specimens from both the morning and evening 
 voidings. If we can get a carbohydrate to go through the 
 kidneys unchanged and yet give heat and force for the system, 
 we will secure a great gain. Alcohol within bounds is a great 
 help in treatment. Spirit is its best form, and California un- 
 colored pure brandy is the best spirit. Next to this comes 
 Scotch whiskey. American whiskeys and French brandies 
 have more sugar from their caramel coloring. Claret is the 
 best wine, and the Rhine wines come next. Champagne, 
 unless absolutely dry, is a poison, and so are the sparkling 
 Moselles. The European physicians allow now and then a 
 glass of dry sherry. To my mind sherry, Madeira, and port 
 should never be offered a diabetic. Gin is too stimulating 
 to the kidneys. Malt liquors of all kinds must be absolutely 
 shunned. Much comfort can be gotten from the effervescing 
 waters. A glass of carbonic acid water with a thimbleful 
 of brandy is as palatable as champagne. 
 
 458 
 
FORTY YEARS IN THE MEI^ICAL PROFESSION 
 
 If your patient has a voracious appetite, take this into con- 
 sideration when testing for sugar. If the stools are large, 
 you may expect tlic pancreas to be involved. If your patient 
 becomes ill from other causes, of course the sugar is flimin- 
 ished, because there is less formed. This may even happen 
 in advanced cases when tuberculosis coexists. Von Noorden 
 suggests that in bacterial diseases they may give a ferment, 
 and cause the cells then to dispose of more sugar, and thus 
 get rid of it in that way. A friend at my elbow suggests, if 
 they can dispose of it thus easily, why cannot they play some 
 important part in its formation ? 
 
 I have seen two cases of diabetes mellitus in persons above 
 middle age get well. One was a colored preacher, of good 
 character and habits, and the other was a married white 
 woman. The man was of large frame and muscular, and 
 not inclined to obesity. The woman was short and stout and 
 quite fat, the mother of a large family, and in good circum- 
 stances. I have seen both cases recently, and neither shows 
 sugar in the urine, and both are fairly well, except the in- 
 firmities of age, both being nearly eighty years old. Some 
 years ago I saw the man a few times, and gave him what I 
 considered good advice. He then disappeared. In a year I 
 saw him again, and he still had a large amount of sugar in 
 his urine. I asked him what he had been doing for himself. 
 He said he had taken some of the medicine (ten drops of the 
 fluid extract of jambul seeds) for a time, and then stopped 
 and lived on the best diet he could get. Two or three years 
 after this my attention was again called to this man. He 
 looked very well, and like anything but a diabetic. I procured 
 a specimen of his urine, and found it normal in every way. 
 He said he felt well, had been pursuing his calling and work- 
 ing at odd jobs, and had eaten everything that came to hand. 
 The woman I kept under constant surveillance. In about 
 two years, under the usual treatment applicable to such a 
 case and the exhibition of jambul, I found the sugar to dis- 
 appear. For several years she has had no sugar, but has now 
 and again attacks of eczema or pruritus. 
 
 459 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 I am well aware that some cases of diabetes stop when the 
 patient becomes gouty and granular atrophy of the kidneys 
 supervenes, and this is a most interesting condition and one 
 causing us to think of many possibilities as to its pathological 
 factors. The cases I have quoted were not such cases : neither 
 had had gout in the form of arthritis, and neither had inter- 
 stitial nephritis. 
 
 Dr. H. D. Beyea has reported an interesting case, where 
 he removed an ovarian cyst from a diabetic, followed by re- 
 covery, wonderful to relate, and, more wonderful still, the 
 diabetic symptoms all disappeared. This case is one worthy 
 of close watching and close study in all of its phases. 
 
 A healthy person, for each two and one-fifth pounds of 
 weight, consumes at rest 30 to 35 calories; in motion, 30 to 
 40 calories ; at moderate work, 40 to 50 calories. A calorie, 
 remember, is the amount of heat required to raise one kilo- 
 gram of water i ° C. 
 
 Von Noorden takes a diabetic woman doing light work. 
 When well, she needed 1925 calories per day; diabetic, she 
 lost 210 calories; therefore she consumed 210 calories of her 
 own tissue. By calculation she lost 38.9 calories through 
 albumin, and therefore, by the consumption of some of her 
 nitrogenous substance, she lost 171. i calories. Fat was the 
 only substance available, and this took 18.4 grammes of fat, 
 each gramme yielding 9.3 calories, making 18.4 X 9-3 = 
 1 7 1. 1 2 calories lost by fat; therefore she must eat albu- 
 minates and fats in excess to keep up with a person in good 
 health. If she eats carbohydrates, they run ofif as sugar by 
 the urine, and furnish no fuel for steam or power. They 
 only check hunger for a little while, and tissue hunger 
 scarcely at all. The point to watch is when she can begin 
 to tolerate some carbohydrates, for albuminates and fats will 
 not do all the time ; she will either become weak and anaemic 
 on them or nervous from loss of nerve-power, or will consume 
 her own tissues to get some, at least, from them. Here is a 
 perfect illustration of how to watch a diabetic and what we 
 are to watch for, and what we may expect under certain con- 
 
 460 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 ditions, even up to diabetic coma. Diabetics excrete much 
 nitrogen because they eat much. If there is more in the 
 urine than goes in by the food, lliere is a consumption of the 
 nitrogenous tissues going on, and we must seek to check it. 
 The more nitrogen wasted in this way, the worse the glyco- 
 suria, and we must check the exhibition of carbohydrates. 
 A toxaemia may arise to affect the protoplasm, and coma may 
 come. Von Noorden gives the nitrogenous substances in 
 diabetic urine as urea, ammonia, creatinin, uric acid, and 
 albumin. The non-nitrogenous substances as acetone, aceto- 
 acetic acid, and beta-oxybutyric acid. Their common source 
 is albumin, body albumin, not albumin of the food. 
 
 Diabetic coma is an acid intoxication of some kind. Some 
 think it due to oxybutyric acid, and some to acetone and 
 aceto-acetic acid. Von Noorden does not think the latter the 
 cause. He thinks diabetic coma comes from a paralyzing of 
 the brain and a destruction of protoplasm by a toxaemia. 
 To me it appears the great loss of the salts of potash, soda, 
 etc., by the urine may be a cause, the absence of these ren- 
 dering more or less inert the protoplasm of the organic cell. 
 Oxybutyric acid in the blood is a sign of its coming. I have 
 never seen pneumaturia or gas in the bladder in diabetes, yet 
 such cases are reported. Germs are probably introduced from 
 without, as by catheterization, and cause it. The skin is 
 usually very dry and harsh, and germs are very active in 
 the diabetic; hence the slightest surgical operation is at- 
 tended with danger. The books give the operation for phy- 
 mosis as a very dangerous one, probably from some local in- 
 fection through the urine. Granulations of wounds are apt 
 to slough, and fractures may be attended by extreme debility 
 and danger, if of the larger bones, bed-sores being a very 
 serious feature if the patient is compelled to rest in bed. In- 
 deed, any accident or intercurrent illness is a cause of the 
 most serious anxiety in diabetics, and sometimes unlooked-for 
 deaths are to be solved by looking for the evidences of sugar 
 in the economy, which had not been suspected by the indi- 
 vidual or possibly by his doctor. 
 
 461 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 . Under thirty years of age most diabetics die of tubercu- 
 losis within a reasonably short time, and the younger the 
 patient the more rapid the disease, as a rule. I have never 
 recognized it under twelve years of age. The better the cir- 
 cumstances of the patient, the better are his chances. This 
 holds good for two reasons. Every advantage that wealth 
 can give is a help, and these people, as a rule, have the ad- 
 vantages of education, and can conduct their case on their 
 own part more intelligently. It is difficult to restrain in diet 
 or otherwise a rough, ignorant, uncouth man, a silly woman, 
 or an irresponsible child. 
 
 Von Noorden says tubercle bacilli are difficult to find at 
 times in the sputa of diabetics with consumption, and that 
 arteriosclerosis is common in some degree or another. Some 
 hypertrophy of the heart is often a help, and a weak heart is 
 serious. Always look to the heart of your patient, and 
 measure his strength by that and other ways, and look to 
 the condition of the arteries, etc. Albuminuria is not a very 
 serious sign, as a rule. If caused by gouty kidney, the sugar 
 may check or disappear. A graver cause may be arteritis. 
 Differentiate by the microscope, observing tube casts, etc. 
 Von Noorden says glycogen clods are found in the kidneys 
 after death. Remember, the lymphatic glands often swell in 
 diabetics; the cause is possibly often tuberculosis. Death 
 from uraemia may come in the kidney cases, so be careful to 
 differentiate such from coma cases. Coma may come sud- 
 denly or be preceded for a longer or shorter time by severe 
 headache, and the symptoms may even simulate intoxication 
 from alcohol or opium, or any other intoxicant. After some 
 hours coma comes on. The pupils are dilated, the breath is 
 one long and one short, cyanosis increases, the odor of acetone 
 is on the breath, an apple or hay odor probably (convulsions 
 are rare). The urine reacts with chloride of iron, and sugar 
 may be present or absent. Recovery is seldom, and in two or 
 three days the patient sleeps away. 
 
 Remedies are of little avail. Alkalies are recommended 
 on general principles. The best reason for giving alkalies 
 
 462 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 is the fcivoral)le action they have on tiic protoi>lasm oi the 
 organic cells. A man cannot live on distilled water as a 
 constant drink. Intravenous injection of the normal salt 
 solution is recommended. Tyson has seen good results from 
 injecting it into the tissues. I should use it very freely 
 by the rectum. Diabetics bear the slightest operations so 
 badly, I w^ould even be afraid of intravenous or tissue injec- 
 tions. If the patient should get well, sloughing would almost 
 surely follow the latter, and sudden death might come with 
 the former. As a rule, you will not find coma coming on 
 whilst the patient holds his fat. If there are any symptoms 
 of coma, a safe rule is to change the diet, whatever it may be. 
 The cause of diabetes, whatever it is, causes rapid oxidation 
 of the tissues, and whilst the fat remains it probably exhausts 
 its force in oxidizing it. 
 
 As I have no prearranged plan in waiting this article, but 
 take matter just as it comes, let us take up thyroid treatment 
 in diabetes mellitus, as we have spoken of fat. The office of 
 the thyroid in the system is probably a secretory one. It fur- 
 nishes probably some material which enters the blood through 
 the lymphatic system, which is essential to the chemical meta- 
 bolism and nutrition of the tissues. This material probably 
 checks a tendency to auto-intoxication by destroying poisons 
 resulting from tissue metabolism. Giving of thyroid affects 
 the nervous system, increasing the heart beat, yet lowering 
 arterial tension. The respirations are increased and the tem- 
 perature is not constant. Headaches and flushings may fol- 
 low. The intellect usually brightens, the appetite increases, 
 tissue waste increases, showing that the remedy increases 
 nitrogenous waste and the oxidation of the fats. The urine 
 show^s no decided changes, as a rule. The secretion of the 
 thyroid is a colloid. Iodine exists in the thyroid at birth, and 
 increases with age. Now. on general principles, thyroid, act- 
 ing as has been described, surely should not be given in dia- 
 betes mellitus, for, among other things, it increases the com- 
 bustion of fats and causes a loss of both these and muscle 
 tissue, just as diabetes does. 
 
 463 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Hear what Dr. William Murrell says. His patient was a 
 woman, with diabetes of probably neurotic origin, arising 
 from vasomotor paralysis, increasing the blood-supply to the 
 liver, kidneys, etc. In twenty-four hours she passed one hun- 
 dred and twelve ounces of urine, containing over twelve 
 ounces of sugar, being over fifty-two grains to the ounce, a 
 very large amount. This was the average for fourteen days. 
 Murrell rightly says that what we want is a drug that will 
 get rid of the sugar from the urine, and yet not restrict the 
 supply of carbohydrates to the patient. The pancreas could 
 only be useful in cases of pancreatic diabetes. He gave in- 
 creasing doses, up to twelve grains, of fresh thyroid every 
 three hours, some inconvenience being noted, until tolerance 
 was established. The appetite was good, and she ate ordi- 
 nary diet, — bread and butter, meat, milk, potatoes, tea, gruel, 
 etc. She practically ate what she craved. Under this treat- 
 ment, from over twelve ounces of sugar daily she came down 
 to a little over six ounces, and in eleven days more to less 
 than three ounces. Now thyroid treatment was stopped and 
 the patient dieted, and she got only fish, beef, tea, milk, and 
 a little toast. The result was, she passed two thousand two 
 hundred and sixty grains more sugar daily on a restricted 
 diet than she did on a full diet plus thyroid treatment. 
 
 How did the thyroid act ? Thyroid contains colloid matter 
 and a small quantity of nucleo-albumin and extractives. It 
 hastens cell action, it increases oxidation of the tissues, it 
 destroys the circulating proteid, and increases nitrogenous 
 waste ; so, in treating obesity with it, the diet should not be 
 restricted. Plenty of nitrogen especially should be taken. If 
 we accept Pavy's theory, that glycogen is converted into fat, 
 we get a clue to the action of thyroid in helping diabetes mel- 
 litus. We only know, says Murrell, that in some cases thy- 
 roid lessens the amount of urine and the sugar excreted with 
 it, and at the same time reduces the body weight. It will es- 
 pecially suit cases in elderly people in which obesity is a 
 prominent feature. This is encouraging, contradictory as it 
 appears, and will teach us to watch for such cases, and will 
 
 464 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 further teach us that there is no empirical way to treat dia- 
 betes, nor, in fact, other diseases, but that every case must be 
 a study, not more as to its idiosyncrasies than as to its physio- 
 logical and pathological peculiarities. Remember that in dia- 
 betes, probably not only is the oxidation of carljohydrates 
 restricted, but their conversion into fats is equally restricted, 
 and glycosuria can only folhnv possibly when the fat-forming 
 cells and the oxidizing cells both cease to arrest the sugar 
 molecule. 
 
 I have seen quite a number of cases of diabetes mellitus, 
 and the rapid cases, as a rule, have been under thirty years 
 of age, and tuberculosis has been the ending of mcjst of them. 
 I do not remember a case to have ended by pulmonary tuber- 
 culosis after thirty years of age. The most chronic and man- 
 ageable cases were those in men after middle age, and a 
 coexistence of gout appeared to prolong life, yet the conven- 
 tional diets of gout and diabetes are apparently so opposed. 
 They are not so opposed, for the gouty patient is quite tolerant 
 of carbohydrates. Study his case, and coax him and watch 
 him, and he will usually respond. Serious accidents to dia- 
 betics, and surgical operations and shocks of all kinds, are 
 most unfortunate. I have seen no reason to believe it to be 
 contagious, but many instances have been offered to prove 
 such to be the case. That bacterial influences affect it greatly, 
 if they do not cause it altogether, at least in some forms, im- 
 presses me gravely. As before stated, I have seen it in the 
 negro, Jews are said to suffer from it in a larger percentage 
 than any other race. They lead active lives mentally, slug- 
 gish lives physically, as a rule, and are great eaters of the 
 carbohydrates. My experience leads me to believe diabetes 
 is hereditary in many cases, and members of such families 
 should be warned of the possible bad eft'ects of high living 
 and the excessive use of carbohydrates, and to especially 
 avoid, as far as poor mortals can, over-work and wear and 
 tear, for, remember, it comes in various forms, and the neu- 
 rogenous form is a common form. Syphilis may be a factor, 
 particularly through the brain, the blood-vessels, or the pan- 
 30 465 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 creas. Take it into account in your differentiation. If you 
 can make out a pancreatic case, above all things use pancre- 
 atic preparations, although experience does not yet give you 
 great encouragement in that line. 
 
 Von Noorden's suggestions as to diet and general treat- 
 ment are golden. If your diet is too low, the albumin and 
 the fat both go. The diet of the diabetic man must give him 
 at least thirty-five calories per kilogram of weight per day. 
 The average for a healthy man is two thousand five hundred 
 calories per day. A healthy man takes in his diet forty per 
 cent, of carbohydrates. In a diabetic most of this goes away 
 in the urine, and does him no good. The more carbohydrates 
 he can tolerate, the better for him. Some tolerate more, some 
 less, and the last are the most difficult cases to treat. To find 
 out this tolerance in your patient is one of your first duties. 
 The worse the diabetes, the more proteids, fats, and alcohol 
 we must use. Among the best forms of the carbohydrates 
 are fruit-sugar, milk-sugar, and cane-sugar. Now and again 
 rest the sugar-consuming cells by withholding the carbohy- 
 drates. Get the tolerance of the patient to carbohydrates by 
 the amount of sugar in the urine, always taking into consid- 
 eration the diet being used. Bread and potatoes are more 
 difficult to abstain from than sugar or wines. 
 
 I had once a dear friend who died of diabetes. He was an 
 able man, and had held distinguished positions, but dieting 
 was very difficult with his diabetic appetite. I have seen him 
 eat a dinner, indulging in every compound on general prin- 
 ciples injurious to one in his condition. After dinner he 
 would, with a good deal of grace of manner, decline sugar 
 in his coffee: " Can't take it ; my doctor forbids it." 
 
 So it is with a great many, indeed perhaps with the ma- 
 jority; they knowingly cheat themselves. Study your pa- 
 tient, and calculate the number of calories necessary for his 
 proper existence. He may need two thousand five hundred, 
 and get by his diet and loss through his disease only fifteen 
 liundred. He will get weak and thin, his fat and strength 
 going with his muscles. Now look out for failure at the 
 
 466 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 heart, coma, and such troubles. Give oceans of fat. Fat is 
 a great factor in the average diabetic. Alcohol will help the 
 fat, it gives fuel, but study the quantity each case may need. 
 Too much may poison the protoplasm of the cells, and thus 
 tissue waste and tissue destruction may go on more rapidly 
 to the disadvantage of the patient. 
 
 Remember, though, in serious progressive cases after a 
 while even the fats break up and increase the elimination of 
 sugar. See how complex are these cases, and what tact and 
 watching they require. Exercise short of fatigue consumes 
 sugar, and is therefore to be recommended. Fatigue in any 
 shape or from any cause is bad. Massage is passive exercise, 
 and even approaches active work. Von Noorden's rest plan 
 is the proper plan of treating almost every case of diabetes 
 mellitus. If your case is a moderate one, and you have gotten 
 its carbohydrate tolerance, rest the sugar-consuming cells for 
 three weeks in every three months, at least. If the case is a 
 serious one, rest it absolutely one month in every three months. 
 Every case is a study. Resting these cases makes them much 
 more tolerant of the carbohydrates when they commence them 
 again. A milk diet is near absolute rest. One litre of milk 
 equals fifty grammes of bread. Rest diet must be a diet as 
 free as possible of every form of carbohydrates. Give lots of 
 fat. One hundred grammes of aleuronat bread equal fifty 
 grammes of wheat bread. Ninety grammes of potatoes equal 
 twenty-five grammes of w^heat bread. Beware of intestinal 
 catarrhal troubles. They are dangerous. Let up on the solid 
 foods. Take milk, spirits, etc. The prognosis in all cases of 
 diabetes depends on many factors. The physical peculiarities 
 of the patient count much ; family history counts much : 
 the mental characteristics of the patient count much ; the 
 circumstances of the patient count much, as well as his em- 
 ployment and his environment. The blood-count and color- 
 test of the blood tell much. The age of the patient counts 
 much. Syphilitic cases and obese cases are most amenable 
 to treatment. Tall, spare, weak people are particularly vul- 
 nerable. 
 
 467 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 After all, the waste of the nitrogenous matters, as indi- 
 cated b}^ the amount of urea passing off by the urine, is the 
 factor that counts more than any other, and this is the factor 
 which determines the difference between a true diabetes and 
 a mere glycosuria. The one is usually permanent, the other 
 may be only temporary. The physician in the case counts 
 probably more than any one factor. Without intelligent ad- 
 vice, the diabetic, as a rule, goes rapidly to destruction. 
 
 As said before, we must learn to distinguish between true 
 glycosuria and true diabetes. The true diabetic usually has 
 a voracious appetite, and he invariably, under such conditions, 
 eats too much. So much sugar passes off in his urine that 
 he must have starches as the material from which to replace 
 it, and he thus craves carbohydrates, and the trouble in prac- 
 tice is, few can resist this craving. As a result of this over- 
 indulgence, fermentation of food takes place after it has been 
 eaten. These patients are always in great danger, for most 
 of them will over-indulge, and an excessive meal of carbohy- 
 drates, combined, I think, particularly with shell-fish and 
 such glycogenic foods, is often followed by severe attacks 
 of acute indigestion and sudden death, for these unfortunates 
 have so little vitality, so little ability to resist the attacks of 
 any disease, as to make them particularly vulnerable to even 
 moderate onslaughts. Such patients should be particularly 
 watched and prevailed upon to reduce the excessive quantity 
 of all foods, and especially of carbohydrates and other sugar- 
 producing materials. Such cases usually need lavage of both 
 stomach and bowels, with such antiferments by the mouth as 
 hydrogen dioxide, the salicylates, with antipyrin and bicarbo- 
 nates of soda and potash if the heart be not too weak. Scotch 
 whiskey or gin, very largely diluted with water and taken 
 regularly, is most useful in such cases; in fact, alcohol is a 
 wonderful remedy here. In case the plan of withdrawing all 
 liquids is tried, a little spirit will make this plan more bearable 
 to the patient. It is in these cases we may look for some pre- 
 monition of the skin of a bronze hue. This comes from 
 destruction of the haemoglobin. The excess of sugar causes 
 
 468 
 
FORTY YRARS IN THE MF^DICAL PROFRSSfON 
 
 dilution of the blood. It has been suggested that this sets 
 free some of the haemoglobin, and this is changed and depos- 
 ited in the tissues and causes the bronze pigmentation. Cir- 
 rhosis of the liver may occur in these cases. 
 
 Now, as to other remedies valuable in the treatment of dia- 
 betes mellitus. Arsenic has been used for a long time, on the 
 theory that it has some specific action on the digestive tract, 
 and that it increases the oxidizing power of the red blood- 
 corpuscles over grape-sugar. My experience with arsenic has 
 led me to abandon it. I doubt if it has any virtue whatever 
 beyond its general tonic properties. Dr. Barney recom- 
 mends the double bromides of gold and arsenic in five-drop 
 doses after each meal, increasing one drop each day until 
 tolerance ceases. In syphilitic cases the indications are 
 plain. Use mercury and the iodides, being careful of mer- 
 cury. Opium and its salts have long held a reputation in 
 the treatment of diabetes. They probably act by locking 
 up the secretions, and there must be some specific action 
 in them over the formation or the destruction of the sugar. 
 I am afraid of opium in chronic diseases as a general thing, 
 it is so horribly demoralizing. Of the salts, codeine is the 
 least objectionable in most ways. It really appears to 
 control the sugar in some way, but I think I know of better 
 remedies, and hence I rarely if ever use it. It is said to do 
 better given with hydrogen dioxide. The alkalies have been 
 used much. It is claimed that they destroy the sugar in the 
 blood and neutralize volatile acids. They may be useful in 
 conditions approaching coma, which we have already spoken 
 of. In gouty cases the salicylates are useful, and in the neu- 
 rogenous form they quiet the nerves. Ergot and lactic acid 
 have been much recommended. I see no reason to use them 
 except in special emergencies that may arise. Fats are at 
 times most useful, and especially in those cases where all, or 
 nearly all, of the carbohydrates are converted into glucose 
 and excreted, and the body is encroaching on its own pro- 
 teids for power, consuming its own tissues. Here give cod- 
 liver oil and whiskey. Slush the system with it, and let 
 
 469 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 the patient eat fat in all conceivable shapes. Help its as- 
 similation with spirits, and so long as they agree and have 
 a good effect, eat fats and drink spirits. 
 
 Upon the theory that brewer's yeast would excite vinous 
 and acetous fermentation in the stomach, and thus convert 
 the excess of sugar there into acetic acid, Dr. George B. 
 Wood years ago recommended yeast. I have used it with 
 little or no benefit, a tablespoonful three times a day. On 
 the theory that the yeast-plant might be antagonistic to cer- 
 tain pathogenic bacteria, I have used it locally and constitu- 
 tionally in diphtheria, with apparently good results. 
 
 Dr. James Gray, of Glasgow, gave rennet, to change the 
 sugar into lactic acid, with repeated good result. Phenacetin 
 and other coal-tar derivatives are said to do good at times. 
 I have had little experience with them. They slow the pulse, 
 and possibly have more or less effect on assimilation and 
 tissue change. 
 
 For eczemas and the different forms of pruritus encoun- 
 tered among diabetics, absolute cleanliness and the applica- 
 tion of chloral washes are the best remedies. Chloral, ten to 
 twenty grains to the ounce, makes a good wash. A strong 
 solution, sixty grains or more to the ounce, is said by good 
 authority to be almost a specific in rhus toxicodendron poison- 
 ing. 
 
 There are two remedies from which I have had recently 
 most remarkable results in reducing the sugar in cases of 
 diabetes mellitus. I refer to the fluid extract of the seeds of 
 jambul. Botanically it is Jamhoo syzygium jmnholanum, 
 Java plum. It grows in the East Indies generally. The wood 
 yields a brown dye. The berry is olive-shaped to globose, 
 from the size of a pea to that of a pigeon's tgg, and black 
 when ripe. It contains one seed enclosed in a thin white shell. 
 Experiment proves that it prevents the conversion of starch 
 into sugar. In ten-drop doses three times a day in all forms 
 of diabetes mellitus except the pancreatic form, in which I 
 have not had an opportunity to use it, it has been very effec- 
 tual in reducing the sugar, but has never absolutely eradicated 
 
 470 
 
FORTY YEARS IN TIN'. M IIUICAL PROFESSION 
 
 it from the urine. The other remedy is piperazine, the use of 
 which I have before spoken of in renal calculus and gouty 
 affections. Piperazine has acted with me just as jambul has 
 acted in reducing the amount of sugar in the urine. It is rap- 
 idly absorbed and passes rapidly through the kidneys, pro- 
 ducing a reddish-brown urine. This is not so marked in 
 diabetes until it has been taken several days and reduced the 
 amount of urine. It checks the saccharifying influence of 
 haemic and other hydrolytic ferments, yet has no destroying 
 influence. It checks diabetes produced by phloridzin. 
 
 Here is an interesting point, and points again to the kid- 
 ney as a possible factor in diabetes mellitus. It is in regard 
 to the combined action of these medicines that I have a word 
 to say. I have in several cases given ten drops of the fluid 
 extract of jambul seed in a tablespoonful of solution of piper- 
 azine, containing twenty per cent, of alcohol, in which were 
 five grains of piperazine, the patient being ordered to take it 
 in a half-pint of plain water. I have only to say that so far 
 the results have been wonderful, and give me great encour- 
 agement in the treatment of this intractable disease. 
 
 During the treatment all diets were used, and a moderate 
 amount of carbohydrates does not appear to seriously affect 
 the gratifying results, and the patient thrives and is kept in 
 good humor. It is scarcely necessary to say that all the rules 
 of hygiene should be observed by the diabetic, and under the 
 surveillance of his medical adviser he should lead the life of a 
 good citizen, clean and clear in mind and body. 
 
 Now as to the all-important matter of diet. This has al- 
 ready been gone over pretty thoroughly as to its chemical and 
 physiological attributes, and it only remains to consider the 
 practical points, and show the foods fit for the sufferer 
 from diabetes mellitus, arranged according to their chemical 
 compositions and physiological action. Here, again, comes 
 in individuality and the specific case you are advising. You 
 cannot lay down a diet for all cases. You can only give cer- 
 tain general rules, and tell the virtues and vices of certain 
 articles in the lists you may see fit to present. The great 
 
 471 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 divisions from which you are to choose are the carbohydrates, 
 the albuminoids, and the fats. 
 
 Substitutes for Sugar. — It is not difficult, as a rule, for one 
 to give up sugar in coffee and tea, but in diet generally it is 
 difficult to do without it, and we need some substitute for 
 the diabetic to use more or less freely, and yet not affect his 
 condition unfavorably. Saccharin is a crystalline nitrogenous 
 body derived from coal-tar. One-half grain of it will sweeten 
 a cup of coffee. A tablet composed of one-seventh of a grain 
 of saccharin, one-third of a grain of sodium bicarbonate, and 
 eight grains of mannite will sweeten a cupful of any drink. 
 It is not very soluble in cold water, more so in hot water, and 
 quite soluble in glycerin. It is three hundred times sweeter 
 than cane-sugar. Two grains a day may be taken for a long 
 time. It is antiseptic, has the property of rendering the urine 
 acid, and is eliminated unaltered by the kidneys, hence its 
 harmlessness in many cases of diabetes, yet from its antifer- 
 ment action it may disturb digestion at times. Saccharin 
 present to the amount of one per cent, in pancreatic solutions 
 lessens their activity. It should not be used in pancreatic 
 diabetes, and I am not much in favor of it in diabetes gen- 
 erally. Mannite may be used. It is the active crystalline 
 principle of manna. It does not contain equal parts of hydro- 
 gen and oxygen, and is not, therefore, easily converted into 
 grape-sugar or alcohol. Fruit-sugar, levulose, sold under 
 the name of Diabetin, is probably the best sugar for the dia- 
 betic if used alone. It is not known to reappear in the urine. 
 It does not disorder digestion. It is sweeter than cane-sugar 
 and is fruity in its taste. Lactose or lactin, or sugar of milk, 
 is more expensive than cane-sugar and not so sweet. It is a 
 form of carbohydrate easy to assimilate, but is not to be 
 recommended in diabetes, yet it does not appear to render 
 milk objectionable in that disease. Glycerin may be used by 
 those who can take it. It often disorders digestion and causes 
 looseness of the bowels. The only cases in which I use it are 
 where the bowels are obstinately constipated, as we often find 
 them when the patient is on absolute diet. 
 
 472 
 
FORTY YEARS IN Till' Mi:i;lCAL PROFESSION 
 
 Drinks. — There is often great thirst, so much of the body 
 fluids going off by the kidneys. Plain water, or water slightly 
 acidulated with a few drops of dilute phosphoric acid or 
 lemon-juice, or with a pinch of bicarbonate of soda or potash, 
 is best. The effervescing waters are grateful to many, per- 
 fectly plain. The alkaline spring waters, such as Vichy and 
 the Saratoga waters, are most grateful and useful. Saratoga 
 Vichy, Saratoga Kissingen, and Saratoga Carlsbad are the 
 best. As to spirits, uncolored California brandy and Scotch 
 whiskey are the better. Colored spirits have more or less 
 sugar in the coloring-matter. Claret is the best wine. The 
 Rhine wines come next. Sparkling wines are poison from 
 the sugar they contain. The best sparkling drink is brandy, 
 whiskey, claret, or Rhine wine in soda-water. These are 
 almost as palatable as champagne, and better than some 
 brands. Malt liquors are suicidal to the diabetic. If he must 
 drink them, he will live longest on those long bottled, the 
 sugar having gone to alcohol and carbonic acid. 
 
 There are foods which on general principles should not be 
 allowed to diabetics. Such include syrups, sweet preserves, 
 molasses plain or compounded, all candies and jams. Honey 
 contains dextrose and levulose, but I think the harm of honey 
 is most because it is eaten with bread or other carbohydrate. 
 Breads and pastry must be avoided ; as a rule, the latter are 
 injurious to well persons. Tapioca, arrow-root, rice, and 
 sago are very injurious. All articles made of Indian corn 
 are less injurious than those made of wheat, but nevertheless 
 should be forbidden, as well as all hot breads made of buck- 
 wheat, barley, and such. Oatmeal is nitrogenous, but has 
 too much carbohydrates. All macaronis in the market are as 
 bad as wheat flour, as we shall see farther on. So are vermi- 
 celli and spaghetti. The white potato is proscribed by most 
 physicians. For absolute diet it must be proscribed. Where 
 some carbohydrates are allowable it furnishes the best form 
 for them if well baked. It has only about twenty per cent, 
 of starch. It is a much-abused carbohydrate in the diets 
 for the diabetic and obese, if used well baked and in no other 
 
 473 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 way. Of course, much water goes off in baking, but the 
 starch is better broken up. CauHflower has more carbohy- 
 drates than cabbage, the former having six per cent, and the 
 latter four per cent. Cabbage particularly may be allowed 
 raw or boiled in moderation. I speak of this because many 
 diet tables disallow it. Parsnips, carrots, and beets are better 
 to be dropped entirely. All beans except green string-beans 
 should be prohibited. String-beans have only about nine per 
 cent, of carbohydrates; other beans run up as high as sev- 
 enty per cent, when dried. Lima beans, green only, run 
 twenty-two per cent., the water not having been driven off. 
 Brussels sprouts may be eaten, as they only contain about 
 three per cent, starch. Most diabetic diet tables leave them 
 out. Asparagus is on an equality with Brussels sprouts. Rhu- 
 barb is objected to in most diet tables. The truth is, it con- 
 tains little of anything, and the small amount of oxalic acid 
 in it makes it very grateful in the early spring. I should 
 allow a little, sweetened with saccharin or diabetin. Clams, 
 oysters, and mussels have glycogen in their soft parts, be- 
 cause these soft parts are their livers. I think they should 
 be used very sparingly, and only raw or plainly cooked, with 
 no flour. For the same reason livers of all animals should 
 be shunned. 
 
 Most fruits are forbidden in a majority of the diabetic diet 
 tables. This, I believe, is correct as applied to all preserved 
 fruits, as they almost invariably contain cane-sugar. Apples 
 and pears contain only about ten per cent, carbohydrates. 
 Sometimes we have to allow something of the kind to appease 
 cravings and regulate the bowels. Apples and pears, espe- 
 cially the tart apples, do the least harm. A few strawberries 
 unsweetened, or sweetened with saccharin, diabetin, or man- 
 nite, may be allowed, or watermelon, ice cold, if craved, as 
 each only has about six per cent, carbohydrates. Raspberries 
 and nectarines are more objectionable. Peaches and black- 
 berries are about in the class with pears, and so are oranges. 
 It is better, as a rule, to avoid them and lemons too. Mind 
 you, these fruits are not urged as diabetic diet, but are only 
 
 474 
 
FORTY YI'.AKS IN 'I'llI'". M\'.])\CA\. l'K'Oi-l-:SSION 
 
 given here to let us out of a (lileninia .sometimes, for the pa- 
 tient may cat things much worse if curbed too much. 
 
 Many of the nuts are useful as food, and some of the oily 
 ones especially may be used by diabetics. Chestnuts are away 
 up in carbohydrates, and should never be eaten by the dia- 
 betic. Peanuts are also objectionable, but less so than chest- 
 nuts. Cocoanut is also objectionable. 
 
 As to allowable foods, they are numerous, but even with all 
 these and no bread, life soon becomes a burden, and in many 
 cases confinement to the list is unbearable. All soups made 
 without the addition of carbohydrates, all edible fish, reject- 
 ing the livers, lobsters, crabs, and shrimp, and about all of the 
 meats may be used, except livers. In cooking them the use 
 of carbohydrates is to be avoided. Eggs are most useful 
 cooked in various ways. As to fats, you must sound your 
 patient as to tolerance of fats, and where tolerated, as a rule, 
 for reasons before given, use them freely ; they save albumin. 
 If the patient crave fats, encourage the taking of them in every 
 conceivable way. Some object to fats on the ground that they 
 form glycerin. There is no good reason given for rejecting 
 them on this score. As to butter, it is among the best of the 
 fats. The little milk-sugar it may contain is no objection 
 whatever. 
 
 A list of vegetables allowable is given here for convenience. 
 Most of the winter and spring greens, as dandelion, cabbage 
 greens, horse-radish, spinach, celery, and plenty of it, okra, 
 lettuce, endives, pickles, kale, cucumbers, cranberries sweet- 
 ened with saccharin, levulose, or mannite, string-beans, which 
 may be obtained all the year, fresh or canned. The soja beans 
 have very little starch; they are oily and unpleasant dried, 
 but I have thought, possibly, we may get a good green ^■ege- 
 table from them by using them half-grown and canning them 
 for winter use. This experiment is worth trying in the in- 
 terest of diabetics. Asparagus is good all the year round, 
 fresh or canned. Of all vegetables, asparagus is least afifected 
 in flavor or otherwise by canning. Onions are debatable food. 
 The Bermuda onion contains too much sugar, undoubtedly, 
 
 475 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 and so do parsnips and carrots. Egg-plant may be used 
 sparingly, if we are put to it for a change. It must not be 
 cooked with carbohydrates, and without these it is Hke pud- 
 ding without sauce. 
 
 Thompson quotes Fagge as saying, " As a rule, all white 
 parts of vegetables in which chlorophyll has not been devel- 
 oped by exposure to sunlight contain no sugar. Boil all 
 kinds of forbidden vegetables in much water, and if they con- 
 tain only sugar and not starch, much of their sugar will be 
 lost, and they may be eaten by the diabetic. Beets are in 
 this class, but I am very doubtful as to beets being under any 
 conditions good food for the diabetic." 
 
 Mushrooms have a little grape-sugar, but so little that they 
 may be eaten freely by the diabetic. The French morel has 
 a mere trace, and the truffle has none. These are great helps 
 for their flavor, and are often great additions to steaks, pig's 
 feet, tripe, kidneys, sweet-breads, and such. 
 
 The diabetic may eat terrapin, a dish for the gods. " Good 
 wine needs no ivy-bush." Terrapin needs no sauce. The 
 only restriction is, be chary of the liver. Butter, pepper, and 
 salt are all that are necessary to bring out the flavor of terra- 
 pin, and this is the diabetic's way to eat it. Corn-starch, 
 flour, and Madeira or sherry only take away from its natural 
 gout. If you must have wine, use a dry Madeira or sherry. 
 Madeira is the gentleman's wine for terrapin, one glass to 
 one count terrapin. Sherry is a good second in the same pro- 
 portion. 
 
 Milk. — Here comes up an important question in the diet 
 for diabetics, — the use of milk. Of course, I refer to cow's 
 milk. In looo parts of fresh milk we get water, 873 ; butter, 
 30; casein, 48.20 ; sugar of milk, 43.90; calcium phosphate, 
 2.31; iron phosphate, .7; potassium chloride, 1.44; sodium 
 chloride, .24; magnesium phosphate, .42; compound of so- 
 dium and casein, .42. Milk is a complete food and will sup- 
 port life. There is little fecal residue, and it is often necessary 
 to add lime-water, or some alkali, to prevent coagula in the 
 stomach when a patient is living on it alone. The scum of 
 
 476 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 boiled or heated milk is fnjni the albuminoids of the milk, 
 and skimming this off renders the milk, of course, weak as a 
 nitrogenous food. There are about one and a quarter ounces 
 of fat in a quart of average whole milk. Casein is the source 
 of albumin in milk, and very much resembles animal albumin. 
 The fat of milk, the cream, is olein, palmitin, butyrin, caproin, 
 and caprin. It owes its peculiar odor to the latter. Butyrin 
 is a compound ether, butyric acid and glyceryl. Exposure to 
 the air renders butter rancid by decomposing the butyrate of 
 glyceryl and setting butyric acid free. 
 
 The sugar is the important matter in milk to be considered 
 for the diabetic. It is a crystallized sugar obtained from the 
 whey by evaporation. Whole milk contains about five per 
 cent, of sugar of milk. In whole average milk Atwater and 
 Woods give the carbohydrates as only 2.3, and in average 
 skim-milk as 2.2. Of course, these come principally from the 
 milk-sugar. I believe milk to be a most important article of 
 diet in diabetes mellitus. It is rich in nitrogen and fat. These 
 come from the globule chiefly. The corpuscles are fat, sur- 
 rounded with a delicate albuminoid coating. The fat here 
 makes the butter, the corpuscle being broken by churning, 
 and letting it out. I believe this is the general idea. Senator 
 thinks the milk-sugar in milk does not increase the glycosuria, 
 as a rule, although some are more tolerant than others of 
 the carbohydrate. Tyson thinks it more difficult to pass into 
 grape-sugar than any other of the carbohydrates. These are 
 matters of clinical experience only, and my own experience 
 conforms to these conclusions. 
 
 The time comes in any case of diabetes mellitus when it is 
 proper and even necessary to rest your patient from mixed 
 diet; to rest him from the carbohydrates, even if he tolerates 
 them to a certain extent. Here you have, with which to ac- 
 complish this, a resort to whole milk, to skim-milk, and to 
 predigested, peptonized, or pancreatized milk, koumiss, and 
 buttermilk. In koumiss the milk-sugar has been converted 
 into alcohol, and is not there to vex your patient. In butter- 
 milk it has been converted into lactic acid. These two articles 
 
 477 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 are in every way a very great help in the diabetic regimen, 
 and should be stand-bys in every case. They are grateful, 
 refreshing, and in every way acceptable. 
 
 You may find a patient who cannot take the little carbo- 
 hydrates in milk even, and so in other forms patients vary as 
 to their capacity. The sugar metabolic limit must be found 
 in these cases by examining the urine. The rest-cure leads 
 to the recuperation of the faculty of the system to absorb 
 sugar, thus checking under-consumption, and yet does not 
 kill the patient by feeding him exclusively on albumin too 
 long a time, and thus rendering his blood too acid, and causing 
 him to consume his own tissues beyond the endurance of life. 
 Never let your patient overstep his carbohydrate tolerance. 
 If the patient needs fat and albumin especially, I see no objec- 
 tion to Devonshire cream. This is taken from heated milk, 
 thus skimming both the cream and albumin. 
 
 Tubes for peptonizing or pancreatizing milk may be pur- 
 chased at the drug-shops with full directions. Horatio 
 Wood's directions are : Dilute a quart of milk with four 
 ounces of water, heat to 140° F., adding two teaspoonfuls 
 of Roberts's liquor pancreaticus, with twenty grains of bi- 
 carbonate of sodium, digesting in a warm place for an hour 
 to an hour and a half, and raising for a moment to the boiling- 
 point. Another receipt is to dissolve five grains of pancreatin 
 with twenty grains of bicarbonate of sodium in one ounce of 
 warm water; add this to one pint of new milk, and keep at 
 a temperature of 110° F. for one hour. It will be less bitter 
 and probably equally effectual if only left a half-hour. In 
 pancreatic diabetes I look upon these preparations as almost 
 indispensable in diet. 
 
 I have spoken of the rest-treatment of diabetes, the rest 
 from everything containing carbohydrates for three or four 
 weeks in every three months. Take a case of a man who will 
 not diet, as a rule, one who takes a drinking-bout now and 
 again, eats and drinks everything, and is in the greatest 
 danger of a sudden ending by coma, cerebral hemorrhage, 
 or heart failure from exhaustion. After a bout, particularly, 
 
 478 
 
FORTY YEARS IN Till': MPLDICAL PROFESSION 
 
 these men are quite pious, ([uite virtuous and docile, and ready- 
 to take advice. Milk is tlie great food with which to com- 
 mence the treatment, skini-niilk, pancreatized milk, or whole 
 milk Pasteurized, aided, if you choose, hy koumiss or butter- 
 milk. Gradually increase the diet, and in three or four weeks 
 you see usually wonderful improvement. In your discreet 
 and bidable patients the same course once a quarter will rest 
 them greatly. Alcohol in proper proportions assists the milk 
 wonderfully and adds to the tolerance of the system for car- 
 bohydrates. Upon the theory that uric acid diathesis, oxalu- 
 ria, and diabetes are different phases of one single morbific 
 entity, Dr. Lupa went on an anti-uric-acid diet, as he termed 
 it, and ate all vegetables, excluding all meats and such nitro- 
 genous foods. He claimed great success in his own and other 
 cases of diabetes. Theory is against this method, and yet 
 theory does not always avail to stop a good thing. 
 
 " Bread is the staff of life," and the staff of life is the 
 one thing the diabetic needs to satisfy his craving. Unfor- 
 tunately, all breads, whilst nearly complete foods, have for 
 their chief ingredients carbohydrates, and these, as a rule, 
 are poison, death, and destruction to the diabetic. Palatable 
 substitutes are difficult, almost impossible, to get, unless they 
 transgress in the rule as to carbohydrates. Our main reliance 
 is to be placed in flours in which more or less of the starch 
 has been washed out, leaving chiefly the gluten, and in flours 
 made from vegetable matter which in nature is comparatively 
 low in starch and sugar. The former are known in the mar- 
 ket as " gluten flours," and the latter have special names, 
 according to what they may be made of, or the party manu- 
 facturing them. 
 
 Let us take up " gluten flour." Through the kindness of 
 Dr. Arthur T. Neale, Director of the Delaware College Agri- 
 cultural Experiment Station at Newark, Delaware, and Pro- 
 fessor C. L. Penny. Professor of Chemistry at the Station, I 
 am enabled to give an analysis of many specimens of gluten 
 flour and special foods purchased in the general market. It 
 is only necessary to go into such work to see how utterly 
 
 479 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 bereft the American physician is of proper aids in fighting 
 this common disease, how much suffering is entailed upon 
 the unfortunate patients, and what ignorance or rascahty, or 
 both, are rife in America in manufacturing dietetic products 
 of such importance and general use. Take a grain of wheat 
 and cut it across. In the centre is a white powder, starch. 
 This is a carbohydrate, carbon, hydrogen, and oxygen. From 
 this we get heat and fat, but no power. The next layer is 
 gluten, a proteid. It is dark-colored, and, in addition to the 
 starch elements, contains nitrogen. Gluten then is a power- 
 producer. Then we get the phosphates and mineral matters, 
 which help to make the bones of the body, etc. The outside 
 is the bran, which is flinty and indigestible, and makes entire 
 flour a bowel irritant. 
 
 Now, white, new-process flour has little gluten and com- 
 paratively much starch, because starch is white and gluten 
 is dark ; and the market demands white flour. Thus we dis- 
 card the flesh-formers in our white flours, and keep only the 
 fuel and fat-producers. The best flour for eating should con- 
 tain from ten to fifteen per cent, of gluten, or more. The 
 patent new-process flours contain much less, and much of the 
 important element of phosphorus is also removed. Gluten 
 flour for diabetics should contain not less than seventy-five 
 per cent, gluten. The books tell us generally that the gluten 
 flour special products of Europe are much lov/er in starch 
 than those we buy in America. Probably they are, although 
 my examinations do not lead me to get much encouragement 
 in England and Germany, at least. Dr. Frilden gives five 
 examples of English gluten flour. They contained 7.6, 16.7, 
 13.26, 68.8, and 11.63 P^^ cent, starch and sugar. This is 
 comparatively a good showing as such flours go. Dr. Kraus, 
 Jr., of Carlsbad, found only five specimens to contain less 
 than thirty per cent, carbohydrates. Four contained between 
 thirty and forty per cent., four between fifty and sixty per 
 cent. This is a bad showing. Wheat flour in the general 
 market contains from sixty to eighty per cent, carbohydrates, 
 
 480 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 accordingly as it is white or dark ; the greater the amount 
 of carbohydrates, the whiter it is. 
 
 To get the starch out of flour it must be waslied, when the 
 starch runs out through a cloth anrl leaves the gluten behind. 
 Gluten may thus be obtained starch free. It is very difificult 
 or impossible to get gluten bread absolutely free from starch. 
 Any bread under twenty-five per cent, starch would be very 
 encouraging as things go in America, or even in Europe. I 
 should at present hope more from the French products. Do 
 not turn your patients loose and tell them to buy gluten flour 
 and live on bread made from it. There are no gluten flours 
 that I know of in this country. They are, all of them that I 
 have examined, frauds, delusions, and snares. Each one can 
 make better himself. Wash the starch out as you use the 
 flour by letting a stream of water run on it in a muslin bag 
 until the water coming through ceases to be milky. Gluten 
 is like glue: by dr3ang it becomes brittle. It will probably 
 not make bread without at least a little starch with it. 
 
 I think there is a bright business opening in this country 
 for a firm of honest men to go into the business of manu- 
 facturing and selling all possible special dietetic products for 
 invalids. This would cover diabetic foods and drinks, obesity 
 foods and drinks, dyspepsia foods and drinks, tissue-building 
 foods and drinks, fuel-producers, flesh-formers, and all such. 
 I know of no such firm in the world properly organized on a 
 basis at the same time of good morals and honest business 
 principles. Messrs. G. Van Abbott & Sons, No. 6, Duke 
 Street Mansions, Grosvenor Square, London, W., appear 
 from their advertisements to carry a large stock of special 
 foods. They have kindly sent me their literature, but I have 
 no samples in time for analysis. They make diabetic calf's- 
 foot jelly, gluten and meat biscuits, carraway, soya, ginger, 
 and gluten biscuits, almond loaves, gluten loaves, soya loaves, 
 bran, gluten, and almond loaves, gluten slices, etc. They 
 appear to get up biscuits and cakes of every conceivable com- 
 position, suitable apparently for all invalids. They prepare 
 31 481 
 
FORTY YEARS JN THE MEDICAL PROFESSION 
 
 diabetic macaroni and vermicelli, gluten flour, almond flour, 
 bran flour, diabetic cocoa and chocolate, etc. This is just 
 such a house as we need in America, honestly and thoroughly 
 conducted. 
 
 There is a new flour out for diabetics, called the Chicago 
 sanitary flour. Bread and cake made from it are said to be 
 palatable. It should be used moderately. It is made from 
 edible pine-nuts. It is yellowish in color, and of a bland taste. 
 It contains no starch and seven per cent, of cane-sugar. Make 
 bread from it with yeast, and nearly all of this sugar goes to 
 alcohol, leaving less than one per cent, sugar. 
 
 The soja bean is a new product from which to make a dia- 
 betic bread. It comes to us from Japan. I have already 
 spoken of it as a vegetable, dry and green. It contains a 
 very little starch, four to six per cent., and much fat. It will 
 prove a desirable make-shift, but it is apt to get rancid from 
 decomposition of its fats. " Every rose has its thorn" in 
 substitutes for our usual bread-stuffs. The flour from the 
 aleuronat-nut is also a late introduction. It is recommended 
 by Tyson, a good authority. I find it very expensive, and will 
 speak of it again. 
 
 Let me speak of macaroni, vermicelli, spaghetti, and alpha- 
 bet noodles. These are usually looked upon rather as gluten 
 foods, and in medical books I have seen them recommended 
 as such. There never was a greater mistake. Every one I 
 have had analyzed has shown that they were made apparently 
 from wheat flour in its purity, and were about as high in 
 carbohydrates as ordinary wheat flour. We ought to have 
 gluten macaroni, vermicelli, spaghetti, and alphabet noodles. 
 They would be very palatable and very useful food. Van 
 Abbott advertises them. I never heard of any in America. 
 The sooner we get them the better, and we must have them. 
 In regard to macaroni and alphabet noodles, I append Dr. 
 Neale's letter. The analyses were made by Professor C. L. 
 Penny. The macaroni was imported Italian macaroni, and 
 the noodles were from the house of Olivier Fils et Cie., 
 Lyon, France. 
 
 482 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Alphabet Noodles. Italian Macaroni. 
 
 Moi.sturc 9-33 9-^4 
 
 Protein 1425 ^3-31 
 
 Gluten, dextrose, and other sugars, and 
 
 similar reducing substances, soluble 
 
 in cold water 2.28 4.14 
 
 Starch 70.38 68.56 
 
 Ash, fat, etc., not determined. 
 
 " In Deutz's work on the adulteration of foods a statement to this effect 
 may be found : Genuine macaroni is made from wheat gluten. Imitation 
 macaroni is made from wheat flour. Both of the above analyses, as far as 
 gluten and starch contents are concerned, might easily be mistaken for 
 analyses of a high quality of wheat flour. If Deutz is right, neither of the 
 above samples belongs in the macaroni class. 
 
 " Yours truly, 
 
 " A. T. Ne.\le, 
 
 "Director." 
 
 From a great number of samples of macaroni products 
 analyzed from the exhibits of the Chicago Exposition in 1893 
 by the United States Government experts, only one sample 
 showed that it was not made wholly from ordinary wheat 
 flour, and in the exception there was only a little common salt 
 and some oil added. So much for macaroni products, both 
 home-made and imported, as a gluten food. A letter from a 
 high official of the Agricultural Department, Division of 
 Chemistry, at Washington, says, — 
 
 " I scarcely think you will be able to find any noodles, spa- 
 ghetti, or macaroni in our markets which are especially rich 
 in gluten. It is claimed that these products are made from 
 flours rich in gluten, but we do not find the percentage of albu- 
 minoids any higher than one would expect from a sample of 
 good wdieat flour. In fact, we have reluctantly come to the 
 conclusion that the so-called gluten flours on the market are 
 not by any means to be trusted, and that the only safe way for 
 prescribing gluten flour is to prescribe a known brand which 
 is sold in original packages." 
 
 I may add to this that the original packages do not make 
 better exhibits than that sold in bulk. To tell macaroni rich 
 in gluten, examine it for the following points : \Mien wet it 
 
 4S3 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 is thrown over rods to dry. If rich in gluten it will appear 
 flattened where it has rested on the rods. If it is not rich in 
 gluten, it will not carry its own weight, and cannot be dried 
 on rods. Any one who has been in Florence, particularly, 
 can remember how much of it is to be seen hanging out to 
 dry. No place seems too foul in which to hang macaroni to 
 dry. The more gluten there is in macaroni the more direct is 
 its fracture, the larger it swells when cooked, and the better 
 it holds its tubular form. If we are paying the price of first- 
 class confectionery for a mere mixture of flour and water for 
 macaroni and such products, it is time for us to know it and 
 to endeavor to turn the attention of honest manufacturers 
 towards the proper utilization of gluten. 
 
 Soja-Bean Meal. — This bean comes to us from Japan, and 
 is said to contain little or no starch, generally less than one 
 per cent. It has a peculiar oily taste, but the analysis shows 
 no excess of fat. Professor Penny's analysis is as follows : 
 Moisture, 8.14; nitrogen, 14.54; equivalent to protein by 
 calculation, 90.97. Starch-like bodies capable of reducing 
 Fehling's solution, trace only. A letter from the Theodore 
 Metcalf Drug Company, of Boston, says, " We find culti- 
 vating the bean in this country increases the amount of starch, 
 and we are awaiting a new supply from Japan, which we an- 
 ticipate will be entirely free from starch." Here is a copy of 
 a letter from Dr. Neale. 
 
 " The statement that the percentage of starch in soja beans is dependent 
 on environment interests us very much. A reasonable doubt exists as to 
 the presence of starch, strictly speaking, in this bean. Years ago attention 
 was directed to this plant by a display of seed made by Japan at the Paris 
 Exposition. At that time claims w^ere made in the Halle Laboratory that 
 no starch grains could be detected in soja-bean meal. I held an assistant's 
 position among the chemists of that station when this test was made, and 
 my recollections of the interest aroused then are now reasonably strong. 
 Last month Professor Chester, of this station, attempted to detect starch 
 in a bean taken from the package sent later to you. He reported his ina- 
 bility to obtain a positive result, quantitatively, by the usual microscopic 
 and chemical (iodine) test. By these tests the absence of starch was indi- 
 cated. The ten per cent, of starch reported by analysis of this bean means 
 starch-like bodies capable of transformation into certain sugars. An as- 
 
FORTY YICARS IN TIIIi: MliDICAL I'KOFESSION 
 
 sumption exists that any carbohydrate may be deleterious to a diabetic. 
 Tlic package of beans sent to you represents a crop grown on the college 
 grounds. The seed came to Newark from Kansas. The Kansas supply 
 was brought to this country from Japan by a member of the Kansas 
 Experiment Station staff. I will follow this matter of environment by 
 comparative analyses of foreign and domestic crops, if Mr. Metcalf will 
 guarantee the origin of his supply. If, however, the slightest question 
 arises as to the source of that supply, a request to the Honorable Sec- 
 retary of Agriculture will doubtless result in an importation through con- 
 sular channels of a quantity large enough for this study. 
 
 " Yours truly, 
 
 "Arthur T. Neale, 
 
 " Director." 
 
 I find soja-bean meal to make a fair cake, which helps out 
 in diet. The meal must be kept well sealed, or it turns rancid 
 from a transformation of its fat. Eaten dried as a vegetable, 
 it serves a purpose in diet, but patients cannot eat them every 
 day for any considerable time. I have not had the opportu- 
 nity of testing them as a green vegetable, but, as I have said 
 before, I have great hopes of their use in this direction. 
 
 Soja-Mcal Muffins (Metcalf). — Take of cream, one cup; 
 eggs, two, entire; baking-powder, one teaspoonful; salt to 
 taste; soja-bean meal, enough to make a batter not too thick. 
 Make into eight cakes. 
 
 Soja and Gluten Gems (receipt of a patient). — One cup 
 gluten flour, two eggs, one cup of cream, one teaspoonful 
 baking-powder, enough soja-bean meal to make a stiff batter, 
 half-teaspoonful extract of lemon. This does away with the 
 oily taste of the bean. Bake in gem pans. With a high-grade 
 gluten flour this makes a good bread. 
 
 Van Abbott, of London, makes a soja biscuit flavored with 
 carraway, which is palatable now and then. They also make 
 a soja and almond biscuit. These are useful and palatable. 
 Almonds save albumin, and so do the fats in the soja bean. 
 Van Abbott also makes a soja-bean bread. These soja prod- 
 ucts do not keep for transportation unless hermetically sealed, 
 which is readily done. 
 
 Professor John Attfield's analysis of a soja-bean flour in 
 1890 was as follows : 
 
 48s 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 Nitrogenous or flesh-forming material 41.24 
 
 Fatty or warmth-giving material 13.70 
 
 Other warmth-giving substances (cellulose, starch, 
 
 sugar) 30.35 
 
 Phosphate or bone-forming material 4.81 
 
 Other natural mineral matter .52 
 
 Moisture 9.38 
 
 Total 100.00 
 
 Probably most of the carbohydrates here were in the form 
 of cellulose, which would not affect it as diabetic food to any 
 great extent. 
 
 Dr. James Tyson and other authorities recommend the 
 flour made from the aleuronat-nut. I have used it, and find 
 it very expensive and not free from other objections. My 
 supply came from a retail druggist in Philadelphia. 
 
 The following analyses have been made by Professor 
 Penny : 
 
 Aleuronat flour : Moisture, 6. i ; nitrogen, equivalent to 
 protein by calculation, 31.81 (nitrogen, 5.73) ; starch-like 
 bodies capable of reducing Fehling's solution, 22.64. 
 
 Sample of gluten flour from a factory in New York State, 
 marked ''Special Diabetic Flour:" Protein, 15.50; soluble 
 sugars, dextrose, etc., 2.20; starch, 59.87; water, fat, ash, 
 etc., to balance. In round numbers wheat flour may have 
 seventy per cent, of starch-like bodies. Wheat bran in com- 
 position closely resembles this sample of gluten flour. 
 
 Sample of gluten grits from the same factory. This is 
 put forth as a thoroughly reliable, palatable, and satisfactory 
 breakfast dish and dessert cereal for diabetics and those suf- 
 fering from obesity, etc.: Protein, 11.56; starch, 73.85; 
 soluble reducing bodies, dextrose ( ?), .42. 
 
 It is a very serious business to be putting such trash as this 
 on the market as a suitable food for invalids in certain dis- 
 eases. How many are using them with a false idea of their 
 own security no one knows, and how many physicians are 
 innocently recommending them will never be determined. 
 This showing, I trust, will put all on guard, and end in a 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 possibility sooner or later of obtainini^ a proper food-supply 
 for these unfortunate invalids. 
 
 Gluten (lour from a Jioston firm: Moisture, 10.90; gluten, 
 15.69; starch, 61.58; dextrose, 1.53. This is a little worse, 
 if anything-, than the New York State sample. 
 
 Sample of white wheat gluten from a Health Food Com- 
 pany in Philadelphia : Moisture, 11. 17; gluten, 16.31; starch, 
 59.17; dextrose, 2.29. This is another specimen unfitted as 
 diabetic food, although it is possibly a little better than the 
 others. 
 
 Wheat gluten from a Michigan Sanitarium Health Food 
 Company: Moisture, 7.54; gluten, 18.28; starch, 67.20; 
 dextrose, 1.53. I expected a better showing from this source, 
 but the analysis speaks for itself. Professor Tyson has 
 recommended the gluten flour of this firm as among the 
 best to be found, and such a recommendation must have 
 given it a large sale. 
 
 Granon flakes from the same company: Moisture, 9.77; 
 gluten, 10.50; starch, 69.52; dextrose, .76. 
 
 Gluten biscuit from the same company: Moisture, 11.62; 
 gluten, 25.19; starch, 60.12; dextrose, 1.40. The analysis 
 tells the story here. 
 
 Nut gluten biscuits from the same company : Protein, 38*; 
 starch, 15.9; soluble reducing bodies, dextrose, 1.17. This 
 is a creditable showing, and these biscuits are among the best 
 of the bread-foods I have found in the general market for 
 the diabetic or the obese. They are evidently shortened with 
 nut oil and have a taste like rich puff paste. This company 
 makes a forty per cent, gluten biscuit which I did not have 
 analyzed. They are very palatable and taste like the egg bis- 
 cuits of the grocery shops. Their twenty per cent, gluten 
 wafers were not analyzed. They taste like hardtack. 
 
 If you can get a proper gluten flour, say, with not over ten 
 to fifteen per cent, of carbohydrates, you can make quite pala- 
 table bread and cakes, but starch and sugar hunger will assert 
 themselves now and again. If stronger bread must be eaten 
 at intervals, the more it can be toasted up to charring, the 
 
 487 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 better it will be for the diabetic eating it. The substitutes 
 for sugar already spoken of may be used, and thus make 
 quite palatable dishes, even porridges. Bran is sometimes 
 added to gluten flour. Do not use too much of this. 
 
 To make bread from gluten flour, make a firm paste with 
 warm water. Dissolve one-quarter to one-half of a com- 
 pressed yeast-cake in a little cold water. Salt to taste. Put 
 the dough in a pan powdered with gluten flour. Place it be- 
 fore the fire, and in two hours it should be raised. Make the 
 dough into small loaves and bake it. To make cake, add four 
 entire eggs and one-quarter pound of butter, and sweeten 
 with glycerin or one of the sugars recommended, — saccharin, 
 mannite, or diabetin. Some flavoring may be added if pre- 
 ferred. A good substitute for milk may be made by a fresh 
 egg beaten up thoroughly and a modicum of sugar of milk 
 added to it with a little water. 
 
 Almond flour is much recommended by Pavy as a food 
 for diabetics. In my experience patients do not take well 
 to it. It does well for flavoring porridge and cakes made 
 from gluten flour. A very little bran added to porridge 
 lightens it, acts on the bowels, and does not do serious harm. 
 Gluten does not dissolve until it enters the system, and should 
 be taken in a state of suspension. 
 
 It is estimated that the American people alone spend ninety 
 millions of dollars annually on adulterated foods. There are 
 imitations of everything good or useful in dietetics. The 
 better things are, the more they are imitated and the more 
 they are adulterated. You can make bread from ground 
 damaged peas, rice, and soapstone. These ingredients have 
 been found in brands of wheat flour, and the scoundrels 
 making such are still unhanged. Peanut oil and cotton-seed 
 oil are both sold as olive oil. The deception here is really 
 more in the name than in the quality, but the fraud is no less 
 glaring. Potato starch is used to adulterate sago, and glu- 
 cose, flour, and clay can make a sugar to be sold as cane- 
 sugar. Potatoes, white and sweet, chicory, peas, beans, and 
 acorns are manipulated and sold as pure coffee, and the 
 
FORTY YK.'VRS IN THE MKDICAL PROFESSION 
 
 coffee-bean itself is now imitated, no coffee whatever being 
 used. Butter has been successfully imitated by oleomarga- 
 rine and sold as butter. Here is the fraud. As oleomarga- 
 rine, people know what they are getting. Filled cheese is 
 very common, and thus skim-milk and lard, or rather fats, 
 are sold as full cheese. As to spices, no man knows what 
 they contain. Condemned hardtack is a favorite adulterant. 
 Sand, bran, sawdust, cocoanut-shells, corn-meal, olive seeds, 
 and all sorts of earths and clays are used as adulterants. Pure 
 cider vinegar is likely to be dilute sulphuric acid flavored with 
 any sour trash available. Chrome yellow, that horrible soul- 
 consuming poison, is, I have no doubt, still used to give a 
 golden egg color to the products of some bakers. Candy is 
 subject to all kinds of adulterants, and the only end to it is 
 when the proper ingredients are cheaper than the injurious 
 ones. Honey is imitated by maple sugar and glucose, and 
 the very combs are imitated to hold it. As to preserves, 
 those sold in the shops are mostly horrors. Glucose, gelatin, 
 cochineal, with flavoring extracts from the coal-tar deriva- 
 tives, compose the most of them, and whatever Providence 
 may vouchsafe to us in the way of fruits, whether the har- 
 vest be great or small, these frauds are always obtainable 
 by ignorant, credulous purchasers, the victims of conspiracy 
 most injurious and most foul. So it is in the furnishing of 
 special dietetic foods for the diabetic, fraud keeps pace with 
 rapacity; and as we progress in the evolution of knowledge 
 to eradicate or check these scourges to mankind, the evolu- 
 tion of greed and deception keeps pace with us, and the 
 sorry victims are sacrificed on the altar of " man's inhuman- 
 ity to man." 
 
 I take great pleasure in introducing here a poem which has 
 come to me merely as a newspaper clipping. I have en- 
 deavored to trace its authorship and its history, but have 
 been able to find nothing reliable pertaining to either, more 
 than the few lines of explanation published with it. I applied 
 to both Mr. Spofford and J\Ir. David Hutcheson. of the Con- 
 
 489 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 gressional Library at Washington, but neither could give me 
 any trace of the composition or of its writer. It has so much 
 merit, and exhibits such deep conceptions of human thought 
 and sentiment, that I deem it worthy of much more careful 
 preservation than the mere ephemeral existence this publica- 
 tion may give it. 
 
 " More or less interest always attaches to anonymous poetic 
 productions, even when the quality is not very high, but the 
 following lines, found in 1807 near one of the skeletons in 
 the Royal College of Surgeons, London, aroused unusual 
 curiosity, not only on account of the unique theme, but prin- 
 cipally because of the poetic perfection displayed. Great 
 efforts were made to ascertain the identity of the writer, and 
 at one time a reward of one hundred guineas was offered for 
 the discovery of the author, but he has ever remained a 
 mystery. 
 
 (I) 
 
 " Behold this ruin ! 'Twas a skull 
 Once of ethereal spirit full. 
 This narrow cell was Life's retreat, 
 This space was Thought's mysterious seat. 
 What beauteous visions filled this spot. 
 What dreams of pleasure, long forgot ! 
 Nor hope, nor love, nor joy, nor fear 
 Have left one trace of record here. 
 
 (2) 
 
 Beneath this mouldering canopy 
 Once shone the bright and busy eye ; 
 But — start not at the dismal void — 
 If social love that eye employed ; 
 If with no lawless fire it gleamed, 
 But through the dews of kindness beamed, 
 That eye shall be forever bright 
 When -stars and suns are sunk in night. 
 490 
 
FORTY YEARS IN THE MEDICAL PROFESSION 
 
 (3) 
 " Within this liollow cavern Inmg 
 The ready, swift, and tuneful tongue: 
 If Falsehood's honey it disdained, 
 And where it could not praise was chained; 
 If bold in Virtue's cause it spoke, 
 Yet gentle concord never broke. 
 This silent tongue shall plead for thee 
 When time unveils eternity. 
 
 (4) 
 " Say, did these fingers delve the mine? 
 Or with its envied rubies shine? 
 To hew the rock or wear the gem 
 Can little now avail to them ; 
 But if the page of truth they sought, 
 Or comfort to the mourner brought. 
 These hands a richer meed shall claim 
 Than all that wait on wealth or fame. 
 
 (5) 
 " Avails it whether bare or shod 
 These feet the paths of duty trod ? 
 If from the bowers of ease they fled, 
 To seek Affliction's humble shed; 
 If Grandeur's guilty bribe they spurned. 
 And home to Virtue's cot returned. 
 These feet with angel's wings shall vie, 
 And tread the palace of the sky." 
 
 491 
 
INDEX. 
 
 Abortion and miscarriage, 1 06. 
 
 Acapulco, 14. 
 
 Agnew, D. Hayes, M.D., 41. 
 
 Alcohol, 269. 
 
 Alcohol in diabetes mellitus, 458. 
 
 Alcohol, retarding digestion, 300. 
 
 Alcohol, when to give, 301. 
 
 Alcoholic drinks, consumption of, 298. 
 
 Aleuronat flom', 486. 
 
 Almond flour, 488. 
 
 Almonds, 371. 
 
 Alphabet noodles, 482. 
 
 American wines, 291. 
 
 Anabolism, 424. 
 
 Analyses of diabetic flours, etc., 485- 
 
 487. 
 Appendicits, 117. 
 Apple and Pear, Alligator, 339. 
 Apples, 319. 
 Argonauts, 31. 
 Ardiritis deformans, 422. 
 Arthritis defonnans multiple, 423. 
 Asepsis and Antisepsis, 99. 
 Atlee, JohnL., M.D., 57. 
 AUee, Walter F., M.D., 57. 
 Atlee, Washington L., M.D., 57. 
 Atropia in tlie eye, 113. 
 Atwater, Professor O. W., 424. 
 Auscultation and percussion, 131. 
 Austraha, fruit in, 315. 
 Auto-intoxication in disease, 192. 
 
 B. 
 
 Bacillus of Eberdi, 150. 
 Bacillus of tetanus, 168. 
 Bacillus tuberculosis, 379. 
 
 Banana, 340. 
 
 Banting and Ebstein, 223. 
 
 Barr, M. W., on the feeble-minded, 177. 
 
 Barton, John Rhea, 55. 
 
 Bartram, John, 314. 
 
 Bean, soja, 482. 
 
 Bee, honey, sting of, and immunity, 169. 
 
 Beer, ale, porter, 274, 275. 
 
 Betel nut, 373. 
 
 Bicycle, 143. 
 
 Blackberry, 353. 
 
 Bloat, cause of, 436. 
 
 Blood, etc., 141. 
 
 Brandy, 272. 
 
 Brandy, American, 295. 
 
 Braun, Karl, 85. 
 
 Bread for diabetics, 479. 
 
 Breads, 228. 
 
 Bromelin, 308. 
 
 Burgundy and clarets, 284. 
 
 Burnett, C. H., M.D., 58. 
 
 Buttermilk, 241. 
 
 California clarets, etc., 293. 
 California hocks, 293. 
 Cahfomia sweet wines, 293. 
 California, wine product of, 292. 
 Camac, C. N. B., M.D., 155. 
 Camac, Wm., iSI. D., 60. 
 Canned foods, 212. 
 Cantaloupes, 346. 
 Carlsbad, 199, 444. 
 Carson, Joseph. M.D., 38. 
 Champagne, 287. 
 Champagne, American, 295. 
 Chern.-, 351. 
 
 493 
 
INDEX 
 
 Chestnuts, 368. 
 
 Chicago sanitary flour, 482. 
 
 Chilean nut, 373. 
 
 Chocolate, 215. 
 
 Clarets, Virginia and New Jersey, 294. 
 
 Climate of San Francisco, 23. 
 
 Clinical Thermometer, 124. 
 
 Cocoa, 215. 
 
 Cocoa-nut, 339. 
 
 Coffee, 214. 
 
 Coma, diabetic, 461, 463. 
 
 Composition of food, 209. 
 
 Consumption, acute, 388. 
 
 Consumption, cure of, 381, 395. 
 
 Convulsions, ursemic, 440. 
 
 Cooper, E. S., M.D., 22. 
 
 Cottage cheese, 241. 
 
 Country doctor, 90. 
 
 Cranbeny, 351. 
 
 Cream, Devonshire, 240. 
 
 Cream nuts, 373. 
 
 Currants, 351. 
 
 D. 
 
 Da Costa, J. M., M.D., 58. 
 
 Dana, R. H., Jr., 19. 
 
 Date plum, 337. 
 
 Deaf and dumb, 183. 
 
 Death struggle, 196. 
 
 Defective classes, 186. 
 
 Dewberry, 353. 
 
 Diabetes and Tuberculosis, 447, 465. 
 
 Diabetes mellitus, 446. 
 
 Diabetes mellitus, cause of, 451. 
 
 Diabetes mellitus, cure of, 459. 
 
 Diabetes mellitus, diagnosis of, 455. 
 
 Diabetes mellitus, diet in, 473. 
 
 Diabetes mellitus, treatment of, 462. 
 
 Diabetes mellitus, true, 468. 
 
 Diabetes, thyroid extract in, 463. 
 
 Diabetic foods, manufacture of, 481. 
 
 Diazo reaction, 150. 
 
 Diet, 197. 
 
 Diet and women, 226. 
 
 Diet in middle age, 248. 
 
 Diet in old age, 249. 
 
 Diet table, 224. 
 
 Dietary studies, 216. 
 
 Diets, improper, 226. 
 
 Digestion, time required for, etc. , 235 . 
 
 Digitalis, 128. 
 
 Division of foods, 200. 
 
 Doyle, A. Conan, 91. 
 
 Drinks in diabetes, 473. 
 
 Ductless glands, 137. 
 
 Duels, 22. 
 
 Durian, 337. 
 
 E. 
 
 Eggs, all about them, 206. 
 Electricity, 143. 
 English walnut, 375. 
 Ether and chloroform, 82. 
 Ether and chloroform in pelvic opera- 
 tions, 83. 
 Ether and oxygen, 84. 
 Examination of urine, 145. 
 
 F. 
 
 Figs, 339. 
 
 Filberts, 371. 
 
 Flour, gluten, 479, 486. 
 
 Food, adulterations of, 488, 489. 
 
 Food fads, 25 1 . 
 
 Food necessary for a man in twenty-four 
 
 hours, 220. 
 Food, uses of, 425. 
 Foods, composition of, 203. 
 Foods, infant, 247, 258. 
 Fractures and compound fractures, 121. 
 Frerichs, 85. 
 Fruit-juices, 312. 
 Fruit, when to eat, 307. 
 Fruits and nuts as diet, 304. 
 Fruits and vegetables, definitions of, 309. 
 Fruits, composition of, 307. 
 Fruits, decay of, 356. 
 Fruits, dried, 312. 
 Fruits, uses of, in the animal economy, 
 
 3"- 
 
 G. 
 
 Gerhard, W. W., M.D., 55. 
 Germain S6e diet, 226. 
 Germs, soja and gluten, 485. 
 
 494 
 
INDEX 
 
 Gihicr, I'aiil, M.l)., iiiid tuberculosis, 
 
 410. 
 Gin, 273. 
 Glaucoma, 113. 
 Gluten biscuits, 4S7. 
 Gluten bread, 488. 
 Glycogenic matter, 447. 
 Glycosuria, temporary, 450. 
 Glycosuria, tnie, 468. 
 Goddard, Paul Beck, M.l)., 55. 
 Gonococcus of Neisser, 108. 
 Gooseberries, 350. 
 Gout, 423. 
 
 Gout, a neurosis, 429. 
 Gout and diabetes mellitus, 454, 460. 
 Gout, nature and causes of, 426. 
 Gout, rheumatic, 422. 
 Gout, treatment of, 430. 
 Grape-fmit, 344. 
 Grape-juice, 296. 
 Grapes, 331. 
 Grits, gluten, 486. 
 Gross, Samuel David, 49. 
 Guarana, 374. 
 Guava, 339. 
 Gynecology, 115. 
 
 H. 
 
 Haemoglobin, 142. 
 
 Hcemostat, 122. 
 
 Haig, Alexander, M.D., 427. 
 
 Haw, 350. 
 
 Hay- fever, 414. 
 
 Hays, Isaac, M.D., 58. 
 
 Headache, gouty, 440. 
 
 Heart, intermitting and in'egular, 435. 
 
 Heart remedies, 12S. 
 
 Hemoixhage from genitals in females, 
 
 107. 
 Hernia, initaut injections in, 119. 
 Hip-joint amputations, 20, 51. 
 Hodge, Hugh L., M.D., ^S- 
 Hospital, United States Marine, 14. 
 Hunger, starch and sugar, 4S7. 
 Hunt, Wm., M.D., 40. 
 Hydrophobia, 77. 
 Hypnotism, 186. 
 H)-podeiTnic Syiinge, 124. 
 
 I. 
 
 Immunity, 93. 
 
 Infants in Hlockley, 224. 
 
 Insane and diabetes mellitus, 455. 
 
 Intestinal toxamia, 195. 
 
 Intubation, 119. 
 
 Iron, 139. 
 
 Jackson, Samuel, M.D., 37. 
 Japanese emhia.s.sy, the first, 19. 
 Japanese Tommy, 19. 
 Jefferson Medical College, 48. 
 Jiggers, 17. 
 Jordan's tables, 305. 
 
 K. 
 
 Kalagua, 412. 
 Katabolism, 424. 
 Kidney, movable, 158. 
 Koch, 77. 
 
 Koch's law, 92, 379. 
 Kola nut, 374. 
 Koumiss, 205. 
 
 L. 
 
 Lamballe, Jobert de, 70. 
 Lane, L. C, M.D., 22. 
 Laryngeal paralysis after typhoid fever, 
 
 153- 
 Lawyer, sea, 16. 
 Lead poisoning, 212. 
 Leaves, why they turn color, 317. 
 Leguminous plants and nitrogen, 161. 
 Leidy, Joseph, M.D., 39. 
 Lemons, 345. 
 
 Levis, R. J., M.D., 34, 63. 
 Liquid air, 127. 
 Lister, Lord, 97. 
 Logan belt)-, 350. 
 Lupus \"ulgaris, 392. 
 L)-ing-in women, 105. 
 
 M. 
 McAllister family, 250. 
 McAllister, Ward, 250. 
 Macaroni, 482. 
 
 495 
 
INDEX 
 
 Maclaren, Ian, 91. 
 
 Madeira and Ward McAllister, 282. 
 
 Maderia wine, 282. 
 
 Malt extracts, 275. 
 
 Malthusian theor}', 163. 
 
 Mango, 337. 
 
 Mangosteen, 337. 
 
 Manzanillo, 14. 
 
 Maragliano's serum, 385. 
 
 Maxwell, R. T., M.D., 21. 
 
 Mayer, Dr., theory of diabetes mellitus, 
 
 452. 
 Medical supervision of families, 114. 
 Meigs, Charles D., M.D., 82. 
 Meigs, John F., M.D., 56. 
 Metabolism, 424. 
 Milk and infants, 245. 
 Milk as food, 236, 259-261. 
 Milk, condensed, 240. 
 Milk, dehvery of, etc. , 263. 
 Milk, evaporated, 240. 
 Milk, impure, 263. 
 Milk, Pasteurized, 239. 
 Milk, Pearson' s rules, 266. 
 Milk, sterilized, 238. 
 Milk supply and police power, 241. 
 Milk, tests of, 264. 
 Milk, Walker Gordon, 241. 
 Mistakes in Diagnosis, 146. 
 Mitchell, S. Weir, M.D., 45, 226. 
 Morels, 363. 
 
 Morton, Thomas G., M.D., 56. 
 Moselle wines, 286. 
 Movement cures, 185. 
 Muffins, soja, 485. 
 Mulberry, 346. 
 
 Murphy and tuberculosis, 394. 
 Murphy' s button, 116. 
 Mushrooms, 357. 
 Mushrooms, rules for gathering, 365. 
 
 N. 
 
 Napoleon III., 71. 
 
 Nash, 43. 
 
 Neale, Dr. A. T., 410. 
 
 Nelaton, 70. 
 
 Newcastle, Delaware, 87. 
 
 Nitrogen in diet, 203. 
 
 Nitrous oxide gas, 137. 
 Noodles, alphabet, 482. 
 Normal salt solution, 155. 
 Normandy, 69. 
 Nuclein, 420. 
 Nuts, 367. 
 
 Oakland, 24. 
 
 Obesity and diabetes mellitus, 454, 
 
 Oertels diet, 225. 
 
 Olives, 345. 
 
 Operations in malignant disease, 108. 
 
 Oranges, 343. 
 
 Origin of life, 98. 
 
 Pancoast, Joseph, M.D., 48. 
 
 Papaw, 308, 338. 
 
 Park, Golden Gate, 28. 
 
 Partridge berry, 348. 
 
 Pasteur, 77. 
 
 Port wine, 282. 
 
 Peach, Doctor Black, 326. 
 
 Peaches, 324. 
 
 Peaches for diabetics, 327. 
 
 Peanuts, 371. 
 
 Pears, 327. 
 
 Pecans, 372. 
 
 Penny, Professor C. L., 415. 
 
 Penrose, R. A. F., M.D., 44, 63. 
 
 Pepper, William, Jr., 36. 
 
 Pepper, William, Sr., 35. 
 
 Pessary, Goddard's, 34. 
 
 Pfeiffer, bacillus, 387. 
 
 Pharmacy and chemistry, advances in, 
 
 134- 
 Philadelphia clinics, 51. 
 Philadelphia Hospital, Blockley, 61. 
 Phloridzin, 451. 
 Pichi, 442. 
 Pine-apple, 341. 
 Piperazin, 140. 
 Pistachio nut, 373. 
 Plasmodium malarias, 147. 
 Plums, 334. 
 
 Pneumonia, chronic interstitial, 383. 
 Poem, anonymous, 489. 
 
 496 
 
INDEX 
 
 I'oke berry, 350. 
 Pomegranate, 338. 
 Preserves and canned fruits, 313. 
 Preventive medicine, 104. 
 Princeton Collej^e, ;i;i. 
 Profession in Delaware, 8g. 
 Profession in Kngiand, 76. 
 Profession in (lennany, 85. 
 Profession in Paris, 74- 
 Pranellos, 336. 
 Prunes, 336. 
 Ptomaines, 188. 
 Piiff-halis, 363. 
 
 Queensland nut, 373. 
 
 Quince, 352. 
 
 Quiz classes in Philadelphia, 42. 
 
 R. 
 
 Rabies, 78. 
 
 Rabies mephitica, 78. 
 
 Rheumatism, 418, 
 
 Rheumatism, pathogenic germ of, 419. 
 
 Rhine wines, 2S6. 
 
 Ricord, 72. 
 
 Rontgen rays, 123. 
 
 Rum, 273. 
 
 S. 
 
 Sailors, 16. 
 
 San Francisco, 13, 21, 24. 
 Sauteme, 285. 
 Schweninger diet, 225. 
 Scurvy, adult, 17. 
 Scurvy, infantile, 252. 
 Serum therapy, 137, 384. 
 Serum treatment in lower animals, 171. 
 Shellbark, 372. 
 Sheny wine, 281. 
 Shipwrecked, 67. 
 Simpson, 76, 81. 
 Sims, J- Marion, 73. 
 Skoda, 85. 
 
 Smith, Francis Gumey, M.D., 37. 
 Smith, H. H., M.D., 38. 
 Souari nut, 376. 
 Special diets, 222. 
 32 
 
 Slelwag(jn, II. W., M.l;., 60. 
 
 Strawberry, 354. 
 
 Strawbridge, (leorgc, M.D., 58. 
 
 Sugar, substitutes for, 472. 
 
 Sugar, tests for, 456. 
 
 Syme, James, M.lJ., 76, 81. 
 
 Sy])hilis, ill. 
 
 T. 
 Tamarinds, 337. 
 Tea, 214. 
 
 Tetanus and treatment of, 166. 
 Thermotherapy, 120. 
 Thyroid extract in gout, 443. 
 Toast, 230. 
 Tracheotomy, 1 1 9. 
 Travers, William R., 447. 
 Trousseau, 73- 
 Truffles, 363. 
 Tubercle, 378. 
 Tuberculin A, 384. 
 Tuberculin O, 385. 
 Tuberculin R, 385. • 
 Tuberculin in diagnosis, 388. 
 Tuberculocidin, 383. 
 Tuberculosis, 377. 
 Tuberculosis and anthrax, 410. 
 Tuberculosis, climates for, 404. 
 Tuberculosis, inhalations in, 41 1. 
 Tuberculosis in lower animals, 390. 
 Tuberculosis, prevention of, 389. 
 Tuberculosis, pulmonary, 380. 
 Tuberculosis, serums for, 408. 
 Tuberculosis, specifics for, 410. 
 Tuberculosis, treatment of, 396. 
 Tjnidall, 76. 
 Typhoid fever, 150. 
 
 Typhoid fever, second time in same in- 
 dividual, 154. 
 Typhoid septicaemia, 155- 
 Tj'phus fever, 64. 
 Tyson, Professor James, 441. 
 
 U. 
 Univei-sity of Pennsylvania, 32. 
 Uraemia, 193. 
 Urea and oxidation, 201. 
 Uric acid, source of, 419. 
 
 497 
 
INDEX 
 
 V. 
 
 Van Abbott & Sons, 481. 
 
 Velpeau, 69. 
 
 Virchow, 385. 
 
 Vivisection, 133. 
 
 Von Grafe, 85. 
 
 Von Langenbeck, 85. 
 
 W. 
 
 Wall disease, 160. 
 Walnut, black, 374. 
 W'alnut, Japan, 375- 
 
 \N'ater as a remedy, 201. 
 Watennelon, 346. 
 Wharton, H. R., M.D., 59. 
 Whey, 241. 
 Whiskey, 272. 
 Widal test, 155. 
 Winebeny, 350. 
 Wine residues, 297. 
 Wine taster, 280. 
 Wines, 276. 
 
 Wines, adulterated, 296. 
 Wood, Professor H. C, 386. 
 Woods, D. F., M.D., 58. 
 
 THE END. 
 
 498 
 
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