All History

SIMPLE ULCER OF THE STOMACH.

BY W. H. WELCH, M.D.

DEFINITION.—Simple ulcer of the stomach is usually round or oval. When of recent formation it has smooth, clean-cut, or rounded borders, without evidence of acute inflammation in its floor or in its borders. When of long duration it usually has thickened and indurated margins. The formation of the ulcer is usually attributed, in part at least, to a disturbance in nutrition and to a subsequent solution by the gastric juice of a circumscribed part of the wall of the stomach. The ulcer may be latent in its course, but it is generally characterized by one or more of the following symptoms: pain, vomiting, dyspepsia, hemorrhage from the stomach, and loss of flesh and strength. It ends frequently in recovery, but it may end in death by perforation of the stomach, by hemorrhage, or by gradual exhaustion.

TREATMENT.—In the absence of any agent which exerts a direct curative influence upon gastric ulcer the main indication for treatment is the removal of all sources of irritation from the ulcer, so that the process of repair may be impeded as little as possible.

Theoretically, this is best accomplished by giving to the stomach complete rest and by nourishing the patient by rectal alimentation. Practically, this method of administering food is attended with many difficulties, and, moreover, the nutrition of the patient eventually suffers by persistence in its employment. In most cases the patient can be more satisfactorily nourished by the stomach, and by proper selection of the diet, without causing injurious irritation of the ulcer.

At the beginning of the course of treatment it is often well to withhold for two or three days all food from the stomach and to resort to exclusive rectal feeding. In some cases with uncontrollable vomiting and after-hemorrhage from the stomach it is necessary to feed the patient exclusively by the rectum.

The substances best adapted for nutritive enemata are artificially-digested foods, such as Leube's pancreatic meat-emulsion, his beef-solution, and peptonized milk-gruel as recommended by Roberts.109 Beef-tea and eggs, which are often used for this purpose, are not to be recommended, as the former has very little nutritive value, and egg albumen is absorbed in but slight amount from the rectum. Expressed beef-juice may also be used for rectal alimentation. The peptones, although physiologically best adapted for nutritive enemata, often irritate the mucous membrane of the rectum, so that they cannot be retained. It has been proven that it is impossible to completely nourish a human being by the rectum.110 Rectal alimentation can sometimes be advantageously combined with feeding by the mouth.

109 Leube's pancreatic meat-emulsion is prepared by adding to 4-8 ounces of scraped and finely-chopped beef l-2½ ounces of fresh finely-chopped oxen's or pig's pancreas freed from fat. To the mixture is added a little lukewarm water until the consistence after stirring is that of thick gruel. The syringe used to inject this mixture should have a wide opening in the nozzle; Leube has constructed one for the purpose (Leube, Deutsches Arch. f. klin. Med., Bd. x. p. 11).

The milk-gruel is prepared by adding a thick, well-boiled gruel made from wheaten flour, arrowroot, or some other farinaceous article to an equal quantity of milk. Just before administration a dessertspoonful of liquor pancreaticus (Benger) or 5 grains of extractum pancreatis (Fairchild Bros.), with 20 grains of bicarbonate of soda, are added to the enema. This may be combined with peptonized beef-tea made according to Roberts's formula (Roberts, On the Digestive Ferments, p. 74, London, 1881).

There is universal agreement that the dietetic treatment of gastric ulcer is of much greater importance than the medicinal treatment. There is [p. 520]hardly another disease in which the beneficial effects of proper regulation of the diet are so apparent as in gastric ulcer. Those articles of food are most suitable which call into action least vigorously the secretion of gastric juice and the peristaltic movements of the stomach, which do not cause abnormal fermentations, which do not remain a long time in the stomach, and which do not mechanically irritate the surface of the ulcer. These requirements are met only by a fluid diet, and are met most satisfactorily by milk and by Leube's beef-solution.

The efficacy of a milk diet in this disease has been attested by long and manifold experience. By its adoption in many cases the pain and the vomiting are relieved, and finally disappear, and the ulcer heals. In general, fresh milk is well borne. If not, skimmed milk may be employed. If the digestion of the milk causes acidity, then a small quantity of bicarbonate of soda or some lime-water (one-fourth to one-half in bulk) may be added to the milk. Large quantities should not be taken at once. Four ounces of milk taken every two hours are generally well borne. Sometimes not more than a tablespoonful can be taken at a time without causing vomiting, and then of course the milk should be given at shorter intervals. It is desirable that the patient should receive at least a quart, and if possible two quarts, during the twenty-four hours. The milk should be slightly warmed, but in some cases cold milk may be better retained. In some instances buttermilk agrees with the patient better than sweet milk. Although many suppose that they have some idiosyncrasy as regards the digestion of milk, this idiosyncrasy is more frequently imaginary than real. Still, there are cases in which milk cannot be retained, even in small quantity.

For such cases peptonized milk often proves serviceable.111 The artificial digestion of milk as well as of other articles of food is a method generally applicable to the treatment of gastric ulcer. The main objection to peptonized milk is the aversion to it that many patients acquire on account of its bitter taste. The peptonization should not be carried beyond a slightly bitter taste. The disagreeable taste may be improved by the addition of a little Vichy or soda-water. Peptonized milk has proved to be most valuable in the treatment of gastric ulcer.

Leube's beef-solution112 is a nutritious, unirritating, and easily-digested article of diet. It can often be taken when milk is not easily or [p. 521]completely digested, or when milk becomes tiresome and disagreeable to the patient. It is relied upon mainly by Leube in his very successful treatment of gastric ulcer. A pot of the beef-solution (corresponding to a half pound of beef) is to be taken during the twenty-four hours. A tablespoonful or more may be given at a time in unsalted or but slightly salted bouillon, to which, if desired, a little of Liebig's beef-extract may be added to improve the taste. The bouillon should be absolutely free from fat. Unfortunately, not a few patients acquire such a distaste for the beef-solution that they cannot be persuaded to continue its use for any considerable length of time.

112 By means of a high temperature and of hydrochloric acid the meat enclosed in an air-tight vessel is converted into a fine emulsion and is partly digested. Its soft consistence, highly nutritious quality, and easy digestibility render this preparation of the greatest value. The beef-solution is prepared in New York satisfactorily by Mettenheimer, druggist, Sixth Avenue and Forty-fifth street, and by Dr. Rudisch, whose preparation is sold by several druggists.

Freshly-expressed beef-juice is also a fairly nutritious food, which can sometimes be employed with advantage. The juice is rendered more palatable if it is pressed from scraped or finely-chopped beef which has been slightly broiled with a little fresh butter and salt. The meat should, however, remain very rare, and the fat should be carefully removed from the juice.

To the articles of diet which have been mentioned can sometimes be added raw or soft-boiled egg in small quantity, and as an addition to the milk crumbled biscuit or wheaten bread which may be toasted, or possibly powdered rice or arrowroot or some of the infant farinaceous foods, such as Nestle's. Milk thickened with powdered cracker does not coagulate in large masses in the stomach, and is therefore sometimes better borne than ordinary milk.

For the first two or three weeks at least the patient should be confined strictly to the bill of fare here given. Nothing should be left to the discretion of the patient or of his friends. The treatment should be methodic. It is not enough to direct the patient simply to take easily-digested food, but precise directions should be given as to what kind of food is to be taken, how much is to be taken at a time, how often it is to be taken, and how it is to be prepared.

Usually, at the end of two or three weeks of this diet the patient's condition is sufficiently improved to allow greater variety in his food. Meat-broths may be given. Boiled white meat of a young fowl can now usually be taken, and agreeable dishes can be prepared with milk, beaten eggs, and farinaceous substances, such as arrowroot, rice, corn-starch, tapioca, and sago. Boiled sweetbread is also admissible. Boiled calf's brain and calf's feet are allowed by Leube at this stage of the treatment.

To these articles can soon be added a very rare beefsteak made from the soft mass scraped by a blunt instrument from a tenderloin of beef, so that all coarse and tough fibres are left behind. This may be superficially broiled with a little fresh butter. Boiled white fish, particularly cod, may also be tried.

It is especially important to avoid all coarse, mechanically-irritating food, such as brown bread, wheaten grits, oatmeal, etc.; also fatty substances, pastry, acids, highly-seasoned food, vegetables, fruit, and all kinds of spirituous liquor. The juice of oranges and of lemons can usually be taken. The food should not be taken very hot or very cold.

For at least two or three months the patient should be confined to the [p. 522]easily-digested articles of diet mentioned. These afford sufficient variety, and no license should be given to exceed the dietary prescribed by the physician. Transgression in this respect is liable to be severely punished by return of the symptoms. When there is reason to believe that the ulcer is cicatrized, the patient may gradually resume his usual diet, but often for a long time, and perhaps for life, he may be compelled to guard his diet very carefully, lest there should be a return of the disease. Should there be symptoms of a relapse, the patient should resume at once the easily-digested diet described above.

CONSTIPATION.

BY W. W. JOHNSTON, M.D.

SYNONYMS.—Costiveness, Fecal retention, Fecal accumulation, Alvine obstruction, Obstipation. Ger. Koprostase, Stuhlverstopfung, Hartleibigkeit, Kothstanung. Fr. Constipation, Paresse du ventre, Échauffement. It. Constipazione. Older synonyms: Constipatio vel obstipatio alvi; Alvus tarda, dura, adstricta; Tarda alvi dejectio; Obstipatio alvarina; Stypsis; Coprostasis (Good).

NATURE AND DEFINITION.—The act of defecation is almost wholly due to the working of an involuntary mechanism which may be set in play by the will, and is in part dominated by it, but which is frequently independent and uncontrolled by volition. Deep inspiration, closure of the glottis, downward pressure of the diaphragm, and contraction of the abdominal muscles are accessory, but not essential, to the expulsion of feces from the rectum. In certain persons, and occasionally in all persons, especially in diseases where the fecal mass is in a semi-fluid or fluid form, the strongest effort of the will cannot resist the expulsive contractions of the rectal muscle. The sphincter is kept in a state of tonic contraction by a nervous centre situated in the lumbar portion of the spinal cord. The fecal mass, supported by the bladder and the rectum, does not at first touch the sphincter; the rectum is usually empty; but when the column has been well driven into the rectum peristaltic action is excited in the rectal walls and the sphincter is firmly pressed upon. The lumbar sphincter centre is now inhibited, and the ring of muscle opens, the accessory and voluntary muscles contract, and the expulsive act is completed. In the well-ordered and healthy individual the rectal walls and the sphincter do not receive the maximum of irritation from pressure of the advancing column but once in twenty-four hours. The habit of having one movement in each day is, it may be believed, in accordance with the natural and physiological demand, although both the number and the hours of evacuating are fixed to a great extent by education. The habit once established, the mechanism of expulsion recurs at the same hour and entirely without the direction of the will. If the desire be resisted, it will be most apt not to return until the same hour on the next day.

Defecation depends for its normal character upon the healthy functioning of the organism, but especially upon the normal processes of digestion. The character of the rectal contents as to composition and consistence, and the time of the arrival of the mass at the sphincter, are [p. 639]regulated by the taking of food at stated hours and by its normal digestion and absorption. Unaltered or partly-changed remains of the ingesta pass down the bowel, mingling with the secretion from the intestinal glands and with mucus and epithelium. As this mass passes into and through the colon, being propelled by regular peristaltic waves, it acquires odor from the development of a substance which is a final product of the putrefaction of albumen.1 Gradually the more fluid elements are absorbed, and in the descending colon a less fluid or semi-solid consistence of the feces is reached. A healthy digestion and assimilation, with active and regular contractile movements of the muscular walls of the small and large intestines, are essential to normal defecation.

14. Food which has but little waste to be got rid of—as milk or beef—leaves a small residuum to be propelled along the intestine, and therefore in one sense is constipating. Insufficient food acts in the same way. An indigestible diet in excess, especially vegetable food, a large part of which is insoluble, constipates by filling the bowel with matter which cannot be got rid of, and chronic catarrh results. The stones and seeds of fruits, as cherry- and plum-stones, raspberry- and currant-seeds, husks of corn and oats, produce acute or chronic constipation with serious symptoms. Intestinal worms (generally lumbricoids) when in large numbers cause obstruction of the bowel;8 and various foreign substances taken by caprice or to take the place of food have produced the same result: among these stick cinnamon,9 sawdust,10 and clay (among the clay-eaters of the South) have been mentioned. Magnesia, insoluble pills, and other medicines sometimes form concretions in the bowel. Enteroliths and accidental concretions form in the intestinal canal and are sources of obstruction. Any foreign body is a nucleus around which concentric layers of phosphate of lime are deposited, and thus a hard calculus is formed. Gall-stones may pass into the canal and there accumulate in such numbers as to interfere with the passage of the fecal matter.

The sigmoid flexure is usually the seat of the greatest dilatation; its expansion may be a cause or a consequence of constipation.12 It may reach a maximum of distension when it fills the entire abdominal cavity, compressing all the abdominal organs and pushing the stomach, liver, [p. 644]and intestines into the thorax. In a case of this kind the circumference of the dilated part was twenty-seven inches.13 The descending colon may be distended with the sigmoid flexure, or the whole colon may be dilated from the upper part of the rectum to the cæcum;14 the same thing happens rarely in the small intestine. In one case, in which there was an accumulation of feces in the sigmoid flexure, the large intestine presented itself as two immense cylinders lying side by side, extending from the epigastrium to the pelvis.15 Each was about five and a half inches in diameter, and together they filled the abdominal cavity. The circumference of the stretched colon varies from ten to thirty inches. Pouches forming little rounded tumors are seen on the outer surface of the colon; they are sometimes hernial protrusions of the mucous membrane through the muscular coat (Wilks and Moxon), or if large they are dilatations of the pouches of the colon.16

Collections of fecal matter may be found in any portion of the colon, but more frequently in the rectum, sigmoid flexure, descending or [p. 645]transverse colon, or cæcum. They lie within the intestinal tube, partly or wholly occluding it, or within lateral pouches, forming tumors which are sometimes quite large. In this last form there is no obstacle to the free passage of feces along the canal. Fecal accumulations occur as small round, oval, or irregularly-shaped lumps (scybalæ), and are often covered with layers of transparent semi-fluid mucus, puriform mucus, or mucus in filaments. The small concretions vary in density; they may be so hard as to resist the knife, and may be mistaken for gall-stones; larger masses, semi-solid or solid, are most commonly seen in the rectum and sigmoid flexure. Here the collection may reach an immense size. In one case fifteen quarts of semi-solid, greenish-colored fecal matter were removed at the autopsy.19 In two other cases the weight of the feces found in the bowel was thirteen and a half20 and twenty-six pounds21 respectively. The whole colon from the anus to the cæcum may be filled with such a mass, as in a case mentioned by Bristowe, where the colon "was completely full of semi-solid olive-green colored feces. The small intestines were also considerably distended, ... and were filled throughout with semi-fluid olive-green contents."22

The color of these collections is black, reddish, deep green, or yellow. In composition the scybalæ, concretions, and larger masses consist of fecal matter, with unaltered vegetable fibre; they may be composed partly of skins of grapes, cherry-stones, biliary calculi, hair, woody fibre, magnesia, or other foreign substances. Where fecal concretions long remain in the intestine they acquire a hardness like stone, and can with the microscope only be distinguished from mineral matter.23 Hemorrhoidal tumors, anal fissures, perirectal abscesses, fistulæ communicating externally or with the gut, are found in connection with constipation. Abscess of the iliac fossa has been observed in the same relationship.24

SYMPTOMS.—In persons who have a daily movement an occasional interruption of two to four days may take place without local or general signs of inconvenience. It is often asserted by patients that one day's omission induces suffering, and recourse is immediately had to laxatives. This may be justified sometimes, but in the majority of cases no actual suffering follows a very rare and short constipation.25 If, however, symptoms do occur after a constipation of one to three days, there is a sense of fulness and heat about the rectum which is greater after stool; when the bowels are moved, it is with effort (provided that no enema or purgative has been taken), and the bulk of the expelled mass is much greater [p. 646]than usual, being moulded and hardened from its longer retention in the rectum. The margins of the anus are tender, and the unsatisfied feeling after stool is due to distension of the hemorrhoidal veins and oedema of the tissues around them—a condition which ends in painful or bleeding hemorrhoids. There are signs of impaired digestion, loss of appetite, a coated tongue, oppression after eating and flatulence, and distension of the abdomen. Headache is apt to be present, with flushing of the face and general discomfort or irritability of temper. These phenomena may all disappear within two or three days by a spontaneous stool or by the use of a purgative.

The skin is often parched, sallow, and is sometimes covered with eruptions, as acne, psoriasis, eczema, erythema, or prurigo. Injuries, wounds, and cracks of the skin heal slowly.

TREATMENT.—The physician can render great service by giving to parents advice which will prevent constipation in children. He should insist upon the importance of habits of regularity in defecation. At the period of puberty in young girls this is of even greater moment, and no opportunity should be lost for pointing out the danger of neglect. As a prophylactic measure in adults counsel should be given suited to the occupation. To persons leading sedentary lives the necessity of exercise ought to be made clear. In the trades little can be done, but in the case of literary men and those who read or write for many hours prevention is easier than cure. Daily exercise, walking or riding, frequent bathing with active sponging and friction of the surface, especially over the abdomen, will be of much service. Avoiding constrained positions where pressure is brought to bear upon the abdomen, as in bending forward to write, is quite an important item. Among ignorant people advice of this kind is rarely attended to, but even here the doctrine of regularity should never cease to be preached. Active business-men, especially young men, need emphatic teaching. They cannot plead ignorance for the habitual and persistent neglect of the simplest rules of health of which they are in this country so often guilty. The symptoms of indigestion which are precursors of constipation should receive due attention, and a mode of life and dietary suited to a complete digestion of the food will favor the timely and proper expulsion of waste matter.

When it is desirable to empty the bowel in acute constipation a warm-water enema for adults and children is the best means. When a laxative is necessary in case of a failure of the enema, one mild in its operation [p. 652]should be chosen—a compound rhubarb pill, one to five grains of calomel, a teaspoonful of Rochelle salts, or half a bottle to a bottle of the solution of the citrate of magnesia or the tartro-citrate of sodium. For children calomel, in doses of one-third of a grain to one grain, is one of the most certain and least objectionable. One grain of powdered rhubarb can be added to this for a more active effect.

Under such circumstances as a blocking up of the bowel with a mass of partially digested or undigested food, fruit-stones, skins, or other foreign bodies, where the symptoms are violent pain, tympanites, and vomiting, the best method is to give large enemata of warm water through a long rectal tube passed as high up as possible, and to administer calomel in doses of one to three grains, repeated every two to three hours until the bowels are moved. Cold can be applied to the abdomen to diminish tympanites and prevent inflammation. Should the constipation not yield and the pain, vomiting, and tympanites augment, the case will then be considered one of intestinal obstruction, and be treated as such.

When called upon to treat chronic constipation, the physician should remember that it is not the symptom, but its causes, to which he should direct attention. Constipation is so often a symptom, a complication, of other diseased states that its management is a matter of secondary importance. Moreover, its causes are so peculiar to the individual and depend upon so many variable habits of life that each case asks for special study. The cure is only to be found by learning the particular cause—the habit of neglect, hurried eating, the use of aperients, uterine displacement, or any of the many causes enumerated.

The digestion and all that concerns it is of primary importance, and to it attention should be at once directed. The stomach and intestinal digestion should be examined separately, and the relative power to digest different articles of food determined. A diet, then, should be selected, not with a view to correcting the constipation, but as to its suitability to the digestive capacity of the patient. No system of diet can be fixed upon as suited to every case: the aim is to secure normal digestion and absorption and normal peristalsis. Many trials may have to be made before a proper dietary can be chosen. When there is indigestion of fats and malnutrition, with pale offensive stools containing much mucus, an exclusive nitrogenous and easily digestible diet—such as is advised in the article on INTESTINAL INDIGESTION—should be prescribed. In constipation connected with membranous enteritis a similar system of diet is proper. The drugs given should be those which aid intestinal digestion, and reference must be made again to this subject, already treated of. Many cases of constipation can only be cured by this treatment; the routine treatment by purgatives and a diet of vegetables and fruits would aggravate and not relieve. A course of exclusive milk or skim-milk diet, if persevered in for some weeks, will cure cases of constipation of this kind without the use of laxatives. Of course a purgative must sometimes be given if enemata fail, but the least irritating one should be selected.

The best diet for cases of atony of the colon and rectum is one which is easily digested and has a moderate amount of waste, as a full colon will stimulate muscular action. Various articles are suggested with a view to excite peristalsis by irritation of the mucous surface, but as such substances are in themselves insoluble and innutritious, it is unwise to resort to them. The following list includes the foods suitable to such cases: Fresh vegetables, as spinach, raw or stewed tomatoes, lettuce, kale, salsify, peas, asparagus, kohlrabi, and other summer vegetables; in winter canned vegetables, if well prepared, take their place. Among fruits, fresh fruit in general, especially grapes, peaches, and oranges; dried fruit, as figs, raisins in small quantity, stewed prunes, and baked or stewed apples, can be tried.

Too much vegetable matter is harmful, as the bowel is filled with an excess of waste, much of which is undigested food; the quantity must be regulated by the appearance of the stools and by the success of the regimen. If the blockade continues obstinately, the vegetable diet should be reduced. The microscope in many cases can alone decide the amount of undigested vegetable matter. Meats are all advisable in moderation. The least digestible, as ham and veal, are to be avoided. Graham-flour bread, brown bread, or bran bread are better than bread made of the best bolted flour. The first is more digestible, and bran bread46 is thought to increase peristalsis, but this is a doubtful effect. Oatmeal well boiled, fine hominy, corn meal, or cracked wheat with milk are pleasant and digestible. A cup of café au lait at breakfast or before breakfast is the best morning drink;47 it has a laxative influence. Tea is thought to have the opposite effect. Milk at breakfast answers well for those who take it with relish. An orange on rising in the morning is a pleasant remedy.

Bernhard Naunyn (born 1839) was the pupil of Lieberkiihn, Reichert, and von Frerichs. Though the author of a number of researches, they include no important discovery. His position as the foremost diabetic authority of the time rests upon his influence for the advancement of both clinical and experimental knowledge; upon his judgment, his teaching, and his pupils; upon the fact that from his great Strassburg school have come the soundest theories, the most fruitful investigations, and the most effective treatment. 

In birth, it is to be noted that Naunyn preceded Kiilz, and was only two years younger than Cantani. He came into this field in the pioneer period when the principle of dietetic management was generally recognized, but the average practice, especially in regard to severe cases, was still a mass of ignorance and inefficiency. As late as 1886, Naunyn stood as the champion of strict carbohydrate-free diet in a German medical congress where most of the speakers opposed it. As one of the few early German followers of the Cantani system, he maintained its feasibility and ultimate benefit, and locked patients in their rooms for five months when necessary for sugar-freedom. 

With experience, he gradually introduced modifications, until the rigid and inhuman method, which a majority of physicians and patients would never adopt, became a rational individualized treatment, with a diet reckoned according to the tolerance and caloric requirements of each patient. The work of various pupils requires mention in this connection. Important investigations of metabolism established the basis for this treatment, the most notable being that of Weintraud, who proved that, instead of having an increased food requirement, diabetics could maintain equilibrium of weight and nitrogen on a diet as low as or a little lower than the normal. Minkowski discovered with von Mering the diabetes following total pancreatectomy in dogs, and established the doctrine of the internal secretion of the pancreas, as well as the first clear conception of a dextrose-nitrogen ratio. After the early acetone investigations and Gerhardt's discovery of the ferric chloride reaction had failed to reveal the cause of coma, the Naunyn school accomplished almost the entire development of the subject of clinical acidosis in the following sequence. Hallervorden (1880) discovered the high ammonia excretion, confirming an earlier discredited observation of Boussingault. Stadelmann (1883) established the presence in the urine of considerable quantities of a non-volatile acid supposed to be acrotonic, correlated the condition with Walter's previous acid intoxication experiments, and theoretically suggested the treatment with intravenous alkali infusions. Minkowski proved the excreted acid to be /8-oxybutyric, and demonstrated the presence of this acid in the blood and a diminished carbon dioxide content of the blood. He, also Naunyn and Magnus-Levy, applied the alkali therapy in practice, and the latter carried out chemical and metabolism studies which made him the recognized authority in this field. Naunyn introduced the word acidosis, saying in definition ( (4), p. 15): "With this name I designate the formation of /8-oxybutyric acid in metabolism." The Naunyn school have consistently maintained that this acidosis is an acid intoxication in the sense of Walter's experiments. They demonstrated striking temporary benefits from the alkali therapy, particularly in diminishing the danger of the change from mixed to carbohydrate-free diet; but the practical results were never equal to the theoretical expectations. With Naunyn, also, acidosis became the principal criterion of severity for the clinical classification of cases. As regards other theories, the Naunyn school have upheld the deficient utilization as opposed to the simple overproduction of sugar in diabetes. They have clearly recognized the necessary distinction between diabetes and non-diabetic glycosurias." Naunyn was next after Klemperer to recognize clinical renal glycosuria. Though observing that "the course of the disease is as variable as can be conceived," he nevertheless upholds the essential unity of diabetes, finding in heredity a link which often connects cases of the most varied types. In regard to the etiology, he considers that "it is certain that disease of the nervous system and of the pancreas can produce diabetes;" other causes seem more doubtful. The nervous disorder supposedly acts indirectly by setting up a functional disturbance in the pancreas or other organs directly concerned. Underlying everything in most cases is, in his opinion, the diabetic "Anlage" or inherited; constitutional predisposition. Naunyn has particularly supported; the conception of diabetes as a functional deficiency, to be treated by sparing the weakened function. He wisely emphasized the importance of doing this at as early a stage as possible, before the tolerance has been damaged and the glycosuria has become "ha- bitual." His plan of treatment is to withdraw carbohydrate gradually, giving large doses of sodium bicarbonate in cases with acidosis as ii, further precaution against coma. A brief increase of the ferric chloride ; reaction is not allowed to interfere with the program. When the glycosuria is successfully cleared up, the aim is if possible to place the patient on a Rubner diet, representing 35 to 40 calories; per kilogram of body weight and about 125 gm. protein, carbohydrate being gradually added and then kept at a figure safely below the tested tolerance. The views concerning exercise agree with those of previous authors; brisk walking, etc., is found beneficial; but overexertion is harmful, especially in severe cases; and some patients seem to do best on a rest cure. When sugar-freedom is not attained on simple withdrawal of carbohydrate, protein may be reduced as low as 40 to 50 gm. daily and the calories also diminished, since diabetics may remain in equilibrium on as little as 25 to 30 calories per kilogram. When necessary as a final resort, temporary under- nutrition may be employed; but prolonged under-nutrition or the loss of more than 2 kilos weight should be avoided. Loss of weight continuing over the third week of treatment requires adding carbohydrate and abandoning the attempt to stop glycosuria. Occasional fast-days are advised if necessary, but only when previous treatment has reduced the glycosuria below 1 per cent; otherwise their effect is indecisive. It is stated that such fast-days are practicable for even the severest cases, and heavy acidosis is not a contraindication; the ferric chloride reaction may diminish on a fast-day. Naunyn has not stated what limitations apply to the use of such occasional fast-days, but Magnus-Levy stipulates that they must never be more frequent than one in eight or ten days, and in very thin patients must be avoided altogether. 

Fasting is nowhere recommended as a treatment for coma by Naunyn. On the contrary, when restriction of diet produces really threatening symptoms, his plan is to add carbohydrate and give up the attempt to abolish glycosuria. Even the persistence of a very heavy ferric chloride reaction longer than two or three days is a signal for adding carbohydrate. The treatment for impending coma consists in maximal doses of bicarbonate and the free use of carbohydrates, especially milk. Naunyn had some conception of limiting the total metabolism, but meant by it only a bare maintenance diet, or the slight and temporary undernutrition mentioned above. Naunyn states that fat does not appreciably increase glycosuria; elsewhere that in very severe cases it may slightly increase glycosuria; Magnus-Levy that it never gives rise to glycosuria. Like others, Naunyn considers that fat is the chief food for the diabetic; that the introduction of fat is the most important art in diabetic cookery . He uses it to complete the full number of calories when other foods are restricted; this applies even to the severest cases on carbohydrate-free diet with strict limitation of protein, where accordingly much fat is given; his principal care is that the patient shall take enough of it; the only reason for limiting the quantity is the danger of indigestion , except when coma impends, in which case fats are replaced by carbohydrates, and butter is especially shunned because of its content of lower fatty acids. Even when sugar-freedom is attainable, certain cases are believed to show an inherent progressive downward tendency. Concerning patients emaciated down to 50 kilograms, with heavy ferric chloride reaction and the usual accompaniments, it is said: "In the face of these great difficulties and dangers, which accompany the energetic management of these very severe cases, the prospects of being successful in permanently removing glycosuria are in general not very great, and usually one will be content with a limitation of it which suffices to bring the patient into nutritive equilibrium, that is, down to 60 to 80 gm. sugar in 24 hours."

" This is commonly supposed to have been an intentional following up of the observations of Cawley, Bouchardat, and others. But according to Dr. A. E. Taylor (personal commumication) the epoch-making discovery was accidental. Dogs depancreatized for another purpose were in a courtyard with other dogs. Naunyn, perhaps mindful of the part played by insects in the history of diabetes, asked, 

"Have you tested the urine for sugar?" 

"No." 

"Do it. For where these dogs pass urine, the flies settle." 

Dr Edoardo Ughi – Italy -1886

THE CARNIVOROUS DIET IN GENERAL AND PARTIAL OBESITY

COMMUNICATION BY DR. EDOARDO UGHI Prof. of Propaedeutic Medical Clinic at the University of Parma

The method to be followed in the treatment of obesity is now the subject of lively discussion in Germany, where it appears that such an affliction is frequent due to abundant nutrition, and perhaps most of all due to the exaggerated consumption of beer. Three systems are now followed in the cure of corpulence, and each of them has valid supporters.

The first, and oldest, used without contest for many years, is that of Banting. It is based on the fact that one must eat much albumin, without starch and without fat. The exact prescription is as follows: in the morning 150 gr. of lean meat with bitter tea and 30-40 gr. of bread; at midday 150-180 gr. of lean meat with a small quantity of legumes, little wine, no beer, no farinaceous foods; in the evening 60-100 gr. of meat and later another 120 gr. In total about 170 gr. of albumin, 10 of fat and 80 of carbohydrates are administered.

The cure of Ebstein consists in giving fewer fats and carbohydrates than the body consumes, with the prescription of eating slowly and stopping at the first sense of fullness.

Oertel subtracts liquids as much as possible, with the aim of producing a desiccation of the body. He permits all foods, but in small quantity, so that the pre-existing substances must be consumed in part. He also recommends muscular exercises, both because much water is subtracted from the body through sweat, and because more fats are consumed and the respiratory muscles and heart are strengthened.

The cure of Schweninger, with which Prince Bismarck was cured, is identical to that of Oertel. He too permits all foods in small quantity, prohibits drinking during meals and prescribes muscular exercises. It cannot be denied that each of these methods is founded on good physiological arguments, and is not in disagreement with the laws that regulate material exchange. Therefore, it is no wonder that each of them is effective in achieving the goal, and is thus preferred by various authors. But objections have been raised against all of them.

It has been said that Banting’s cure should not be adopted, because it is poorly tolerated, and gives rise to gastro-enteric disturbances due to the large quantity of meat that must be introduced. Oertel’s cure is burdensome due to the thirst that must be suffered, and Ebstein’s is long and uncertain. It suffices, moreover, to read the debate that took place between these two authors and the various opinions expressed within the Medical Society of Leipzig, last year, by Wagner, Hoffmann, Heubner, Taube and others, to recognize how results and assessments vary. I therefore gladly take this occasion to bring to the attention of the medical public my not insignificant experience on the subject, having treated many sufferers of obesity over various years. I will thus be able to demonstrate the advantages of the exclusive carnivorous diet in obesity, and in general the tolerance that the organism presents for such a diet, which should therefore be more easily utilized even in other cases. It should be noted that I consider here, with many German authors, not only the general increase of fat in the organism as obesity, but also more specifically that limited to certain organs (heart), in such a way as to disturb their function and give the same phenomena as general obesity. I therefore distinguish between absolute and relative obesity.

1st Case. -- B.L. 30 yo, weighs 126 kg

1st Case. — B. L. aged 30, whose father died of apoplectic stroke and was very obese, is 1.88 m tall, weighs 126 kg, and suffers heart disturbances, without having any valvular defect: when climbing stairs, and walking at only a moderate pace, he is seized by strong shortness of breath; moreover this gentleman is affected by dyspepsia due to chronic catarrh of the ventricle. He habitually took two meals a day, a soup and a meat dish for breakfast, a soup and two dishes for dinner, plus 300 gr. of bread, and usually drank a liter and a quarter of wine and almost no water. I suspected that the aforementioned disturbances were caused by obesity and fatty infiltration of the myocardium. The weak and sometimes irregular pulse, the cardiac tones also weak and not very clear, and the arrhythmia that was observed, confirmed me more in my suspicion, so I subjected him to the following dietetic cure: For each day: lean meat from 700 to 900 gr., broth 300 gr., a bottle of wine, and when he ate a smaller quantity of meat, I allowed two or three eggs. I also prescribed that the individual maintain his habits strictly, that is, to always do that exercise to which he was accustomed, not to exert himself more than usual and to drink the usual quantity of water, etc. In five months of practicing these dietetic and hygienic prescriptions, his body weight decreased by 22 kg, that is, it went to 104 kg; the shortness of breath and heart disturbances disappeared, the conditions of digestion improved. For two years now he has returned to his habitual regimen, and his weight oscillates between 106 to 108 kg.

2nd Case. – G.L. 96.5 kg to 88 kg and maintained two years

2nd Case. — G. L. complains of dyspepsia, shortness of breath and inability to resist in the work of grocer; he is 1.73 m tall, weighs 96.500 kg; apart from obesity, I found no sick organ, except for a slight gastric catarrh due to excessive use of wine. The individual is accustomed to taking two meals a day, and in total took a soup, two dishes (sometimes meat, sometimes vegetables), 300 gr. of bread, and drank 2 or 2½ liters of wine, very little water and often made no use of it. I subjected him to the identical cure of the previous case, because in this case too I believed that obesity was the principal cause of the shortness of breath and inability to resist at work. The individual maintained his habits in work, walking, etc. After three months of said cure the weight descended to 87 kg, the shortness of breath and dyspepsia disappeared, and the individual could frankly resist, without need of tiring himself, his occupations. Two years have already passed since the cure, and the weight has oscillated between 87 to 88½ kg.

3rd Case. – Mr. U. O. 87.5 kg to 73 kg over 5 months

3rd Case. — Mr. U. O., 1.69 m tall, weighs 87½ kg, suffers no ailment, except for slight dyspnea when climbing stairs. The individual takes three meals a day: in total he eats a soup, 450 gr. of bread, 300 gr. of meat, and drinks a liter of wine, a black coffee and little or no water. For 5 months he takes 200 gr. of broth, 700 gr. of meat, two or three eggs, and drinks a liter of wine, as usual, nothing or almost no water, does not modify his occupations and habits at all. At the beginning of this cure he felt weakened, afterwards he noticed no ailment. In these five months the weight descended to 73 kg; a year has passed since the end of the cure, and now he weighs 78 kg. Currently he has no longer the slightest trace of shortness of breath.

4th Case. – C. D. 45 yo, 102 kg to 89 kg over 4 months

4th Case. — C. D. aged 45, 1.66 m tall, weighs 102 kg, and suffers from shortness of breath, frequently also from dizziness. The cardiac impulse is weak, as are the cardiac tones; after prolonged efforts the individual remains very exhausted, and then a slight degree of cyanotic color is seen on the lips, face and also hands: it is in these moments that he complains of strong dizziness, to free himself from which the individual resorts to bloodletting. I believed that following fatty infiltration of the myocardium, systolic insufficiency had arisen, hence the cyanosis, shortness of breath, dizziness due to venous stasis. This man eats moderately: a soup, 300 gr. of meat, 350 gr. of bread, drinks two liters of wine. For 4 months he abandoned the soup and bread, and reduced the wine by one liter. In this time, he took a broth of 300 gr., meat 750 to 800 gr., some eggs and one liter of wine. During the cure he did not modify his habits in working, walking, etc. at all. When the cure was finished, the weight went to 89 kg, the shortness of breath diminished, the cyanosis only occurs at some moments and in slight degree, the dizziness is much less frequent and lighter.

5th Case. – B. Appio, 35 yo, 98 kg to 88 kg

5th Case. — B. Appio aged 35, 1.60 m tall, weighs 98 kg, suffers very much from shortness of breath, somnolence, cyanosis, dizziness, sleeps a very agitated and interrupted sleep, has an irritating cough with frothy serous expectoration, and has strong edema in the lower limbs: this man finds himself almost unable to discharge his duties as a tobacco seller. In this man are found in the maximum degree all the phenomena of the previous case, and certainly they arose through the same modality, except that in B. there is severe edema in the lung, legs and perhaps also in the brain, given the disturbances already mentioned and the cries he emits at night. The examination of the heart does not permit admitting any valvular defect, only the 2nd tone of the pulmonary is found anomalous, which is much reinforced relative to the first; a fact that is explained taking into account that there is strong congestion and edema in the lung. B. eats much soup (two or three portions), 300 gr. of bread, little meat, drinks a very large quantity of water and only half a liter of wine per day. I had the individual continue for three months to take from 700 to 800 gr. of meat, some eggs, a broth of 200 gr. and his usual quantity of wine (½ liter) and water. Weighed after this time, he is no more than 88¼ kg. Now he is well; the edema in the legs and lung has disappeared, moreover all the other facts have almost dissipated, except for a slight degree of shortness of breath. The cure ended at the end of November last, and until today the patient has remained in the conditions just described. I note that this man led a sedentary life before the cure, and during the same.

6th Case. – B. G. 42 yo, 110 kg to 99 kg

6th Case. — B. G. aged 42, 1.85 m tall, weighs 110 kg, suffers from dyspepsia and has impeded movements; has dilatation of the ventricle. This subject eats a kg. of bread per day, in addition to a very abundant soup and a dish; drinks 2 or 2½ liters and little water. For three months I arranged so that the individual did not change habits, did not walk more than usual, did no work more than usual, and always drank the same quantity of water, which he was accustomed to in the past. In these three months he ate a kg. of meat and two eggs per day, and drank a liter and ¼ of wine, 300 gr. of broth per day; after this term he weighed 99 kg. During the cure he improved in digestion, and movements became easier. Having returned to the habitual diet for a year, he now weighs 102.500 kg. The phenomena of altered digestion have renewed.

7th Case. – B. Lawyer, enormously obese loses at least 15 kg

7th Case. — B. Lawyer, 1.68 m tall, is enormously obese, orthopneic, edematous (in the lower limbs); had several attacks of asystole, and due to these serious facts had to abandon his profession and go to the city. Due to the gravity of the aforementioned symptoms, it was not possible for me to establish a physical examination of the circulatory center and therefore a certain diagnosis. This gentleman was always a good eater and a discrete drinker, but I could not say the quantity of food and drink he introduced daily. I saw this gentleman only once, not being his doctor, and I advised him to the identical cure of the first two cases. After about three months of such cure, I learned that all the imposing symptoms had disappeared, but that some shortness of breath remained. A short time ago I met the aforementioned gentleman and saw that he must have decreased in weight by at least 14 or 15 kg. I hope to be able to know where he currently resides and thus specify many of the aforementioned facts.

8th Case. – B. M., 65 yo, 90 kg to 83 kg

8th Case. — B. M. aged 65, 1.55 m tall, weighs 90 kg, and is almost unable to walk due to strong dyspnea. This lady leads a sedentary life; takes daily a coffee and milk with bread, a soup, two dishes (more often meat), 200 gr. of bread and drinks a bottle of wine and very little water. I did not want her to change her habits, except in food; during the cure she therefore led an extremely sedentary life. For two months she continued to take daily 700 to 800 gr. of meat, some eggs, two broths (400 gr. in total), and her habitual bottle of wine. After this time the lady weighed only 83 kg, and walked, moderately, without shortness of breath.

9th Case. – Mrs. Z. G., 32 yo, 92 kg to 84 kg

9th Case. — Mrs. Z. G. aged 32, daughter of an extremely fat mother, weighs 92 kg, has no serious disturbance, only feels heavy, and cannot therefore attend to her affairs with that agility to which she was accustomed in past years. At night she is almost always seized by tingling in the limbs on which she lies. She uses mixed food, but prefers vegetables, and drinks a bottle of wine per day and little water. For two months I had her completely abandon vegetable foods, and allowed her a broth of about 200 gr., 700 to 800 gr. of meat, two eggs and her usual wine. This lady was always very active, and during the cure did not modify her habits at all. Weighed after the cure was finished, she was only 84 kg; she acquired complete freedom of movement, and the tingling completely disappeared.

10th Case. – G. Adele, 39 yo, 95 kg from much use of vegetable food, down to 86 kg

10th Case. — G. Adele aged 39; her father is very obese, and she weighs 95 kg, and for a long time has had shortness of breath, cough, edema in the lower limbs. This lady makes much use of vegetable food, and hardly eats meat except in winter, drinks almost a bottle of wine every day. Having made a delicate examination of the heart, I could find nothing morbid, only the tones were weak, and the radial pulse also weak and small. To explain the phenomenological syndrome, in addition to taking into account the general adiposity, I also had to resort to fatty infiltration of the myocardium and the diminished strength of the same due to this fact. For 70 days continuously she took 700 to 800 gr. of lean meat (for the previous cases too I always gave lean meat), a pair of eggs, a broth of 200 gr., and the usual quantity of wine. During this cure she did not change her habits in any way. Weighed after the cure, she was no more than 86 kg, and her sufferings had almost totally disappeared.

I add to my cases the following treated by my esteemed friend Dr. Guido Musiari.

11th Case. – Mr. Cotti Giuseppe of Noceto, 40 yo, 137 kg to 97 kg

11th Case. — Mr. Cotti Giuseppe of Noceto, aged 40, 1.88 m tall, weighs 137 kg; is not dyspneic, and it is surprising to see much agility preserved in his movements. This gentleman eats and drinks much, following which a strong dilatation of the ventricle was established. Three years ago, Mr. Cotti ingested a very strong quantity of ice-cold water, and immediately afterwards was seized by an epileptiform attack. The doctor thinking that the attack had arisen from a reflex fact (dependent on the ventricle), advised this man to follow a predominantly carnivorous diet, allowing only a very small quantity of bread, a small soup, meat at will, some eggs and a moderate quantity of wine; the patient has continued for almost three years to put into execution the prescribed diet, and in this time his body weight has diminished by 40 kg, that is, he weighs 97 kg. I note that this man used potassium bromide for a long time, the epileptiform attack still repeating from time to time, but Cottis mental faculties are not altered at all.

SUMMARY TABLE [Table showing 11 cases with columns for: Case number, Initial body weight, Diet used, Duration of cure, Final body weight, and Observations. The table details the results of the carnivorous diet treatment for each patient, showing significant weight loss and improvement in symptoms across all cases.]

From this exposition results:

1) 1st That the exclusive, or almost exclusive, carnivorous diet was well tolerated in all cases, and never gave rise to disturbances; indeed, the dyspeptics improved greatly in their sufferings, and the individuals, after becoming accustomed to it, suffered from flatulence when they returned to the ordinary diet.

2) 2nd That the carnivorous diet always produced a notable diminution of body weight, with improvement of the general state.It especially served to dissipate shortness of breath and all phenomena related to obesity of the heart and weakness of the respiratory muscles, for which Oertel so much vaunts his own method. Finally, I must add the singular observation, that in many of my patients the skin acquired through the use of meat a more intense color than it had before. Some of the men confessed to me that before the cure they also had impotence or almost impotence in coitus; after they became thin, they regained their virile potency.

Physiology gives us reason for these results, and supports them with its laws.

It is true that man can make use of all aliments, but it must be recognized however that the gastro-enteric tube is more conveniently conformed for animal foods, as in carnivores. Therefore, the carnivorous diet must be suitable for him. This moreover satisfies very well the norms to which any system of cure for corpulence must correspond, that is:

1st That the individual does not consume fats, or bodies capable of forming them, in quantity greater than that necessary for the maintenance of the body.

2nd That the individual consumes a part of the fat accumulated in the organism.

In the cases we have reported, the individuals consumed 700 gr. of lean meat per day, with slight addition of wine and other substances.

If we calculate with Voit that an adult man must, on average, introduce with food 18.3 gr. of nitrogen, in the form of albumin, and in total 328 gr. of carbon, the 700 gr. of meat are truly more than sufficient to cover the loss of nitrogen; indeed they give 23.81 gr. of nitrogen, instead of 18.3, but are totally insufficient to supply the 328 gr. of carbon. In fact, according to Voits calculations (Hermanns Handbuch der Physiologie, Bd. VI, pag. 407), it would be necessary for this purpose to eat 2620 gr. of lean meat. Let us also put in the calculation about 70-150 gr. of alcohol, contained in the wine consumed by these individuals, which, as was demonstrated by Albertoni and Lussana (On alcohol, on aldehyde and on wine ethers. Lo Sperimentale 1874), and recently repeated ad litteram by Bohland, copying the work of our compatriots without remembering it, burns almost entirely in the organism, and gives CO₂ and H₂O; nevertheless there always remains a notable deficit in the combustible carbon introduced, that is about half of the necessary, which must be covered by the fat previously accumulated in the organism, which is consumed, thus producing a notable diminution of body weight. Some of my patients did not truly show an increase beyond the ordinary in body weight and a large general deposit of fat, but instead showed well manifest the phenomena dependent on abnormal deposit of fat within the heart and respiratory muscles, whence shortness of breath and other related symptoms. Oertel justly calls attention to such a condition, and insists on the fact that his cure serves to dissipate it. I am pleased to note here that also in the cases reported by me a happy outcome was always obtained with the carnivorous diet. Regarding etiological conditions, heredity often plays a role in my patients. Few of them made use of truly superabundant food, although they belonged to the well-to-do class and had a certain alimentary budget of luxury. But in face of daily observation, that many persons with a luxury budget much greater than that of my patients, and not all of them, do not become obese, one is forced to admit for the development of such an affliction a particular disposition to the formation of fat from albuminoids and carbohydrates. It results finally that meat alone, when there is fat to burn, suffices very well to maintain life for months.

"Sir, - On Friday, January 8th, I read the account of Dr. Salisbury's treatment in the Pall Mall Gazette, and determined to try the effect of it in my own case. Seven years ago, I weighed 11 st. 12 lbs. (height, 5 ft. 9 in.), and when I trained for my college-boat I always lost five pounds. A month ago, I weighed 14 st., so I was at least two stone above my weight. If any of my lean brethren wish to know how I felt, let them put on a top coat with two stone of shot stowed away in the pockets, and wear it for a single day. When my friends congratulated me on my aldermanic appearance, their compliments were as gall and wormwood to my soul. If they had felt as I did, that the hills of life were growing steeper, and that the pleasure of living was contracting in a daily narrowing circle, they would have condoled with instead of congratulated me.

For the last six weeks, I have lived on lean meat and hot water, or its equivalent, and yesterday I weighed 13 stone. I have taken a pint of hot water (130° Fahr.) at 7 A.M.; a pint of "schoolroom-tea" with a squeeze of lemon in it at 11.30 A.M.; the same at 3.30 or 4 P.M.; and a pint of hot water (130° Fahr.) at 10 P.M.; a pound of beefsteak at 8.30 A.M.; a pound and a quarter at 1.30 P.M.; and a pound at 6.30 A.M. This has been hot, but preferably cold, and has been varied with hare, chicken, etc.

The result is this. I am a stone less in weight; I am six inches less in girth; my gouty "heirlooms," in the shape of "hereditary deposits," have disappeared; my flatulent indigestion has vanished; my mental and bodily activity have doubled; I spoke on Thursday for an hour with less effort than I did in December for ten minutes; I sleep for seven hours without moving; I can wear gloves and shoes a size smaller; I have lost my tendency to catch cold; my muscles are daily hardening; my kidneys are doing their duty nobly; my figure is altering so rapidly that my tailor is in despair, but I am triumphant.

When I have completed the course, if you will spare me room, I will finish my tale, and relate the lessons I have learnt in dietetics and therapeutics during the experiment. - Yours faithfully, Ben Rhydding, Leeds. JOHN FLETCHER LITTLE."

Anonymous, The Gathering Call, February, 1932, pp. 16-22

"We were very zealous and conscientious believers in the Testimonies and other writings of Mrs. White being given by inspiration of God until one who was very closely associated with her work and in whose integrity we had perfect confidence, told my companion and myself many things connected with that work which showed us it was subject to very much human manipulation, though our informant seemed to be trying to uphold the work as of God. We could not doubt the truth of what we heard, and when later we saw truth in the Bible which these writings contradicted, we had no hesitancy to “maintain the Bible and the Bible only as the standard of all doctrines and the basis of all reforms.”

In 1912, we were in Battle Creek for some weeks. One day while at the home of a friend she called our attention to a lady who was passing and said, “There goes Miss Fannie Bolton. Wouldn’t you like to meet her?” We replied that we should. We had once asked why she had separated from Mrs. White’s work and the answer had been given that she had told some things that she should not have told. We had never before seen Miss Bolton."

When we had opportunity we told her that we would like to have a talk with her regarding her experiences while connected with Mrs. White’s work as one who was of much interest to us was still there and had told us of some things. Miss Bolton said she would meet us that and the following afternoons in a park where we could talk without interruption. The following is a crude report of that interview just as I wrote it with pen and paper as Miss Bolton talked. I could add many items which I heard from her later, but this is all that I ever wrote down just while she told it and I have not changed any of the wording. I am sorry some personal items appear but I do not wish to change it in any way now, and nothing that I heard later discredited anything that is here written.

She [Fannie Bolton] was converted to S. D. Adventism about the year 1885. Was very zealous. Had previously attended Evanston College in Illinois. Experienced in writing essays which girls passed off as their own productions. Thru Elder George B. Starr, who had brot [sic] the “truth” to her she was called to work with Sister White. She was very conscientious in following out all instructions given in the Testimonies and discarded articles of diet condemned by them. It seemed a wonderful thing to her that she should be called upon to help in the work of a prophet of the Lord.

Elder Starr went with her to the station in Chicago where she was to meet Sister White and party and go with them to Healdsburg, California. This was about two years after she had become a Sabbath keeper. Elder Starr was anxious to personally conduct her into the presence of Sister White, but she was not readily found. He asked Eld. W. C. White regarding her whereabouts but he simply replied that she was somewhere about in the company. At last, in a corner of an eating room, rather screened off from others, she was found making a breakfast of raw oysters, with vinegar, pepper and salt in evidence before her. Sister Fannie was a young, inexperienced girl, but surprise, horror and bewilderment took possession of her. She was shocked beyond expression and Eld. Starr took her aside as he noted from the expression of her face how she felt and told her she must not let it trouble her that Sister White did this, that she needed such refreshment to fit her for her long, tiresome trip, and that raw oysters are very easily digested. But Sister White from this time seemed like a Sphinx to Sister Bolton. [See Starr’s comments, p. 118]

There was quite a party of them and they occupied a tourist car to themselves. One day she saw Eld. W. C. White enter the car with an open brown paper spread in his hand on which was a piece of bloody thick beefsteak. This looked horrible to her, but it was handed to Miss Sarah McEnterfer who cooked it an an oil stove and it was passed to the company after being cut up. Marion Davis and Fannie Bolton did not eat of it. Most or all of the others did.

"First, we may endeavor to ascertain through reliable travelers, missionaries, many of whom are educated in medicine, and resident physicians, what diseases of the skin prevail in extraordinary frequency, severity of type, or unusual form among tribes or communities, where a restricted diet of any kind has been long followed. Thus, among the natives of the northwest coast, fresh salmon forms the only food for several months, and dried or smoked salmon the exclusive or larger part for the rest of the year. The Eskimo lives almost wholly on blubber and raw meat, and other northern people mainly on pemmican. The inhabitants of some immense inland plains subsist almost entirely on fresh beef or mutton. Some tribes find their nourishment in the milk of animals. Millions of eastern people have no other diet than rice and a little fat."

Meanwhile, also contrary to our common impression, early Americans appeared to eat few vegetables. Leafy greens had short growing seasons and were ultimately considered not worth the effort. They “appeared to yield so little nutriment in proportion to labor spent in cultivation,” wrote one eighteenth-century observer, that “farmers preferred more hearty foods.” Indeed, a pioneering 1888 report for the US government written by the country’s top nutrition professor at the time concluded that Americans living wisely and economically would be best to “avoid leafy vegetables,” because they provided so little nutritional content. In New England, few farmers even had many fruit trees, because preserving fruits required equal amounts of sugar to fruit, which was far too costly. Apples were an exception, and even these, stored in barrels, lasted several months at most.

"It may safely be affirmed that all chronic diseases which afflict the human organism, aside from those arising from injuries, poisons, and infections, have their genesis and development in something we are doing every day; or at least, in something to which we expose ourselves at regulary and frequently repeated intervals. These various occurrences include drinks and food; the kind, condition and proportions of each used ; the state and rapidity with which they are taken in ; the intervals at which they are drunk and eaten, and the quantities of each consumed."

Apart from that problematic special effectiveness, still more effective in supporting Tanchouism was no doubt LeConte's further return to the charge, in 1888. By then he had been re-elected president of the University of California; and now his medium of publication was the Tenth Biennial Report of the California State Board of Health (Sacramento). On page 181 of the report, President Le Conte uses almost the same words he had used forty-two years before as a young doctor in Georgia: “It is the opinion of M. Tanchou that cancer, like insanity, increases in a direct ratio to the civilization of the country and of the people ...”

On page 182 of the Board of Health report there is a mixture of the old wording and a new, and there are new statistics: “Perhaps the habit of making necroscopic examinations may be more common in the French metropolis than it is in England, and thus a greater number of internal cancers may be detected and registered. But it is hardly reasonable to suppose that the disparity growing out of this circumstance would amount to the enormous proportion of 4 to 1.

“In view of M. Tanchou's idea, that the mortality from cancer is in direct ratio to the intensity of human civilization, it may be to some extent consolatory to the inhabitants of England to discover that their recent mortuary records, from 1860 to 1867, indicate a very remarkable increase in the death rate from this disease.”