Air, food, and Exercises: 
AN ESSAY ON THE PREDISPOSING CAUSES 
OF DISEASE. 
By A RABAGLIATI, 
M.A., M.D., F R.C.S., EDIN., 
HONORARY GYNECOLOGIST, AND LATE SENIOR HONORARY SURGEON, 
BRADFORD ROYAL INFIRMARY; 
CONSULTING MEDICAL OFFICER, BRADFORD CHILDREN’S 
HOSPITAL. 
SECON D EDITION. 
/ o 
NEW YORK : ' 
WILLIAM WOOD & CO., 
1898. 
(All tights reserved.') “ HOW LITTLE DOES HEREDITY COUNT AS COMPARED WITH 
Conditions.”—Henry George. 
“ People shelter their own Sins under Accusation of 
their Race. John Ruskin. PREFACE TO FIRST EDITION. 
The papers which form the basis of the following 
short essay originally appeared, for the most part, 
in The Scalpel, during the year 1896. They have 
been much amplified, and could indeed easily be 
amplified still more, as they probably will be if the 
essay is received with any favour. The difficulty 
has been not to say but to refrain from saying all 
that the writer thought on a subject he feels to be, 
if not the most important, the most important but 
one with which humanity can interest itself. The 
main proposition elucidated in the essay may be 
said to be this : that there are three chief pre- 
disposing causes of Disease, as there are, conversely, 
three chief predisposing causes of health ; and that 
these are Air, Food, and Exercises. In other words 
it may in the main be said to be, that proper 
relations between the human organism (and no doubt 
other organisms also, though these are not now in 
question) and Air, Food, and Exercises, give as 
their resultant Health ; while improper relations 
between the human organism and Air, Food, and 
Exercises, result in Disease. Of these three sets of 
causes, far the most important, in the writer’s view, vi. 
is Food. This, opinion is of course not peculiar to 
the writer, many medical authorities having, from 
time to time, stated substantially the same view. 
But many authorities who might perhaps agree 
with him in his main proposition, so long as it 
remained an abstract one, might refuse their assent 
if the general statement were translated into the 
concrete and particular. How the writer has been 
forced to the adoption of his general view and to 
its translation into detail, will be more or less 
evident according to the interest and attention 
which the reader may care to bring to the study of 
the essay itself. 
As a corollary to the main proposition regarding 
the predisposing causes of disease, arises the opinion, 
that if the organism is properly managed as regards 
these, then the exciting causes of disease need not 
give us much trouble or concern. The exciting 
causes of disease are such causes as cold, heat, 
rain, damp, drought, storm, wind, fatigue, the un- 
avoidable anxiety of life, and the microbes which 
we fear so much and against which we are being 
advised to take precautions so elaborate that, in 
the words of a recent French writer, their very 
ghost or spectre seems to haunt us. Certainly the 
discovery of these last seems to have added a new 
terror to life. Of course, in excess, some of these 
exciting causes, it would be impossible to withstand 
and live. A fatigued man who should fall asleep 
in the snows of Mont Blanc without any covering vii. 
would probably never wake again, however well 
he had managed himself as regards Air, Food, and 
Exercises. But even in these circumstances his 
resistance would be greater had he been properly 
fed, than if his blood had previously been for long 
loaded with digestive waste. And similarly with 
the effects of violence. An injury inflicted on a 
healthy man would have far less effect than the 
same amount of violence inflicted on a man im- 
properly fed, and in a generally unhealthy state 
of body. The former would behave like the trained 
and drilled and properly fed soldier, of whom it 
has been well said that “ he takes a great deal of 
killing ” ; while the latter would probably succumb 
to a much less amount of violence than the other 
would easily throw off. But, while no doubt a 
sufficient amount and intensity of the exciting 
causes of disease might be acting, as would kill or 
make ill any man, still the corollary is, that, when 
men and women are properly managed, the ordinary 
exciting causes experienced in daily life, will exert 
little or no effect on them. And if they are made ill 
for a time, the illness will probably be slight. This 
the writer also believes to be true as to germs and 
microbes. We must all be under the continual 
influence of these, for they appear to be almost 
omnipresent. When in good health we oxidise 
them off, and suffer nothing. It is only when we 
are ill, or it is at least mainly when we are ill, that 
is, when we are mismanaging ourselves as regards viii. 
Air, Food, and Exercises, that they have power to 
hurt us. Or at least, as is shown in the essay, one 
of the two factors in the case is determined by 
our state of health, the other being the infecting 
organisms themselves. 
It is not denied that there is a fourth predisposing 
cause of disease, viz. :—Heredity ; but gradually, 
perhaps very gradually, the writer has been driven 
by the evidence to conclude that heredity counts 
for very little as a predisposing cause of disease and 
of health, among adults at least, if not even among 
persons who have passed the tender years of early 
childhood. If ten per cent, of the diseases for which 
medical men are consulted may be ascribed to 
heredity, the writer thinks that this is an outside 
estimate. But if ten per cent, of such diseases are 
due to heredity, then ninety per cent, of them are 
acquired. If the writer’s real opinion were asked 
for, he would be disposed to say that probably 
five per cent, would be a fairer estimate for the 
hereditary diseases incident to adult humanity than 
even ten. The exact proportion, however, does not 
much concern him. He sees well enough that a 
controversy almost interminable might be raised 
on this question, and that a long and no doubt most 
interesting, and even fascinating, investigation would 
have to be entered on before the question was 
settled. If time and opportunity are given to him 
he may even be tempted to attempt to add something 
to this interesting inquiry. But at present he is ix. 
content to say that the large, the very large, propor- 
tion of the ailments of adult humanity are acquired. 
Heredity seems to determine organisation, and such 
considerations as initial resistance. But resistance at 
any moment subsequent to the moment of birth 
seems to be, if not entirely, then for the most part 
acquired. How far the views propounded in the 
essay will be accepted remains to be seen. Some 
may think them reasonable, or reasonable in the 
main. Others probably will not. The preconceptions 
of readers and thinkers regarding heredity will be to 
some extent a determining factor of their judgment 
on this point. For his own part, the writer is 
unfeignedly thankful that he has been able to free 
himself somewhat from the trammels of the opinion 
that heredity is a great cause of the diseases of 
adult life, or of what for brevity may be called 
adult disease. So vastly different has his stand- 
point become, that whereas formerly he thought 
(under the domination, as it now seems to him, of 
received opinion) that heredity was a most important 
factor in the determination of adult disease, he now 
thinks it is a very small one indeed. He is 
disposed, indeed, to go so far as to say that a 
medical man who should be allowed a free hand 
and who should have handed over to his care 1000 
children of 5 years of age carefully selected from 
dyspeptic, anaemic, consumptive, rheumatic, ecze- 
matous, gouty, influenzal, bronchitic, pneumonic, 
varicose, erysipelatous, apoplectic, diabetic, and X. 
carcinomatous parents, would be able to rear as 
many of them, or as many within from 5 to 10 
per cent., as he could of 1000 children of the same 
age carefully selected from what are supposed to 
be healthy parents. He does not know if in the 
present state of medical opinion this view will be 
considered outrageous or not. It is very difficult to 
find out what is the state of medical opinion on this 
question. When in daily life such a view has been 
propounded to the laity they have generally appeared 
staggered by it, and hence unwilling to accept it. 
The laity receive their views on this question, to 
some extent, no doubt, from their own observation, 
but still more from the medical profession. On 
the occurrence of serious and chronic illness, the 
medical man consulted almost invariably makes 
careful and even minute inquiry (among other 
things) into the family history of the patient. If 
the case be one of consumption, gout, or cancer, 
eg., the medical adviser seems to attach the 
greatest importance to the question whether other 
cases of a like nature have been known in the 
family. No wonder, therefore, if the non-medical 
public follow the lead of the experts. But the 
medical friends to whom the writer has propounded 
his views on this question of the effects of heredity 
in the transmission of disease have also, as a rule, 
seemed to think the proportions of children rear- 
able, if the comparative experiment above suggested 
could be made, would vary more than the writer xi. 
does. It would be exceedingly interesting, and 
even of the utmost possible importance, to have 
such a challenge accepted and its terms put to 
the test. It would not, perhaps, be very easy to 
have the challenge accepted ; only the State or a 
large municipality could do it. But it has seemed 
to the writer sometimes that material for at least 
one group of the children in question might, 
perhaps, be found from among those born in large 
workhouses. The more the writer thinks about the 
question, and the further his experience extends 
into what is thought to be, or what is called 
hereditary disease, the more confirmed does he be- 
come in his view. He has not found, e.g., hereditary 
headaches, that is, headaches in the sons or 
daughters of men or women who suffered in that 
way—he has not found such hereditary headaches 
more difficult to treat than headaches occurring in 
those whose parents did not suffer in such ways. He 
has been able to cure such headaches in the children 
of those who, for want of proper treatment, were 
allowed to carry them to their graves. As to 
consumption and cancer, the two diseases that in 
common opinion are associated with hereditary 
transmission, he believes that a complete answer 
can be given. In the case of consumption the 
answer has been given in the essay. The experience 
of the army and of other large bodies of men 
does not appear compatible with the view that 
consumption is a hereditary disease, while it is wholly xii. 
compatible with the view that it is acquired. As to 
cancer, he does not know whether in medical opinion, 
cancer is considered to be a hereditary disease. To 
attempt therefore to prove that it is not, might be 
like first erecting a man of straw and then knocking 
him down. But if the views advanced in the essay 
are correct, and if cancer is mainly a food-disease, 
then it is not necessary to assume that it is 
hereditary ; or at all events it is not necessary to 
assume that cancer will be more likely to occur in 
a daughter because her mother unfortunately died 
of it. The age of five years has been mentioned as 
the age of selection of the children in the challenge 
above mentioned. That is because, in the writer’s 
view, if disease is inherited, or in the comparatively 
few cases in which it certainly is inherited, the 
disease has generally either been grown out of, or 
it has destroyed the affected life by that time. 
Would he accept ihe challenge and be willing to 
carry out the experiment if the children were handed 
to him at birth ? Well ; he does not think that 
such a condition need compel him to increase his 
margin of difference by more certainly than five per 
cent. He does not in fact think it would be 
so much ; and he would feel quite confident, 
that if he were granted a total margin of io or 12 
per cent., even at birth, he would be able to win 
the challenge. The opinions which we hold are 
determined by a large number of experiences 
extending over the length of time during which xiii. 
the subjects in question have been considered. In 
proportion to the extent of the experience, and 
still more in proportion to the closeness of the 
attention which we have been able to bestow on 
our experience, will be the value of the resultant 
opinion. It would be, for the most part, quite 
impossible to analyse the various factors, which, 
in the aggregate, go to form an opinion. No memory 
could carry the details. Only the net result can 
be given, and every one will have his own estimate 
as to the value of this resulting view. For himself 
the writer can only say that closer inquiry at the 
oracle of nature, on the part of a mind, so far as 
he knows, perfectly candid and impartial at the 
outset, and more extended observation of disease 
has not made him less hopeful, but, on the contrary, 
much more hopeful in advising patients. Even if 
this state of mind should prove to be founded on 
delusion, he is thankful for an honest belief in a 
hopeful delusion. Hope is too uncommon, and 
pessimistic fear is on the other hand too common 
an attitude of mind, not to be thankful for the 
existence of the one, nor to rejoice heartily for the 
disappearance of the other. But he is convinced 
that it is no delusion, his general experience of 
practice founded on better views encouraging him 
every day to believe that, as his vision has become 
clearer, so his powers of help are greater than they 
were before. There are many disappointments still; 
but great as they are, they are fewer than formerly. xiv. 
And no doubt the management of a delicate and sus- 
ceptible organisation in his own person has been of 
much value in teaching the proper treatment of disease; 
while he believes that it has not diminished his sym- 
pathy for the weakly, the sick, or the suffering. 
There seem to be many analogies (heightening 
the belief in the unity of nature, with all that that 
may mean) between the advice offered by the medical 
adviser and that offered from a different standpoint 
by the spiritual pastor and teacher. Not the least 
of these resemblances is shown in the perfect 
simplicity of the terms with which each deals. Right 
and wrong, truth and falsehood, duty, obedience, 
hope, hate, and love are terms which all can under- 
stand, and may fairly be compared in this respect 
with the Air, Food, and Movements which form the 
subject matter of medical discourse. The doctrine 
of original sin is quite comparable with the inquiry 
into the heredity of disease; and if both seem 
difficult to understand at first sight, the difficulties 
seem to get less the more closely they are investi- 
gated. There seems to be no evil anywhere which 
is not due to breach by some one of the laws of 
nature. And both the spiritual and the medical 
adviser are at one in asserting that not impulse but 
duty, not the taking of what we like, but the liking 
of what is good for us, and moderation in the use 
of that, is the privilege of humanity; and that with- 
out self-government there is and can be no health— 
spiritual or physical. Both say to us in so many XV. 
words, that it is the glory of humanity to keep the 
body under; and, better is he that ruleth his spirit 
than he that taketh a city. And if the one says 
to us that it is futile to make clean the outside 
of the cup and of the platter, if within they are 
full of extortion and excess; so the other tells us, 
or ought to tell us, that if we make sound and 
healthy the inside of the physical body, then the 
aggressive surrounding germs will attack us in vain 
from the outside, since within there is no place or 
lodgment fit for their habitation and development. 
PREFACE TO SECOND EDITION. 
In the short space of two months, and before a 
single medical journal has reviewed the book, the first 
edition has been exhausted, and a second is called 
for. With the exception of the correction of an error 
in figures on pp. 146-7, and one or two trifling verbal 
alterations, the second edition appears in practically 
the same form as the first. On pp. 146-7 the number 
of deaths in England and Wales between the ages 
of 25 and 65 years has been altered from 227,330 to 
173,125 ; and an error or two dependent on the 
first error have been corrected. The deaths between 
5 and 65 years of age had been erroneously inserted 
in place of those occurring between 25 and 65 years. 
The error was considerable, but it did not affect the xvi. 
principle or spirit of the argument, although it 
affected somewhat its detail. 
Of criticism there has been hardly any. Of 
laudation there has been a good deal; and this 
has, no doubt, had a great influence in causing 
the rapid sale of the book. One reference to 
private criticism may perhaps be permitted. A 
medical friend writes to me in reference to my 
statement that “ carboniferous foods are, to a very 
large extent, burned off in the pulmonary apparatus 
and mucous membrane.” He says that carbon is 
oxidised by protoplasm throughout the body, and 
the carbonic acid gas is exchanged for oxygen in 
the air cells. I admit this. But still it cannot be 
denied, surely, that some combustion takes place 
also in the pulmonary apparatus and mucous 
membrane. I still think that the expression “ to a 
very large extent” is correct. In another place I say 
“ not entirely of course,” having in my mind exactly 
what my friend means by his statement regarding the 
combustion of “ protoplasm throughout the body.” 
As he goes on to say that he does not dispute my 
position that catarrhs are set up chiefly in persons 
whose blood contains waste matters, I do not think 
I need further refer to his criticism. 
One or two other matters will have to be dealt 
with, but neither time nor space allows me to do 
so now. I am very grateful for the way in which 
the essay has been, so far, received. 
December, i8gy. AIR, FOOD, AND EXERCISES. 
IN current literature, professional and lay, we are 
continually being told of the progress of medi- 
cine and surgery. I have nothing to say as to the 
latter, though, perhaps, in the words of a recent 
writer, “ the cry of operate, operate, ought to have 
(sometimes) been rather diagnose, diagnose.” But 
I do not deny, I rather re-echo the assertion, that 
when operations are necessary, they are much safer 
in the performance, and much more curative in their 
results, than they used to be. Perhaps surgical 
operations have sometimes been too rashly under- 
taken. Some authorities think they have ; but this 
is a matter of opinion. But I don’t here deal with 
surgery. As we shall see, its influence on the 
duration of life has been comparatively small, on 
the whole, though in individual instances, no doubt, 
it has been very brilliant in its results. As to 
medicine, however, what has been the result ? 
Increased length of life? On the average, yes. 
But in detail and at particular ages, what are the 
results ? They are certainly worth examination ; 
and I fear that he who carefully examines them 
will not rise from his task so full of the great 
Progress of 
Medicine : in 
what it really 
consists. 
Surgery 
excluded, from, 
scope of 
inquiry. 2 
advances of medicine as he was when he began 
his inquiry. His song will not be so full of 
jubilation and triumph as some of us seem to 
think it. Of course, I know (as who does not?) 
that while the death-rate of the whole community in 
England and Wales was 2233 per 1000 per annum 
in the years 1838-40, when the Registrar-General 
first began to compile his statistics, or 22‘63 on the 
average of 1844-5-6, it had fallen to 20’6 per 1000 
on the average of the years 1891-3, the last years 
for which the returns are available. That is no 
doubt a great advance. Measured in percentages, 
it means that in fifty years the death-rate has fallen 
nearly 8 per cent. ; or otherwise, we may perhaps say 
that the average duration of life has increased from 
44'2 years to 48'5 years in fifty years. This difference 
of 4’3 years’ increase of life, multiplied into 29,731,100, 
the estimated population of England and Wales in 
1893, means an addition of 127,843,730 years of life 
to the community in a generation. When we think 
of numbers like this, we seem to be justified in joining 
in the song of triumph which resounds on every hand; 
and I do not say that there is not much to be thank- 
ful for, so far as this result goes. This represents the 
gross sanitary advance in fifty years, what we may 
call the gross advance, medical and surgical, which 
characterises the half century. Beside it, even the 
addition of 30,000 years of life which a great ovari- 
otomist recently claimed that he had made through 
his own personal instrumentality to the life of his 
Diminished 
Death-rate. 
Increased 
length of life 
since i8j8. 3 
day and generation (great as it undoubtedly is as 
the influence effected by one man, now happily 
imitated by many others) pales into insignificance. 
It illustrates the different figures dealt with by medi- 
cine and surgery respectively. Where the surgeon 
speaks of adding thousands of years of life to his 
generation, the physician (as represented by hygiene 
and sanitation) speaks of millions. The millions, no 
doubt, include the thousands, but the total result goes 
to show that great as the influence of improved 
surgery has been, it has been comparatively small 
as compared with that of improved medicine, speak- 
ing of it in its widest sense as including sanitation. 
And further, sanitation is without drawback, while 
surgery is not. For, in considering the improvement 
effected by the latter, we are compelled to remember 
that at least some lives have been shortened, where 
surgical operations have ended fatally; since it 
cannot be contended that all the lives cut short by 
surgical operations would have terminated so soon 
had the patients been let alone. It will never be 
possible to estimate to what figures such losses would 
amount ; but, whatever they are, they ought to be 
deducted from the gross addition made to human life 
by surgery. I am not, however, about to engage in 
the task of ungenerously depreciating the beneficent 
effects of improved surgery, but am merely pointing 
out that surgery has comparatively small influence on 
the length of life of the whole community, on the one 
hand, and that, on the other, surgery is weighted with 
Surgery 
cannot be said 
to have 
increased the 
length of life 
of whole 
community. 4 
some unavoidable drawbacks which do not obtain in 
the domain of sanitation. All that is added to human 
life by sanitation is pure gain, for I think I need not 
now and here discuss the question already settled, 
whether, in saving the weaklings, sanitation can in 
any sense be said to have deteriorated the race. 
Assuming that as settled, the question remains in 
what form has the gain been effected ? The gains of 
the last fifty years, so far as I am able to judge, are 
mainly two. I speak, of course, of the gains on the 
large or great scale. We have very much diminished 
the mortality from the fevers, or what are known as the 
zymotic diseases, and we have very much diminished 
the mortality from consumption. In the five years 
1850-4, the mortality from the fevers amounted to 
5234 per million per annum on the average. In the 
five years 1875-9 it had fallen to 3911 per million per 
annum. In 1892 there died from the zymotic diseases 
in England and Wales 82,099 persons, or at the rate 
of 2792 per million per annum, out of the estimated 
population of 29,405,054. In 1893 the death-rate 
from the zymotic diseases was 3165 per million per 
annum, a rate higher than that of 1892, but still about 
40 per cent, less than that of the quinquennium 
1850-4. 
In the case of consumption the mortality in the 
five years 1850-4 was at the rate of 2811 per 
million per annum. This had fallen to 2130 per 
million per annum in the five years 1875-9; and 
in 1893 was at the rate of 1468 per million per 
Gains of the 
last jo or 60 
years, two ; 
diminution of 
Fevers ; 
diminution of 
Consumption. 5 
annum, a rate identical, it may be observed, with 
that of 1892. This is a reduction of 47 per cent, 
in the mortality from consumption, or not very 
much less than a half; and both in the case of the 
zymotic diseases and in that of consumption the 
change must be looked upon as extremely satis- 
factory. 
If now we come to inquire how it is that these 
gains have been effected, the answer is obvious. 
These changes are the result of the sanitary efforts 
of the last generation and of the present. We have 
expended vast sums in improving (sometimes even 
in creating) drainage, abolishing cellar-dwellings, 
diminishing over-crowding, opening up and widening 
narrow streets, opening public parks and recreation 
grounds, and generally in efforts to purify the air 
and abate nuisances; and we have obtained vast 
benefits as measured by the figures just stated. One 
of the incidental effects has been very much to 
benefit life at the earlier ages, and to diminish 
sickness and mortality during childhood and youth, 
since the effects of the zymotic diseases and of 
consumption are mainly felt at early ages, the large 
majority of cases of these diseases occurring under 
25 years of age. 
So far as I am able to judge, however, the 
diminution in the mortality from the fevers and 
from consumption constitutes the whole of the 
sanitary gain during the past forty years. If we 
come to think of it, it will be evident (I fancy this 6 
is generally admitted) that the results have been 
obtained by directing attention to one of the requi- 
sites of life, viz., Air. Improving drainage, abolishing 
cellar-dwellings and over-crowding, widening streets, 
and providing parks and breathing spaces, mean in 
one word, purifying the air ; and by this means all 
these gains have been effected. 
But besides the effects of providing more and 
purer air, there is another cause of the diminished 
general mortality in the United Kingdom which is 
not sufficiently emphasised. By failing to realise 
its importance, we erroneously attribute to sanitation 
effects due to another cause, so exaggerating the 
importance of sanitation, which, however, requires no 
fictitious aids to add to its consequence. I refer to 
the diminution which has taken place, and which 
appears to be still going on, in the birth-rate. The 
birth-rate rises and falls under the operation of 
various causes connected with the prosperity or 
otherwise of the people ; but speaking broadly, the 
birth-rate in England and Wales was about 35‘5 per 
iooo persons living fifty years ago, and it is about 
30'5 to 31 per 1000 now, a fall of between 12 and 13 
per cent. This fall in the birth-rate, however, though 
applying in a general way to the whole of the United 
Kingdom, is much more accentuated in some places 
and in some parts of the country than in others. It 
is more marked in the West Riding of Yorkshire, eg., 
than in London. In Bradford the birth-rate is the 
lowest, and a good deal the lowest, of all the large 
Attention to 
A ir the cause 
of these gains. 7 
towns (with populations of 200,000 inhabitants and 
over) in the United Kingdom, and its birth-rate has 
been persistently falling for a long time. Thus, in 
1881 it was 33 per 1000; in 1885 it was 29; in 1891 it 
was 28'6; in 1893, 2y6; and in 1894 it was 26-6 
per 1000 persons living. In London in 1894 the 
birth-rate was 30^9; practically the same rate as that 
of the country generally. The lowest birth-rate of 
all the large towns of England next to Bradford was 
in Nottingham, and there the birth-rate was at the 
rate of per icoo. In Bristol it was 29‘6, 
almost as low as Nottingham. In Hull it was 35. 
Now, why do I refer to this point? Because a low 
birth-rate implies a low death-rate, and a high birth- 
rate implies a high death-rate. But as we estimate 
the good effects of sanitation in accordance with the 
fall in the death-rate, we may easily overlook the 
influence which a low birth-rate has in lowering the 
death-rate. But how, it may be asked, does 
a low birth-rate lower the death-rate; and how 
does a high birth-rate increase the death-rate ? 
In this way. Of all the deaths that occur there 
take place about two-fifths of them under the 
age of 5 years. We shall see this for the country 
generally. In Bradford, in 1893,4632 deaths occurred, 
and of these 1839, or almost exactly two-fifths, took 
place under 5 years of age. But 45 per cent, of all 
the children born into the world die before they are 
5 years of age. If, therefore, a smaller number of 
children are born into the world than formerly (and 
Diminished 
Birth-rate a 
cause of the 
diminished 
Death-rate. 8 
that is the meaning of a low birth-rate), obviously 
there will be a smaller number of the population 
living to afford so high a mortality, and therefore the 
general mortality rate will prove lower, not only 
because of general improvement in the public health, 
but also because a smaller proportion of the popula- 
tion are living at what may be termed the very fatal 
ages. An illustration will make this clear. Suppose 
a town of 200,000 inhabitants has a birth-rate of 30 
per 1000, whereas formerly it had a birth-rate of 35. 
Obviously, 6qoo children will be born where 7000 
used to be: that is, 1000 fewer children will be living 
in that town under the new birth-rate than under the 
old one during a given year. Now suppose that one- 
fifth of the children born died under 1 year old 
(which I regret to say is the rate at which children 
born in Bradford died in 1893—198 per 1000). Then 
1200 children would die as against 1400 had the 
former birth-rate been maintained. This would 
reduce the deaths by 200 in a year, or 1 per 1000 per 
annum in a population of 200,000, a diminution quite 
sufficiently marked to appear to justify the statement 
that that town was at a higher level of health than 
others. 
Another point. A large proportion of all the 
cases of fever that occur, happen among children 
under 5 years of age—a large number of cases of 
measles, scarlatina, diarrhoea, &c. Now, as under 
a lower birth-rate, a smaller number of persons 
susceptible to these ailments are living at a given 
A falling 
Birth-rate 
leavers the 
Zymotic or 
Fever Death- 
rate. 9 
time, it follows that fewer of these cases will occur, 
and therefore that a lowered birth-rate lowers not 
only the general mortality as we have seen, but that 
it lowers also the zymotic or fever mortality. From 
these considerations it appears that a mere diminu- 
tion of mortality is not necessarily a mark of 
improvement in the public health, and that many 
corrections may have to be made before we are in 
a position to estimate justly the state of the public 
health, as shown in the mortality returns of the 
Registrar-General or in those of local medical officers 
of health. 
But of important agents through which health is 
greatly affected, there are, besides air, at least two 
others, and these are Food (I do not discuss the effects 
of alcohol) and Movements or Exercises. What have 
we as a people been doing in these particulars? 
Our sanitarians and medical officers of health have 
preached sanitation, and they have denounced over- 
crowding, and they have done both to some purpose ; 
but where are the instructions regarding food, and 
where are the recommendations as to methodised 
exercise or movements, whose object is to keep the 
body supple and lissome? As to the latter, it 
must be admitted that something has been done. 
Gymnastics have been introduced into the schools 
to a much larger extent than was the case thirty 
or forty years ago. And perhaps adults do pay a 
little more attention to keeping the muscles in 
exercise than used to be the case. Possibly the 
But food and 
exercises 
exert great 
influence on 
public health 
as well as air. 10 
need for doing so is better understood. In the case 
of children and young persons of school age I 
think this is so. In the case of adults we hear 
too little about the necessity of exercises. At 
any rate, whatever be the causes, and notwith- 
standing the great advances which have been 
made in reducing the death rate from fevers and 
consumption, with the consequent improvement 
in the death rate of the earlier ages of life, 
there is still very much that is unsatisfactory in 
the Registrar-General’s returns. For instance, in 
1893 there occurred in England and Wales 569,958 
deaths, and of these 216,833, or say two-fifths, 
occurred among children under 5 years of age. At 
the other extreme of life we find that 125,795 
persons attained the age of 65 years or over. Over 
85 years of age 11,570 persons died; from 75—85, 
47,170 persons died ; from 65—75, 67,055 persons 
died. In other words, adding all these three last 
numbers together, only 22 per cent, of the people, 
or very little more than one in five, attained the 
age, not of 70 years, which we look upon as the 
natural term of humanity, but an age short of 
that by 5 years. In 1892 the results were practi- 
cally the same: out of 559,684 deaths occurring in 
that year, 205,864, or about the same proportion of 
two-fifths, occurred among children under 5 years 
of age; and only 134,097, or about 24 per cent, 
of the whole, were registered as occurring above 
65 years of age. As an actual fact, then, it may be 
Too little 
attended to. 
Two-fifths of 
the total 
mortality in 
England and 
Wales takes 
place under 
5 years of age. 11 
said that to-day in England, in spite of all our 
progress in medicine and surgery, only one out of 
four or one out of five persons born into the world 
attains the age, not of 70, but even of 65 years; 
while about two-fifths of all the deaths that happen 
occur among children under 5 years of age. These 
results do not appear to be satisfactory. In our 
towns it is the same. In 1892 there were registered 
in Bradford 3927 deaths, and of these only 926, or 
23 per cent., were of persons over 65 years of age. 
I may perhaps have to refer to the rate of mortality 
among children under 5 years in Bradford, and to 
show that if it has fallen (as it has) it is because a 
smaller number of children are born than there 
used to be. 
But to pursue the inquiry into the general state of 
the public health. The result of the improvement 
effected in the last thirty or forty years, looked at as 
a whole, has been to diminish mortality at the early 
ages. More children reach maturity now than was 
the case formerly; but above the ages of 35 for men 
and of 45 for women the mortality has increased on 
the whole rather than diminished. 
Thus, comparing the rates of mortality among 
1 
males at various ages in the three years 1844-5-6, 
with that of the mortality of males at the same ages 
in 1891-2-3, the following results appear:— 
From 5—10 years of age, in the former period the 
mortality averaged 84 per 1000 living. In the 
latter period it was 4-8. From 10—15, in the former 
Only about 
one-fourth of 
the population 
reach even 6j 
years of age, 
not 70. 
Comparison 
of present rate 
of mortality 
with that of 
jo years ago 
at different 
age periods. 
Males. 12 
period it was 4‘8 per 1000 against 27 in the latter. 
From 15—20, &8 per 1000 in the former period 
against 4/2 in the latter. From 20—25, the mortality 
averaged 9 3 per 1000 in the former period against 
only 57 in the latter. From 25—35 it was 9‘6 in 
the former period and 7-5 in the latter. But from 
the ages of 35—45 the mortality was 124. per 1000 
in the former period and I2‘8, or '4 per IOOO more, in 
the latter. From ages 45—55 years, the mortality 
was 17*3 per 1000 in the former period and 20’8 in 
the latter, a very considerably higher mortality in the 
later years. And the same obtains between the ages 
of 55 and 65 years, for in the former period the 
mortality was at the rate only of 307 per 1000 while 
in the latter it was no less than 38. Going still 
higher in life (although I have hitherto spoken only 
of the mortality of persons up to 65 years of age), it 
appears that in 1844-5-6 the mortality of persons 
between 65 and 75 years of age was at the rate of 
667 per 1000, while in 1891-2-3 it was 75-8. And 
from 75—85 years of age it was in the former 
period against 152 in the latter. Above 85 years the 
ratio was rather in favour of the latter period, being 
at the rate of 3017 per 1000 against 319*1 in 
1844-5-6. 
In the case of females the following are the 
figures:—From 5—10 years of age, in 1844-5-6 the 
mortality was at the rate of 8'2 per 1000. In 
1891-2-3 it was 47. From 10—15 it was 5’2 per 
1000 in the former period against 2-8 in the latter. 
The same for 
females. 13 
From 15—20 it was 77 in the former period against 
4‘2 in the latter. From 20—25 it was 8‘8 in the 
former and 5 in the latter. From 25—35 the 
mortality was iot in 1844-5-6, against 7 in 1891-2-3. 
From 35—45 the rate was I2'2 in the earlier period 
and io‘8 in the latter. From 45—55 the rate in the 
earlier period was I5‘2 per 1000 and 16 in the latter; 
while from 55—65 it was 277 in the earlier period 
and 312 in the latter. Up to 45 years of age the 
mortality among females was considerably lower in 
the earlier period than in the latter. From 45—55 
the rates were about the same, with fractional 
worsening in the latter period. From 55—65 the 
rate of mortality was considerably worse in the latter 
period than in the earlier. At the higher ages we 
find the mortality from 65—75 years of age to have 
been 60 per 1000 in 1844-5-6, against 66‘2 in 
1891-2-3. From 75—85 it was 134T per 1000 in 
the earlier period and I40’2 in the latter; and above 
85 it was at the rate of 2967 in the earlier period 
and only 274'8 in the latter. Apparently when 
women survive to extreme old age now, they have a 
better chance of continuing to survive than they had 
fifty years ago ; but with this exception the mortality 
is now greater than it used to be at all ages above 45. 
And, as has been seen, the same thing holds for men, 
except that their increased mortality begins at 35 in 
place of 45, as is the case with women. 
In 1892 there died in England and Wales 170,104 
persons between the ages of 25 and 65 years. In 
Expectation 
of life 
now better at 
the extremes : 
scarcely any 
better at 4 
the middle 
periods. 14 
1893 I73>125 persons died at those ages. These 
deaths constituted nearly one-third of the whole 
mortality. Surely this cannot be considered satis- 
' factory. That nearly one-third of all the deaths that 
• happen should take place between the ages of 25 and 
65 years, in early adult life, in middle age, and in 
early old age, that so large a proportion of these 
deaths should happen in the very prime of life seems 
to me the opposite of satisfactory ; and considerations 
of this sort keep arising in my mind when I am told, 
as I so often am, of the enormous advances which 
have been made in medicine and surgery. A more 
suitable attitude of mind, it seems to me, instead of 
boasting of our advance, is to reflect that in a properly 
constituted society hardly any of those deaths ought 
to have happened. And what was medicine doing 
that she did not prevent them ? A few fatal accidents 
must no doubt have happened (6614 deaths occurred 
in England and Wales in 1893 from accident, between 
the ages of 25 and 65), and perhaps some few deaths 
must have occurred from unavoidable causes among 
such large numbers of people, but if 20 per cent, were 
set aside for such contingencies (and surely that is 
a large proportion), the fact remains—the appalling 
fact, it seems to me—that something like 136,000 
people lost their lives in England and Wales in the 
year 1892 who ought not to have died. And they 
fell, with all the obligations of life on them still 
unfulfilled, leaving children fatherless and motherless, 
and in most cases unprovided for, the while that we 
About 
one-third of 
total mortality 
still 
occurs between 
23 and 63 
years of age ; 
that is, in the 
prime of life. 
136,000 
persons died 
in England 
in 1892 
between ages 
of 25 and 63 
years ; 
and this after 15 
are looking on, and continually singing triumphant 
songs about the great progress of medicine and 
surgery. They have advanced no doubt. Bacon’s 
aphorism regarding medicine, that it has been magis 
elaborata quam amplificata, rather laboured than 
advanced, is, I was going to say, true no longer ; but 
really, in view of the facts just quoted regarding the 
mortality at the middle periods of life, I do not know 
if I am justified in saying so. But I certainly am 
justified in saying that, whatever advances have been 
made, there is still much, very much room for improve- 
ment. 
Let us try to see further into the facts. Of the 
569,958 deaths occurring in England and Wales in 
1893, 216,833 were deaths of children under 5 years 
of age, almost exactly two out of five. Of what 
did the other three die? There were 353,125 deaths 
remaining to be accounted for, after deducting the 
deaths of children under five years of age, and of 
these 173,125 persons died between the ages of 25 
and 65. Of what did they die? But, first of all, 
why did they die at all ; or if 20 per cent, of the 
number must have succumbed to the unavoidable 
risks of life, what about the 138,500 or so remaining? 
And, as I asked before, what was medicine doing that 
she did not prevent them ? If human beings have 
vitality enough to reach the age of 25 or 30 or 35 
years, why should they not live to the ordinary term 
of humanity ? Why not, at any rate, to 65, if not 
70? It is for medicine to say why. I think it must 
deducting 
one-fifth for 
possibly 
unavoidable 
causes. 16 
be taken as a principle that if human beings have 
energy enough to live to adult age, they ought to 
live to old age, or at least to the three score years 
and ten which have for so long been considered the 
term of human life. In other words, death before 
70, or at any rate before 65 (which is giving a full 
margin of five years, and making by so much less 
the task of medicine), death before 65 years of age 
is preventable, and ought to be prevented. With 
this principle in our minds, let us proceed in our 
’ inquiry. The commonest cause of death in England 
is bronchitis. It is also an increasing cause of death, 
as we shall see. It is supposed to be due to cold, 
but the climate is no colder than it was a generation 
ago. I am going to call in question the belief that 
bronchitis is due to cold. I am sure that bronchitis 
is far more the effect of improper feeding than of 
cold. I am certain, in other words, that bronchitis 
is far more a matter of food than a matter of 
climate. I believe that cold is often the exciting 
cause of bronchitis, but I think heat is as often 
the exciting cause. The true statement, I suppose, 
is that in those predisposed to it cold is often the 
exciting cause, and so is heat, but that without 
the predisposition neither cold nor heat would induce 
bronchitis, for I believe that humanity is intended 
and fitted to endure without damage both cold and 
heat. And predisposition—what is that ? I believe 
that predisposition can, theoretically, in most cases 
of disease, and as a matter of fact, and practically 
Bronchitis the 
commonest 
cause of death 
in England, 
accounts for 
about 
one-tenth of 
mortality. 
Is Bronchitis 
due to cold ? 17 
in nearly all cases of bronchitis, be defined in terms 
of the influence on the economy of air, food, and 
work. As I must return to this question later, I will 
here go on to say that in 1893, among the persons 
who passed the deadly age of nothing to 5 years, 
there occurred 34,114 deaths from bronchitis, or 9'6 
per cent, of the 353,125 deaths which, as we have 
seen, occurred in England in 1893 among persons 
over 5 years of age. Pneumonia (also an increasing 
cause of mortality) accounted for 22,464 deaths over 
5 years of age, or 63 per cent, of the 353,125 to 
be accounted for. From asthma there occurred 2282 
deaths, or -6 per cent. I add asthma to bronchitis, 
because I believe it to be nearly always catarrhal, as 
bronchitis is, and as pneumonia often is; for “pure 
spasmodic asthma” is so rare that I at least do not 
remember one case of it in the last ten years; and 
the cases I saw before that time only seemed so 
through my ignorance, and because of the tyranny of 
the preconceptions handed down to me from a 
bygone generation. These three diseases then— 
bronchitis, pneumonia, and asthma—accounted for 
16 3 per cent., or about one-sixth of the 353,125 deaths 
in England over 5 years of age. From diseases of the 
circulation (heart and vessels) there occurred 47,678 
deaths out of the 353,125 to be accounted for, or 13*5 
per cent, (only 780 deaths occurred from this cause 
under 5 years of age, so that in infancy it is 
practically of no moment as a cause of mortality). 
But it seems to me that apoplexy, although classified 
Pneumonia 
also an 
increasing 
cause of death. 
Further 
analysis of 
mortality. 
Diseases of 
circulation. 18 
among diseases of the nervous system, is really a 
disease of the arteries, as, indeed, so is hemiplegia for 
the most part, so I think we ought to add the 24,291 
deaths from these causes (nearly 7 per cent, of the 
353425) to the 13*5 per cent, caused by diseases of 
the circulation, which would then stand at 20'5 per 
cent, of the whole mortality above 5 years of age. 
From phthisis and scrofula there took place 44,579 
deaths, or 12‘6 per cent, of those to be accounted for. 
Cancer (from which hardly any deaths occur under 5 
years of age, only 94 deaths being due to it in 1893) 
accounted for 21,041 deaths, or nearly 6 per cent.; 
and from diseases of the digestive system 19,997 
deaths occurred, or 5-6 per cent. By these causes 
we have accounted for 68 per cent, of the total 
mortality above 5 years of age, leaving to be 
accounted for 32 per cent., as the effect of the 
continued fevers, the parasitic diseases, dietetic 
diseases, accidental causes, violence, old age, and 
ill-defined causes of death. 
I suppose it will be admitted that the diseases 
from which a people are suffering are an index 
of the habits of that people. If certain diseases 
are increasing as causes of mortality, I take it that 
there must be reasons for that in the habits of the 
people. Now habits appear to resolve themselves, 
not wholly perhaps but mainly, into the continuous 
effects on the economy of air, food, and work, or 
exercises or methodised movements. 
Of course accident and violence are causes of 
Consumption, 
Cancer. 
Diseases of a 
people are 
an index of 
the habits of 
that people. 19 
death, but in comparing past periods with the present 
in the history of this people, is there any reason to 
think that accident and violence are commoner as 
causes of death than they were ? I think not. 
Legislation has been active in this direction as well 
as in others; and in compulsory fencing of machinery, 
defence from dangerous places, compensation for 
injuries sustained in the prosecution of daily occupa- 
tion (which, if not compulsory, is at least much more 
common than it used to be), and in other ways, has 
taken what steps it could in the way of preventing 
death from accident and violence. I do not know 
that much importance can be attached to the figures, 
and I do not lay much stress on them, but so far as 
can be made out there is no increase of mortality 
under this heading among the people cf England, but 
if anything there is a diminution. Thus the deaths 
returned as from accident in 1868 were in the pro- 
portion of 30,867 to 1,000,000 deaths from all causes, 
while in 1893, a quarter of a century afterwards, they 
were at the rate of 29,615 to 1,000,000 deaths from 
all causes. There is at least no increase of mortality 
from this cause. In 1868 there were 681 deaths 
returned as due to accident and negligence per 
million persons living; in 1880 there were 589 per 
million living; and in 1892 there were 553. But 
if death from accident and violence is not increasing, 
but, if anything, diminishing in the country (and 
after all accident is a comparatively small cause of 
mortality), it will be interesting to inquire what 
Accident not 
so important a 
cause of 
mortality as 
before. 20 
diseases are increasing in fatality. It is evident 
that some must be increasing, since we have seen 
that a great diminution of death from fever and 
from consumption has occurred, and yet that the 
mortality of men from 35 to 65 years of age is 
rather greater, or at least no less than it was forty 
years ago. Here are some figures which seem rather 
striking. Bronchitis is the commonest cause of 
death in England. It accounts for something 
like one-tenth of the total mortality, or in other 
words something like 100,000 deaths out of every 
million deaths that occur take place from bronchitis. 
This is sometimes called the proportional number, 
and I propose to make use of this expression. 
Comparing then the mortality from bronchitis in 
various years, we find that the proportional number 
to a million deaths from all causes was 67,765 in 
1868; 89,346 in 1869; 109,881 in 1880; 119,455 in 
1892; and 99,456 in 1893. With the usual ups and 
downs that characterise statistical figures, like the 
rising tide which overtops a rock and then falls back 
for some time, rising again till not only that but other 
and higher points are submerged in turn, it is plain 
that bronchitis is now a rising or increasing cause of 
death, and that it accounts for a larger proportion of 
the total mortality than it used to do. In other 
words, its proportional number is greater. From con- 
sumption on the other hand the proportional number 
is smaller. Thus in 1868 its proportional number 
was 107,869; in 1869, 106,422; in 1880,91,414; and 
Proportional 
number 
of Bronchitis 
increasing. 
Proportional 
number of 
Consumption 
diminishing. 
Heredity not 
the cause of 
this. 21 
in 1893, only 76,553. We know the causes of this 
fall, as has been already said ; and they are, in one 
word, sanitation leading to the purification of air. 
Heredity is not the cause. We have not treated the 
ancestors of persons suffering from phthisis ; we have 
treated their children, the persons themselves, not 
indeed altogether those whom we found suffering 
from the disease, but those who might suffer. And 
we have treated these potentially phthisical people 
by supplying them with a larger amount of air and of 
cubic space per head. This is particularly noticeable 
in the case of the army and other large assemblages 
of men, such as inhabit prisons and penitentiaries. 
The commission which sat in 1858 to investigate the 
causes of consumption in the army after the Crimean 
war did not, in making their recommendations to 
Parliament, say one word as to the family history of 
our soldiers. They did not, so far as I know, throw 
out a single hint that it was desirable to recruit the 
army from men in whose families consumption was 
not prevalent. It did not seem to have occurred to 
them to inquire whether the parents or brothers or 
sisters, not to mention grandparents, uncles, aunts, 
or cousins, of the recruits had suffered from con- 
sumption, or whether, as the phrase is, consumption 
was prevalent in their families. The men themselves 
were to be accepted or rejected on the merits of their 
personal state or personal history, just as was the 
case before the inquiry, and as has been the case 
since. What the commission recommended was that 22 
after the men were enlisted the cubic space allotted 
to them in barracks should be very considerably 
increased; and when the recommendation was carried 
out, the mortality from consumption fell, as is well 
known, from 12 per 1000 per annum, at which point 
it stood about the time of the Crimean war, to V2 
per 1000, or exactly one-tenth of its former rate. 
Similar results have followed the provision of a larger 
air-space to residents of prisons and penitentiaries, 
not to speak of hospitals and infirmaries. And 
similar results, though not quite so satisfactory, 
because governmental or municipal control of the 
civil population is not so complete as it is in the case 
of soldiers and prisoners, have followed better 
sanitary conditions among the people at large. Place 
the soldiers back again, place the prisoners back 
again, place the community back again in the old 
conditions as to cubic space or as to cellar dwellings, 
over-crowding, narrow streets and absence of public 
parks, and the former rate of mortality from phthisis 
will recur, whatever care we exercise in choosing our 
population from families free from the taint of 
consumption. 
Then as to pneumonia, the proportional number 
of deaths from this disease in 1868 was 41,761; in 
1880 it was 47,728 ; in 1892 it had risen to 65,914 ; 
and in 1893 it was 67,104. It is clear that this also 
is an increasing cause of mortality. 
Other increasing causes of mortality are apoplexy, 
diabetes, and cancer. 
Proportional 
number of 
Pneumonia 
increasing. 23 
From apoplexy in 1868 the proportional number 
of deaths was 22,258 to a million deaths from all 
causes; in 1869 it was 22,506; in 1880 it was 
27,095; in 1892 it was 30,603; and in 1893, 29,737. 
As to cancer, as is well known, the facts are very 
striking. Thus in 1868 the proportional number of 
this disease was 18,627 ; in 1869 it was 18,964 ; in 
1880 it was 25,189; in 1892 it was 36,365 ; and in 
1893, 37,082. The proportional number of this 
terrible disease has all but doubled in twenty-five 
years. It is, however, somewhat reassuring to notice, 
and the fact should not be forgotten, that the 
increase in the proportional number of cancer is by 
no means equal to the diminution in that of phthisis ; 
or in other words we have as a people gained very 
much more by the saving effected by the decrease of 
consumption than we have lost by the increase of 
cancer. Cancer, on the worst view that can be 
taken of it, is not among the commonest causes of 
mortality ; it is, for instance, not to be compared 
with bronchitis, or pneumonia, or consumption ; 
while, as compared with the aggregate of these three 
causes, it may almost be considered a bagatelle. 
Diabetes is a very small cause of mortality ; but, as 
in the case of cancer, the increase is very marked. 
Thus in 1868 the proportional number was 1408; 
in 1869, 1496; in 1880 it was 2008; in 1892 it 
was 3593 ; and in 1893, 3653. It has more than 
doubled in a quarter of a century. Something may 
perhaps be due in respect of diabetes to better 
Also of 
Apoplexy. 
Cancer. 
Much more, 
however, 
gained by 
diminution of 
Consumption 
than lost by 
increase of 
Cancer. 
Diabetes. 
Better 
diagnosis not 
the main 
cause of these 
changes. 24 
diagnosis, and to more accurate naming. Less 
attention was paid to diabetes twenty-five years ago 
than is paid now, and I think probably the diagnosis 
was less exact. But I do not think that this holds 
good of any of the other diseases I have referred to. 
My recollection goes easily back to 1868. I think 
that medical men could and did as easily differentiate 
bronchitis from pneumonia, and both from phthisis, 
as they do now. If some cases of bronchitis were 
returned under the heading of phthisis, I think a 
similar proportion of cases of phthisis were included 
under that of bronchitis, and the same I believe to be 
the case as to pneumonia. And I think the diagnosis 
of cancer and even diabetes was correct enough 
twenty-five years ago to ensure practical accuracy 
and to eliminate substantial error, so that I do not 
think that mere change of naming accounts for 
much of the change under these headings, though 
it may account for some. As to apoplexy, its 
diagnosis was, I think, as substantially accurate in 
1868 as it is now. It seems, therefore, that we must 
admit a considerable real increase, as well as an 
apparent one, in the incidence of these diseases. As 
to cancer, some have said that as it is an affection 
of advancing life, and as there are more persons 
living now at advanced ages than there used to be, 
we must expect a larger proportion of cases of 
cancer, the inference being that we should even 
welcome their occurrence as a proof that we are 
living longer than we used to. But surely this fact 25 
(if it is one) could not account for a doubling in the 
proportional number of cases of cancer. Granting, 
for the sake of argument, that it justifies the 
expectation of an increase, I do not think it can 
possibly account for such an increase. This con- 
sideration dissatisfies me with the view just referred 
to. 
I have seen so large a number of young women, 
say from 20—30 years of age, suffering from cancer, 
that it has sometimes seemed to me as if cancer was 
attacking the population at the present time at earlier 
ages than it used to do. This impression was so 
strong on my mind that I thought it well to inquire 
further into it. On further examination, however, it 
does not seem as if the impression is a sound one. 
A fair method of making the inquiry appeared to be 
to find what proportion the cases of cancer appearing 
at ages, say 25—35, 35—45. and 45—55, bore to the 
total mortality from cancer at different periods of time, 
say twenty-five years apart from one another. When 
this is done for 1868 and for 1893, the following facts 
appear :—In 1868, out of a total mortality from cancer 
of 8880 cases, 366, or 4 per cent., occurred among 
persons from 25—35 years of age. In 1893, 638, or 
3 per cent., out of 21,135 cases occurred. At ages 35— 
45, 115 1 cases, or 12 per cent, of the total, occurred in 
1868 : in 1893, 2225 deaths occurred, or iO'5 per cent. 
Between the ages of 45 and 55 years, 2086 cases 
occurred in 1868, or 24 per cent of the whole; at 
the same ages in 1893, 4648 cases occurred, or 22 
Is Cancer 
appearing at 
earlier ages 
now than 
formerly ? 
No. 26 
per cent. The figures do not come out as I expected. 
In fact, so far as they go, they appear to show that 
cancer is appearing rather later in life than it used to 
do, not earlier as I feared ; and it must be said of an 
inquiry of this sort that it only shows how much 
mistaken one may be, and how unwise it is to trust 
to impressions if facts can by any means be obtained 
instead. I can only suppose that seeing a con- 
siderable number of cases occurring in somewhat 
early life so impressed and depressed one by the 
experience as to lead one to attribute an exaggerated 
importance to them, and to make unwarranted 
inferences from them. 
Before going further I think I ought to set down 
one or two considerations regarding cancer and 
conclusions I have arrived at, because they form part 
of the argument to be advanced later. First of all, 
cancer appears to me to be a dyscrasia or culmination 
of mal-nutrition in tissue. When any part of the 
body gets into this dyscrasic ill-nourished state, it 
breaks down into a softish invasive or aggressive 
tissue, which involves neighbouring parts in similar 
action, spreading along the lymphatics and involving 
the glands, and destroying the patient by exhaustion. 
It is very often accompanied by passive effusion of 
large quantities, even pints of fluid into the serous 
cavity nearest to the site of the disease. Thus pints 
of fluid may be found in the pleural cavity after 
death from mammary cancer, or in the peritoneum 
from uterine cancer. (The first stage of cancerous 
Propositions 
1-egarding 
Cancer. 
It is the 
culmination of 
mal-nutrition 
in tissue. 27 
growth often takes the form of stony hardness, but 
this gives way to softening, and sooner or later, to 
ulceration in every case.) This cancerous dyscrasia 
is, however, as I have said, only the culmination, or 
the final stage in a long series of processes, each of 
which is a mark of ill-health, such as tonsillitis, 
pharyngitis, dyspepsia, anaemia, bronchitis, pneu- 
monia, asthma, rheumatism, or rheumatoid arthritis, 
leucorrhoea with dysuria, which affections have pre- 
ceded the onset of the malignant or cancerous disease.' 
These affections, or some of them, have generally 
been present for years before the cancerous changes 
appeared. I do not of course say that the person 
suffering from cancer will be found to have suffered 
from all of these affections, though some will, but 
almost all will be found to have suffered from some 
one or other of them ; and in some cases malignant 
disease is present, along with the milder disorders 
mentioned. Thus, one of my colleagues at the 
Bradford Infirmary asked me to see a woman, aged 
about 50, in whom he had accidentally discovered 
cancer in the cervix uteri. She had no symptoms of 
any moment; and I corroborated his diagnosis. The 
woman was being treated for rheumatoid arthritis, 
having the finger-joints enlarged, thickened, stiff, and 
more or less painful, when her faial but previously- 
unsuspected cancer was discovered. 
Miss H., set. 45, had her left breast removed for 
carcinoma in Bradford in 1895. At that time she was 
suffering so severely from lumbago that she would 
Always 
preceded by 
o?ie or more of 
a succession 
of minor 
ailments, 
commencing 
generally with 
indigestion. 28 
have had to be in bed on that account alone, even if 
no question as to the state of the breast had arisen at 
all. 
Mrs. M. came to me in 1895 with a recurrence of 
scirrhous cancer of the mamma, which I had removed 
eighteen months before. She was 66 years of age 
and was then suffering besides from bronchitis with 
over-distension of the air-cells, and had a weak, 
flabby, dilated heart. The cancer was in her case 
only the culmination of a long series of steps in mal- 
nutrition which, even if they had occurred without the 
onset of cancer, would have been of themselves 
sufficient to destroy life. I dare say it will be said 
that cases like these prove nothing, since any one may 
have lumbago, or rheumatoid arthritis, or bronchitis, 
or emphysema, or a weak, flabby, dilated heart, while 
comparatively few suffer from cancer. But I think, 
on the other hand, that if in person after person who 
presents herself to us suffering from cancer we find 
(as we generally do) on inquiry a history of long- 
continued suffering from dyspepsia, or rheumatism, 
or gout, or bronchitis, we cannot put the previous or 
concomitant affections down as accidental, or think 
that no importance should be attached to them. It 
seems to me that the proper view to take is to con- 
sider these ailments as steps in the general process of 
continuous ill-health and to view the cancer as the 
culmination of that process. Apoplexy and Bright’s 
disease are other terminations of this long-continued 
process of mal-nutrition ; and these affections often 29 
terminate life in persons who, had they lived, would 
or might have suffered from cancer. And at any 
time of course such persons are liable to be carried 
off by an intercurrent attack of broncho-pneumonia 
or of influenza, &c. There seems, however, to be in 
operation, generally, or as a rule, what we may view 
as a particular case of the general law of parcimony 
in respect of the occurrence of fatal disease in the 
body. When one fatal disease is in operation it is 
not usual to find also another present in the same 
person at the same time. There are exceptions to 
this rule, no doubt, as when what is popularly termed 
“ a complication of diseases ” is present. And, no 
doubt, degeneration, when it takes place, is apt to be 
general, a weak, dilated, and flabby heart being 
present, as well as bronchitis and emphysema, along 
with the concurrence of albuminuria, and so on. But 
generally speaking the weakness manifested by 
patients is apt to take a particular form, and we see 
them suffering from pneumonia alone, or bronchitis 
alone, or rheumatism alone (and yet how many 
rheumatic persons are continually “ taking cold ” as 
it is called), or cancer alone, or apoplexy alone. It 
would probably be more correct to say that these 
affections rise into such prominence as to over- 
shadow the others, since when a patient is about to 
succumb to a fatal disease it is often a matter of 
accident whether he falls before this, that, or the 
other. 
How do these various diseases arise ? They for 
Law of 
■parcimony in 
disease. 
How various 
diseases arise. 30 
the most part begin with dyspepsia or indigestion, 
very often of the fermentative sort, the patient 
complaining of being blown up with wind after 
eating, or of having pain or heartburn. This leads to 
imperfect formation of chyme and chyle, which in 
turn leads to imperfect formation of blood. Very 
often such persons have lost their teeth, which decay 
and break away owing to continued exposure to a 
too acid state of the secretions. The imperfectly- 
made blood is loaded with undigested particles which 
it carries to the tissues. These in turn are not 
properly nourished, and various consequences ensue, 
the chief of which may be summed up in one 
word: that the tissues which ought to have been 
firm, elastic, and resilient, become soft, swollen, and 
flabby, and prone to various inflammatory disorders. 
Thus the muscles ache when used, and weariness sets 
in after very slight exertion; mucous membranes 
become soft and swollen, and various catarrhal con- 
ditions ensue, as tracheitis, bronchitis, diarrhoea, 
leucorrhoea, sore throats, headaches, or herpetic 
eruptions on the lips; and “ colds ” occur too easily 
and seemingly without cause, or from insufficient 
cause; or rheumatism may occur, or an attack of 
rheumatic fever; while later in life some of the 
graver or more chronic forms of disease may appear, 
as diabetes, Bright’s disease, or heart disease. If 
things go on, still more grave conditions may arise ; 
an intercurrent attack of severe broncho-pneumonia 
or of influenza, followed or accompanied by pneu- 31 
monia, may make its appearance and perhaps even 
carry off the patient. 
Before, however, these, or the gravest of these 
affections have shown themselves, a condition has 
arisen, I think in all cases, but certainly in almost 
all, to which comparatively little importance has 
been attached, and which, indeed, to a large extent, 
appears to have escaped notice. I have just referred 
to the state that the blood gets into as a consequence 
of indigestion, and as the effect of the mal-assimi- 
lation of food, and of the imperfect elaboration of the 
digestive juices, whose function it is to refresh and 
enrich the blood. The blood in that case becomes 
loaded with waste matters which ought to have been 
oxidised off; and the corpuscles themselves, instead 
of being round and smooth, and sliding or gliding 
along one another as a rouleau of coins does, become 
serrated at the edges and sticky and adherent 
to one another, and to the interior of the blood- 
vessels in which they flow. One inevitable result of 
this, as all know, is that passive congestion of the 
tissues takes place, that the interiors of the vessels 
become blocked by the opposition offered to the flow 
of the blood along their course, and especially along 
the finest capillaries, and that in short the inflamma- 
tory process has begun. Of this, as it has been so 
long and thoroughly studied, I do not propose to say 
anything. Every one knows how exudation occurs 
and how effusion and fibrinous deposition takes place 
in the cellular tissue, or in the heart valves or other 
Occurrence of 
■passive 
congestion of 
m uscle-sheaths. 
Perimysitis. 32 
places, and the dire consequences of this are well 
known. But it is to a condition anterior to this that 
I wish to draw attention. Before these gross damages 
have taken place in the body, slighter changes have 
occurred which can always be detected by examina- 
tion, but which nevertheless seem to me to have 
attracted far too little notice. I do not know that I 
can better draw attention to this than by means of an 
illustration. If a stockbroker or private individual 
has taken up more stock than he can carry, he is 
obliged to unload, and this he does on to the public, 
or on to his friends as he can, by disposing of his 
stock by sale or otherwise. The blood loaded with 
waste unoxidised particles, as I have described, from 
the digestive system, finds itself compelled, so to say, 
to unload. The combustion taking place in the 
bronchial mucous membrane does not go on quickly 
enough to rid the blood of the waste unoxidised 
material. The blood then quietly deposits its extra 
load in the least hurtful places, and as the blood 
courses along the vessels lying in the muscle-sheaths, 
and in the muscle-septa (where every surgeon knows 
he must pick up the vessels which he wishes to tie 
during his operations, and where every anatomist 
knows he must trace them out during his dissection), 
it drops there as much of the waste material as it can 
get rid of. The consequence of this process is that 
these muscle-sheaths become passively congested and 
loaded with waste matter. I have no doubt at all that 
this passive congestion, and the presence of this waste 33 
matter in the muscle-sheaths, is the main cause of the 
weariness and facility of fatigue from which so many 
people suffer, as well as of the nameless pain and 
spreading aching which passes along their limbs after 
even slight exertion. Some hours, say three or four, 
after a meal it has happened to many persons that 
they feel a sudden weariness for which they cannot 
account, and for which the little exertion they have 
undergone is no sufficient reason. What is the cause 
of this? They are often puzzled by it, and inquire of 
the doctor as to the cause. The cause is that the 
time has come in the digestive process when the food, 
or some of it, has found its way, in the form of chyle, 
into the general circulation ; that, the food being 
imperfectly assimilated, the chyle has been imper- 
fectly made or formed ; that unelaborated material 
has therefore been poured into the blood current; 
that the blood has therefore been loaded with waste 
and unassimilated materials which it at once begins 
to relieve itself of, and by preference it relieves itself 
by depositing these on the muscle-sheaths, which, 
therefore, do not work smoothly and easily. They 
appear to cry out for fatigue, whereas in fact 
they cry out because they are more or less 
poisoned by bad blood containing ptomaines 
and other unassimilated materials. The blood is 
said to contain uric acid. No doubt it often 
does ; but it is very unlikely that uric acid 
is the only poison carried by the blood to the 
tissues. No doubt other materials mentioned in 
Weariness 
after a meal: 
how caused. 
Is it related to 
Rheumatism ? 34 
other parts of these observations are carried to the 
muscles (and other tissues) as well as uric acid ; 
and very likely some materials not yet known to 
the physiologist or therapeutist accompany them. 
They may, however, all be conveniently classed 
together under the general name of waste-products 
from the digestion, or unassimilated digestive 
materials. One can even see how a meal too large, 
even if it is properly digested (which, however, it 
is not likely to be), may cause the feeling of 
fatigue in this way, since more chyle may find its 
way into the blood than can be conveniently 
assimilated in a given time, and so, by over-loading 
the muscles, may cause the puzzling feeling of 
fatigue without exertion, or perhaps what is as 
puzzling till we think about it, the feeling of 
being very tired when we wake in the morning at a 
time when the rest of sleep ought to have refreshed 
and invigorated us. During sleep the laying down 
of digested (and undigested) stuff has had plenty of 
opportunity to quietly take place. It does take place 
accordingly ; and if we have taken too much food 
the day before, much more if our food has been 
unsuitable and imperfectly digested, the organism 
cries out, we wake stiff and partially poisoned, and 
think we are too tired, and may even think we are 
under-fed, and by taking more food do ourselves 
still more damage. Similar phenomena occur during 
waking hours and times of work ; and when this 
overloading of the blood with undigested material 
Why we some- 
times awake 
tired in the 
morning. 35 
has occurred to a considerable extent, and has been 
deposited along the muscles, other facts may be 
noticed. Thus, as the slight contraction caused in 
the muscles by the presence of the waste material 
passes from point to point along the course of the 
long muscles of the limbs, so does the aching spread, 
and one can read in the faces of patients during 
exertion (or even feel in one’s own body) the peculiar 
slow gliding effects of it. I suppose I must not call 
this rheumatic pain ? Not wholly to my surprise, 
I found on a recent occasion that the medical 
profession has not made up its mind what is 
rheumatism and what is not. I have no doubt on 
the matter myself. I am certain that the condition 
is best named perimysitis rheumatica. I imagine 
that if Dr. Haig were asked about it, and supposing 
he admitted the existence of the condition 
(which, strange to say, not all medical men 
do), he would say it was due to the presence 
of uric acid in the blood in the first instance, 
which is deposited in the muscle-sheaths in the 
second. Is it due to the presence of lactic acid in 
the blood ? Is it due to the presence of other 
products of imperfect digestion ? What about 
butyric acid ? Or others ? As a rule, in the con- 
dition leading to this state of things the urine is very 
acid, far more so than it ought to be. I believe that 
this very acid condition of urine often leads on to 
nephritis and ureteritis, cystitis, urethral caruncle, 
and other troubles ; but I do not wish to deal with 
Is Perimysitis 
rheumatica 
a good and 
proper name 
for it ? 36 
this now. But some acid seems to be at the bottom 
of it. However this may be, as I do not wish to 
stir up controversy, I will speak of the condition not 
as perimysitis rheumatica (though I do not doubt 
it is so), but simply as perimysitis, or perhaps better 
still as myalgia. Myalgia then is present in a vast 
number of persons in whom its existence does not 
seem to be suspected. It is I believe the foundation 
in altered structure of much organic disease, just as 
the foundation in altered function is the dyspepsia or 
indigestion on which in turn it depends. It is found 
in childhood, it is found in youth, it is found in 
middle life, and it is found in old age. Grasping the 
muscles with a broad gentle firm grip will demon- 
strate its existence in all these classes of people. 
Nine out of ten of the young women who find their 
way to our consulting rooms are suffering from it; 
and it is very common indeed among men also, 
though not so common, owing mainly I have no 
doubt to the different way in which men still live 
as compared with women. When the myalgia affects 
the abdominal muscles, it is often called ovarian 
neuralgia, but in the great majority of cases the 
affection is neither ovarian nor neuralgic, it is 
myalgic. Not that there is no such disease as 
ovarian neuralgia—I am far from saying that—but 
I am sure ovarian neuralgia is often a diagnosis 
when the proper diagnosis ought to be abdominal 
myalgia, or spinal myalgia, myalgia of the muscles 
of the abdomen or of the spine. These affections 37 
are often called nervous, mainly because they go 
and come rapidly and because women (and men) 
suffering from them say to-day that they are very 
ill and to-morrow that they are quite well, while 
the next day they are as ill as ever—and all this 
though no organic lesion can be discovered to 
account for their complaints. Dr. Haig has lumin- 
ously told us how to account for these sudden 
changes—at least I have got from him a satisfactory 
explanation of these erratic and otherwise inexplic- 
able changes, although he has not, so far as I am 
aware, had these precise facts in his mind or under 
his observation. But the explanation of them no 
doubt is that at one time when the women complain 
so bitterly, uric acid (is no other acid competent 
to account for the condition ? Must it always be 
uric acid ?) is floating in the blood and clouding all 
the powers of perception, and of enjoyment, and of 
motion. At another, when they feel much better, 
the uric acid (the same parenthetical question recurs) 
has been deposited from the blood into the tissues 
(the muscle-sheaths, e.g.), and the blood being cleared, 
the person feels very much better. But the evil has 
of course not been cured, and the same conditions 
which induced it before may easily bring it on again ; 
and so the patient who yesterday felt so well because 
the uric acid was out of the blood, feels to-day as ill 
again as ever because the uric acid is again floating 
in the blood and reinducing all its former ills. This 
explanation also incidentally shows how a succession 
Affections not 
necessarily 
‘ ‘ nervous” 
because they 
come and go 
suddenly. 38 
of these alternations leads to chronic and organic 
disease, inasmuch as the tissues are being more and 
more loaded with uric (and other?) acid and are 
undergoing structural damage which may soon 
become irreparable. 
But the muscle-sheaths are not the only places in 
which these changes occur. The nerve-sheaths 
suffer in the same way. They also offer at first 
places in which the blood may easily unload itself of 
its waste-matters. Hence we have various neuralgias, 
as eg. of the supra and infra-orbital nerves, of the 
great or suboccipital, and by and bye of the great 
sciatic or anterior crural, or of the intercosto-humeral, 
or, in fact, almost any and every other nerve. These 
affections are known in practice under the names (to 
take only a few instances) of megrim, suboccipital 
neuralgia, sciatica, pectoral angina (though this last 
is often an affection of the heart-muscle—cardiac 
mysitis ?—itself), and so on. My own conviction is 
that these also are rheumatic affections, and are 
really most of them cases of perineuritis rheumatica; 
but, of course, I do not press this view, being 
compelled for the present to accept the neutral name 
neuralgia, so as to avoid controversy. It may, 
however, be observed, in passing, that names like 
neuralgia and myalgia (and ostealgia and perios- 
tealgia might be added to them) are not good names 
for diseases at all; they are not pathological names ; 
they are what I have elsewheie called functional 
names, indicating, that is, changes of function in 
Neuralgia. 
Perineuritis 
rheumatica. 
Names of 
diseases ought 
to be 
founded on 
anatomy. 39 
the parts referred to in the roots of the words. Their 
very existence is itself a proof, or at least their 
existence raises a suspicion, that the diseases pointed 
to by them have not been clearly or definitely 
diagnosed. To say that a woman has neuralgia is, 
after all, only to tell her in Greek terminology what 
she told us in English, when she came complaining 
that she had pain. By calling her ailment neuralgia 
we imply that the pain is associated with some kind 
of change in some nerve. We also (I suppose) 
imply that the nerve-change is functional and not 
organic. When this last implication or suggestion is 
analysed, however, I have a strong suspicion that 
very little is meant—except, perhaps, that we do not 
know very precisely much as to the nature of the 
nerve-change. It would probably be much better 
in most cases to say this plainly, if it is so. I think, 
however, that often we could go a good deal further 
than this, and that we could often (if we tried) tell 
her not only what nerve or nerves are affected, but 
also how they are affected. In this case we could 
give to her disease a pathological as distinguished 
from a physiological or functional name. In fact, 
our name would (or might) be scientific. Neuralgia 
of the face, or megrim, is a diagnosis sometimes 
made by doctors. But perineuritis supra-orbitalis 
dextra (vel sinistra) is a scientific name so far as it ' 
goes, and any instructed person can at once see the 
difference between the former functional or physio- 
logical names, and the latter pathological, anato- 40 
mical, and scientific name. If we could go further 
and call the affection perineuritis supra-orbitalis 
rheumatica (or simplex, supposing we thought it so), 
it is evident that we should have advanced still 
further towards the giving of a scientific name to the 
complaint. I think we often could go this length, 
but, of course, I do not wish to press my own 
opinions. It will be sufficient if the attention of 
competent persons is drawn to the subject. But I 
think that any one who really turns the question 
over in his mind will find himself very much 
dissatisfied with such names as megrim, sciatica, 
lumbago, neuralgia, and the like as names of diseases. 
All that we do by using such names is to translate 
into Greek or Latin terminology the complaints 
made to us by patients in the vernacular. Definite- 
ness in ideas is one of the marks of progress in 
science ; and definiteness in naming speedily follows 
in the train of definiteness in thinking. And the 
translation of this observation in respect of the names 
of diseases is that they should be founded on 
anatomy, rather than on physiology, that they should 
point to the structure affected and how it is affected, 
rather than to the changes in function consequent 
thereon. In short perineuritis is a real and good 
name, while neuralgia is not. Neuritis is of course 
also a good pathological name, but I have instanced 
perineuritis because perineuritis is so much com- 
moner an affection than neuritis (and perimysitis, or 
perimyositis, than mysitis, or myositis). 
They should 
not be 
functional 
names. 41 
If, following out the principles pointed at in these 
intercurrent observations, we search for a name or 
term to denote the presence of waste materials in the 
blood, due to the imperfect assimilation of food, or 
other causes, we might choose, say, Triphtliaemia 
to rub), or Xenciemia (|ews, strange or foreign). 
I prefer triphtliaemia; and although unwilling to 
introduce a new name, am compelled to do so, in 
order to avoid the need of using the cumbrous para- 
phrase, “accumulation of waste materials in the 
blood, whether from imperfection of digestion, or 
from breaking down of the tissues of the body 
themselves from imperfect nutrition, over-fatigue, or 
other causes.” The presence of uric acid in the 
blood might be called oxy-urichcemia, or urichcemia, or 
of lactic acid (if there is such a condition — the 
chemists must tell us) by oxy-lactichcemia, or lactich- 
cemia. 
But besides the muscle-sheaths and nerve-sheaths, 
the brain-membranes are apt to become passively 
congested by the tendency of the blood to unload 
upon them. This leads to two main sets of 
symptoms, either on the one hand to increase of 
irritability, nervousness, and too keen sense-percep- 
tion, in which every faculty becomes preternaturally 
acute, sleeplessness being often concomitant; or, on 
the other hand, to dulness of intellect, thickness of 
perception (as if the faculties were wrapped in cotton 
wool, patients sometimes say), general hebetude, 
impairment of memory, with restless and perhaps 
Triphthaemia 
Xenaemia. 42 
dreamful sleep : sometimes too deep or heavy 
sleep. I scarcely like to call these conditions 
meningitic ; nevertheless I believe they are so. 
The state is comparatively rarely serious, not often, 
happily, going on to the inflammation that leads to 
effusion and coma. Nevertheless it does so occasion- 
ally, and I have known one or two cases of death 
from it in young women, which at the time seemed 
inexplicable; and also cases where insanity has 
supervened, due, I suppose, to passive congestion of 
the meninges. In older women also it is the cause, 
I believe, of the delirium that not infrequently sets 
in after ovariotomy or other abdominal operations, 
which, as surgeons, we are sometimes so much 
puzzled to explain. 
Lastly, besides the muscle-sheaths, the nerve- 
sheaths, and the brain-and-cord-membranes ; the 
periosteum, the tendons and the arthritic ligaments 
offer sites on which the blood can and does unload 
itself, and we have various forms of periostitis and 
of arthritic tenonitis set up in these cases. How 
often in “ hysterical ” girls, so called, do we not find 
swellings of the metacarpal and carpal bones, and 
more or less stiffness of the joints ? I have seen 
such affections called “ nervous ” even by experienced 
and distinguished practitioners. I take the liberty 
of christening them periostitis, arthritis, and arthritic 
tenonitis, and saying that they are not nervous at all. 
Perhaps I ought to call them periostealgia and 
arthritic tenonalgia, in order to avoid controversy, 
Passive 
meningeal 
congestion 
a cause of 
insanity after 
operations. 
Periostitis 
often 
confused with 
Neuralgia. 43 
although I do not conceal my own view, that 
periostitis rheumatica, and tenonitis rheumatica would 
be truer and more instructive names, just as I think 
that meningitis passiva rheumatica would aptly name 
the affection of the brain-and-cord-membranes to 
which I have just referred. 
Such names as periostealgia and tenonalgia 
would, however, be bad or functional names, which I 
have no wish to introduce or be sponsor for ; and if I 
allowed the diseases referred to, to be so called, it 
could only be so under protest and as a makeshift, 
until clearer ideas began to reign in this department 
of medicine. 
If any one objects to meningitis as a name for the 
passive congestion underlying the attacks of delirium 
and even insanity, which so often follow great 
surgical operations in elderly men and women, let 
him recall to mind the congestion of tendons, and of 
the parts about joints (e.g. the elbow or knee), which 
is often present for years before an attack of acute 
inflammation and effusion occurs. A patient 
suffering from such an acute attack will have his 
tendons floating in a bath of serous effusion, which 
slowly absorbs and leaves the parts stiff for a long 
time afterwards. The passive and mild congestion 
may have been present for a long time, often for 
years, before the acute attack with serous effusion 
occurred, and could have easily been diagnosed by 
the tenderness present in the tendons and about the 
joints. Indeed, had proper treatment been adopted, 
Meningitis 
passiva 
rheurnatica ? 44 
the acute attack need not have occurred. So it is 
with the membranes of the brain and cord. They 
also are often passively congested for a long time 
before there sets in an acute attack, accompanied by 
delirium, effusion, and coma. Their condition could 
not indeed have been directly discovered in the same 
way that that of the tendons and joint-structures 
could ; but it could have been easily inferred from the 
tenderness detectable in the sheaths of such nerves 
as the supra- and infra-orbital and others, which 
sheaths are the direct anatomical continuation of the 
brain-and-cord-membranes. Or the congested state 
of these membranes could have been inferred from 
the great tenderness to pressure that can be made out 
in the parts about the occipital condyles ; and had 
proper treatment been early applied, the delirium or 
insanity could have been prevented, inasmuch as the 
acute congestion would not have occurred. 
In any case, I think the parts named are the parts 
of the bodily structures on which the blood most 
readily unloads its undigested and unoxidised waste 
materials ; and these parts are found to be tender, yes, 
and very tender in the large majority of persons of 
both sexes over 30 years of age who follow the habits 
of a town life. They are to be found, indeed, in very 
many under that age, but are much commoner as 
time advances a little and as people get older. They 
seem to me to form the basis on which, as a super- 
structure, chronic disease is raised or builded ; and 
they lie at the basis of chronic bronchitis, recurring 45 
rheumatism, recurring pneumonia, gout, diabetes, 
apoplexy, and cancer. I do not, for instance, believe 
that there ever existed a chronic bronchitic sufferer 
who did not also have periostitis of the sternum ; nor 
does there often exist a sufferer from cardiac disease 
who does not also have periostitis or periostealgia of 
the 4th, 5th, and 6th left ribs. And yet where are 
these conditions described in the text books? The 
descriptions are conspicuous by their absence. And 
some, perhaps I should say many, medical men even 
deny their existence. But they do exist, they exist 
too surely ; and they are the foundation on which, I 
believe, the chronic diseases, among which must be 
reckoned cancer, are built up. 
These perimysitic, perineuritic, periostitic, and 
tenonalgic affections, I should think, do not exist to 
the same extent among country dwellers as among 
the inhabitants of towns. My experience, of course, 
is almost wholly among the latter, for when country 
dwellers in this part of England present themselves 
for advice they almost always, though living nominally 
in the country, are following the ways and habits of 
town dwellers, being often engaged in mills and other 
business pursuits. I do, however, from time to time 
have to advise countrymen belonging to the farmer 
class ; and on a recent occasion was much interested 
in the conditions obtaining in the person of a young 
master farmer accustomed to ride and drive and to 
lead an outdoor life with abundance of physical 
exercise, although he had to use his wits and exercise 
Chronic 
Bronchitis 
invariably 
accompanied 
by periostitis 
of breast- 
bone ; and 
often of ribs. 
These 
affections 
oftener found 
in towns than 
country. 46 
his brain quite as much as the ordinary town dweller. 
He was entirely devoid of any trace of perimysitis, 
perineuritis, or periostitis. He could bear grasping and 
firm pressure of all his muscles without flinching; 
and also pressure over the supra-orbital, infra-orbital, 
and other nerves, and pressure over the maxillary 
articulations without experiencing any pain at all. 
His axillary boundaries back and front, the pectoral 
muscles, the latissimi dorsi, teretes, and the trapezii 
muscles, the supra and infra-spinati and the rest could 
all be moved under firm pressure without causing any 
pain to their owner. Perhaps there was the slightest 
tenderness when the sterno-mastoids were moved 
under pressure, but this was literally the only trace 
or sign of the affection which I could discover ; all 
the muscles of the lower extremities being firm and 
elastic and resisting pressure without any suspicion 
of aching or tenderness at all. Quite certainly that 
youth could trip and catch himself up suddenly with- 
out suffering, as so many town dwellers would do, 
from aching and stiffness next day or the day after ; 
and no doubt his immunity was due to more exposure 
to the open air, leading to better digestion of food, so 
preventing the accumulation of waste matters in 
the blood, and to an abundance of physical 
exercise oxidising off any accumulation which 
might by accident have been deposited in the 
muscle-sheaths. And no doubt exposure to 
cold and wet (in fact it was so) did not 
induce in him those trying rheumatic experiences 47 
which town dwellers, though doing all they can 
by care and warmth to avoid, are still such 
sufferers from. The town dweller may indeed get 
into the robust physical condition of my young farmer 
friend by a combination of dietetic management and 
muscular exercises ; but this state is rarely attained, 
and when it is, it is after considerable effort and 
labour ; while the farmer receives naturally, and as it 
were as a gift from nature, what the other has to 
strive for so keenly and for so long a time. 
Now, in studying cancer with a view of arriving at 
its causes, if possible, several things strike us. In 
what I have to say, let me observe, I refer to 
carcinoma or epithelioma. I do not exactly except 
sarcoma, because I do not know whether what I 
have to say includes sarcoma. But for the same 
reason I cannot include it under my observations. 
In fact, I do not know what are the causes of 
sarcoma, and shall be more than grateful to 
whoever can enlighten me. First, then, it does 
not attack children, or scarcely at all. There 
were 20,353 deaths from cancer in England and 
Wales in 1892, and of these only 103 occurred 
among children under 5 years of age ; and I have 
already said that only 94 deaths among children 
occurred in 1893. These facts seem to me to dispose 
or almost to dispose of the view held by some that 
cancer is a hereditary disease. If it were hereditary, 
surely it would appear earlier in life, or at least a 
larger proportion of its incidence would fall earlier in 
Propositions 
concerning 
Cancer, 
It scarcely 
attacks 
children ; 
therefore, 
probably not 
hereditary. 48 
life. Inherited syphilis, e.g., appears immediately or 
soon after birth, and farther, it is apt to modify the 
whole development of the organism, altering the 
development of eyes, teeth, nose, and limbs. In fact 
it is probable that no part of the developing or 
growing organism escapes when a child is affected by 
severe inherited syphilis, since no part seems to 
escape its stunting influence. But whether this is so 
or not, inherited syphilis appears early and modifies 
the growing organism in more or fewer of its parts. 
I can understand that a disease which appears early 
in life may be inherited. If we find a history of 
syphilis in the ancestors I can even understand our 
being forced to the conclusion that the disease must be 
inherited ; and indeed whether we can find evidence 
of the parental or ancestral disease or not, I can still 
understand our being compelled to this conclusion, 
since we may be able to eliminate the possibility of 
its being acquired through, e.g., nurses or otherwise. 
But I confess to finding great difficulty in accepting 
the proposition that disease appearing, like cancer, 
after 40 or 50 years of age, is probably hereditary. 
It seems to me far more likely that it is acquired. 
When such a disease ensues at such a time of life 
we have to ask ourselves this question. Is it 
more likely that what the ancestors did forty, 
or fifty, or sixty, or seventy years ago (for even 
when parents have cancer they often acquire it 
many years after their children are born), is it 
more likely that what the ancestors did so long ago 
Some points in 
the hereditary 
transmission 
of disease. 49 
is the cause of the cancer in the children ? Or 
is it more likely that something which the children 
have done during their forty or fifty years of life 
is the cause of the cancer? It seems to me that 
as a question of probability the latter is far more 
likely. I can’t help thinking that a hereditary pre- 
disposition or tendency would probably have shown 
itself much sooner than that. The organism can 
be modified for health or for disease in much less 
time than forty or fifty years; and in much less 
time than twenty years, or ten years, or even five 
years. I have seen cases which make me think that 
one may succeed in modifying patients out of so 
intractable conditions as rheumatism, e.g., in two or 
three years, even when they were 50 years of age 
before coming under treatment. I believe, indeed, 
that the nutrition of the organism in young people 
can be modified in a period of time far shorter 
than this. A few months, and even a few weeks 
(six or eight weeks occasionally) sometimes suffice 
to modify the constitution favourably when one has 
to treat it for chronic disease. If this is so, there 
can be no question therefore that forty or fifty 
years is far more than sufficient to account for the 
onset of cancer (and I should unhesitatingly say the 
same for twenty years, and even for ten years) in 
persons who may be found to be suffering from it. 
In the case, therefore, of a mature person having 
cancer, whose mother or father also had it, the most 
likely supposition or explanation appears to me to be 50 
that both parent and offspring lived in such a way as 
to induce it. And the law which appears to govern 
this set of facts is one which I have formulated 
elsewhere to the effect that “ like causes acting on 
like organisms in succeeding generations induce like 
effects.” So far as I know this is the chief law of 
heredity in disease. 
Second.—Cancer attacks women more than men. 
In 1892 12,806 women died of it in England, and 
only 7547 men. 
Third.—I have already said that there has been a 
vast increase in the mortality from cancer in this 
generation. In 1868, out of a million deaths from 
all causes, 18,627 occurred from cancer. In 1892 the 
proportion was 36,365 ; and in 1893 37,082. 
But fourth,—The increase has been nearly equal 
among men and women. Although women still die 
of cancer in a larger proportion than men, the 
preponderance of the proportion is continually 
diminishing. In 1868 2743 males died of cancer 
in England, as against 6137 females. The proportion 
of women was more than two to one. In 1892 7547 
men died of it and 12,806 women. The preponder- 
ance of women was only as five to three, not six and 
seven-tenths to three, as in 1868. The increase of 
cancer as a cause of mortality among men between 
the years 1868 and 1892 was 4804, and the increase 
among women was 6669. Had the proportions of 
1868 been maintained the increase among women 
ought to have been 10,748 instead of 6669, as it 
Formulation 
of the chief 
law of heredity 
of disease. 
Cancer among 
women. 
Cancer has 
nearly doubled 
in a 
generation. 
Increase of 
Cancer 
as great among 
men as among 
women. 51 
really was in 1892. The increase among women is 
still rather greater than among men, but the pre- 
ponderance of the increase has greatly diminished, 
and is, in fact, approaching equality. 
Fifth.—Whatever the causes are, they take some 
years to act, since children are practically free from 
the disease. And it seems to me, sixth, that the 
causes of a disease which does not affect children, 
which take some time to act, and which are affecting 
men and women almost alike, must be something 
connected with the habits of the people, and (as the 
disease is increasing) the causes must be such as are 
acting more strongly now than they did twenty-five 
years ago. The sphinx of cancer, therefore, from 
behind a veil of apparently impenetrable mystery, pro- 
pounds to us this conundrum. What are the causes of 
that increasing fatality which does not affect children, 
which is slow in acting, which used to affect women 
much more than men, but which is affecting both 
sexes in proportions constantly approximating to 
equality, and which are different from what used to 
obtain twenty-five years ago ? An answer rises to the 
pen which I have no doubt is the true answer; but I 
will not give it now. In fact, we are not prepared 
for it, and I should not have allowed the question 
to be put yet had it not been that I was anxious to 
finish w'hat I had to say about cancer while discussing 
the subject. But, in order to find an answer if we 
can, let me go back to some of the diseases 
mentioned a little while ago, and which we also saw 
The causes of 
the increase of 
Cancer must 
be some change 
taking place in 
the habits of 
the people. 
What change? 
A nswer 
obvious ; but 
will be given 
later. 52 
to be increasing in the country. If I am right 
in thinking that cancer is the culmination of mal- 
nutrition in tissue, or that it is one culmination of 
mal-nutrition in tissue, steps towards which are 
made by other diseased conditions already named, 
it follows that an inquiry into the causes of these 
preliminary and simpler diseases may throw some 
light on the causes of cancer. The argument is that 
' various of the diseases named, viz., in particular, 
bronchitis with asthma, pneumonia, rheumatism, 
apoplexy, besides minor ailments, such as tonsillitis, 
tracheitis, pharyngitis, herpes (the conditions, popu- 
larly classed under the general expression “ taking a 
cold,” or “taking a chill”)—the argument is that these 
are all dependent on a general condition of blood, 
which I have called triphthaemia, or the accumu- 
lation of waste matters in the blood, whether from 
imperfection of digestion and assimilation of food or 
from other causes. If it can be shown, as I think it 
can, that the commonest form of this triphthaemia is 
brought about by one set of causes for the most part, 
then some progress will have been made towards the 
understanding of these affections, and through them 
of cancer, and of the causes of its increase. I propose 
to commence with bronchitis, whose immense increase 
in this generation I have already instanced. I think 
the evidence is indisputable—altogether conclusive— 
that bronchitis is practically due to an excess in the 
diet of starchy and saccharine or sugary foods. The 
people who suffer from bronchitis (which accounts 
To reach an 
answer 
consider causes 
of other 
increasing 
diseases, as 
Bronchitis. 
Exciting 
causes of 
Bronchitis 
and 
predisposing 
causes. 53 
now for about one-tenth of all the deaths in England 
and Wales) are the people who live to a great extent 
on such foods as bread, potatoes, rice-, sago-, and 
tapioca-puddings, jam, and sugar. The popular 
opinion that bronchitis is due to cold is true only to 
this extent, that exposure to cold will bring on an 
attack of bronchitis in those persons who are pre- 
disposed to it by having consumed larger quantities 
of those foods than they have assimilated. Such 
exposure will not bring on an attack of bronchitis, 
or will scarcely do so, in persons not so fed. One 
of the most striking facts, it seems to me, which goes 
to show this is that in persons predisposed to it 
(by wrong feeding, as I contend) an attack is often 
induced by the effects of heat. The theory then 
commonly set up is that the person became over- 
heated, perspired perhaps, and then was exposed to a 
draught, and so “ took a chill.” It does not follow 
that the precise time or place where the “draught” 
occurred can be pointed out. Neither is it necessary 
to show how the “ over-heating ” occurred. The 
person sometimes, it is true, has had some extra 
exertion inducing free perspiration, but often enough 
there is no evidence of this brought forward, and too 
often none is required. Very often the fact that the 
weather was hot, in the one case, or cold in the other, 
is all the evidence that is required to account for the 
attack of bronchitis. The theory is so convenient and 
so adaptable that one is almost sorry to show any 
scepticism as to its truth. A theory which accounts 
Heat often 
an exciting 
cause of 
Bronchitis. 54 
for the attack of bronchitis, when the weather is cold 
and damp, and ingeniously also accounts completely 
for it when the weather is hot and dry, such a theory 
is notone lightly to be discarded. Nevertheless, in the 
hard and unsympathetic court of reason it is necessary 
to examine it, and even cross-examine it. Is not the 
human organism intended, or if that word is too 
teleological for the thinking of to-day, is not the 
human organism adapted to endure both cold and 
heat and some exertion also? Is it not fitted to live 
and thrive in hot weather and cold weather, in dry 
weather and in wet weather, in wind and rain, and 
in calm also ? Or, at least, may not a human 
organism go on performing its part in life, and 
performing it efficiently, whatever be the conditions 
of its environment in these respects? Of course it 
can. But to admit this implies the giving up of 
the convenient theory before referred to, that it 
was the heat or the cold, or the wetness or the 
dryness, or the wind or the calm which did the 
mischief. Is it not, in fact, self-evident, when we 
come to examine the question, that the causes of 
bronchitis, or the “ taking cold,” must be in the 
organism itself for the most part when causes 
so various induce the same condition of illness ? 
Obviously it must be so. If outer conditions of 
environment vary, and if yet the illness comes on, 
it is plain that the organism itself must be the 
chief cause. When this is seen, and the difficulty 
comes to be faced, how causes so diverse and even 55 
opposite can induce the same condition of illness, 
refuge is taken in the theory of predisposition, 
or tendency on the part of the organism to 
be affected with the disease in question.. And 
even heredity is invoked, or what may perhaps 
be paraphrased as “ predisposition inherited from 
ancestors,” to account for the facility with which 
one “ takes cold.” One’s father or mother suffered 
in this way, and so do we. Yes ; but the question 
arises, what caused this state in father or mother? 
It can hardly be assumed that they in turn got 
their predisposition or tendency from thtir parents, 
and so on indefinitely. Surely it began sometime. 
I believe it begins in any given generation. The 
question arises, if the father or mother suffered in 
this way, how did they live ? What did they eat ? 
What work did they do? And the same questions 
arise regarding the attacks in the present generation. 
How do we live who get bronchitis? What do we 
live on ? Obviously this is a much simpler question 
to answer than the one : how did our ancestors live ? 
And if we find sufficient reason in the habits of our 
own life to account for our illness, perhaps it will 
not be necessary to invoke family predisposition or 
heredity at all as a cause. 
As regards bronchitis, the following experience 
occurred to me. In November, 1892, a well-built 
substantial matron of 52 years of age came to me, 
saying she had suffered for twelve years from what 
her medical advisers called bronchitis and asthma. 
Heredity not 
the cause even 
when ancestors 
had it. 
Proofs as to 
causes of 
Bronchitis. 56 
She said the attacks were very severe, and were 
coming on at continually diminishing intervals, and 
with continually increasing severity. Attacks which 
used to be three or four months apart were appearing 
at eight weeks’ and six weeks’ and even three or four 
weeks’ intervals, and she was becoming worse and 
worse. The question was, could anything be done 
for her. This seemed an unpromising problem to 
attempt to solve in the case of a woman no longer 
young, who had suffered for so long a time. She 
was not exactly ill, however, at the time, as she 
was able to present herself for treatment. On 
examination she was found to have catarrh of the 
larynx, trachea, and bronchial tubes, there being sibilus 
and rhonchus present; and I thought that there were 
some evidences also of emphysema. The question 
was, what were the causes of the recurring attacks ? 
Unless they could be obviated other attacks would 
certainly take place. On inquiry, however, it was 
quite plain what the causes were. Bread and butter 
and tea for breakfast at 8.0 a.m.; meat, potatoes, 
Yorkshire pudding, rice pudding, or jam pudding, 
with bread for dinner at i.o ; tea, with bread, butter, 
and jam, at 4.30 or 5.0 ; and bread and milk or boiled 
oatmeal for supper at 8.0, constituted the woman’s 
ordinary diet, and in my opinion accounted suffi- 
ciently for her attacks. At any rate, considering that 
she was taking far more carboniferous food than she 
was assimilating, and believing that the laryngo- 
tracheo-bronchial mucous membrane was congested 57 
and irritated by the excessive work thrown on it in 
its futile attempt to oxidise off all the waste material 
carried to it by the blood, I advised an alteration of 
the diet to three meals a day, and that she should 
take bread only twice, and jam and sugar not at all. 
If she wanted any supper, she was to have simply a 
glass of milk, not bread and milk, nor any oatmeal 
porridge. She came at weekly intervals for a few 
weeks. It was a little difficult to keep her confidence, 
because two or three previous medical advisers had 
said that the food taken had no influence on the 
bronchitis. However, she persevered, losing weight 
under the treatment, but losing also the congestion 
of her pulmonary mucous membrane. 
After the lapse of about five weeks she informed 
me that judging from her former experience, she 
might expect to have a new attack, “ but,” she added, 
“ I am not going to have one.” She has not had 
any attack since. It may be said that the history of 
this case proves nothing ; that the recovery was a 
coincidence; and that she would have recovered, 
whatever she had done and whatever food she had 
eaten. I don’t believe this. In view of the facts 
that she was not young, that she had suffered so 
many years (no less than about a quarter of her life), 
and that the opinion that carboniferous foods are to 
a very large extent burned off in the pulmonary 
apparatus and mucous membrane is a physiologically 
correct opinion, and therefore that the excess of these 
foods consumed was the main cause of the bronchitis, 58 
since an excess-consumption of these foods throws too 
much work on to the bronchial mucous membrane, 
which becomes, therefore, congested, much in the same 
way as a fire becomes choked when fed with too much 
dross—in view of all these considerations I am com- 
pelled to the conclusion that the recovery was no mere 
coincidence, but was really the effect of the treatment. 
If the case stood alone I might think so, but it does 
not. The same treatment has relieved many sufferers 
both before and since. In fact, it fails only in those 
cases where there is something more present than 
mere bronchitis (eg., phthisis), or where age is so far 
advanced and organic disease has gone so far, that 
recovery is no longer possible. The evidence for 
this view is so strong in my mind now that I venture 
to lay down the dogmatic position that the chief 
predisposing cause of bronchitis is the consumption 
of an excess of starchy and saccharine foods. But 
bronchitis accounts for about a tenth of the total 
mortality of the country, and, therefore, the inference 
is that one-tenth part of all the fatal illness in 
England and Wales to-day is amenable to hopeful 
treatment; and, further, that by proper dietetic 
management bronchitis is preventable. This state of 
opinion is, of course, a very important and very serious 
one. If, however, we are in the presence of a physio- 
logico-pathological law of human nature, the prin- 
ciple can be put into operation by others. If it is, I 
make bold to venture the prediction that the law will 
be vindicated, and that bronchitis will not only be 59 
cured by the inculcation of a suitable diet and regi- 
men, but that it will also be found possible by similar 
means to prevent it ; to prevent it, that is, as a rule 
(for I suppose there must always be individual 
exceptions), between the ages of 5 and 65 years. 
In the following case, chronic bronchitis, lasting 
for many years, led on to a severe attack of pneu- 
monia, to which the patient speedily succumbed ; 
but the causes of the bronchitis and of the pneumonia 
plainly were the same as in the matron just described. 
Quite recently (in April, 1897) I saw a stout man 
54 years of age in consultation with his family doctor. 
The patient had suffered for years from what his wife 
called asthma and bronchitis, the symptoms being, a 
more or less constant cough, with whistling sounds to 
be heard in the breathing and increase of the cough 
when he hurried or undertook exertion. The man 
was a teetotaler (how often, by the wajr, are effects 
which are really due to wrong eating, attributed to 
alcohol. They could not at least be so attributed in 
the case of a life-long teetotaler). As I say, when 
we saw the man together he had most severe and 
extensive pneumonia, and the attendant medical man 
had justly given an almost hopeless prognosis, too 
speedily verified in fact. Now what had that man’s diet 
been for many years ? I asked the question of his wife, 
and she told me as follows—He was in the habit of 
taking tea and bread and butter for breakfast at eight 
a.m. At dinner (12.30) he would have meat, York- 
shire pudding, bread, and rice pudding. He had 60 
abstained from potatoes for some time, because he 
thought them watery, and that they puffed him up, 
and tended to make him fatter than he was. (Note 
here how the public frequently abstain from one sort 
of unsuitable food, but through ignorance, undo, by 
indulging in others of the same nature, all the good 
effects of their abstinence. Had the man been as 
enlightened as to the evils of frequent bread-eating 
as he was in respect of potatoes, how much better 
for him would it have been !) Tea at six p.m., of 
bread and butter and tea. Supper, nine p.m., oatmeal 
porridge. The plain causes of the chronic bronchitis 
and of the pneumonia which supervened on it were 
the bread taken four times a day (twice would 
have been enough), the Yorkshire pudding, the rice 
pudding, and the oatmeal, which formed practically 
the whole of his diet. If he had taken three meals 
a day it would have been much better for him, and 
if he had taken two meals, I believe he would have 
been living now without the help of doctors. 
The suggestion made by a supposed critic that 
the bronchitic and asthmatic matron before referred 
to was on the point of recovering at any rate, at the 
time I saw her, and that it was, therefore, quite 
fallacious to attribute her recovery to the treatment, 
raises the question : What kind of evidence ought to 
be required to prove that the recovery of a patient 
suffering in certain ways was due to the treatment, 
and not to coincidence ? Obviously the mere fact 
of recovery is not sufficient to show the connection 
The kind of 
evidence 
required to 
prove connec- 
tion between 
treatment and 
recovery. 61 
between treatment and recovery, because it is known 
that persons do from time to time recover from 
ailments to which they have been long subject, and 
that they do this even when, on the one hand, no 
special treatment has been adopted ; and, on the 
other, they sometimes unfortunately fail to recover, 
even when subjected to the most skilful treat- 
ment. All that can be known, it is said, in many 
cases, is that a patient suffering in certain ways 
was subjected to such and such treatment, and 
that he recovered. It does not follow that the 
recovery was the result of the treatment, although it 
followed its application. The recovery may have 
been due to something else, and to assume that 
it was the effect of the treatment, because following 
on it, is illogical and a fallacy. This fallacy is, 
of course, well known in the study of logic as the 
post hoc ergo propter hoc fallacy. A process (recovery) 
may be post hoc (after treatment), but it does not 
at all therefore follow that it was propter hoc (due 
to it). This fallacy is no doubt of very wide 
application in medicine, so wide, indeed, that it 
is apt to vitiate many processes of reasoning, and 
to render invalid the fairest inductions regarding 
treatment. Still, the very fact that it is so well 
known offers a certain amount of security against 
our being confused by it ; and, in point of fact, 
medical men are generally quite alive to its 
insidious character. But it is not, after all, the 
only fallacy in medical logic ; nor, indeed, is it 
Post hoc ergo 
propter hoc 
fallacy. 62 
the chief one. I question whether its force has 
not sometimes been exaggerated. Men talk some- 
times as if no canons of reasoning were applicable 
to this part of the domain of knowledge, and as 
if the nexus between cause and effect was entirely 
inexplicable. This is evidently an exaggeration, 
and may lead to the acceptance of fallacies as great 
as that which it is desired to avoid. There seems 
at least to be one fallacy in medicine of much 
greater power than this. The fallacy of fallacies 
in medical logic, it seems to me, is not the post 
hoc ergo propter hoc fallacy, but this : That we tend 
to expect that continuous effects will follow the 
action or application of continuous causes. The 
law of the economy, on the other hand, is 
that “ Constant causes, acting on the economy, 
show themselves, not in constant, but in inter- 
mittent or periodic effects.” Causae continuae, vel 
immutabiles: effectus intermittentes, vel temponbus 
incertis recurrentes. 
One ought not perhaps to speak of causes as 
acting constantly or continuously on the human 
or on any animal economy. Probably no such 
thing is possible with a changing organism so 
constituted and so situated. What appear to be 
causes acting continuously are not really so, but are, 
on the contrary, causes which act very frequently 
or at short intervals of time; and the law of the 
economy in this respect is, that causes which act 
frequently or at short intervals of time show them- 
The fallacy 
of fallacies in 
medicine. 63 
selves in effects which recur at longer and uncertain 
intervals of time. Causae, brevibus temporibus 
recurrentes, effectibus, longioribus et incertis temporibus 
recurrentibus, sese monstrant. Amylaceous and 
saccharine foods taken in excess at short intervals 
over long periods of time (four or five times a 
day for weeks, e.g., or months) show themselves, 
not at first, at any rate, in continuous attacks of 
bronchitis, but in attacks which occur and recur 
at much longer intervals, as, e.g., weeks or even 
months apart. But to expect that because causes 
are acting day after day, and week after week, 
and month after month, they will therefore show 
themselves in effects which must be constantly 
present, is a far subtler fallacy than the post 
hoc ergo propter hoc fallacy, and may be termed 
the fallacy of intermittent effects. I do not know, 
indeed, whether it may not on analysis be considered 
a phase or form of the other. Both, at any rate, 
have to do with, and are apt to vitiate our conclu- 
sions regarding the nexus of cause and effect. 
Patients (to take an instance of this fallacy of the 
intermission of effects) often say to their doctor: “ I 
“do not think the causes of my illness can be as you 
“say, and for this reason ; I do this always, but I am 
“not always ill. You say” (let us suppose) “that 
“ food is the main cause of my illness; but, though 
“ I take always the same kinds of food, I am not 
“always ill. I have an attack of illness, and then 
“ completely (?) recover.” (Is recovery complete, 
Causes acting 
frequently at 
short intervals 
manifest 
themselves in 
effects which 
appear at 
longer 
intervals and 
endure longer. 
Fallacy of 
intermittent 
effects. 64 
however?) “Then, after a time, perhaps several 
“months, I get another attack, and again recover. 
“ I may make some change in my diet during the 
“illness, and when in the hands of the doctor, but, 
“when I recover, I go on to my usual diet and 
“regimen, and it may be months before I have 
“ another attack.” The answer to such common- 
sense criticism is : Constant causes show themselves, 
not in constant, but in periodic effects. The diet 
may be wrong, may even be constantly or recurringly 
wrong, and even for long periods of time, but 
its effects are not therefore constantly apparent. 
Especially in youth, the tendency to recovery is 
so strong that patients recover from illnesses 
even when their causes continue to act. They 
get other attacks, no doubt, but recover even 
from these, and they go on having attacks and 
recovering for a long time, even for years in some 
cases. When the causes continue to act, the attacks 
of illness tend to come on at shortening intervals, and 
generally with increasing severity. After a time, no 
doubt, the intervals between attacks become so short 
that they tend to disappear altogether, in which case, 
of course, sufferers are always ill—their disease is 
truly chronic or long-continued. Even then, however, 
they are not always equally ill ; the illness is at one 
time more pronounced, and at another less so, so 
that a chronic illness is noticeably periodic before it 
becomes chronic, and even after it has become 
chronic, the periodicity of its exacerbations and 65 
recessions can be detected by careful and accurate 
observation. But before this stage is reached, the 
periodicity of attack and recovery, of invasion and 
recession, forces itself on our attention without any 
necessity for accurate or careful observation at all. 
But the failure to perceive the causal nexus, and the 
tendency in our minds to expect that, because causes 
seem to be continuous, effects will be so also, seems 
to me to be the chief and most subtle fallacy in 
medical logic. 
This tendency of disease to be periodic before 
it becomes chronic is a very interesting fact in 
medicine. When thought about it cannot fail to 
class itself with the tendency of many other 
events to show periodicity, also; for instance, in 
politics, government by one party in the State 
is apt to be followed by government by a party 
holding views more or less opposed to it. In morals, 
egoism or individualism is very apt to be followed by 
a wave of altruism or socialism. In commerce, 
periods of inflation are followed by periods of 
depression, and vice versa, and periods of calm and 
sane prosperity by bursts of insane panic. Even in 
inorganic affairs the same tendency—or may one call 
it law?—is noticeable. The tide does not rise con- 
tinuously, neither does it fall steadily. Both in its 
rise and fall it moves irregularly. When rising, 
we see a wave or perhaps two or three waves in 
which each crest overtops the last one, followed 
by one or two which do not reach so high, and 66 
yet we know that the tide is flowing, because if 
we wait a little we shall find a wave or two 
which overtop even that which was the highest 
some time ago. And so with the falling tide, 
when we have watched a long recession proceeding 
for some time, each ebb flowing further out than the 
last, we are surprised to find one or two waves 
which do not recede so far, and we may even be 
tempted to question in our minds if the tide is really 
receding. But a little further observation settles the 
question, for in due time a still further recession, 
followed, perhaps, by one or two still lower, shows 
that beyond all question the tide is on the ebb. We 
find, therefore, that although we have movement 
forward or backward, as the case may be, the move- 
ment is not continuous, but is made up of alternate 
elevation and recession, of alternate advance 
and retreat. This movement, so noticeable in 
all these directions, and with special reference 
to disease in the present instance, has been spoken 
of sometimes as a movement in circles. As 
the curves are not equal, I would suggest thinking 
of it as motion (progressive or retrogressive, as 
the case may be) in spirals, and further, would 
say it is a motion not in regular but in irregular 
spirals. A succession of equal circles cutting 
each other regularly in the centre might give the 
idea of circular motion, but would be far too 
regular for even a mathematical representation of 
natural progression. 
Natural 
motion not 
continuous. 
Might be 
(Ungramma- 
tically repre- 
sented by 
zig-zag lines, 
or by curves 
or spirals. 67 
Thus— 
these circles are too regular and too equal to 
represent the variety and alternation of natural 
progression. 
The spirals here shown are, perhaps, a little 
more like it. 
But even these are too regular. And natural 
motion, the motion of nature, would be more nearly 
represented by curves or spirals such as those below, 
whose spirals are not equal either in size or rhythm. 
A—Attack 
R—Recession. 
If we suppose the crest, or culm, of the curve to 
represent the height of an attack of disease, then 68 
the various points A would represent these crests. 
The lowest points, R, where the curves begin 
again to ascend, would stand for the points of lowest 
vitality or depression which precede convalescence. 
It will be observed that the highest points 
differ in elevation, as so also do the lowest points. 
Neither are either the sizes of the curves nor their 
distances from one another equal. If each spiral 
represents a periodic attack of any disease (bronchitis, 
e.g.), this would mean that the attacks are not equal 
in severity, and also that the intervals of time 
between them are not equal. If the straight line 
indicated the standard of health, it would be found 
that the early attacks rose well above the line and, 
before convalescence, sunk well below the line. The 
later attacks, on the other hand, when disease is 
becoming truly chronic, indicate very little elevation 
or depression ; but some of the spirals are often found 
below the standard of health, the prevailing tempera- 
ture, for instance, in many chronic diseases (as 
rheumatism, Bright’s disease, heart disease, e.g.) 
being sub - normal, or below 98-4°F. Lastly, 
it may be noticed that the succession of crests 
and recessions might be diagrammatically repre- 
sented by a zigzag line, in which case a figure 
not unlike our ordinary temperature chart would 
arise. And contrariwise, an ordinary temperature 
chart, showing the changes of temperature from 
morning to evening, might be converted into a 
succession of irregular spirals by joining the culms 69 
and depressions and filling in the curves. Here, for 
instance, is a copy of a temperature chart taken 
after the performance of a slight surgical operation in 
which the elevations and depressions are represented 
by spirals in place of the zig-zag points usually 
shown. 
Perhaps I ought to observe in passing that 
the division of diseases usually made into acute 
and chronic is not a logical one. An acute 
disease is a severe disease, and a chronic disease 
is a long - continued one; but as diseases are 
often both severe and long-continued, it follows 
that they are often both acute and chronic 
at the same time. The division of diseases into 
acute and chronic, indeed, attributed to Asclepiades 
of Prusa, in Bithynia, offers one of the most 
interesting instances of an alleged reform, being 
really a retrogression, because it can be shown that 
Hippocrates, who preceded Asclepiades, had spoken 
Division of 
diseases into 
acute and 
chronic not 
logical. 70 
of diseases as being mild faSos) and severe or acute 
(ogvs), and had also spoken of diseases as being short 
s Or dXiyoxgovios) and long Or 
or naKfos), so keeping things which were distinct 
in fact, clear and distinct in his mind and in 
language. And yet the so-called reform of 
Asclepiades has held its own ever since his time, 
displacing the clear and logical ideas of Hippo- 
crates in this particular. Tn Latin the word lentus 
is often used of the chronic diseases. As lentus 
means tenacious, hence slow, sluggish, hence lasting, 
and as long diseases are generally somewhat mild, 
there has been no relief to the ambiguity derived 
from the use of Latin terminology, such, eg., as 
the use of the word mitis for mild or slight would 
have given us. 
With modern methods of observation we are in 
a much better position than was either Hippocrates 
or Asclepiades ; and it would be very easy to define 
the terms mild, sub-acute, and acute, as also the terms 
short and long, as applied to diseases, in such a 
way as to make them perfectly clear, and so 
prevent their respective meanings from becoming 
confused as they are at present. An acute disease, 
for example, might be defined as one in which the 
temperature rises above I02’5° or ic>3cF., while 
the pulse-rate is over 120 a minute. A sub-acute 
disease or condition is one in which the temperature 
ranges between ioo° and I02’5° or I03°F., and 
the pulse-rate at from 100 to 120. A mild disease, 
Suggested 
definitions of 
acute, sub- 
acute, mild, 
chronic, and 
brief. 71 
again, is one in which the pulse does not rise say- 
above ioo a minute, and the temperature ranges 
between normal and say ioo°F. to ioo’5°F. The 
per-acute diseases referred to by Galen — who 
unfortunately defined them in terms of length, and 
not in terms of intensity or severity—might be 
taken to mean those states of body in which the 
pulse-rate is over 130 or 140, and the temperature 
104° or 105° and over. The only reason why 
Galen defined those conditions as diseases which 
last three days is that such intense fever generally 
consumes or destroys the organism if it continues 
for that length of time; but, of course, intensity 
or severity in disease is a totally different thing 
from the length of its duration, and ought to have 
a totally different name and definition. 
By chronic, on the other hand, is meant a disease 
lasting twenty-eight days or over. This is the 
general meaning, or the meaning generally received ; 
but, in fact, chronic diseases—with the phases of 
exacerbation and recession, which we have seen to 
characterise them—generally last much longer than 
this—months, for example, or years. Hippocrates 
called them chronic or poly-chronic. By short or 
brief diseases—the brachy-chronic of Hippocrates— 
might be defined those diseases which last less 
than twenty-eight days. In fact, they generally 
last three or four days, or a week, or up to ten, or 
twelve, or fourteen days perhaps; being generally 
pretty severe while they do last. Hippocrates saw 72 
this plainly enough, and in one of his aphorisms 
says that acute diseases can be judged or deter- 
mined (by the observer) in fourteen days—a most 
unfortunate expression, as it happens, since it has 
been supposed to mean that he defined acute diseases 
as those that last fourteen days, so justifying that con- 
fusion between severity and length of duration in 
diseases which has obtained for so long a time. 
The words of Hippocrates are ra o£ea ru>v voo-rjuaruv 
tv Tf<T(rocge(rKal?>eKa TjfjiTjegricnv Here a good 
deal may turn on the meaning we attach to the 
word It seems, however, clear that what 
Hippocrates did mean was, not that acute diseases 
were those which last fourteen days ; but this, that 
in fourteen days the observer will generally be able 
to determine what sort of disease his patient is 
suffering from, and what the issue is likely to be ; 
whether the continuance of the illness is likely to 
be long or short, and also whether it is likely to 
be fatal or otherwise. These propositions are true 
enough ; and in fact we can usually form opinions 
on these points before even fourteen days have 
elapsed from the commencement of the illness 
we may be treating. It must be admitted that 
Hippocrates was not always quite clear in his 
language regarding acute and mild diseases on the 
one hand, nor as to short and long ones on the 
other (see, for instance, a passage in 
where he says that acute diseases up 
till the sixtieth day, after which they become 73 
chronic), but his confusion was never so dark as 
that of the so-called reformer who came after him, 
and who misled his successors in turn. The remarks 
made and the descriptions suggested for mild and 
acute and long and short conditions will, it is hoped, 
show how a disease may in its course be now acute 
and then mild and again sub-acute, and that these 
conditions have no necessary connection with the 
length of their duration; and they will, I hope, 
therefore have proved my statement that the 
division of diseases into acute and chronic is" not 
a logical one. 
The fact that patients recover, and recover 
again and again from illnesses, even when the causes 
of the illness persist or go on acting, is a most 
important one in medicine. It is connected with 
what I have called the fallacy of fallacies in 
medicine, viz., the intermittent influence of con- 
stantly acting causes, or what I perhaps ought to 
have termed the effects at long intervals of time 
of causes acting frequently or at short intervals. 
In fact it seems to be the obverse of that condition 
of things, since the organism shows cnly at intervals, 
or intermittently, the effects of causes acting so 
frequently as almost to be justly termed constant 
causes. But this phase of the question explains 
what is so frequently thrown out as a taunt to 
medicine and to medical men, viz., that patients 
seem to do as well (or as ill) whatever is done for 
them by the medical attendant, and whatever 
Why patients 
recover from, 
recurrent 
attacks of 
illness, 
independently 
of treatment 
or causation. 74 
fashion may prevail in medical practice at the 
time. When it was the fashion to bleed, to cup, 
and to blister, patients recovered. Even medical 
men may be occasionally heard to make this kind 
of observation in terms not too respectful to their art; 
and the lay public say it with no effort to veil 
the contempt they feel for the medicine man and 
all his ways. And they add that when fashion 
no longer prescribed bleeding and blistering and 
clystering, but recommended starvation, patients 
still recovered; and, lastly, they say that now 
when neither blistering and bleeding, nor starvation 
is the fashion, but when, on the other hand, efforts 
are made to “keep patients up” by feeding, &c., 
they recover just the same. If these statements 
are true (and they are true, more or less, though 
not entirely), it is suggested, then there is nothing 
in medicine and medical treatment at all ; and 
that the long-suffering public would be as well 
without them. True, surgery is excepted. It is 
not denied that surgery has advanced, and that 
it has some pretensions to being a science, but 
medicine—the very idea of science or scientific 
art is alien to it; so it is said. Now, I have 
already said that I do not wish to discuss surgery 
in these remarks ; still less do I desire to 
belittle it. I have had some experience in surgery, 
and a fair share of surgical success in my 
time, not less than the average; but I say deli- 
berately that surgery has had very little influence 75 
in affecting the life interests of the community, 
although, no doubt, in individual cases its results 
have been very useful and very brilliant. Will any 
surgeon say that surgery has, on the average, added 
even one year to the lifetime of the community ? 
It would be impossible to maintain such a proposi- 
tion, and it therefore follows that surgery (even 
granting that it is the practice of a scientific art) is 
of very little moment indeed as compared with 
medicine in affecting the well-being and the length of 
life of the whole community. When, therefore, 
surgery is excepted from the sweeping denunciation 
and obloquy meted out to medicine, the exception is 
of comparatively little moment. The art medical, as 
a whole, is still depreciated ; but to what does the 
denunciation of medicine amount? Chiefly to this, 
that those who denounce it have not seen the law 
that constant causes acting on the economy show 
themselves not in constant, but in intermittent 
effects. And of course they have been unable to 
understand how patients recover from acute or severe 
diseases (or succumb to them on the other hand) 
rather by the inherent power of the organism to 
right itself; rather by the inherent power of the 
organism to return to more or less stable equilibrium 
after disturbance, than by the methods of treatment 
to which it has been subjected. It does not even 
in that case follow that treatment is without 
influence ; for undoubtedly the organic powers may 
be husbanded by good treatment, or they may be 
To except 
surgery from 
the general 
denunciation 
of medicine is 
useless, because 
surgery has 
not appreci- 
ably added 10 
the length of 
life of the 
community. 
Medicine has. 
Surgery no 
doubt often 
very brilliant 
in special 
cases, and most 
valuable and 
necessary. 76 
dissipated by bad treatment ; the patient may 
be partially poisoned by wrong feeding or by 
alcohol, or he may be damaged by blistering, 
bleeding, or purging, or partially narcotised by opium. 
But still the proposition holds true in the main, 
that treatment (unless of course it is outrageously 
unreasonable) has comparatively little influence 
in acute diseases. But acute or severe diseases 
are often single attacks in recurrent diseases ; 
and recurrent diseases are often in their way to 
becoming chronic. Will any one maintain that 
treatment is of no value in chronic disease ? That 
treatment, being good, cannot lengthen the intervals 
between recurrent attacks ? or that it cannot diminish 
their severity? or that treatment cannot rid a patient 
altogether of recurrent attacks, say, of headache, 
or asthma, or bronchitis, or influenza? Or will 
any one seriously argue that treatment is not bad 
if it fails to lengthen the intervals between such 
attacks? Or if it does not diminish their severity? 
Or if in certain cases it fails to abolish them 
altogether? And is treatment not to be blamed 
if a patient loses his life at middle-age, when the 
medical man had a fair chance to help him out of 
his difficulties ? While, therefore, the proposition 
is true that in the acute diseases the organism tends 
to recover by its own inherent power even when the 
causes of the illness persist, it does not, therefore, 
follow that treatment is of no avail, nor that it 
makes no difference what kind of treatment a 
The power of 
medical treat- 
ment tested 
rather in the 
management 
of chronic and 
recurrent 
diseases than 
in that of the 
acute and 
short. 77 
patient is subjected to. But in recurring and chronic 
diseases, on the other hand, it makes all the 
difference in the world whether a patient is skilfully 
handled or otherwise. And the tests of skill in 
these diseases are contained in the answer to the 
questions, Did the patient have subsequent attacks ? 
Were they as severe ? Were they as frequent ? 
The test of skill is hardly contained in the answer 
to the question, Did the patient recover from a single 
attack ? In other words, we may put our proposition' 
in this rather paradoxical form. The test of skill 
in medical treatment is not recovery, it is at least 
not immediate recovery from a single attack of 
illness ; because the organism will recover, what- 
ever (within some rather wide limits) we do or do 
not do for it. On the other hand, the test of 
skilful treatment is undoubtedly remote recovery 
though it is not immediate recovery: I hope, at 
least, that the discussion of these points has 
emphasised the importance of remembering that 
patients often recover from illnesses even when the 
causes persist, and that causes acting frequently 
and at short intervals of time show themselves, not 
so much in illnesses recurring at short intervals as 
in those occurring and recurring at longer intervals. 
This principle it is, too, which is the reason for 
the important principle or canon of treatment, that 
persons subject to recurring attacks of illness ought 
to be treated during the intervals rather than during 
the attacks. Galen, indeed, saw this when, as 
The tests of 
skill in treat- 
ment of 
recurrent 
diseases. 
Does patient 
get subsequent 
attacks ? 
As severely ? 
As often ? 
Persons suffer- 
ing from 
recurrent 
attacks of 
illness should 
be treated in 
the intervals, 
rather than in 
the attacks. 78 
epitomised by Andreas Lacuna Secobiensis, he says 
administramus remedia, quum morbus non adcst, 
sod futurus timetur—we administer our remedies 
during the interval rather than during the attack : 
or, when in his own words he says dhk dicfirjs nazovoys 
T03V voarjuaroov ovx elai Kal°oi tu>v /Soj/S/j/xdrcoi/, Kai fir] ovtqdv 
vocrrjudrov elcrl Kacgui (fravegov, un ovk emvoia 
fiovov aXXa Kai imocrTacrei 8ia<fiegovo-iv. It is because the 
organism recovers from severe illnesses by the 
rebound of its own vital powers that this principle 
is true; and the ancient master of medicine could 
not fail to perceive it, although unfortunately his 
modern successors have not kept it so clearly in 
view as they might have done. The severity of 
attacks of illness is proportioned to the extent 
or magnitude of the exciting causes on the one 
hand compared with the resistance of the organism 
on the other, or what we may call perhaps its 
predisposition. And predisposition is in turn deter- 
mined rather by the previous and long subsisting 
relations between the economy and air, food, and 
exercises, than by the inheritance transmitted to it 
by its predecessors. Predisposition in adult life 
depends far more on personal management than 
on our ancestors, far more on acquired than on 
inherited characters. 
What has been said regarding disease further 
shows us how attacks are periodic before disease 
becomes chronic, and how, even after disease has 
become chronic, periodicity can be detected in its 79 
aggravations and recessions. On the other hand 
(and this is quite as important as the other con- 
sideration), when a patient is in course of recovering 
from a chronic illness, the recovery is not as a 
rule continuous any more than was the onset of 
the illness. There is a period of recovery and 
then a period of relapse. We know that the patient 
is recovering because the intervals between the 
attacks are lengthening ; or perhaps because the 
attacks themselves are less severe, when they set 
in. If we find the intervals lengthening and the 
attacks becoming less severe we may be quite sure 
that the patient is recovering, although we are 
often justified in inferring recovery from the 
presence of only one of these conditions, either 
from lengthening of the intervals between the 
attacks or from diminution in their severity. 
There is another thing which perhaps ought 
to be mentioned. When we commence the treat- 
ment of a chronic disease (very frequently, as we 
have seen, a periodic disease), when we have directed 
attention to its causes, and have altered them so 
far as we can, the first thing to happen, say, in 
a few weeks after these changes have been made, 
and when we are looking for improvement in the 
patient’s condition, is that he has, instead, an 
attack more severe than perhaps he has ever had- 
before, or more severe than he has had for a 
long time. In this case both patient and doctor 
are apt to be discouraged and tempted to think 
The correct 
treatment of 
recurring ill- 
nesses is often 
followed by a 
few very severe 
attacks of the 
illness. 80 
that the treatment has not been directed on right 
lines. But this does not follow. The increased 
severity of the attack is the effect, not of the treat- 
ment but of the previous long continuance of wrong 
conditions. Effects in medicine are remote from 
their causes. It is not what we do to-day that 
makes us ill to-morrow. In particular it is not the 
starchy and saccharine food we consume to-day 
which gives us bronchitis to-morrow. It is the 
repetition of it day after day, and perhaps week after 
week, or even month after month previously, which 
by its cumulative effects produces the illness. Few 
of us appear to be able to see so far as this. In 
point of fact, the illness is a beneficent attempt of 
nature to rid herself of the waste matter which has 
slowly accumulated in the blood and tissues for a 
long time. In the highest sense of the term, the 
illness, bronchitis, rheumatic fever, influenza and 
pneumonia, or whatever it be, is salutary ; as we 
may easily perceive if we reflect that usually a long 
period of health follows on the early attacks, and this 
even when, being ignorant of the causes, we allow 
them to re-accumulate after it. So in the case in 
question, it is not the diminution of the starch and 
sugar which has caused the disappointing attack of 
bronchitis ; but it is the slowly accumulating effects 
of the previous consumption of too much starch 
and sugar. (This, by the way, is, not improbably, 
the explanation of what is often called the cumulative 
effects of remedies on the body.) These, acting over 81 
a long time, have modified the organism so that it 
has (as far as possible) become habituated to unsuit- 
able conditions; and when these are altered to those 
of health, the organism has to become re-habituated 
to the new conditions. It cannot do this all at once. 
There is a struggle, consequently, between the old 
unhealthy conditions and the new ones, though they 
are more suitable to health; and the most usual 
translation or expression of this struggle is a severe 
attack of illness of the kind to which the patient 
has been subject. The explanation may, of course, 
be simply that the long continuance of improper 
conditions was bound to result in an attack of 
illness sooner or later, and that it has come now. 
I think myself, however, that, in whatever way it 
comes, or whatever may be the exact explanation 
of the fact, the attack of illness seems to come earlier 
where treatment has been commenced than if we do 
not interfere. So frequently at least have I seen 
this occur, even when the remote result of treatment 
has been perfectly successful, that I am in the habit 
of warning patients that we may have to deal with 
one or more severe attacks of their customary illness 
before improvement sets in, and that it is most 
important therefore not to lose heart. 
One implicate of these considerations is the canon 
that emerges when considering the causes of 
diseases, and may be thus expressed. “ If we find 
recurring attacks of disease, we should look for 
a constant cause.” Is it a question of recurring 
Canon for 
treatment. 
If recurring 
attacks show 
themselves, 
look for a con- 
stant cause. 82 
attacks of dyspepsia, of bronchitis, of rheumatism, 
of influenza, of endometritis, of “ovarian neuralgia” 
(myalgia ?), of erysipelas of the face, of nephritis, or 
of any other disease? Then we may be sure that 
the cause is constant, and it is the business of the 
doctor to find it out. Nor is this so difficult as at first 
sight it seems to be ; for probably the cause (the main 
or chief predisposing cause, that is, for causes are 
always multiple) is some improper relation between 
the economy and its environment, some imperfection 
or some abnormality in the reaction of the economy 
to air, or food, or work, or physical exercises. 
There is one phase of criticism of the sort I 
have been discussing to which I ought further to 
refer. Supposing that the woman referred to, in 
place of having suffered for twelve years from 
recurring attacks of her malady, had presented 
herself for treatment after or during her first attack. 
She did send for a doctor when in that condition. 
Now, supposing that medical man had said—“The 
“cause of your malady is mainly an excess of 
“ carboniferous foods—diminish these and you will 
“ have no more attacks.” Let us suppose further 
that the advice had been taken and that the patient 
had remained well. If, further, the medical adviser 
had quoted that as a case showing the connection 
between bronchitis and carboniferous foods, the 
critic would have been able to say many things. 
As first, it was by no means certain that the woman 
would have other attacks; many people have one 
Further diffi- 
culties con- 
nected with 
the post hoc 
ergo propter 
hoc fallacy. 83 
attack of bronchitis, he would have said, and no other 
for years and years ; she recovered in the ordinary 
course of nature, and she would probably have 
recovered under any reasonable treatment, and 
whether she had diminished her consumption of 
carboniferous foods or not. The critic would have 
been at a great advantage in that case ; for although 
the medical adviser might have shown even unusual 
insight in concluding that the attack was the first of 
a series and not a mere separate or single occurrence, 
there could have been no evidence, at least no 
convincing or satisfactory evidence, for the correct- 
ness of his view, nor therefore for the value of his 
treatment. In that case the public might well ask, 
“ Who shall decide when doctors disagree ? ” And 
yet one doctor would have been right and the other 
wrong, although he who was wrong would probably 
have been able to convince even a jury of qualified 
colleagues of the truth of his opinion, and to have 
carried by a large majority a vote in his favour in a 
medical society. 
Such inquiry as has been made into the law of 
the continuance and recurrence of disease on the one 
hand, and its recession on the other, has thrown 
some light on the subject, and has put us in a better 
position as regards the critic. It does not lend any 
colour to his suggestion that the bronchitic and 
asthmatic attacks referred to were about to cease, at 
any rate. The opposite was in fact more likely. 
The causes of the attacks were continuing, and there- 84 
fore further attacks might have been expected. It is 
not the rule that attacks of illness which have been 
recurring for some time should suddenly (or even 
gradually) cease. It is the rule rather that they 
should continue to recur. If they cease suddenly, 
the probability is either that some change in their 
causes has taken place, or that some new phase of 
the illness may be expected to ensue. Changes 
in the direction of cessation or of diminution 
in the causes will, as we have seen, show them- 
selves rather in a diminution in the severity of 
the attacks and in a lengthening of the intervals 
between them than in their sudden and complete 
cessation (there may perhaps, as has been said, 
be one or two very severe attacks before improve- 
ment sets in). In the case in question the attacks 
of bronchitis and asthma were not only diminished 
in severity and frequency—they were made to cease 
altogether — more suddenly, it is true, than had 
been anticipated. But the improvement, whether 
coming suddenly as it did, or more gradually as had 
been rather expected, had been confidently predicted 
as the result of the treatment, and although, perhaps, 
the prediction may have sounded hazardous and even 
arrogant at the first interview, its terms were more 
than fulfilled. Although expecting the improvement 
to be more gradual, and perhaps that the woman 
would have one or more very severe attacks before 
it fully set in, still I can have no doubt that the 
recovery was due to the treatment, that it was 85 
propter hoc and not merely post hoc, that it was due 
to the advice she got, and not to mere coincidence. 
We may doubt the existence of a law of nature 
until we have seen it in operation. But if, after 
seeing it in operation, we have an opportunity 
of making circumstances in which its scope and 
influence may be felt, and if then we find our 
prediction as to its effects completely verified, our 
belief in the existence of the law becomes much 
stronger, and becomes indeed a conviction. This 
is what happened in the case in question. I had 
seen, or thought I had seen from other cases and 
from physiological evidence, that an excess of 
carboniferous saccharine and starchy foods is the 
main cause of bronchitis and asthma (which is very 
often oedematous bronchitis, due to the growth of 
saccharo-myces in the bronchial mucous membrane ? 
A kind of swarming of the bacillus there ?) I 
confidently predicted that if that excess of these 
foods was removed the patient would recover ; the 
excess of these foods was removed and the patient 
did recover, after having suffered for twelve years. 
No other change was made in her surroundings 
or habits. As to cold, the alleged cause of her 
suffering, she was told she need not mind it par- 
ticularly, but that did not prevent her recovering 
in accordance with the prediction. What further 
evidence can we have in this life and with our 
limited powers over nature than this ? I can have 
no doubt as to the causal sequence of treatment 86 
and recovery, especially as in similar cases before 
and since I have been able to obtain similar results. 
I have asked, what further evidence can we have ? 
Well, there is further evidence possible. Put that 
woman back again under the old conditions. Let 
her return to her bread and to her sugar, to her 
rice, sago, tapioca, and Yorkshire puddings, to her 
potatoes and to her jam, to her bread and milk— 
or oatmeal—suppers. Let her do this and she will 
have her bronchitic and asthmatic troubles back 
again in a few weeks or a few months. I do not 
recommend the performance of this experiment, but 
I know very well what the result will be if it is tried. 
And, of course, nature being above and beyond us 
and comprehending and governing us all, will yield 
the results to all who care to put themselves into 
proper conditions ; and what has been done in 
one case may be done in any which is similarly 
circumstanced. 
If bronchitis is due to an excess of carboniferous 
foods it ought to be possible, since bronchitis is 
growing very much as a cause of death in England, 
to show that these foods are being consumed to a 
greater extent now than formerly. I do not myself 
doubt that this is so. Still it is a very difficult thing 
to prove. I think there can be no doubt, if the habits 
of the average members of the community are exam- 
ined, that they mainly live on a diet of bread, 
potatoes, puddings, and sugar. In the case of bread, 
they have emasculated it and deprived it of its 87 
sustenance by removing the outside of the wheat 
grain in what is called refining the flour. When 
people live, as so many do, on a diet of white bread 
and tea and sugar three or more times a day, it is no 
wonder if they look pale and pasty-faced, and if they 
keep continually taking “ colds.” One has often been 
struck by the pallor of the operatives returning from 
work in the mills, when many of them can be seen 
together, and their undernourished appearance forces 
itself on our attention. Perhaps some of this appear- 
ance is due to confinement indoors, and yet mill 
owners are now compelled by law to ventilate their 
premises better than they used to do, and many mills 
provide a larger amount of air-space than the work- 
people can obtain in their own houses. I cannot 
help thinking that a great part of the cause of 
this unhealthy appearance is the white bread 
and butter and tea diet which these people live 
on for economical reasons often three times a day. 
It does not seem possible to prove from the Board 
of Trade Returns how or to what extent the con- 
sumption of carboniferous foods is altering in the 
country. So much depends on the amount of the 
home crop, eg., of wheat, potatoes, &c., that it seems 
impossible to discover from this source how the diet 
of the people is altering. One thing certainly is 
very striking, and that is the large increase which 
seems to be taking place in the consumption of 
sugar. In 1866 there were retained for home con- 
sumption in the United Kingdom 41 lb. of sugar, 
Consumption 
of sugar in 
the United, 
Kingdom. 88 
raw and refined, for each person in the population. 
In 1871 the corresponding figure was 461b. per 
head per annum. In 1876 it was 581b. In 
1881 it was 57lb. In 1886 it was 661b. ; and 
in 1892 it was 771b. per head per annum. Too 
much weight should not, perhaps, be attached to 
these figures, because since 1874, when sugar was 
admitted free of duty, the amount used per head of 
the population includes the proportionate amount of 
raw sugar refined and re-exported. But still, I 
think there can be no doubt that the consumption 
of sugar per head of the population has greatly 
increased in recent years. There seems to be a 
greatly increased quantity of jam consumed. The 
trade in that and in sweet-meats seems to have 
grown to great proportions in recent years. And 
one is struck in travelling by railway, for instance, 
to see the quantities of sweet-meats consumed, 
whether by the elegant young lady who eats them 
out of her bon-bon box with a pair of tongs, or 
the mill girl who pulls them out of the plebeian 
paper bag. All classes seem at least to think that 
their strength can be kept up and they can best 
meet the labour of travelling and of walking by 
the free consumption of sugar. 
It is customary to point to the increase in the 
consumption of meat in England in recent years. 
The quantity imported has no doubt greatly 
increased. I do not think it is worth while to 
quote the figures, because there is no means of 
Increase of 
meat consump- 
tion probably 
not the cause 
of the increase 
of Cancer. 89 
comparing the quantity of home-grown meat 
consumed with that of foreign production. But 
even if it be that the consumption of meat per 
head has increased of late years (and I do not 
know whether this is so or not, though it seems 
probable on the whole), the increase is not nearly so 
great as the increase in the consumption of wheat, 
and flour, and sugar, so that it seems as if the 
increase in the consumption of the carboniferous 
foods was very much greater than that of nitrogenous 
foods. But any one can see for himself how highly 
carboniferous the English diet is by running it over 
in his mind. Bread and butter, with tea, for breakfast 
(with or without bacon or eggs). Dinner at one, 
of meat and potatoes and pudding—little meat and 
much potato and pudding—with bread. Afternoon 
meal of bread and butter again and tea, about four; 
and supper of bread and cheese and beer, or perhaps 
oatmeal porridge, at eight. Let any one realise of 
what this diet consists, and he will see how much 
labour it compels the bronchial mucous membrane 
to do in order to oxidise it off, and what great 
likelihood it involves that congestion and inflam- 
mation will be set up in it, and how certainly 
bronchitis and broncho-pneumonia must be among 
its consequences. Many domestic servants also insist 
on having a cup of cocoa or tea or coffee, with 
bread and butter, at eleven in the forenoon, so 
that these women are eating bread, and mostly 
white bread, no less than five times a day. The 90 
marvel is, not that they should suffer from dyspepsia, 
anaemia—triphthaemia rather ?—rheumatic fever, and 
frequent colds, but that they should ever be well. 
The mistress dare not suggest the reduction of 
meals to three in the day, and when the doctor 
does so he is not listened to. 
So far, I have considered the connection between 
bronchitis and carboniferous foods. I think there can 
be no doubt that bronchitis and asthma are due (as 
their main or chief predisposing cause, though not of 
course their chief exciting causes) to the ingestion 
into the economy of larger amounts of carboniferous 
foods than are assimilated. These foods being to a 
large extent burned off in the mucous membrane of 
the lungs, that structure, accordingly, becomes con- 
gested and inflamed because it has too much work 
thrown on it. When the inflammatory action spreads 
to the sub-mucous tissue and to the air-cells, broncho- 
pneumonia arises; the “cold” is more severe, and the 
patient may be compelled to go to bed. With an 
ordinary “ cold,” i.e., slight inflammation of the 
mucous membrane of the upper part of the wind- 
pipe, or of that of the bronchial tubes ( Tracheitis or 
bronchitis rnitis, or /enta), he generally manages to go 
about, and the “ cold ” works itself out. But if, as so 
often happens, a chronic congestion of the mucous 
membrane and of the sub-mucous tissue has existed 
for some time, a sudden increase of these conditions 
may occur, the inflammatory action may spread 
to the air-cells, and a sudden attack of what is 91 
called pneumonia may set in, at once placing the 
patient in extreme danger. Very often there is 
severe headache and pain in all the limbs with 
fever, lasting for a day or two, after which 
the pneumonia declares itself; and the whole 
condition is then called influenza, accompanied by 
pneumonia. Before we became accustomed to look 
for influenza in 1891, it seems to me we used to 
call these conditions bronchitis, broncho-pneumonia, 
and pneumonia—in popular language “ a severe 
cold,” or “ a severe feverish cold.” No doubt the 
infectious character of influenza is striking, while 
bronchitis has not been so much considered an 
infectious disease. And yet how common it is, and 
was, to see “ colds ” starting with one member of a 
family and attacking one person after another in the 
household, till almost every member of it had 
suffered. Since 1891, it seems to me, we have had 
the infectious character of these affections forced 
more on our attention than formerly ; but the minds 
of most practitioners, I think, must always have been 
impressed by the infectious character of “ colds.” 
This character had at least always been associated 
with severe “ running colds in the head,” as they 
have been called. In such cases the spray of vapour 
given out at each cough or sneeze may easily be 
supposed to set up similar action in a neighbour 
when lighting on his mucous surfaces, and when 
carried in by the air entering his nostrils. And even 
when the cold is not characterised by the same free 
How 
Pneumonia 
and Itifluenza- 
wiih-Pneu- 
tnonia depend 
on an excess of 
starchy and 
saccharine 
food. 92 
expulsion of watery vapour, it may readily be 
conceived that particulate matter given off by the 
breath of a person suffering from influenza may 
enter the respiratory tract of a neighbour, and there 
set up a similar action. Especially will this be the 
case if the respiratory mucous membrane of that 
neighbour is already in a congested state, with its 
resisting power therefore weakened. This congestion 
and weakened resistance is brought about to a large 
extent, as we have seen, by the consumption of 
larger quantities of carboniferous foods than are 
assimilated ; so that it comes to this, that the persons 
who are most susceptible to the influence and to 
the infection of influenza, are exactly those who 
live largely on bread, potatoes, puddings, and sugar. 
From my observation I should say that those are 
just the persons who get it, and that when we hear 
that a person has had influenza several times, five 
or six or seven or more times as some are said 
to have had it—and when in obedience to the 
canon which we formerly saw to obtain, we look 
for a constant cause for these recurring attacks, we 
shall find that the diet of those people has largely 
consisted of one or more of these foods. I am sure 
from what I have seen that this is so. Although 
both sexes suffer from influenza, still it is on the 
whole the women rather than the men who suffer 
from the repeated attacks that are under consideration 
now. The only reasons for this are that women 
consume these foods on the whole to a larger extent 93 
than do men, and that women place themselves under 
the influence of methodised exercises as a rule to a 
much less extent than men. If these considerations 
are so (and it seems to me that on the whole they are 
true to nature), it appears to follow that influenza is a 
preventable disease, and that no one, or hardly any one, 
need have it (infection or no infection), a conclusion 
which, I must say, is quite clear in my mind. Of 
course a period of preparation, and even a long 
period, may be required to alter the constitution of 
susceptible persons, so as to render them insus- 
ceptible ; and the longer must that period be, the 
longer the predisposing causes have acted previously. 
But as the predisposing causes of influenza seem to 
be an excess of carboniferous foods, and the absence 
of methodised movements, the translation of this 
abstract proposition regarding the altering of the 
constitution resolves itself into this, that we must 
diminish the amounts of carboniferous foods con- 
sumed, and prescribe exercises twice a day, in order 
to render persons insusceptible to take influenza. 
That the alteration of constitution can be effected 
I have no doubt, under 45 or 50 years of age at least, 
though it may take a long time to do. Constitution 
being the resultant at any and every moment of the 
interaction between the economy and its environ- 
ment, that is between the economy and its air, food, 
and movements ; it follows that the constitution can 
be slowly changed by altering its relations to these 
three things. Reasoning of this sort enables us to 
Influenza a 
preventable 
disease. 
Definition of 
“ Constitu- 
tion." 94 
translate predisposition, which has hitherto been so 
mysterious, and even metaphysical, a consideration, 
into terms of the action on the economy of air, food, 
and exercises, or movements. According as the 
economy is properly or improperly managed in 
respect of these three things does its resistance 
become greater or less. Predisposition in one word 
seems to resolve itself into resistance. Or one 
ought perhaps rather to say ; predisposition is the 
opposite of resistance : it is inverse resistance. It 
seems a mere play upon words to say that no one 
can suffer from any ailment who had not the 
predisposition to do so ; and yet a great writer has 
delivered himself of this truism as regards the 
acquisition of physical characteristics. If the resist- 
ance of the organism to the poison of influenza (or 
to any other influence) is great, then predisposition 
is small or slight. If, on the other hand, predis- 
position is strong, then resistance is slight. Predis- 
position and resistance seem to be inversely as one 
another, the greater the one the less the other, and 
the less the one the greater the other. If health is 
maintained by proper management, then the economy 
is able to oxidise off and to resist without illness 
a much larger amount of the poison of influenza 
than if the air it uses is foul, the food it consumes 
is unsuitable, difficult of digestion or innutritious, 
and the movements it performs insufficient or 
excessive, or not properly methodised. If health is 
at a standard sufficiently high as regards these 
Definition of 
' ‘ Predisposi- 
tion.” 95 
conditions, it seems as if the poison of influenza 
would or might have no effect at all. In other 
words, influenza might thus be prevented. It seems 
to me a great step forward to have seen our way 
to the conclusions, first that bronchitis is both 
curable and preventable, and now that influenza is 
preventable, while even its infectious character can 
be modified, since if we do not possess on the one 
hand the congested mucous membrane, which is due 
to wrong eating, nor on the other the congested 
muscular-sheaths, which are due to this cause and 
the absence of methodised exercises, we shall most 
probably prove insusceptible to the disease. The 
person who attends to these things need not, I 
think, have any fear of catching influenza ; but if 
he does, it will probably prove so trivial that it 
matters very little whether he takes it or not. 
While dealing with the term “ Constitution,” and 
giving it the definition suggested, perhaps I ought 
to draw attention to two other words often used 
in this connection, and to attempt to define them. 
I mean the terms “ Diathesis ” and “ Heredity ” or 
“ Atavism.” Evidently there are three natural 
divisions of the causes which may affect the state 
of an individual. There is first the present condition, 
which is what I have wished to denote by the term 
constitution. The constitution of an individual is 
the state at any moment resulting from the changes 
produced by the interaction between the individual 
as he started at birth and his circumstances or 96 
environment up to the time at which his state is 
being considered. Each change in environment alters 
the organised being. As the environment is always 
changing (in the element of time if nothing else) it 
follows that the constitution is always changing. 
With each alteration of environment the constitution 
shows a new condition, a new mobility, a new state. 
But by the term “Atavism” or “Heredity” we refer 
to the influence which his progenitors have exerted 
on the individual. It is evident that this (unlike 
constitution, which is changing every moment with 
each change in environment) is fixed and determined. 
Ancestors while they lived were no doubt always 
changing with the changes of their environment, 
just as we do. But when a new individual comes 
into the world, the modifications which his ancestors 
have exerted on him cease. Whatever these modifi- 
cations are or were that they remain. Heredity or 
atavism is the state of the individual as determined 
by ancestry. Constitution, on the other hand, is the 
changing state induced by his own circumstances, 
particularly his relations to air, to food, and to 
exercises. The former is fixed and determined. 
The latter is continually changing as the environment 
changes. Atavism probably determines, or is one of 
the factors which go to determine, the development 
and organisation of the descendants. Organisation is 
undoubtedly inherited, or some part of organisation 
is undoubtedly inherited. That one man should, 
when full grown, measure 5ft. 9m., and another 
Definition of 
Atavism or 
Heredity. 
The 
constitution of 
our ancestors. 97 
man only 5ft. 6in., is one of the facts into which 
atavism probably or almost certainly enters. The 
colour of hair and eyes and the general appearance, 
gait, &c., are probably also largely determined by 
the same cause. We cannot overlook or fail to 
recognise facts so noticeable as these. But it is 
a question, for instance, whether an organism 
which, under favourable conditions, would reach a 
height of 5ft. 9in., might not, under unfavourable 
conditions of feeding, &c., fail to reach more than 
5ft. Sin. or 5ft. Siin. The organisation which is trans- 
mitted or inherited can apparently be modified by 
conditions of environment. The child of a micro- 
cephalic idiot whose brain weighed only 2lb. would be 
very unlikely to possess a brain which weighed 41b.; 
and if both parents were microcephalic, it would be 
in the highest degree improbable that the children 
would have well-developed brains of normal size 
and weight. This would be a fact of organisation, 
as I should express it, not exactly of disease ; for 
though such a brain would be small and incapable 
of normal human intellection, still it might be 
healthy and sound so far as its powers went. I 
suppose that the dwarfs described by Stanley in his 
African journey would be human beings, though no 
one would expect to find among their descendants 
individuals equal to the normal human standard ; 
and yet, as among other tribes of the human race, 
some members even among the dwarfs would 
probably be taller than others. In a wide and 
Atavism gi 
to deter mi, 
organisatio 
Does it go 
determini 
Disease f 98 
comprehensive sense, humanity may be said to be 
transmitted or inherited ; and vve see humanity to 
be well demarcated from the bovinity, or caninity, 
or felinity which characterise other orders of animals. 
But the question which interests us from time to time 
in the course of this inquiry is rather the inheritance 
of disease than of organisation. And it will be seen 
that the view which has forced itself on the writer 
is that disease is transmitted very rarely indeed, so 
rarely that while possibly io per cent, of the disease 
one sees may be due to inheritance, certainly 
at least 90 per cent, is acquired. I think, indeed, 
that it is impossible to believe that even 10 per 
cent, of the disease which one sees affecting persons 
in adult life can by any means be due to inheritance. 
I mention that as an outside proportion, one beyond 
which inheritance of disease cannot possibly extend, 
and believing that the proportion is, in fact, much 
less. I hope to return to this point later, 
But there is another natural division in the life 
history of an individual, and that is his state during 
the intra-uterine life, that is, from the moment of 
conception till birth. To this I propose to confine 
the term diathesis. I have known cases in which 
facts occurring during the intra-uterine life had an 
important influence on the individual. To go no 
further, premature birth is admittedly a damage 
to a life, and a danger to the rearing of a 
child. And supposing the difficulties and dangers of 
that time to be overcome, it is conceivable that a 
Definition of 
Diathesis. 99 
person may be left weaker or with less vitality than 
if he had not had to contend with them. Of course 
diathesis, in this restricted sense, runs into and 
becomes continuous with constitution, since at the 
moment of birth diathesis ends and constitution 
begins. Like atavism, however, diathesis is fixed 
and determined at birth. It may be modified for 
a very short time, while atavism cannot, or its 
effects can be modified only a very little. But 
constitution can be modified as long as life lasts. 
These uses of these words, it may be said, are 
arbitrary; but the states pointed to by them are 
real and natural. It is no doubt true that the three 
terms are loosely used as more or less synonymous 
with one another, but this leads to confusion in 
thinking, if, indeed, the loose use of the terms is not 
caused by confusion of thought. As we have three 
terms in common use, and as we have three natural 
states to be named, it seems to me it would be well 
to confine our terms to the meanings suggested, 
so that we should clearly know when each term 
was used what was meant by the word. If these 
uses are objected to, better terms should be proposed. 
Perhaps a word may be permissible regarding the 
infectiousness of “colds” and of influenza. The 
observation applies to infection and infectiousness 
in general. It is this : that we assume too readily 
that a number of cases of illness occurring simul- 
taneously, or at short intervals after one another, 
are caused the one by the other; while, in fact, they 
Infectious?iess 
from case to 
case ; or as 
successive 
effects of a 
common cause. 100 
may be induced by a common cause. For instance, 
a number of cases of influenza may, each of them, 
be set up by exposure to cold (or heat, for these 
cases are common in hot weather), acting on persons 
whose bronchial mucous membrane is congested by 
improper feeding in the way suggested, and this in 
case after case ; or they may be induced the one by 
the other by the passage of the infecting bacillus, 
or whatever the cause may be. Inasmuch as the 
members of a household live similarly, we can see 
how a predisposition to take influenza (or any other 
affection—bronchitis for example) may have been 
induced in all its members, and can hence easily 
understand how person after person might suffer, 
even although the one did not affect or infect the 
other. The different cases may have been successive 
or concomitant effects of a common cause, as well as 
cause and effect of one another. The danger, how- 
ever, of confusing causes and effects with the 
concomitant or successive effects of a common cause 
is one which is always present with us in medicine, 
especially as regards the incidence of infectious 
disease. A number of persons in a household may, 
for example, each of them be poisoned by sewer gas 
which, let us suppose, enters the house and infects 
each person in turn with diphtheria ; or, the first case, 
having been so caused, may have caused the second 
case by direct infection, and the second the third, 
the third the fourth, and so on. And it is possible, 
nay, I think it likely, that even the predisposition 101 
to take the disease at all may have been brought 
about by improper feeding, so that, even with the 
ingress of the sewer gas the family might have 
escaped, had the members of it been differently 
managed as regards food and methodised exercises. 
Food and exercises could thus act powerfully in 
modifying the resistance of the organism, which 
indeed they no doubt do. 
Now it seems to me that rheumatism and the 
condition known as anaemia are other phases of the 
effects on the economy of a super-abundance of the 
same carboniferous foods as caused bronchitis, severe 
colds, influenza, broncho-pneumonia, and pneumonia. 
These named affections, as has been seen, appear to 
be rather direct or immediate effects of the over-con- 
sumption of these foods, while rheumatism is its most 
striking indirect or remote effect. Bronchitis and 
rheumatism appear to me to be different phases or 
manifestations of fundamentally the same condition. 
When the carboniferous foods overload the economy, 
an early and common effect is to set up bronchitis 
and broncho - pneumonia, and so we see the 
tendency to “take cold” very marked in childhood 
and early life. But so we do with rheumatic fever, 
which seems to me to be occurring more often in 
childhood and early life than it used to do. On the 
whole, however, rheumatism seems to occur later in 
life than the susceptibility to “ take cold.” And yet 
it is astonishing how common is the muscular tender- 
ness which I have described, to be found among 
The predis- 
position to 
Rheumatism 
and to Anccmia 
also due to 
excess of 
carboniferous 
foods. 102 
young children when examination is made for it. I 
have found it at least at all ages after seven or eight, 
and I may add (what might indeed have been 
anticipated) that it is much more quickly responsive 
to treatment in children than when occurring in 
older persons. Slight alteration of the diet and the 
prescription of well-directed exercises generally 
suffice to get rid of it in a short time. As time 
goes on the tissues become harder and firmer, and 
more capable of sustaining both exertion and 
exposure than at more tender ages. If, in the 
habits of life, a larger amount of carboniferous food 
is taken than is consumed, the blood comes to be 
loaded periodically after each meal with an excess 
of the products of these food-stuffs. In due course 
the blood is laid out on the extended curvilinear 
surfaces which form the muscle-sheaths, the nerve- 
sheaths, the brain- and cord-membranes, the perios- 
teum, the synovial sheaths of tendons and joints, and 
the joint ligaments, for the purpose of nourishing 
these tissues. When this occurs, these flat or 
extended surfaces not only receive nourishment from 
the blood, however ; they act as filters and receive 
from it the waste material floating in it. It is in 
fact a very favourable circumstance that they do act 
in this way, since they thus act as purifiers of the 
blood, which is therefore sent on to do its work for 
the nutrition of vital organs in a better state than if it 
had not been relieved of its waste in this way. But 
this process explains the existence of such conditions 103 
as muscular rheumatism, facility of fatigue (for how 
can waste-laden muscle-sheaths work long and 
smoothly ?), neuralgia, neuralgic and periostitic head- 
aches, periostitis, and by and bye joint stiffness and 
joint thickenings. One of the most striking facts 
which go to show the relation between bronchitis and 
rheumatism is (what I have mentioned before) that 
periostitis of the sternum (and often also of the ribs) 
is invariably present in sufferers from chronic or 
frequently recurring bronchitis. And, as might have 
been anticipated, whenever our eyes are opened to 
the relations between the two affections, we find that 
persons who are subject to chronic bronchitis are also 
subject to attacks of rheumatism, and are apt to 
spend their time suffering, now from a severe cold 
and then from rheumatism. 
Another of the conditions often arising from the 
same causes is the state known by the name of 
anaemia. It is found mostly in young women, 
although not by any means unknown among men. 
The main reason I believe that it is commoner 
among young women than among men is because of 
the differing habits and differing tastes of the sexes 
as regards food and exercises. As I have said, I think 
triphthcemia would be a better name for it, triphthcemia 
carbonifera f perhaps if we gave it its full name. 
(Perhaps I ought here to say in parenthesis that I do 
not exclude the existence occasionally, still less the 
possibility, of the occurrence of a triphthcemia nitro- 
genosa, due to an excess in the blood of waste 
Connection 
between 
Rheumatism 
and Anosmia 
through 
Triphthcemia 
Carbonifera. 104 
products from the over ingestion and mal-assimilation 
of nitrogenous foods. But I am now pointing at 
what I believe to be far the commonest form and 
cause of triphthcemia, the triphthcemia carbonifera). 
The variety of it most commonly met with in early 
? life might be called triphthcemia chlorotica from the 
greeny yellow complexion so often shown by these 
young people. In later life, when the causes of 
the condition have not been attended to, and when 
the use of the carboniferous foods has been persevered 
in, and to some extent, though an imperfect one, they 
have been assimilated (and especially when beer or 
stout has been added to the diet), the persons 
become fatter and fuller and redder in the face. We 
then find present the variety of the disease which we 
may call triphthcemia rubra ( T. erythrea). This is 
often apparent in middle-aged men, fat and puffy, and 
breathing rapidly on slight exertion, and subject to 
attacks of rheumatism, or what they prefer to call 
gout; or liable to be laid up with attacks of influenza 
accompanied by more or less broncho-pneumonia. 
Women in this condition can often be recognised 
(besides that their appearance betrays them) by 
being compelled to hold a screen between their faces 
and the fire ; and sometimes they are subject to 
attacks of erysipelas of the face. This ailment in 
fact sometimes attacks young women, and I have 
seen one or two most interesting cases of it, 
particularly one in a young woman who had suffered 
for seven years from recurring attacks of it, till her 
Ancemia a 
rheutnatic 
affection. 
Might be called 
Triphthcemia 
Carbonifera 
Chlorotica. 
Erysipelas 
Faciei also an 
effect of 
Triphthcemia 
Carbonifera. 105 
face was swollen almost beyond recognition. For 
nine months before I saw her she had been quite 
unable to follow her occupation of a weaver. I had 
all the evidence that one can have in such circum- 
stances that the ailment was due to an excess of 
bread eating, because, first, the attacks ceased when 
bread was diminished to once a day. Second, the 
attacks recurred when the girl found herself so much 
better that she thought she could do as she liked. 
And third, the attacks again ceased when the bread 
was cut down to once a day. She has done her work 
now for nearly two years, and thoroughly recognises 
on what her ailment depended. But many middle- 
aged women who have triphthcemia rubra suffer 
from recurring attacks of erysipelas of the face 
(which they cleverly treat by applying evaporating 
lotions of whiskey and water, or eau de cologne 
and water, to the face on linen), and I have no 
doubt at all that the main predisposing cause is an 
excess of carboniferous foods in the diet. Some- 
times the triphthcemia ciilorotica of youth passes 
into the triphthcemia rubra of middle age, and 
this again (as I shall hope to show later) into 
the yellow or green “ cachexia,” as it is called, 
which is so characteristic of the presence or of the 
suspicion of the presence of malignant disease, and 
of pernicious anaemia. But I think I have seen cases 
where the triphthcemia chlorotica and T. pallida of 
youth becomes the cachexia of middle life, with all 
its disease and early death, without the inter- 106 
currence of triphthcemia rubra at all. (Another of 
the conditions which is very often associated with 
and is no doubt the outcome of triphthcemia rubra 
in middle-aged persons of both sexes is eczaema; 
and still another is thickening of the vein-coats 
leading to varicosity, but I do not wish to enter on 
the consideration of these conditions now.) 
As to Triphthcemia chlorotica, or what is com- 
monly called ancemia, so far as its general symptoms 
are concerned, the breast-pain (periostitis sterni), the 
palpitation, the distress in breathing and in going 
up hill, the tenderness of the ribs and the con- 
comitant tenderness of the intercostal and other 
muscles (periostitis costarum et perimysitis musculorum 
intercostalium), so far as these symptoms are con- 
cerned, I have no doubt that the affection is a 
rheumatic one. The most convincing proof that can 
be offered for the correctness of this view is that 
inflammation of the heart and pericardium is so 
often associated with it. Many a woman who has 
been told she has anaemia in early life, finds in later 
life that she has heart disease ; but this is often only a 
further and more developed stage of what may have 
been called a functional or haemic murmur at the 
more tender age. Another proof of the rheumatic 
character of anaemia is the fact that sufferers 
from it often have rheumatic fever at some other 
period of their lives, either before the anaemia 
or after it; while after middle life, very many of 
the early sufferers from anaemia come to suffer from 
Eczcema 
and Varicose 
Veins. 107 
rheumatic affections of the joints. Then as to 
influenza, with its broncho-pneumonia, many persons, 
male and female, who suffer from it also take 
rheumatic fever, either before they have influenza, or 
subsequently; so that it seems to me that there is an 
alliance in kind or nature between these affections. 
I recently signed a death certificate in the case of 
a man aged 36 years, who some years before had 
rheumatic fever, who eighteen months before his death 
had influenza, which was followed by severe endo- 
carditis and peri-carditis eventuating in hypertrophy 
and dilatation of the heart. In course of time these 
were accompanied by passive effusions into both 
pleurae, oedema of the lungs, and finally by a passive 
effusion of the cerebral meninges, while his aspect 
at the commencement of the series of maladies, 
which terminated his life, unmistakably pointed to 
the same anaemia or triphthcemia chlorotica as is so 
commonly found in young women. 
This case, and others I have seen, lead me to 
observe that one of the most striking marks of 
profound illness, if, indeed, it is not the most striking, 
is the occurrence of passive effusion into natural 
cavities, such as the pleural, or peritoneal, or 
pericardial, or meningeal cavities. Such effusions 
are often found in the last stages of cancer, as I have 
said already ; and cases like the one just detailed 
show how very serious their occurrence is. The 
gravity of the case is usually great even if the 
effusion remains straw-coloured, serous, and more or 
The occurrence 
of passive 
efusion, 
especially 
sanguineous 
effusion, 
into a natural 
hollow cavity 
is one of the 
most striking 
marks of most 
profound 
illness. 108 
less watery ; but when it is pink or red and 
sanguineous, and still more, perhaps, if it is brown 
or chocolate-coloured, its import is even of graver 
significance. Of course, I do not include under this 
statement effusions such as are found in acute 
pleurisy (though even then they are important, and 
when occurring, eg, within the cerebral membranes, 
generally portend a fatal issue). It is the passive 
effusions occurring in chronic or recurrent disease 
that I refer to. Nor is it difficult to understand how 
their gravity should be so great. As in the young man 
referred to, the blood in these cases has become 
loaded with waste materials from the digestion 
and from the absence of methodised exercises. 
It has, in the first instance, relieved itself 
of this waste on to the muscle-nerve,- and 
bone - coverings. The process still continuing, 
an attack of rheumatic fever has occurred, 
leading to deposition along the ribs and heart, and 
very likely the pericardium (no perceptible damage, 
however, being discoverable in the heart after the 
illness had cleared away). But the process being 
still continued, and the blood still receiving waste 
unassimilated stuff from the digestion, is obliged (so 
to say) to get rid of it somewhere. The muscle- 
nerve,- and bone-coverings being full, important organs 
are called on to relieve the blood, and an attack of 
influenza follows, which intercurrently sets up 
inflammation of the heart, whose consequences (this 
time) are never cleared away or absorbed. The 109 
system being now damaged, and unfortunately the 
causes of the illness still continuing, the series of 
changes I have described occur, and the patient 
succumbs with passive effusion into the pleural 
cavities or between the brain-membranes. When I 
saw the man it was too late to save him ; but I 
cannot help thinking that had the efforts made in 
this direction been begun sooner, say twelve months 
before they were commenced, and had the diet and 
regimen been then altered, the result might have 
been different. 
A similar relationship seems to manifest itself 
when the treatment of these affections is considered. 
Bronchitis, as has been seen, is well and easily 
treated by diminishing the carboniferous foods ; and 
a good adjunct is washing out the waste matter 
from the blood by alkalies taken in hot water before 
food. Rheumatism, on the other hand, is safely 
tractable in this way, but requires, further, the use of 
methodised movements to cope with it successfully ; 
while the treatment of triphthcemia chlorotica is greatly 
aided by the same method of cure. It seems to me, 
indeed, that the administration of iron is of little or 
no use in many cases of anaemia until these means 
of management have been first used. At least I 
have seen many cases of anaemia in which iron has 
been long administered with little or no benefit, but 
which yielded to alkalies in hot water before food, 
accompanied by a diminution of the carboniferous 
foods, and by the prescription of methodised muscular 110 
movements under pressure. The same treatment is 
very valuable for rheumatism, especially for mild and 
long-continued rheumatism ; in fact, it seems to me 
that without the prescription of methodised move- 
ments under pressure, the treatment of rheumatism 
is, comparatively speaking, valueless and fruitless. 
This, again, is quite in keeping with what was before 
said of the relationship between bronchitis and 
rheumatism, the latter being a further stage of 
triphthcemia carbomferci, a less direct or more indirect 
effect of the over-ingestion of carboniferous foods, 
while the former is the direct effect. More effort and 
more prolonged treatment is therefore required for 
the alleviation and cure of rheumatism than is 
required for the successful management of bronchitis, 
but the principles of management, and the treatment 
of both sets of affections, are essentially the same. 
Whether, therefore, we look at the diseases, their 
causes, or their treatment, it seems to me the alliance 
between bronchitis, influenza, and rheumatism 
becomes more and more apparent, and the conclusion 
that they are all in reality different phases of 
triphthamia carbonifera becomes more and more 
firmly fixed in one’s mind. 
Up to the present point we seem to have seen 
evidence for the belief that a main part of the pre- 
disposing causes of bronchitis, broncho-pneumonia, 
and pneumonia is the use in the diet of a larger 
quantity of carboniferous foods than is assimilated. 
Another form in which this proposition may be 111 
stated is that the person who eats properly cannot 
u take cold ” ; and in this form the statement seems 
a very revolutionary one. It would not indeed be 
correct to say that no amount of such exciting 
causes as cold, or heat, or wind, or calm, or rain, 
or drought, affect him or her who eats properly. 
But it would be quite correct to say that these 
things affect him much less than if he is improperly 
fed ; and we might even go so far as to say that 
unless they act with very great power indeed—that 
is, that unless one is exposed to them for a very 
long time, and in very great intensity, the influence 
of these causes will be very slight indeed. We 
have also seen reason to think that, if properly fed 
and properly exercised, persons would not suffer from 
rheumatism. And lastly, we have even seen some 
evidence for the opinion that influenza, although 
an affection probably most suitably classed among 
the continued fevers, is also influenced by the 
same predisposing causes, and that we may ven- 
ture to believe that it also will have no influence, 
or very little influence, on him who manages him- 
self properly as regards diet and exercises. This 
view, however, seems to accord but little with current 
medical opinion. How little in keeping with it it 
is will be apparent if we reflect that in the last 
annual report of the medical sickness and accident 
society, it is stated, without comment, and apparently 
quite as a matter of course, that claims were paid 
during the year on forty-five cases of influenza 
Persons who 
eat properly do 
not “ take 
cold.” 
Bronchitis, 
Rheumatism, 
Ancemia, 
Influenza, all 
preventable. 112 
occurring among medical men. If influenza is a 
preventable disease, the medical profession do not yet 
appear to have been able to utilise the fact so far as 
to have obtained immunity for themselves any more 
than for their patients. Many would probably say 
that their views of the nature of influenza were much 
modified by the demonstration—supposing it to be 
quite complete—that the disease is due to the growth 
of a micro-organism. Quite recently, at the meeting 
of the British Medical Association at Carlisle, a 
suggestion was made that perhaps rheumatic fever 
also should be classified in the group of the continued 
fevers or zymotic diseases. But even if it should 
come to be generally believed that both influenza and 
rheumatic fever ought to be classified among the 
zymotic diseases, and that their course is charac- 
terised or accompanied by the growth of particular 
micro-organisms in the blood and tissues, this view 
might still be compatible with the opinion that both 
might be prevented by the use of proper diet and 
exercises. At least I see no incompatibility between 
the two views. For it might be argued, and with 
much force, that by the slow accumulation in the 
blood of waste products, due to the mal-assimilation 
of improper food, and to the absence of oxidation 
which might have been effected by proper exercises, 
to the slow occurrence of triphthaemia, in short, 
the condition of the blood and tissues might be so 
altered as that they would form a suitable nidus or 
soil for the development of the micro-organisms in 
Even if 
diseases are 
associated with 
the growth in 
the blood of 
organisms, the 
predisposition 
to them may 
still be 
caused by 
improper food 
and absence of 
methodised 
exercises. 113 
question. The micro-organisms, which are the 
recognised causes of certain diseases, we must not 
forget, existed before our discovery of them. Certain 
circumstances are no doubt favourable to their 
growth and development in the human organism. 
Certain other conditions of the organism are, on 
the other hand, no doubt unfavourable for the 
development in it of micro-organisms. It is surely 
making no great demand on credibility to suggest 
that the healthy state of the body induced by a 
supply of and proper amount of pure air, by proper 
assimilation of proper food, and by the use of 
exercises might bring about the conditions unfavour- 
able to the growth of the micro-organisms ; while 
on the other hand imperfect assimilation of improper 
food, and the absence of exercises, with the respira- 
tion of vitiated air might induce conditions favourable 
for their growth and development. The group of 
continued fevers or zymotic diseases is almost 
synonymous and almost co-extensive with the 
diseases due to the growth of micro-organisms in 
the blood and tissues. It seems always a question 
whether in their study of the nature and treatment 
of these zymotic diseases, the medical profession 
may not have been disposed to lay too much 
stress on the nature and growth of the infecting 
micro-organisms, and too little perhaps on the condi- 
tion of the person in whose tissues they may have 
found a lodgment. Of the two things, the seed may 
perhaps have received too large a share of attention, 114 
Relations 
between 
seed and soil— 
between germs 
of fever and 
state of body. 
while the soil, that is the state of the blood and tissues 
of the person in whom the seed grows, may have 
received too little. Different circumstances may no 
doubt determine to which of these two things most 
attention should be directed. In the case of a narrowly 
diffused and very large micro-organism (like bacillus 
'anthracis, eg, the immediate exciting cause of wool- 
sorters’ disease) it may be sufficient to prevent the 
importation of the material containing the organism ; 
or if this cannot be done, to disinfect, and perhaps 
destroy, the power of the micro-organism, without 
troubling ourselves much as to the state of health 
of those persons who handle the wool which harbours 
it. But in the case of a widely-diffused and very 
small micro-organism like that causing tubercle 
(or influenza, eg) the conditions may be so entirely 
different as to render it almost hopeless to attempt 
to prevent contact with the micro-organism, it being 
necessary to devote our energies, on the other hand, 
mainly to rendering the body so healthy that it 
shall be able to throw off the attacks of the micro- 
organism ; in other words to render the body 
unfit for the growth of the bacillus in it. It is 
unfortunate if at any time a due proportion is 
not maintained between these two sets of con- 
siderations. The short-lived furore made by Koch’s 
treatment of consumption has seemed to me a case 
in point illustrative of the absence of this due pro- 
portion, too much attention, it seems to me, having 
been given to the culture and nature of the tubercle- 
Why the 
injection 
treatment of 
Consumption 
fell flat. 115 
bacillus, while too little was devoted to the condition 
of the patient to be treated. The bacillus was 
treated, rather than the person ; the disease rather 
than the patient. There may have been some 
excuse for this, however short-sighted it was. The 
discoveries of science have been so great and brilliant 
in so many directions in recent years that the 
intellect has been dazzled by them. We have seen 
principles apparently quite firmly fixed in philosophy 
so rudely shaken that we have sometimes tended to 
think that there are no fixed principles at all. Koch 
and his co-labourers are therefore to be excused if 
they failed to appreciate the true bearings of his 
discovery, and if their intellects were blinded by its 
brilliancy, especially considering the manner in which 
the discovery was forced into public notice before 
the time was fully ripe. But, no doubt, time will 
rectify errors of this sort. New ideas and new 
discoveries will be harmonised with knowledge 
already gained, and assimilated to principles already 
established. Methods of treating disease formerly 
found useful will not necessarily cease to be so, 
because new ideas have arisen regarding the 
immediate exciting causes of disease. The modus 
operandi of the treatment will rather become 
better understood. The administration of large 
doses of iron, or painting it with nitrate of silver 
solution, to take an example, will still be useful in 
the management of erysipelas of the face, even 
if the disease should be proved to be due to or 116 
associated with the growth of a micro-organism 
in the blood or tissues. But the discovery of such 
a cause, supposing it to be complete, would no doubt 
throw light on the modus operandi of the remedy ; 
while further investigations, by showing how 
the organism came to grow in the body, the sources 
from which it sprang, or from which it entered the 
organism, and the gradual changes in nutrition which 
rendered the body a suitable soil or nidus for its 
development, might enable us to advise the public 
how to prevent the disease altogether, and so to render 
it unnecessary to administer remedies for it at all. 
This desirable end, however, the culmination and 
goal of medical inquiry, will be reached, if at all, 
surely as much by proper management of the body 
as by attention devoted to the growth of the bacillus 
infecting it; as much, it seems to me, by efforts to 
render the body or macro-organism healthy as by 
efforts to deal with micro-organisms growing in it. 
Now one of the principal ways in which the body 
or macro-organism can be rendered so healthy as to 
make it into a soil unsuitable for the growth of 
micro-organisms, is by supplying it abundantly with 
good and pure air; and this is the chief reason, no 
doubt, why the great and costly attention which, 
under the inspiration of sanitarians, has been paid 
to free ventilation in the past generation, has 
been followed by such marked results. This is why 
opening up narrow crooked streets, opening public 
parks, and abolishing so far as possible cellar- 
Prevention 
better than 
cure. 117 
dwellings and over-crowding, have been followed by 
so marked a reduction of the death-rate from fever 
and consumption. I do not know that these diseases 
when they do occur are any more tractable now than 
they used to be. Perhaps we understand more about 
the management of fevers than we used to do. It 
may be so to some slight extent. But the main 
reason why fevers and consumption account for so 
much smaller a proportion of mortality now than 
formerly is not so much because we manage them 
better as because we have fewer cases of them to 
manage. Consumption is certainly still a very 
deadly disease to treat, although its incidence is 
now only half or less than half of what it was 
a generation ago. But so striking is the con- 
nection between the presence of overcrowding and 
the extent and prevalence of the fevers and consump- 
tion, that we have come to view them as on the 
whole dependent, and that directly, on the presence 
of bad air. I do not demur to this view. On the 
contrary, I agree with it in the main. But I should 
like to point out here two diseases which are classified 
among the fevers ; one of which is almost wholly, 
and the other to a great extent, dependent on 
improper food-conditions, rather than on bad air- 
conditions. I refer, of course, to diarrhoea and 
typhoid fever. Typhoid fever is no doubt largely 
due to bad air, and it is impossible to overlook the 
evidence that has induced us to think that it has 
been often caused by the introduction of sewer gas 118 
Classification 
of Diarrhoea 
and Typhoid 
among the 
fevers. 
Due to 
bad air and 
bad food. 
into dwellings. But, on the other hand, besides that 
contaminated water may cause it, it is sometimes 
due to bad food, or it has been alleged to be so, on 
what seems to be good authority; as witness the 
recent report of the scientific commission appointed 
to determine the connection between the prevalence 
of typhoid fever and the consumption of oysters 
grown in water impregnated with sewage. That 
report seemed to leave no doubt that in some 
cases typhoid fever is due to improper feeding, 
or to food contaminated by sewage. This is, 
indeed, only what we might have expected to 
discover regarding the causation of a disease which 
expends its virulence mainly on the alimentary canal. 
If we had known nothing about it inductively it 
seems to me that we should naturally have sought 
for its cause in some improper food-conditions, just 
as on the other hand we might have expected that 
a disease due to bad air would have expended its 
force mainly on the blood or on the respiratory 
apparatus. As to diarrhoea, this presumption would 
seem to obtain even more than in the case of typhoid 
fever. Its virulence also is expended mainly on the 
alimentary canal, and it is most rife and abundant in 
autumn, when the hot, dry weather might be expected 
to set up decomposition in food, which might conse- 
quently irritate the intestinal tract. Of course it may 
be suggested that over-crowding and bad ventilation 
may act as causes aggravating the decomposition and 
fermentation in question, so that we may still view 119 
diarrhoea as a disease due to bad air. Even in this 
case, however, fermentation in food may be looked 
on as an irritant primarily of the alimentary canal, 
in whatever way the fermentation may have been 
caused. It is rather a striking commentary, it seems 
to me, on this suggestion, and it appears to cor- 
roborate the view that diarrhoea at least is due 
to improper food-conditions rather than to bad air- 
conditions, that its incidence and mortality have 
been only very slightly diminished by all the costly 
sanitary improvements of the last generation, 
while those of some other fevers have been reduced 
very much indeed. The mortality from diarrhoea 
also seems to vary from period to period, and 
from quinquennium to quinquennium, while that 
of the fevers in general has gone down somewhat 
steadily, coincidently with the improvements effected 
in sanitation. Thus, in the three years 1858— 60 
the mortality from diarrhoea was at the rate of 
777 per million persons living. In 1861—4 it was 
at the rate of 874. In 1866—70 it was 1063. In 
1871—5 it was 1000. In 1876—80 it was 832. In 
1881—5 it was 606. In 1886—90 it was 667. 
The mortality from typhoid fever has shown a much 
more satisfactory diminution, having fallen from 
390 per million per annum in 1869, to 309 in 1876, 
to 212 in 1881, to 184 in 1886, and to 168 in 1891. 
But in 1893, which was a rather bad year for 
zymotic diseases, it stood again at the rate of 229 
per million per annum. 
Diarrhcea has 
not diminished 
like the other 
Fevers. For 
this reason. 120 
As influenza has now been shown to be 
associated with the production of a bacillus, or as 
it is likely that it is so, probably it also will be 
classed among the zymotic diseases. But if the 
views detailed in these observations are correct, the 
predisposition to it is due to improper feeding, 
being produced, as a main part of its cause, by the 
consumption in excess of amylaceous and saccha- 
rine foods. And certainly the incidence of influenza 
on its last invasions has occurred after all the care 
that has been spoken of as having been given to 
sanitation and ventilation, which have, therefore, 
not prevented its ravages. While, therefore, the 
zymotic diseases in general and consumption 
are those diseases which are associated with 
the growth of micro-organisms in the body, and 
while these micro-organisms thrive best, as a rule, 
in bad and impure air, and in conditions due to 
over-crowding, so much so that we may say, on 
the whole, that the zymotic diseases and consumption 
depend on bad air and imperfect ventilation as a 
main part of their cause ; still, there are exceptions 
to this rule ; and the chief exceptions to the rule 
are, as we have seen, typhoid fever, diarrhcEa, and 
influenza. 
And, lastly, I would ask the question, still in 
reference to the causation of these zymotic diseases, 
whether, although their causation is plainly connected 
with bad air, since the effort to obtain good air 
has had so much influence in reducing their incidence 
Although the 
fevers due to 
bad air, may 
not the predis- 
position to be 
affected by 
them be due to 
improper 
feeding ? Cases 
pointing to 
this. 121 
and mortality—I would, I say, ask this question : May 
not improper feeding be a main part of the cause why 
the predisposition of the organism to harbour these 
micro-organisms is induced in the economy? Grant- 
ing that micro-organisms as a rule cause the fevers, 
and granting that imperfect ventilation and bad air 
offer the conditions most suitable to the life of the 
organisms whose existence is so hurtful to the human 
economy, may not improper feeding of that economy 
for a long time (say for weeks or months) be a cause 
in turn of the predisposition on the part of the 
economy to be affected or infected by these hurtful 
micro-organisms or small existences ? For my part 
I have no hesitation as to the answer which should 
be given to this question. I feel quite certain that 
improper feeding is frequently a precursor in children 
of an attack of measles, eg., and I believe that the 
amount of infection to which children are exposed 
would frequently fail to affect them if it had not been 
that they had previously taken more food than they 
had been able to assimilate, and that for a consider- 
able period of time. How often, for instance, does 
it happen that Charles or Gerald, or Mary or 
Gladys, falls ill of measles just after a return from 
the country or seaside, “ where they did so well, 
doctor, and had such wonderful appetites.” The 
mother has been rejoicing at the child’s improved 
appetite, and the great benefit that the change 
has been doing him, and then all her hopes 
have been damped by the occurrence of that 122 
nasty infectious illness, which has undone all the 
benefit of the country or the seaside. A sensible 
mother will sometimes indeed ask the question— 
Was not the appetite too good? Did not the child 
do himself harm by eating so much ? And would 
not she have done better to control his appetite and 
to restrict him to what she felt was sufficient for 
him ? I believe that very often this is so, and 
that the excess of food taken, being imperfectly 
assimilated, has led to the formation of tissue of 
unstable equilibrium, and to the existence of blood 
loaded with unoxidised material, which has in turn 
fallen an easy prey to the fermenting influences of a 
fever poison like that of measles or scarlatina— 
poisons to which the child was probably often 
exposed before, and which he would easily have 
oxidised off again, but for the unfortunate state of 
his blood, brought about by that wonderful appetite 
which so rejoiced his parent’s heart at the seaside. 
From these considerations we may easily see how, 
although the immediate exciting causes of the 
fevers may be exposure to bad air containing the 
micro-organisms which severally induce them, the 
predisposition to be affected may have been much 
aggravated by improper feeding. We come thus to 
a remarkable parallel between the causation of the 
fevers, and of inflammatory diseases like bronchitis 
and pneumonia. For just as we saw that the imme- 
diate exciting causes of the latter are such influences 
as cold, heat, fatigue, wind, storm, and so on, and 
There is a 
parallel there- 
fore between 
• the predispo- 
sing causes of 
inflammations 
and of fevers. 123 
that these causes require to be present, and acting in 
much greater intensity when persons are improperly 
than when they are properly fed, so that properly 
fed persons will scarcely suffer from them at all, 
while improperly fed persons suffer severely from 
very small amounts of them ; so in the case of the 
fevers we discover that like principles hold true, and 
so it comes about that we may define the fevers as 
diseases induced by such exciting causes as micro- 
organisms conveyed to the economy mainly by bad 
air, but requiring for their development the predis- 
position in the organism caused by improper 
feeding; just as the inflammatory diseases are 
those due as their immediate exciting causes to 
exposure to cold, heat, wind, wet, &c., acting on 
an organism predisposed to be affected by improper 
food-nutrition. And I might have added that 
the predisposition to inflammatory diseases on 
the one hand, and to fevers or zymotic diseases 
and to consumption on the other, induced largely 
by improper food conditions, is aided greatly by 
the absence of methodised exercises. In order, 
therefore, to alter predisposition it is incumbent on 
us to feed the body properly and to exercise it 
methodically and proportionately. Predisposition 
to disease is often, in our thinking, associated with 
the state of the ancestors of the persons pre- 
disposed. No doubt the state of the ancestry is 
a potent factor in the production of strength 
or weakness in the children. In the meantime, 124 
How to alter 
the 
predispos ition 
to disease, 
however, it will be well for us to associate 
predisposition with such factors as healthy feeding 
and proper exercises—factors which we have 
it in our power seriously to modify, rather than 
with the state of the ancestry of the persons in 
question—conditions which it is, of course, quite 
beyond our power to affect. The blood and tissues 
are made healthy on the one hand, or they may be 
made unhealthy on the other, by the quality of the 
air respired, by the food consumed, and by the 
exercises indulged in, far more frequently than by 
the insertion into them of a drop of pus or matter 
from a putrefying wound, if we accidentally prick 
ourselves in managing such. And yet, while we 
manifest the greatest horror if the latter accident 
happens to us, we are quite calm in presence 
of the slow poisoning that is continually going 
on from the respiration of impure air, the 
ingestion of improper food, and the absence of 
methodised exercises. Perhaps I ought not to say so 
regarding the respiration of bad air. We are alive 
to the dangers of that, and have taken important 
and costly steps to obtain good air. But we do not 
adequately realise the danger of blood-poisoning 
which overhangs us continually by the consumption 
of improper food, and by the retention of waste 
products in the blood through the absence of 
exercises. By far the most potent cause of blood- 
poisoning is undoubtedly what finds its way into 
the blood through the mouth. If we come to think 
Blood-poison- 
ing mostly 
induced 
through the 
food. 125 
of it, there is nothing and can be nothing in the 
body, no diseased products deposited in it anywhere 
for instance, which, or the sources of which, were not 
first in the blood. And there can in turn be nothing 
in the blood which was not first in the food we have 
consumed, or in the air we have breathed. There 
are no other sources from which the materials of 
disease can find their way into the body. This 
statement ought to be qualified indeed as regards 
the occurrence of real hereditary disease, as when a 
child is born diseased (syphilised, eg), or when 
a poisoned wound occurs, but these occur so 
rarely that for practical purposes the statement 
holds true. With these qualifications (not very often 
required, but when they are required, being as a rule 
visible and plain enough) we may, it seems to 
me, accept as true the following propositions :—ist, 
Materies nalla rnorbifica in corpore invenitur quae 
non prius in sanguine inventa est. And 2nd, Nihil 
in sanguine quod non prius aut in cibo aut in aere. 
From the discussion which has preceded, we 
have seen that the diminution of the fevers and 
of consumption, in both cases amounting to from 40 
to 50 per cent., is the one improvement which has 
taken place in the last fifty or sixty years, and is the 
only justification for the statement regarding the 
great advance in medicine so frequently made. Our 
further consideration of the question leads, however, 
to the conclusion that, much as has been done in this 
direction by attention to air, much more might still 
With slight 
qualification 
we may say :— 
1. There is 
no disease 
producing 
material in 
the body which 
was notfirst 
in the blood. 
2. There is 
nothing in 
the blood 
which was not 
first in the 
food or in the 
air. 
Occurrence of 
Infectious 
Fevers might 
be stilt further 
reduced by 
attention to 
food and 
exercises. 126 
be added to it by attention to food and exercises. 
In fact, it seems to me that by proper attention to 
these things we might put an end to the infectious 
and zymotic diseases altogether. 
Be this, however, as it may, we seem to have 
seen evidence for the view that the affections I 
have mentioned, bronchitis, pneumonia, rheumatism, 
and influenza, have the foundation laid for their 
occurrence in the body, in the slow and gradual 
silting up of the tissues by the effects of what I 
have called triphthaemia carbonifera. Many other 
pathological conditions are probably explicable by 
like considerations. I have mentioned incidentally 
the relation between triphthaemia carbonifera and 
the occurrence of facial erysipelas, and have hinted 
at the connection of triphthaemia with varicose veins 
and some other affections, far enough apart in 
character although at first sight they may have 
appeared to be. Many others may also be explained 
in the same way. Why, for instance, do many 
persons suffer from headache when they walk—or 
even drive—in a wind ? Because the involuntary 
and often unconscious resistance which we make 
to wind is effected by putting muscles on the stretch, 
and particularly the muscles which attach the head 
to the trunk. But in triphthjemia carbonifera these 
muscles are in a state of passive congestion ; their 
origins and insertions are tender, and when therefore 
they are put on the stretch the tender points are 
drawn upon, and the pain so set up, speedily 127 
spreading over the occiput and the rest of the head, 
causes the headache of which we complain. Why 
again do women suffer from apoplexy more than 
men? In 1892, according to the Registrar-General, 
there died in England and Wales 9299 females of 
apoplexy out of 15,157,111 females living. In the 
same year 7829 males died out of 14,247,943 living. 
The female death-rate from apoplexy was at the rate 
of 613 per million living, while the male death-rate 
from the same disease was 549 per million living. 
Year after year similar proportions obtain. Why is 
this ? I have no doubt it is because women affect 
most the sorts of food which cause triphthaemia 
carbonifera, and because the use which by preference 
they make in their food of bread, and cakes, and 
puddings, and sugar causes a slow congestion of the 
vessels, alters their structure, causes a slow accumula- 
tion of waste undigested material to be deposited in 
their coats, and alters their elasticity so that after a 
time on slight exertion they give way before the 
pressure of the blood current. And no doubt the 
absence of methodised movements and of muscular 
exercises in women accounts for some of the 
excess also. In fact it is plain that as life advances 
in women so fed, exercises become dangerous, 
and in treatment have to be recommended with 
the greatest care, since even slight exertion may 
cause rupture in vessels which have become so 
inelastic from mal-nutrition. Men, on the other 
hand, still prefer a different sort of diet and use 
Why women 
die of Apoplexy 
more than 
men. 128 
exercises to a greater extent than women ; and 
although they have more exertion than women, their 
vascular nutrition is better, and so the vessels bear 
strain better than do those of women. The habits 
of men and women, in towns especially, are fast 
approximating to one another, and the differences 
in the incidence of disease, which still obtain, will 
probably tend to become less marked, unless some 
changes can be induced in the habits of the people. 
A fact like the greater incidence of apoplexy 
among women than among men seems exceedingly 
difficult of explanation at first sight. For my own 
part, I confess that I thought that the opposite 
condition obtained, and that men suffered from 
apoplexy more than women. I thought that as they 
did so (as I wrongly supposed) this was a staggering 
blow to my theory of the causation of the disease ; 
and it was only after an examination of the facts 
as stated by the Registrar-General that I was 
reassured. But the reassurance, and the ability 
to reply to what had seemed a crushing objection 
to the theory, has confirmed me in a belief 
of its truth. It may, perhaps, be objected that 
according to the theory, women ought to suffer from 
bronchitis more than men, since women live more 
largely on the foods which induce it. In point 
of fact, they do not so suffer. In 1892 there 
died 56,024 males out of 14,247,943 from asthma, 
bronchitis, and pneumonia, or at the rate of 3932 
per million males living. Out of 15,157,111 females 129 
on the other hand, there died only 50,657 persons 
from these causes, or at the rate of 3342 per million 
living. But that a smaller proportion of females than 
that of males died from these diseases is, I think, 
explained by the fact that females are less subjected 
than are males to exposure to weather, and that 
although improper feeding is the main or chief pre- 
disposing cause of bronchitis, still it is not the only 
one by any means, the exciting causes being exposure 
to cold and hardship, &c. 
Another of the pathological states due to improper 
feeding, and explained by the theory, while inexplic- 
able without it, is the greater incidence of pruritus 
ani in women than in men. It undoubtedly depends 
on their food and not on their sex. Just as many so- 
called family diseases are due to family habits, so, 
many diseases of the sex organs are due to the 
different habits of the two sexes. No doubt pruritus 
ani in women is often associated with pruritus vulvae, 
but this is an anatomical accident: the property or 
essence of the disease is its existence: its accident is 
that it appears in a particular place. Volumes have 
been written on the miseries of the affection, and 
numberless applications recommended for its relief. 
Alteration of the diet, with the administration of an 
alkali in hot water before food, may be guaranteed to 
relieve it in three or four days, and to cure it in six or 
eight weeks. I promise this with the greatest 
confidence in all cases in young and middle-aged 
women, and am never disappointed when patients do 
Pruritus and 
Caruncle 
due ‘Jo 
TriphthcBmia 
Carbonifera. 
Diseases of 
sex mostly due 
to habit. 130 
as they are told ; and this is one of the affections in 
which patients do, as a rule, do as they are told, 
because the annoyance they suffer is so great that 
they will generally do anything whatever to obtain 
relief. The same treatment is equally efficacious in 
the management of urethral caruncle, but may 
require a much longer time to effect a cure. If time 
and space permitted, many other diseases could be 
referred to, “ angina pectoris,” for instance, as 
it is called; and many others. I may add 
here what I am firmly convinced of, viz., that the 
diseases of women in general, the little ailments they 
have, the frequent complaints they make, amounting 
often not to illness but to malaise, or being “out of 
sorts,” are due, not to their sex but to their habits, 
and in particular to their habit of eating too often. 
They feel “ faint,” from indigestion really, but they 
think it is from want of food. No doubt taking 
food relieves them at the time, and when the feeling 
comes back they again relieve it by taking more 
food, and so the vicious circle or round is continued— 
the faintness due to indigestion is first relieved and 
then aggravated by food—the food causing the 
faintness and the faintness causing the desire for 
food—until serious disease is set up, rheumatism 
or anaemia, or perhaps ulcer of the stomach. 
It is not that women are gluttonous—a very few 
of them are no doubt—it is not so much that 
they eat too much as that they eat too often, that 
they suffer from those trifling but frequently 131 
recurring ailments that are so characteristic of 
the sex. And in accordance with these considera- 
tions, it is astonishing how much benefit can be 
given to those women who are sensible enough to 
take the advice to eat three times rather than four 
times a day; yes, and in many cases to eat twice 
rather than three times. 
A case of pruritus ani et vulvae, which strikingly 
proves on what the causation of this most trouble- 
some affection depends, may be mentioned here. A 
stout, fat woman, set. 41, who had suffered from this 
complaint for a long time, presented herself as an 
out-patient at the Bradford Infirmary in August, 
1896. She had suffered from time to time for no less 
than seventeen years from the intolerable itching 
which characterises this affection, and had sought 
advice and assistance from several quarters, though 
without obtaining relief, among the rest from 
a hospital at Sheffield eleven years before I saw 
her, and from other quarters. She used to suffer 
from diarrhoea (due no doubt to fermentation 
of carboniferous foods), but this had subsided of 
itself before she came under my care. She had 
been subject to attacks of “ influenza colds ” from 
time to time, that is, had attacks of sneezing 
with cough, but had never been laid up with 
bronchitis proper. When I saw her she had 
very disturbed nights on account of the itchingj 
which made her scratch herself in her sleep some- 
times till blood was drawn. By the simple advice 
Pruritus ani 
( Eczcema ) 
depends on an 
excess of 
starch in the 
diet. 132 
of recommending her to take bread only once 
a day, and greatly diminishing other forms of 
carboniferous foods, I was able entirely to relieve 
this long-standing ailment, so that in about five 
weeks from the time of her coming under treatment 
she was able to sleep right through the night. In 
another fortnight, all the eczaematous spots (I suppose 
that pruritus ani really is eczcema f) had healed. 
There now occurred a rather remarkable incident. 
For some time I lost sight of the patient, she 
having absented herself from the out-patient room 
from the end of December, 1896, till February, 
1897, when she was nearly as bad as ever again. 
What was the reason of this relapse ? She told me 
that she had had a miscarriage, and had been 
obliged to consult a medical man. He had put 
her on the conventional treatment usually adopted 
in that condition, ordering her to live on gruel, 
bread and milk, rice and milk, &c. The increase 
of starch taken brought back the itching, and 
she was obliged to make her way back to the 
Infirmary as soon as possible to obtain relief again, 
in which she was not disappointed. This is, there- 
fore, a case in which a medical man—first, alleges 
that the main cause of an ailment lasting for 
seventeen years is wrong eating (and particularly 
that it is eating too much bread) ; second, in which 
he, therefore, recommends that bread be taken only 
once a day. Thirdly, the patient recovers, or 
practically recovers (she was not perfectly well), on 133 
taking his advice. Fourthly, she is compelled to put 
herself under advice for another ailment; and for 
the management of that ailment is recommended 
to live on the kind of food which was alleged to 
be the main predisposing cause of her first ailment. 
Fifthly, the first ailment returns in accordance with 
the original statement. Sixthly, the ailment again 
disappears when she again follows the original advice. 
I do not know what more clinical evidence could be 
demanded by the most sceptical in the way of a 
demonstration as to what the causes of the ailment 
were. The logical methods of agreement and of 
difference combine to demonstrate that the main 
predisposing cause of pruritus ani (eczcema) is wrong 
eating, and in particular that it is the consumption in 
excess of starchy food. And that conclusion applies 
not to this case alone, but to practically all cases 
where the experiment is made. The conclusion 
that the alleged cause is really the main cause has 
become firmly fixed in my mind, and has indeed the 
force of a law of nature or of human organisation. 
And, of course, any one can for himself put the law 
• , ,. , ... , . 
into action where appropriate circumstances arise. 
There is, however, a further line of evidence 
possible, in order to prove this conclusion up to 
the hilt. If, as I suggest, starch (and sugar) is the 
cause of pruritus ani, how does starch (and sugar) 
cause it? Probably by carrying down into the 
' J J ° 
stomach and thence into the intestines, and thence 
. . 
again into the blood, some spore or seed which 
Is pruritus 
ani caused, by 
some spore 
taken into the 
blood through 
the 
digestion ? 
Might it not 
be possible to 
demonstrate 
the existence 
of this spore 
in the food ? 
in the chyle ? 
in the blood f 
in the tissues ? 134 
grows by preference at the orifice of the bowel. 
Might it not be possible to demonstrate the existence 
of this spore first in the starch granule of the food, 
and second in the blood ? (Thirdly, possibly in the 
elaborated chyle ?) Perhaps this is the way in 
which the penicilium finds its way into the urine ? 
Perhaps saccharo-myces is the cause of pruritus 
and ecz<zma ? If not, perhaps some other spore is? 
Let me suggest this line of investigation to some 
of our clever young microscopists and culture-experts 
who have more leisure on their hands than older 
practitioners. It would probably prove most useful 
to medicine, and most profitable to themselves. They 
might, perhaps, incidentally be able to show the 
connection between the occurrence of herpes labialis 
and the existence of such a spore ? And might 
possibly be able to show that herpes labialis and 
pruritus ani are the same disease in different situa- 
tions? and due to the same or similar causes? And 
perhaps other surprising conclusions might follow ? 
The investigation does not seem to me particularly 
difficult to any one possessed of the necessary dex- 
terity, knowledge, instruments, and leisure. If it 
should prove that this is a true suggestion, one can 
easily see how the outward application of antiseptics 
and germicides might relieve indeed by destroying 
the local growth, but could do no real good, until 
the supply was cut off by altering the diet. As 
well might one marvel at his failure to eradicate 
noxious weeds from his garden, who contented 135 
himself by rooting up the growing plants, while 
taking no pains to prevent the entrance of seeds 
from outside. 
Now I can imagine that some (if there are any 
such) who may have followed the argument in 
these remarks so far, and who may perhaps have 
been disposed to yield a certain measure of assent 
to it, and to the views I have so far expressed, will 
pull themselves up and refuse to go further. It 
is my opinion, that cancer also is a disease mainly 
caused by an excess of carboniferous foods in the 
diet. In greater detail, I believe that cancer is a 
disease, the predisposing causes of which are mainly 
improper feeding, and that the form which that 
improper feeding takes is generally the consumption 
of larger quantities of bread, potatoes, oatmeal, rice, 
sago, tapioca, sugar, and Yorkshire pudding (one 
or more of these foods) than are assimilated. I 
have made a point of inquiring into the habits of 
a large number of persons who have come under my 
observation suffering from cancer. By cancer I 
mean, as was said before, carcinoma or epithelioma. 
I am not able to include sarcoma, but on the other 
hand am not able, for want of experience, to 
exclude it from my statement of opinion as to 
causation. The general result of my inquiries 
regarding carcinoma or epithelioma, which is, of 
course, far the commonest form of cancer, is that 
the persons suffering from it have lived largely on 
the foods named. A very common statement has been 
Cancer is also 
a result of 
Triphthccmia 
Carbonifera. 136 
“ I have never liked meat.” I know that recently a 
surgeon has written to say that the consumption of 
meat is, in his opinion, the cause, or a main part of 
the cause, of the increase of cancer. That does not 
coincide with my experience. I do not say that the 
over ingestion of meat as a food might not cause 
cancer. I think, on the other hand, that the long 
continued consumption in excess of any sort of food 
might possibly eventuate in producing the disease, 
when in course of time the tissues had become loaded 
with waste matters such as ptomaines, the poisons 
generated by various bacilli, and, generally, with 
unassimilated material introduced into the blood 
through mal-assimilation of food. But so far as my 
experience goes, the cases of cancer I have seen have 
not been caused by an excess consumption of meat, 
but have, on the other hand, been brought on by an 
excess consumption of saccharine and starchy foods, 
or at least have occurred in persons who were fond 
of these foods and not of meat. For instance, I saw 
in the Bradford Infirmary a woman, aged 42 years, 
“ suffering from a large infiltrating malignant growth 
from lips of cervix-uteri ” (House-surgeon’s note). 
I had never seen the woman before. There was no 
doubt as to the diagnosis; but I said to the resident 
medical officer, “You will find, if you inquire, that 
that woman has lived largely on carboniferous foods.” 
It is well known of course in hospitals that young 
men know, as in most departments of life, much 
more than their seniors. And the mistakes of older 137 
men, when they commit them, are treated far more 
hardly than those of younger ones, which are 
generally quietly passed over. This is perhaps right 
enough and to be expected. One ought therefore 
to feel very sure of the soundness of his deduction 
before venturing to give himself away in that 
manner regarding a patient whom he had never 
seen before, and on the mere strength of a 
theoretical and practical conclusion regarding the 
causes of the ailment from which she suffered. Had 
I been wrong, no doubt I should have heard more 
about it. However, my young friend inquired, and 
ingenuously wrote the following note, which I read 
on my next visit :—“ Patient is fond of bread ; 
never takes potatoes ; eats rice ; never liked meat; 
bad teeth.” I saw with Dr. H. a man aet. 56, suffering 
from cancer of rectum. His diet had been bread 
and butter and tea for breakfast, sometimes oat- 
meal porridge. Dinner: meat, potatoes, bread, and 
rice, sago, or tapioca puddings, often Yorkshire 
pudding. Tea: bread and butter and tea. Supper: 
oatmeal porridge. The whole diet here is starchy, 
except the small piece of meat (viz. : 2 or 
3 oz.) at dinner. That starchy food, taken 
over a course of years, had fermented in 
his digestive tract—how often these sufferers say 
they have had a “ poor stomach ”—had poisoned his 
blood, loading it with waste matters, and had, I 
have no doubt, led to the production of the cancer. 
I asked the matron of our small Cancer Hospital 138 
to give at random the diet of the first three cancer 
cases she chose to question. Here is the result:—i. 
Mrs. B., aet. 55. Breakfast, 7.30, tea, bread, bacon 
or egg. 11.30, cheese, bread, beer. 1.30, meat, 
potatoes, vegetables (green ? A.R.), milk—or York- 
shire—pudding. 5.30, bread, butter, tea. 10, meat 
and bread. Note that this woman had five meals a 
day. She had bacon or egg for breakfast and 
meat twice daily, which is unusual. But she had 
bread four times a day, and if Yorkshire pudding 
be counted (and it is really the same thing as 
bread), five times. But she survived to 55, and I 
have no doubt might have survived to 65 if she 
had had the sense to keep to three meals, like, say, 
her breakfast, dinner, and tea, with proper intervals 
between them. 
2. Mrs. S., aet. 69. 8 a.m., tea, bread, bacon, 
or egg. No lunch. 12.30, meat, potatoes, some- 
times vegetables (green ? A.R.), and potted meat- 
4.30, bread, butter, tea, and remains of dinner. 10 
p.m., potatoes, milk, or porridge. 
I have not much to say about this case. The 
woman survived to 69, and it may be said she 
had lived her day, and must be expected to die of 
something. I incline to think that had she had one 
meal after dinner in place of two she would have 
been healthier, and would probably have lived 
longer. But I give the case as I got it. 
3. Miss F., aet. 44. 8 a.m., tea, bread, and 
butter. No lunch. 12.30, potted meat and bread 139 
taken at the mill. 4, bread and the remains of 
dinner. 7, tea, bread, and butter. 9.30, bread and 
beer. Bread here was taken five times a day, 
and once with beer. As bread takes five hours to 
digest, often longer, let any one imagine the state of 
fermentation that that poor woman’s digestive tract 
must have been in day after day for say twenty 
years, with “tea” following dinner in three and a-half 
hours, another “ tea ” following the first in three 
hours more, and a third “tea” following the second 
in two and a-half hours. The only meal which was 
allowed any approach to a reasonable time for its 
digestion was breakfast ; and dinner followed that 
in four and a-half hours, while five and a-half hours 
would have been much better. No wonder the poor 
thing did not survive beyond 44 or 45 years. 
These are cases of women in the humbler walks 
of life. But their well-to-do sisters are doing the 
same thing in a different way. One of them told 
me recently that she had tea and cake, or tea and 
bread and butter, at no less than three different 
houses in one afternoon, and all within two hours 
or even an hour and a-half of one another. Well 
for her if the attack of indigestion which ensued 
on that series of indiscretions shall teach her more 
sense, and help her to prevent the irreparable damage 
which in one form or other, probably enough the 
onset of cancer, is certain to ensue if she persists 
in so insane a course. And yet how many women 
are living like this ! Here is another case : Mrs. L., 140 
set. 50. Breakfast, 8 a.m., bread and butter, tea. 
Dinner, 12, meat, potatoes, Yorkshire pudding, rice 
pudding, bread. 4.30 p.m., bread, butter, tea. 8, 
bread, butter, stout, or Quaker oats, or oatmeal 
porridge. This perpetual fermentation of food 
resulted in the production of a malignant ulceration 
of the mouth of the uterus. 
It seems to me from these cases, which could be 
multiplied indefinitely, that an excess of fermenting 
foods is a main part of the predisposing causes of 
cancer, the over ingestion and too frequent eating of 
starchy foods. And the reason why men are fast 
approximating to women in falling under the same 
terrible scourge is this, that they are, owing to the 
circumstances of their lives, approximating more 
and more to the habits of the women in the times 
and materials of their food. It is not a question 
of sex at all. It is a question of habit. I should 
like to detail this next case. Mrs. J., set. 44, a 
“ neurotic ” woman, full of ailments, with pains 
everywhere ; “ hysterical ” she was called by young 
doctors who knew no better ; and no doubt as 
soon as one ailment was prescribed for, twenty 
new ones had arisen. But that “ neurotic ” woman 
is now suffering from cancer of the cervix uteri ; 
and here is an account of her diet. She has always 
had a “ poor stomach ” (and no wonder) and can 
hardly take any breakfast. Would take just a cup 
of tea about 8. Then about 10 some bread and 
cheese with bitter beer or milk. Dinner at 1 (when 
Sex only an 
apparent cause 
of disease. 
Habit the real 
cause. 141 
the bread and cheese and bitter beer were still 
churning in her poor stomach), “ not particular as to 
her dinner,” but would get potatoes or bread and 
butter and tea. Never was much of a meat eater, 
and never touches it now. At 3 or 3.30 (two hours 
or two and a-half hours after dinner) tea and bread 
and butter. About 7, supper of biscuit and cheese 
or glass of beer or porter. Always had a good 
home. 
Surely I have made good my suspicion regarding 
the connection between cancer and carboniferous 
foods ? I think I have. In a former part of these 
observations I showed how cancer often follows on 
rheumatism. I also showed reason to suspect 
that rheumatism is due to an excess consump- 
tion of carboniferous foods ; and I showed the 
connection between rheumatism and bronchitis 
and broncho - pneumonia. I also showed the 
dependence of bronchitis and broncho-pneumonia 
(and influenza) on the consumption of carboni- 
ferous foods and the absence of proper exercise. 
Also it will be apparent to whoever really thinks 
about it and takes account of what he sees, on what 
the so-called “ cachexia ” of carcinoma depends. 
He will be able to trace its commencement 
in the pasty pallor of dyspepsia, its continuance 
in the greeny-yellow colour of anaemia, in the 
earthy or ashy appearance of rheumatism, and 
its termination in the yellow or orange colour of 
patients suffering from the profound mal-nutrition 
The Cachexia 
of Cancer. 142 
of pernicious anaemia and of carcinoma. The blood 
gets loaded more and more with waste materials at 
different stages of our life-history ; and in meeting 
our friends, or even in passing strangers in the 
street, a comparatively small observation of their 
appearance will enable us not only to tell their 
age, but to say on what foods they mainly live. 
There is high authority in medicine for the 
belief that disease is one. This view, which the 
father of Greek medicine seemed to reach by a 
sort of intuition, has also been forced on us by 
the considerations advanced in these observations. 
There seems to be strong probable evidence for 
the belief that herpes labialis, tonsillitis, tracheitis, 
bronchitis, rheumatism, pruritus ani, caruncle, diabetes, 
apoplexy, erysipelas faciei (Bright’s disease ?), and 
carcinoma, are all different phases or manifestations 
of the triphthaemia carbonifera, of which I have 
spoken. I have not said anything regarding 
the predisposing causes of Bright’s disease, and I 
do not now go into the differential diagnosis of 
the various forms of it. (For practical purposes, 
as distinguished from theory, however, is there 
much advantage in separating the various forms 
of fatty, gouty, and granular kidney from one 
another ? Are they not all to be treated alike ?) 
But as to the predisposing causes of Bright’s 
disease, and as showing their connection with 
those of the affections already named, it seems to 
me that the following considerations are instructive. 
Disease is one, 
with many 
different 
phases or 
manifesta- 
tions. 
Suggested 
mode of 
causation of 
Bright's 
Disease. 143 
The processes which bring on perimysitis, perineuritis, 
periostitis, and arthritis have been dealt with at some 
length ; and it was shown, or suggested at least, that 
the blood, loaded with waste materials from imper- 
fect assimilation of food, rids itself of these waste 
materials on to the muscle-sheaths, nerve-sheaths, 
and bone-coverings when laid out on these extended 
surfaces to nourish their tissues. Suppose, now, that 
the process by which the blood is loaded with waste 
materials still goes on. Suppose (not an unlikely 
supposition, in fact, a highly probable one) that the 
blood carried to the kidneys for their nourishment by 
the renal arteries is also, like that carried to the 
muscles, loaded with waste and imperfectly assimi- 
lated materials. It will obviously be liable to lay 
down in the various portions of the kidney-structure 
some of the foreign materials of which, so to say, it 
wishes to rid itself, or which it is physically incon- 
venient to convey, and which, therefore, get filtered 
out in the process of nutrition. In this way tubuli 
may easily become blocked, congestions and inflam- 
mations may occur, interference with proper excretion 
may take place, and disease be induced. I have, in fact, 
no doubt that these are the ways, or some of the 
ways, in which disease does insidiously begin in the 
kidneys, and that many cases of Bright’s disease 
are so induced. There is a very general opinion 
that Bright’s disease, with inflammation of the 
kidneys, bladder, &c., is more due to the consumption 
of such nitrogenous food as meat than to an excess of 144 
carboniferous material like bread and rice puddings. 
This view may be correct. Renal diseases are no 
peculiarity of men, but they are undoubtedly more 
prevalent among men than among women, and men 
eat as a rule more meat than women. Worry is also 
an alleged cause. I suppose men suffer from worry 
more than women ? although both sexes have their 
share of that tribulation which seems to be the 
invariable inheritance of the human race. No doubt 
alcohol is also a cause, but I am not in these 
observations considering the effects of alcohol. On 
the other hand, I can recall to memory several 
cases of Bright’s disease, into the causation of 
which neither alcohol nor an excess of meat-eating 
entered as a predisposing cause. The history in 
none of these cases justified the belief that this 
was so. In one instance a middle-aged man, who 
never took meat more than once a day, lost his 
life from Bright’s disease under my care. If food 
was a predisposing cause, or the chief predisposing 
cause in that case, it was rather bread eaten too 
often than meat, for the man not infrequently made 
his dinner of tea and bread and butter. It could 
not be alcohol, because, although not a teetotaler, 
he was one of the most temperate of men. I 
think, as I write, of other cases into which neither 
alcohol nor meat entered as a predisposing cause, 
at least so far as could be made out; but in all 
of these the food habits of the patients indicated a 
fondness for bread, potatoes, puddings, oatmeal 145 
porridge, and the cereals. Into the causation of 
other cases, no doubt both alcohol and meat entered 
as predisposing causes. On the whole, however, 
while recalling many cases to which the rule would 
not apply, I am indisposed to oppose the prevailing 
medical opinion which suggests that an excess 
consumption of nitrogenous foods is a predisposing 
cause of Bright’s disease. But if this is so, it still is 
induced by improper feeding; and in view of this 
consideration we must still add it to the long list of 
diseases which appear to be due, as their main pre- 
disposing cause, to improper feeding and the mal- 
assimilation of food. And this reasoning leads us to 
agree with Hippocrates in his remarkable anticipation 
of the discovery that disease is one. But we are not 
content to rest in this theoretic conclusion, for we are 
at once compelled to translate it into a practical 
inference, which seems irresistibly to follow, viz.} 
this : The same cottrse of treatment which enables 
us to get rid of small and slight ailments like the 
occurrence of herpetic and serous eruptions about 
the lips and small idcers inside the mouth and on the 
tongue; the same treatment which acres sore throats 
and inflammations of the wind-pipe and of the 
bronchial tubes; the same course of treatment which 
helps us to get rid of rheumatism and eczcema and 
which cures erysipelas of the face; the same course of 
management which cures these diseases will prevent or 
postpone the onset of influenza, of apoplexy, of Bright's 
disease, of diabetes, and of carcinoma. Now, one ought 
Bright's 
Disease may he 
due, as its chief 
predisposing 
cause, to 
meat-eating. 146 
to speak modestly in face of an inference of this kind, 
with its far-reaching and even tremendous conse- 
quences ; but I am compelled to state here my entire 
submission to the irresistible force of its logic, and to 
add that more than once now have I seen abundant 
reason to feel satisfied with the beneficence of its 
practical effects. Of course the human organism must 
wear out, and we must die of something; but I, at 
least, am satisfied that death from diabetes, Bright’s 
disease, influenza and pneumonia, apoplexy, and 
carcinoma ought not to happen, and will not happen, 
under 65 to 70 years of age, at least, in those who 
attend to the predisposing causes of these diseases so 
often mentioned, improper relations between the 
body and food, and improper relations of the body 
to methodised exercises. As we saw formerly, about 
one-third of all the deaths that occur happen between 
the ages of 25 and 65 years. As has been said, 
there were in 1893 in England and Wales 353,125 
deaths of persons over 5 years of age. Between 
the ages of 25 and 65 years 173,125 of these deaths 
occurred. Now, supposing that we admit that a 
proportion of these were unavoidable. Among 
large numbers of people, variously conditioned, 
no doubt some deaths must happen. The only 
question is as to what is a fair and reasonable 
allowance for these necessary deaths. Including 
the small number of persons who die from accidents, 
I have thought that 20 per cent., or one fifth of the 
173,125, would be a reasonable allowance to make 147 
for unavoidable deaths. Some might make the 
allowance more ; some less. If we consider a 
reasonable deduction to be a fifth, there still remain 
138,500 deaths which occurred in the year 1893 in 
England and Wales which ought not to have 
occurred till later. This is a very large number, 
and it is more than half of all the deaths that 
occurred in that year over 5 years of age. 
To think that 138,000 deaths are occurring 
in England every year which ought not to 
occur, to think that that number of people, or 
something like that number of people, are dying in 
our country in the prime of life, when life is most 
valuable (because for the most part persons at those 
ages are surrounded by children dependent on them), 
and to think that these deaths are, in a very 
practical sense of the term, preventable deaths, seems 
to me an appalling reflection. What the prevention 
or the possibility of the prevention of these deaths 
means is almost unrealisable. 
One reflection, however, may be indulged in. 
The sanitary and general gains obtained in the 
country are in the diminution of fevers and of 
consumption ; and by means of these gains, some- 
thing like four years have been added to the 
average duration of the life-time of the people. 
But these gains have been made, on the whole, in 
the early ages of life, as I showed in a previous 
part of these observations, when I pointed out also 
that the expectation of life was no better, or hardly 148 
Gain to life at 
early ages nut 
equal to gain 
at mature 
ages. 
■ any better, now at the middle periods of life 
than it. was fifty or sixty years ago. The 
gain is of course great, but not so great 
as if the addition had been made to the 
expectation of life at the middle periods, nothing 
like so great in fact, because life under 25 
years of age, though useful and valuable, is so, 
after all, more in promise than fulfilment. It is, at 
any rate, nothing like so useful and valuable as at 
the middle periods of life, when important obligations 
have been undertaken to society, which it is of the 
utmost consequence should be fulfilled. Now, if 
what I am urging is true, if the diseases to which 
I have so often referred can be cured, and can be 
prevented by alterations in our habits as to food 
and exercises, how great would be the benefits so 
obtained. They would be the very benefits we are 
in search of, for these are diseases of the middle 
periods of life and of the later periods rather than 
of the earlier. And the gains to the life of the 
community would be benefits rather to the parents 
than, to the children, as has for the most 
part happened in the gains made by reducing 
the fevers and consumption. This would of course be 
the case if carcinoma could be prevented. Of course 
I do not say that if women were to live on meat or on 
any other sort of food as much as they do on bread, 
or if they were to use it as often, that they would not 
perhaps suffer from cancer as they are doing now. I 
think it might be some other disease to which they 149 
would succumb. Of course I do not know; but 
I am quite certain that the cases of cancer I have 
seen, far too many, I am sorry to say, are not due to 
an excess of meat eating, but are due to an excess of 
starchy and saccharine foods. 
We can now listen with less perturbation of spirit, 
and we are no longer in despair when we hear the 
conundrum propounded by the sphinx of cancer: 
“ What are the causes of that fatality which does not 
affect children, which takes time to act, which affects 
women more than men, but which begins to affect 
men more than it used to do, and which is different 
from what obtained twenty-five years ago?” It is 
mal-assimilation or bad digestion leading to bad 
sanguification, leading to mal-nutrition of tissues ; and 
the bad digestion is due to too frequent feeding, and 
to too frequent eating, as a rule, of starchy and 
saccharine foods. The veil has been lifted, the 
mystery has been cleared up ; and is no longer 
impenetrable; and from behind the place where it 
was, rings out hopeful and clear to all those who 
listen : Rejoice, all ye who suffer, for your pains will 
soon be over, but your children need not suffer as you 
do. Your disease is incurable, indeed, but it was and 
is preventable ; and the means of its prevention are 
the simple ones known to all and within the power of 
all, the proper use of air and of food and of 
methodised movements. 
I shall be told, no doubt, that even admitting that 
many persons suffering from cancer have been shown 
The answer to 
the conundrum 
of the Sphinx. 150 
to take a large quantity of carboniferous food, or 
rather, perhaps, have been shown to take it often 
or too frequently, still it does not follow that 
wrong eating was the main predisposing cause 
of the cancer. The disease may have been due 
to something else ; and of course, as I have said, 
other medical men attribute cancer to meat- 
eating. I can only say about this last opinion 
that it is certainly not borne out by the inquiries 
I have been able to make into the habits of 
persons suffering from cancer, as I have just showed. 
Cancer truly, although it probably affects the poor 
more than the rich, is not at all confined to the 
poor, whose means may not allow them to buy 
meat. It devastates also the homes of the rich, 
who can have as much meat as they wish. I 
should like to observe in passing, that there 
are other foods besides the starchy and saccharine 
stuffs on the one hand, and meat on the other, 
large and numerous varieties of foods too much 
neglected, as I hope to say soon. But it seems 
to me that even among the rich who can get 
anything they wish, or require, those among 
them who have suffered from cancer have been, as 
a rule, given to the habit of too frequent eating, 
mainly of bread, and sugar, and cake, and pudding- 
stuffs. 
Another line of argument with which one is 
continually being met is that of heredity. The 
grandmother had cancer, it is said ; no wonder there- 
No proof that 
Cancer is 
hereditary. 151 
fore if the mother had it ; and the daughter’s 
chances of taking it are therefore all the greater. 
But is this sequence common ? I do not find it so. 
It much oftener happens, it seems to me, that the 
grandmother died of bronchitis, say, or of pneumonia, 
or of “ old age,” or of a “ complication of diseases,” 
while the mother died of influenza, perhaps, or of 
apoplexy, or Bright’s disease, or from some other 
cause. But even when this is so, and when no history 
of cancer can be made out in the family, there is a 
kind of medical pessimism which is still dissatisfied, 
and is apt to darkly hint that although no cases 
are known, still some may have occurred in the 
family and may have been forgotten. But even 
if cases can be discovered, the question still 
remains, how did those persons who suffered from 
it get the cancer ? How did they live? They have 
lived, as a rule, I find on inquiry, in the ways I 
have described ; and these predisposing causes are 
sufficient, in my judgment, if long enough continued, 
to induce cancer in any average human being. Like 
causes acting on like organisms in succeeding genera- 
tions have induced like effects. What else could we 
have expected ? Again, it is said—but the pre- 
disposition, has not that been transmitted ? I have 
already answered that suggestion. Predisposition 
is inverse-resistance ; it is weakness ; and it is 
created no doubt sometimes by the inheritance of 
a weakly organisation, but mainly by the mis- 
management of that weakly organisation by 152 
improper relations to air, or to food, or to methodised 
movements, or by improper relations to one or 
more of these. But surely if cancer were inherited, 
or if predisposition to it were inherited, it would 
appear early in life ? But it is well-known that 
a very small fraction indeed of the cases 
appear in childhood. The fact is that we are 
all predisposed to everything. Any human being 
may have any human ailment. It depends on how 
we manage ourselves whether we suffer or not. It 
depends comparatively little on how our ancestors 
managed themselves. I am sure that only a 
small percentage of the disease we see is here- 
ditary. Far the largest proportion is due to 
our own actions. There is really no end to the 
suggestions that are made by the theory of the 
heredity of disease. If you say that no cancer has 
been known in the family, then you are told that the 
Bright’s disease in the mother, or the pneumonia in 
the father, shows family weakness and accounts for 
the cancer in the son or daughter. And when one 
suggestion has been combated, another is made. 
Our ancestors must have died of something ; and so 
must we in our turn. But if they or we die at 45 or 
50 or 55 years of age, when we ought to have lived 
to 65 or 70, or even longer, it will be well to inquire 
if we cannot account for the premature decease, 
before we bow down in despairing worship and 
terror before a hereditary fetish. 
I am tempted to mention here very shortly a set 
All human 
beings are 
predisposed to 
all human 
ailments. 153 
of incidents which recently came under my observa- 
tion in this connection. A lady about 30 years of 
age said to me: “ I am afraid cancer is in our family. 
You see grandmother had it; and mother has it. I 
fear it is in the family.” I happened to know that 
the grandmother had died at 75 of cancer of the 
oesophagus. I do not know anything of her habits, 
nor could my informant tell me, so I could say 
nothing as to the cancer in that case. But the old 
lady had been very strong and healthy, and had 
brought up a large family of children, of whom one, 
my informant’s mother, was then suffering at 63 from 
cancer of the pylorus. The coincidence of these two 
facts had terrified my informant, who thought that all 
her mother’s children would probably be swept away 
by cancer. But death at 75 is death at old age, and 
at that age it is likely that most human beings will 
die of something. The grandmother certainly had 
lived her life, and a long and healthy one. The next 
thing was to consider how long she had been ill. My 
informant could not say; but it could not of course 
have been more than, say, a couple of years. How- 
ever, I said, “ Suppose we make a most wild and 
extravagant supposition, and suppose that grand- 
mother suffered for twenty years before she died, she 
would begin at 55 years of age in that case. But 
your grandmother was 35 years of age when your 
mother was born. Is it likely, is it possible that 
your grandmother transmitted to your mother that 
which she did not have herself for twenty years after 
Cases of 
Cancer in 
successive 
generations of 
the same 
family do not 
necessarily 
prove heredi- 
tary 
transmission. 154 
your mother was born?” In point of fact, it was 
nearer forty years than twenty. What she did 
transmit was organisation ; it was humanity. And 
any human organisation may suffer from any human 
ailment. It depends on the circumstances to which 
it is exposed. I knew more about the mother. I 
knew that for many years she had suffered from 
dyspepsia before the cancer set in ; and I knew, 
but, alas, without then understanding the significance 
of it, that living mainly on carboniferous foods was 
the cause of the long-continued dyspepsia which 
eventuated in the cancer. But I also knew that 
the cancer had been in existence for less than a 
year, and was able therefore to ask my informant 
another question : “ Is it likely, is it possible 
that your mother can have transmitted to you 
that which she did not have herself till many years 
after you were grown up ? ” 
This little incident is more important than it 
appears to be, because on this kind of evidence 
is apt to be built up our theory of the hereditary 
transmission of disease. The mere coincidence of 
the occurrence of a disease in mother and daughter, 
or father and son, is considered sufficient proof of 
hereditary descent. No inquiry is made into the 
circumstances, into the causes. I said to my 
informant, “ Surely if you were going to get cancer 
from your grandmother or your mother, it would 
have appeared before you were 30 years of age ? ” 
—which seemed somewhat to re-assure her. But 155 
then came of course the suggestion: “Yes, but the 
predisposition—may not I have inherited the pre- 
disposition to cancer ? ” Well, of course she might 
have inherited the predisposition to cancer ; in fact 
she must have inherited it ; but so has all the human 
family, because it is a human ailment ; and any of us 
may have anything. It depends on our circumstances, 
on our environment. 
This fetish of heredity, as I think I may fairly 
call it, so blindly and superstitiously is it invoked, is 
one of a pair which seem to be dominating us at the 
present time. The other member of the pair is germs. 
Those of our diseases which are not attributed to 
heredity are said to be due to germs; and 
between heredity and germs, the average member 
of the long-suffering human family has a very poor 
time of it. It seems as if there was no escape for 
him. I have said something about germs and shall 
not return to the subject now. 
While I am referring to the subject of family 
disease, or diseases which, as the phrase is, “ run in 
families,” I should like to say again that, in my 
opinion, many cases of what is looked on as family, 
disease are really cases of the expression by the 
body of family habit. Families undoubtedly have 
similar organisation. We cannot fail, in looking at 
families, to see likeness (with many points of 
unlikeness, however) in size, form, expression, habits, 
peculiarities, methods of movement, and many other 
characteristics. The shortest expression 1 can find 
Cases of 
so-called 
family disease 
very often the 
organic 
expression of 
family habit. 156 
Organisation 
inherited! not 
disease. 
for this is that families have and transmit similarity 
in organisation ; the family organisms are similar. 
Now, when members of a family manifest similar or 
the same diseases, it is not, it seems to me, because 
the diseases have been transmitted, but because, 
having similar organisations, and treating them 
similarly by living alike, that is (mostly), by eating 
alike, they therefore, and naturally, suffer alike. 
Like causes acting on like organisations in succeeding 
or in the same generations have induced like effects. 
Now, no doubt, we do occasionally see the same 
diseases manifested by different members of families 
in different generations. But a far commoner 
experience, I think, is to find, not so much that 
families manifest the same diseases as this : that they 
manifest not the same disease, but some others which, 
though seemingly quite different, are really due to 
the action of similar causes. How often, for instance, 
do we find that, while elderly members of the family 
suffer from cancer or from rheumatism, or while one 
parent has rheumatism and the other has cancer, one 
of the daughters suffers much from fermentative indi- 
gestion, or even from ulcer of the stomach, perhaps 
with recurring attacks of herpes labialis, another 
suffers from recurring sore throats, and another is 
anaemic, while perhaps one of the sons has bronchitis 
or gout. When our eyes are opened to the causes 
of these affections, and when we see their dependence 
on improper feeding, and particularly on the con- 
sumption of an excess of starch and sugar in the 157 
diet, we see that they are examples rather of the 
effects of bad family habits than of family disease, 
and we can understand better the otherwise 
inexplicable fact that one or two members of 
the family attained advanced life, while the rest 
succumbed early to one or other of the affections 
mentioned. They probably lived longer because 
they lived differently. Of course I do not mean to 
imply by this that there may not be very different 
amounts of resistance in different members of the 
family, just as there may be differing amounts of 
resistance in different machines turned out from the- 
same shop by the same maker. But machines 
made by the same maker, and of the same or 
different qualities, may be so treated as to last long 
and do good work, or may early be racked to pieces 
by being set to do work for which they were 
not intended and not fitted. Or they may be 
burned out by too large or too fierce fires, or 
come to a premature end by neglect of oiling and 
of tightening up loose screws or bolts. Or some 
undetected flaw in the metal of their composition 
may have led to the giving way and to the 
destruction of the machine. In just the same 
way, different members of a family may have 
different initial resistances, or even if endowed 
originally with equal and similar resistances, 
they may be overworked or properly worked, 
or may be properly fed and nourished. Or, 
on the other hand, being improperly fed and 
Different 
members of 
families have 
very different 
resistances, 
partly natural 
or in-born, 
but mostly 
acquired. 158 
nourished they may come to an untimely end 
in consequence. 
But as to the way in which carboniferous foods, 
or too frequent eating of carboniferous foods, for 
that is what seems to be the question—as to how 
these may cause cancer, it will be well to say 
something. The starch granule when it gets into 
the stomach, and later into the intestines, generates, 
or is apt to generate, carbonic acid gas. The 
oxidation of food-stuffs maintains the body heat, 
and the place where the heat is mainly generated 
(not entirely, of course) is the mucous membrane of 
the lungs. If this mucous membrane has more 
work thrown on it than it can comfortably accom- 
plish, it becomes congested and inflamed ; and 
bronchitis ensues. The foods whose oxidation main- 
tains the body-heat are largely the carboniferous, 
starchy, and saccharine foods ; and hence the 
commonest effect of an excess of these stuffs is 
“ taking cold ” or a bronchial attack, as has been 
seen. But before a person “ takes cold ” imperfect 
assimilation of his food has generally occurred. The 
gastric juice or stomach-secretion has little or no 
action on starch. This is so well known that one may 
say that the main digestive problem before chemists, 
physiologists, and therapeutists, in recent years, has 
been how to enable the economy to assimilate 
starch. Hence we have seen recommended such 
agents as lactopeptine, malt extracts, diastol, diastase, 
and taka-diastase, not to mention Benger’s proposals 
How excess of 
carboniferous 
foods is a 
predisposing 
cause of 
Cancer. 159 
to supply starch in a predigested form. When starch 
has broken up into carbonic acid gas and other 
compounds, what happens? For one thing, over- 
acidity of digestion in the stomach and intestines 
is very apt to occur ; and for this alkalies, as soda, 
potash, bismuth, are often given ; and some of the 
carbonic acid is no doubt neutralised in this way. 
But the remainder of it, and the new carbonic acid 
gas which is continually being generated, acts as a 
sedative to the mucous membrane of the stomach 
and intestines. It acts as a narcotic; in other 
words it paralyses the mucous membrane more or 
less, or its action is exerted in that direction. 
The consequence of this, or one consequence, 
is that the intestinal follicles gape or open too 
widely, and when they do this they take up 
particles of food not yet properly elaborated, and 
larger than the follicles ought normally to do. The 
conditions therefore are imperfect chymification in 
the stomach, and imperfect chylification in the 
intestines. Following this process further, we trace 
these imperfectly elaborated and large particles 
coursing in the lacteal vessels, and conveyed into 
the blood. What becomes of them there ? In 
early life they often find their way to the lymphatic 
glands and there set up suppuration. But in later 
life the lymphatic glands appear to have more 
resistance. The unassimilated particles of stuff 
coming from the food are conveyed by the lacteal 
system to the veins, and by the veins to the heart 160 
and the general circulation directly, or they find 
their way to the portal circulation first and to the 
general circulation afterwards. In the course of the 
general circulation they may become still further 
elaborated, partly no doubt by aeration, and partly 
by a secondary digestion which takes place in the 
muscle-sheaths and muscle-septa. Hence, when the 
blood is conveying many more such unassimilated 
particles than it ought to do, the occurrence of 
bronchitis and of the perimysitis, &c., to which I 
have formerly referred. But some of the particles 
may escape elaboration in either of these ways. 
There may be so many of them that the 
processes of the economy are unable to deal 
with them, and its provisions to overtake them. 
What becomes of them then ? Is it impossible that 
some of them, say one or two, for argument’s sake, 
may find their way into a fine capillary vessel, just 
capable, let us suppose, of conveying one blood 
corpuscle at a time? If these particles are larger 
than this, if say they measure a two-thousandth of 
an inch or more, is it not evident that they will be 
likely to cause a block in the circulation ? To form 
in fact the commencement of a block, which by the 
accumulation behind it of blood corpuscles and of 
other unelaborated and unassimilated particles, may 
form the nucleus of an infiltration into the cellular 
tissue or of a tumor formation ? In young persons 
with appetites beyond their digestive capacity, and 
who may not be under good domestic management, 161 
medical or other, such particles appear frequently 
to find their way to the capillaries of the skin, to 
form little blocks in this way in the skin and 
subcutaneous tissue, and to show themselves as 
acne spots. The little accumulations, in a short 
time, break down, undergo a process of very limited 
necrosis, suppurate, and are separated by thinning 
of the cuticle or perhaps by the needle point. From 
time to time, if the process goes on, larger accumu- 
lations may occur, and boils perhaps may form. Or 
perhaps some localised abscess may form, as quinsy 
in the tonsil or whitlow in the finger or thumb, some 
injury perhaps seeming to be the starting-point in 
the latter case. It is a happy circumstance that so 
very often these small suppurations occur in parts 
near the surface of the body, and accessible therefore 
to help. How much graver would be the conse- 
quences, for instance, if even small suppurations of 
this sort were apt to form in internal organs, as 
within the capsule of the liver or in the brain-mem- 
branes. And how very serious is it, in fact, when a 
larger accumulation of this sort forms and breaks 
down in the shape of a peri-nephritic or peri-hepatic 
abscess, neither of them excessively uncommon ; or 
of a pelvic abscess, as occurs so often. 
Every medical man must have seen samples of 
infiltrations in all these sites. The pelvic abscess 
is so frequent as to require no further reference. 
But I should like to mention cases of each of 
the others as samples of what, though they occur 
Mode of 
formation of 
A bscesses about 
i7iternal 
organs. 162 
less frequently, most practitioners must have wit- 
nessed. Not long ago I saw in consultation a fat, 
flabby, middle-aged woman, a milliner, who, besides 
directing her business, also took her own turn at 
needlework. She was in a highly feverish state, 
gravely ill in fact, and complaining of pain in the 
region of the liver, besides suffering from inflam- 
mation of the lungs, which seriously alarmed the 
medical men who saw her before me. Diagnosing 
abscess in the cellular tissue around the liver, we 
removed over a pint of some of the most offensive 
pus I ever had to do with. The woman succumbed 
to the complication of frightful diseases from which 
she suffered. I may mention that her food had con- 
sisted largely of bread and butter and tea several 
times a day. No doubt this had acted in the usual 
way, by loading the blood with carboniferous waste, 
which, after being deposited in the muscle-sheaths 
and bronchial mucous membrane, had infiltrated the 
air-cells of the lungs, and the cellular tissue in the 
abdominal wall outside the liver, and also the cap- 
sule of the liver itself. In course of time the infil- 
trated stuff broke down, suppurated, putrefied, and 
led to the lamentable issue. Such cases are not in my 
experience so common as those in which abscesses 
form in the loose fat around the kidneys and in the 
neighbouring abdominal wall, several cases of which 
I recall to mind (all in men, as it happens), and two 
of them in persons given to the consumption of beer 
and alcohol. All of them recovered when the pus 163 
was let out, though all were seriously ill. But the 
process by which the tissue broke down and the 
matter formed, was quite similar to that which led to 
the peri-hepatic abscess mentioned, and to others 
which also recur to my memory. 
But very often suppuration does not occur. A 
slow infiltration of particulate matter takes place 
in some part of the body, perhaps about the 
lactiferous vessels of the mamma, perhaps about 
some portion of the intestine, perhaps about the 
os and cervix uteri. There is generally some 
determining cause why this infiltration should occur 
in one place rather than another. In the os and 
cervix, for instance, there has often been present 
long-continued catarrh, with perhaps some loss of 
thin watery fluid, due to lowness of vitality, caused 
in turn by imperfect nutrition. A passive congestion 
in fact has been present for a longer or shorter time, 
and this passive congestion determines the occur- 
rence of the infiltration. In other situations the 
determining cause may be perhaps supposed to be 
the congestion caused, say, by a blow. Of course it 
was not the blow that did it. There was present 
before that a long-continued state of low vitality 
due to imperfect nutrition caused by long-continued 
improper feeding and the absence of proper 
methodised movements ; and what the blow did was 
to light up this slow passive congestion into sudden 
activity, and more or less acute congestion. Then 
the infiltrating process goes on. There is plenty of 164 
material in the blood to be deposited wherever any 
determining impulse may direct, and it is deposited 
accordingly at the seat of selection. Whatever be 
the seat or site, we may be in doubt at first whether 
the infiltration is simple or malignant, that is, whether 
its character is such as that it may be expected to 
become re-absorbed, or whether on the other hand it 
will go on increasing in size, hardening at first, and 
subsequently softening, ulcerating, breaking down, 
and spreading. Some forms of course are quite 
easy to distinguish. In others it is impossible for 
a time to say. Different forms seem to shade off 
into one another by insensible gradations. But the 
difficulty of distinguishing does not usually exist for 
long, for as a rule we soon have evidence one way or 
other. But sometimes suspense and anxiety take 
possession both of the observer and his patient, and 
that for a considerable period. Sometimes re-absorp- 
tion occurs, and sometimes when we had not 
expected it, suppuration takes place, and the body is 
relieved of the slowly-formed and offending material. 
Occasionally, it has seemed to me, it has been 
possible by timely treatment, to modify suspicious 
processes, and by attention to diet and general 
management, to prevent the development of malig- 
nant growths. Of course this may be too hopeful an 
attitude of mind, though I do not think it is ; it is 
a kind of thing impossible of proof. If such a 
formation, it may be said, was really cancerous, it 
would not go back. If it did go back it was not 
Diseased 
deposits or 
infiltrations 
which seem 
malignant, 
that is, 
cancerous, 
may sometimes 
be absorbed ? 165 
cancerous. Such reasoning may be correct, though 
I rather doubt it, inclining rather to the view that 
there may be threatenings of cancerous formation 
and deposition on several occasions, before it really 
takes place, and that treatment on such occasions 
may not only help in preventing malignant formation 
at the time, but also, by modifying the constitution, 
delay and even prevent its subsequent development. 
That it is possible to prevent the formation of 
malignant growths if we have the opportunity of 
advising patients early enough, I have no doubt. 
I think it depends on the way in which we live, 
whether we suffer from them or not—under 65 
years of age at least, and perhaps even 70 and 
later. Of course, as old age advances, more and 
more degeneration must be expected to ensue, and 
no efforts may suffice to prevent the development 
of cancer or other fatal disease. But at earlier ages, 
and up to 65 at least, why should it be impossible 
to prevent such development ? And what should 
be the steps taken towards attaining this end ? 
Evidently putting the body into suitable conditions, 
and into suitable conditions mainly as regards the 
three simple and fundamental things so often referred 
to, proper air, proper food, and proper movements. 
As to air, I need hardly say anything. Every 
one knows the necessity for an abundant supply of 
good air, and the bad effects of overcrowding and 
of vitiation of air. There is no difference of opinion 
on this point. 
If opportunity 
given early to 
the medical 
adviser he may 
be able to so 
advise as to 
prevent the 
onset of 
Cancer. 166 
Some funda- 
mental ideas 
regarding 
foods. 
But the case is different as to food. There is the 
utmost difference of opinion as to what is the proper 
food for man, different doctors giving very different 
advice. If I attempt to say a few words on this most 
important subject, I feel that the last word has by no 
means been spoken on it ; and yet it must surely be 
possible to lay down a few simple principles. A 
mixed diet is said, I think by all authorities, to be 
most suitable for man. The conformation of his 
digestive tract seems to determine that. Assuming 
this to be true, we may still ask. is it necessary to 
have a mixture at every meal ? Suppose we start the 
day with a mixed meal, in the ordinary way, with 
bread and butter—brown by preference, as being 
more nutritious than white—tea or coffee, eggs and 
bacon. Would it not be w'ell to have the other meals 
made of one sort of food each—a meat meal, for 
instance, and a vegetable and fruit meal ? But, first, 
as to the number of meals. I believe the most 
common and the most fatal habit as regards food is 
taking it too often. There ought to be a sufficient 
interval between meals to allow of the one being 
digested before the next one is taken. Five hours is 
the least interval that ought to occur between meals ; 
and six would in most cases be better. The 
Roman habit as regards food seems to have 
been to take it once a day, for we find Celsus 
writing that for sound people he recommended 
that food should be taken twice. Bis die potins, 
he says, quam seinel ciburn capcre. Two meals is 
A mixed diet 
suitable 
for man. 
Number of 
meals taken 
in a day. 
Time that 
ought to elapse 
between them. 167 
practically the European habit in many places, the 
day being begun with a simple cup of coffee at seven 
a.m., and nothing eaten with it, while lunch is taken 
about eleven or twelve, and dinner about half-past six 
or seven. In this country, breakfast is taken about 
eight, luncheon about one p.m.—dinner about 12.30 
by the working classes often—and dinner about 7.30, 
or tea by the working people about six. But these 
are not by any means the only meals in many cases. 
Not infrequently lunch is taken in the forenoon, at 
10.30 or eleven, boiled bread and milk, for instance, 
or some tea and bread and butter, and the well-to-do 
classes invariably, one may almost say, have after- 
noon tea and bread and butter, with tea-cake or 
sweet cakes, between lunch and dinner. Such people 
really eat five times a day, or at least four times ; 
and if they go out in the evening, as, for instance, 
to the theatre or some place of amusement, they 
often eat again on coming home. It seems to be 
.thought by many that these little extra diets do not 
count. It is nothing, people say. I believe that there 
is and can be no more fatal habit than that of too 
frequent feeding. It is not very common, perhaps 
—except among servants, but who suffer more from 
indigestion than they ?—to find a meal taken about 
eleven a.m., between breakfast and lunch or early 
dinner ; but such a practice must be most severely 
condemned wherever it is found, for it is utterly 
impossible that breakfast can be digested before such 
a meal is taken—a basin of bread and milk, for 168 
instance, or some jam tart—or that in turn it can be 
digested before lunch or early dinner is taken. The 
same reasoning holds good for the afternoon tea meal. 
I am sure that much disease takes its origin from 
it. Lunch is still undergoing digestion. If by 
chance one were made sick, that would be evident 
enough. All the materials of the food could be 
distinguished for at least four hours after they have 
been taken. How can it be wise or physiological to 
add some other sort of food to a stomach which is still 
engaged in the act of clearing off the last meal ? How 
can it be wise or physiological to have two supplies 
of food undergoing digestion, at two different stages, 
in the same stomach, at the same time ? And yet 
this habit is indulged in by almost the whole 
community all over this country, from the working 
woman, who, feeling “faint,” has her tea at 4.30 
p.m., having dined at one, to her richer sister, who 
has it about the same time, and sometimes twice 
or thrice in an afternoon, for the same reason. Do 
I then think that this indication of “ feeling faint ” 
is not to be met ? That nature is not to be 
listened to ? I do not say so. I think we can 
meet it rationally, and we can meet it beneficially, 
and we can meet it safely. It often really is caused 
by dyspepsia, but it cannot be wise to combat it 
by taking more food, which, though relieving it for 
the moment, aggravates the trouble later. Persons 
who suffer from this feeling of faintness cannot 
distinguish between gnawing due to dyspepsia, and 
Concerning 
afternoon tea. 169 
hunger for which they mistake it. And they would 
find as much relief from taking a glass of hot 
water or a cup of weak tea as they do from the 
little meal, which is so grateful to the palate, 
but which in course of time loads their blood 
with undigested particles, destined later to cause 
sore throat, or a cold, or rheumatism in early 
life ; and in later life much more serious things. 
I do not myself think it is the tea which does the 
mischief. It is most refreshing, and there seems no 
objection to it, if not taken too strong or too often. 
It is the bread and butter or cake or biscuits which 
do the mischief, by supplying the materials by 
means of which fermentation is set up, with all its 
evils. In the natural as well as the spiritual sense 
man shall not live by bread (and cakes) alone. In 
fact, it is not necessary, and it is positively hurtful to 
eat too often ; to eat one meal, however small, before 
the previous one is digested. The same considera- 
tions obtain as regards early lunch. Let persons who 
feel faint have a glass of hot water or a cup of weak 
tea if they like at eleven a.m., but by no means let 
them eat then. By one o’clock they will be ready for 
some more food. Some dine then, and some have 
luncheon. If the former, three or four ounces of 
cooked meat with potatoes may be taken, though 
the boiled onion is just as cheap and more laxative, 
and does not generate gas so much ; and that 
may be followed by some cooked apples or pears, 
or what other fruit may be in season. Any green 170 
Recommenda- 
tions 
regarding 
Diet. The 
food of grown 
people ought 
not to have too 
much body 
in it. 
vegetable, as the Brussels sprouts, or spinach, 
or cauliflower, or tomatoes, or haricots verts, 
might be taken in place of the potato or the 
onion ; and I think the stewed fruits are better than 
rice, sago, or tapioca, or other starchy pudding. 
Those who lunch at mid-day could have had the meal 
described, minus the meat. It will be said, I dare 
say, that there is no “ body ” in such a meal. Well, 
I admit that there is much less body in it than in a 
meal consisting of potatoes, bread, and rice, or other 
pudding. But I recommend it just because there is 
less body in it, for I feel sure that our ordinary diet 
has too much body in it, and that it is the cause of our 
rheumatism and gout, and of our general weakliness 
and premature old age. Those who have dined at 
mid-day could have the ordinary tea meal at 6.30, 
brown bread and butter and tea, and perhaps an egg, 
and any green vegetable like lettuce or water cress 
or tomato that might be in season. No supper ; or if 
any is wanted, a cup of cocoa may be taken or a 
glass of milk. It is better not to eat anything then. 
Those who dine in the evening could have clear soup, 
fish, meat, and stewed fruit, with any green vegetable 
in season, with cheese, if desired. Much variety is 
allowable, and, indeed, desirable, if food is to 
be enjoyed, and to perform its function in the 
body. I feel sure that by carrying out one or 
two very simple and very easily performed sugges- 
tions regarding their food, our people might 
escape much illness and loss of time through illness, 
Experience 
of abstaining 
from solid 
food at break- 
fast time. 171 
and much suffering. By the simple device of eating 
twice a day, or at most three times, with not 
less than six hours’ interval between the meals, of 
substituting the onion or green vegetables for the 
potato, of substituting cooked fruits for rice, sago, or 
tapioca, or hominy puddings, and by taking bread 
not oftener than twice a day, if we do eat three 
times, the health of our people would be very much 
better. As I have said, the habit on the European 
Continent in many places is to eat twice a day. In 
England it is more difficult to do this, because the 
habits of the country hardly allow luncheon to be 
taken till one or half-past one o’clock. Few of us 
like to go without food beyond a simple cup of coffee 
till that hour. I know, however, from experience 
that it is quite possible to do this, and to thrive on 
it. The evening meal can then be taken at eight 
or so, and the day is thus pretty fairly divided in 
regard of the times of taking food. Another 
plan is to breakfast at the usual time, say 
at 9 a.m., and to dine about 6 p.m., and this 
also divides the day pretty well. The cheapness 
and handiness of bread, the often-quoted remark 
that it is “the staff of life,” and forgetfulness that 
this observation was made by the prince of satirists, 
who wrote the “Tale of a Tub,” in ridicule of the 
Romish doctrine of Transubstantiation, and is not 
a divine or quasi-divine command regarding food, 
are the reasons, I suppose, why our people, and 
especially the poor among us, take bread three or 
Bread the 
staff of life. 172 
four or five times a day, to the great damage of 
their health, as shown by the great increase of 
bronchitis, influenza - cum - pneumonia, pneumonia 
itself, rheumatism, apoplexy, diabetes, and carcinoma. 
I name bread as the class-name, not meaning 
literally that all these evils are always due to it, 
although in fact they very often are, but meaning 
that an excess of starch and sugar in the diet, 
and the too frequent consumption of these foods, 
are the main predisposing cause of these maladies. 
Of course, as I have said before, eating any class 
of food-stuffs five times a day, or four times a 
day, perhaps even three times a day, will, in course 
of time, set up disease in the body; but that 
which in point of fact is doing the damage is the 
starch, and its chief form is bread and the cereals. 
If somewhat heavy meals are taken under the 
stimulus, more or less healthy and natural, of good 
appetite, we are apt to be tired or fatigued when that 
food gets into the blood ; and the well-to-do among 
us find tea so refreshing that we take it in the 
afternoon and eat something at the same time, not 
realising how bad are the effects of too frequent 
feeding. The cup of tea or the glass of hot water, 
in the afternoon, seems to be beneficial rather than 
otherwise. It seems to stimulate digestion, exciting 
the stomach and intestines to complete the assimila- 
tion of the previous meal, while it helps to relieve 
passive congestions of the internal organs generally. 
It also relieves thirst. An excellent practice I think 173 
also is the plan resorted to now by a good many 
people, of beginning the day with from half a pint to 
a pint of hot water, an hour before breakfast. If the 
evening meal of the day before has been taken at a 
reasonable time, it will be wholly digested when one 
wakes in the early morning; but thirst will be 
quenched for much of the rest of the day, and 
congested capillary vessels in the digestive viscera 
relieved by this practice. It seems a strange thing 
to say ; but I may as well say it since I think it; 
that I believe that the peri-hepatic abscess in the 
milliner which I have just referred to would not have 
occurred so soon had she taken a pint of hot water 
night and morning for some months previously. The 
free ingestion of warm fluid into an empty stomach 
and intestines (I am supposing that she had abstained 
from taking supper) night and morning would have 
relieved the engorgement about the liver, and if the 
abscess had formed at all, it would not have 
formed so soon. In other words, I believe that 
her life would have been prolonged had she 
adopted this plan. But if the woman had eaten 
less frequently, say, not oftener than three times a 
day; better still, had she eaten twice a day 
only, the probabilities seem to me very great 
indeed that she would have had no peri-hepatic 
abscess at all, nor any inflammation of the lungs ; 
and, in fact, I believe that she would have been 
living now. When things had got to the point 
described, neither medicine nor surgery could save 
Taking hot 
water night 
and morning 
an excellent 
plan. 174 
the woman, although the help of both was sought, 
at the hands of exponents of reputed skill. Her 
ailments were indeed incurable, but it seems to 
me quite certain that they were preventable, and 
that the simple prescription to a woman leading a 
sedentary life, that she should eat twice a day only, 
would have saved that valuable life. It is on 
simple things that our health depends. It is our 
habits in simple things that make or mar us. 
Few of us appear to be able to see the connection 
between the state of our health and our habits as 
regards food. But there really is plenty of evidence 
visible to the observant eye, and all that is wanted 
is plain common sense in attending to our own 
sensations and experience. Any one, for instance, 
and to take a common case, who may have tried 
the plan of taking tea and bread and butter on 
waking early in the morning for work or study, 
and who will compare the effects of these with the 
effects of plain hot water (or even weak tea alone), 
will not fail, I think, to be favourably impressed by 
the advantages of the latter course. The former 
seems to produce dyspepsia, while the latter relieves 
it. Eating too late at night seems to cause one to 
wake dull and heavy in the morning, tired, and with 
a dry clammy mouth ; and starting the day with hot 
water is one of the best remedies for this condition. 
Of course, a still better plan is to arrange the time 
and quantity of the meals of the previous day so as 
not to require this assistance. Even in that case, 175 
however, the hot water in the morning does not seem 
to do any harm. In fact, by flushing the capillary 
vessels it seems to do good. It seems better at that 
time of day even than the cup of weak tea taken by 
some. Of course strong tea is bad. I quite agree 
with the prevalent opinion in this respect. 
I insert here three propositions regarding the 
number of meals taken, and their effects on health 
and longevity. I believe that obedience to the advice 
implied in them would be of the greatest benefit 
to the people. I also, in a fourth proposition, ask 
a question which is worthy of consideration. 
It will be observed that the kind of food taken is 
not now in question. If health were not maintained, 
further advice might be taken regarding the kinds or 
sorts of food most suitable to each. 
1. Of two adults, similarly constituted and 
similarly circumstanced, that one will be likely to 
have fewer illnesses, and to live longer, who eats 
four times a day than the one who eats five times. 
2. Of two persons, similarly constituted and 
similarly circumstanced, that one will be likely to 
have fewer illnesses, and to live longer, who eats 
three times a day than the one who eats four times. 
3. Of two persons, similarly constituted and simi- 
larly circumstanced, over 50 or 55 years of age, that one 
will be likely to have fewer illnesses, and to live longer, 
who eats twice a day, than the one who eats thrice. 
4. I ask the question, whether after 60 or 65 
years of age, it would not be better to adopt the 176 
plan referred to by Celsus ? and whether, therefore, 
of two persons over 60 or 65 years, similarly con- 
stituted and similarly circumstanced, that one would 
not be likely to have fewer illnesses and to live 
longer (in possession also of his faculties) who should 
eat once a day, than the one who should eat twice ? 
By means of the diet suggested, modified, of 
course, in such ways as will produce variety and 
palatability, I feel sure that many of the small 
ailments from which we suffer may be prevented. 
At least such a diet would be one of the means of 
preventing them. But there are tests as to what 
management suits us, and what does not. For 
instance, the occurrence, or recurrence, of small and 
trifling indispositions, such as slight colds, eruptions 
about the lips, sore throats, waking in the morning 
more tired than when we went to bed, and so on, ought 
to be the signal that we are not managing ourselves 
properly. We ought then to try to find out in what 
respects the regime is wrong, whether in respect of 
air (too much closeness of the bedroom, e.g.), or of 
food, or of exercises. It goes without saying that the 
occurrence of graver ailments is such a signal; but 
indeed when we are incapacitated by severe illness, 
and especially by the recurrence of severe illness, the 
signal can no longer be disregarded. We are 
compelled to reconsider our regime and to seek 
advice. But it would have been much better not to 
have let things go so far. 
Before leaving this part of the subject, however, 
Tests whereby 
persons 
seemingly in 
health 
may know if 
they are eating 
wrongly. 177 
I should like to refer to one important point as 
regards cancer particularly, viz., its tendency to recur 
after removal. The analogous fact as regards the 
chronic diseases is that when a person recovers from 
one attack (say one attack of albuminuria, for 
instance, or chronic bronchitis) he is apt to have 
another, and even a succession of attacks. But the 
recurrence of cancer after removal is very striking 
and very disappointing, both to surgeon and patient. 
Of course one of the reasons why cancer recurs is 
that, before being operated on, it had in many cases 
infected the whole constitution through the lymphatic 
vessels and glands. When this is so it is easy to see, 
not only that it will be likely to recur, but that it is 
certain to do so, in fact impossible that it should not 
recur. If we think of it, indeed, we shall find that 
it is not so much a recurrence which has taken place, 
as a progression of the disease. It has not been 
eradicated because it was impossible to eradicate it. 
All the infected glands could not be removed. They 
were found to lie too close to great arteries, and 
especially too close to great veins, interference with 
which would have killed great portions of the body, 
and might indeed have killed the whole. But even 
when this extreme risk has been run, and when, for 
instance, a whole upper extremity has been removed 
in the hope of curing mammary cancer, the disease 
recurs all the same. Why ? Because the nutrition 
of the body has become so impaired as to have 
become totally depraved. The functions have become 
Why Cancer 
recurs after 
removal ? 
ist, Because 
not wholly 
removed ; 
because it could 
not be. 2nd, 
Because the 
continuance of 
its inducing 
causes has re- 
induced it. 178 
disorganised and the tissues have reached the 
culmination of mal-nutrition in one direction. The 
causes which have led to this state of things have 
been acting for so long a time that they have 
modified, unfavourably modified, the whole organism, 
so that it can no longer recover, but goes on repro- 
ducing the removed disease, either at the site of 
removal or elsewhere. 
Sometimes, however, things have not gone so far 
as this. We may be consulted quite early about a 
small cancerous formation and may be able to remove 
it before (so far as can be known) the glands have 
become affected. But even when this is so, another 
consideration should be borne in mind. Mere removal 
of an abnormal growth, whether cancerous or simple, 
is not sufficient in the way of treatment. Attention 
should be directed to the causes inducing the occur- 
rence of the growth in the first instance, so that they 
may be modified ; or that an effort should be made to 
modify them. If this is not done, what is to hinder the 
formerly acting causes from so acting again as to 
re-induce the former condition ? From causing a 
recurrence, for instance, of a simple tumour like uterine 
fibroid ? Is not the duty of the surgeon too often 
considered to be performed when he removes by his 
operation the growth or other abnormality for which 
he has been consulted ? Nothing being said, or far 
too little being said, regarding the causes of the 
malady, too frequently the continued action after the 
operation of the old causes re-induces the old malady. 
A surgeon s 
duty not 
fulfilled when 
he removes a 
growth. 179 
It will be said, I dare say, that this is not so ; that it 
is only cancer or malignant disease in some form 
which recurs. A fibroid tumour will not recur, it 
will be said, nor will other forms of simple growths, 
as they are called. In point of fact some fibrous 
tumours do return after removal, even if the majority 
of them do not. And in some situations it may be 
said to be the rule that when some fibrous tumours 
are removed, others form in the neighbourhood, 
even if the very same ones do not recur. 
And as regards the division of tumours into 
simple and malignant, besides the criticism that 
naming diseases simple on the one hand, and 
malignant on the other, is a piece of circular 
reasoning too often (the disease was malignant 
because it returned, and it returned because it was 
malignant) ; besides this, we are apt to forget 
certain essential facts. For instance, even if a 
fibroid tumour may not recur, does nothing form in 
its place? Does the patient remain quite well? In 
many cases, no doubt, he does. Some simple tumours, 
a small mass of adventitious fat, for instance, are 
no more an indication of general involvement of 
the whole body, are no more the local manifesta- 
tion or expression of a general state, than would 
be the accidental occurrence of a supernumerary 
finger or toe. To remove either the fatty tumour 
or the supernumerary digit, especially if it were done 
with a little skill, would probably have no effect 
on the general nutrition of the body, or on its 180 
general circulation. Similarly with the removal of, 
say, an inflamed sebaceous cyst. The removal of 
this, it might be hoped, would be fallowed by no 
general disturbance ; nor would the existence 
of an inflamed sebaceous cyst necessarily mean 
anything more than the existence of a slight local 
ailment. Even here, however, I suppose in strict- 
ness a slight local inflammation ought to be 
viewed as the local manifestation of a gene- 
rally disturbed circulation ? Different views might 
perhaps be taken of this question. When we come 
on, however, to consider the existence of a wen, and 
especially the existence of a succession of wens in a 
person, one new growth, or a group of new growths, 
appearing after the removal of one or of a group of 
others, and especially if the process of the recurrence 
of such growths were to go on for an indefinite 
length of time, we insensibly begin to introduce new 
considerations. We still, perhaps, speak of the 
occurrence of simple tumours, but we begin to pre- 
suppose in the person suffering from them a special 
tendency to their formation ; or by some phrase of 
that sort we begin to infer something like a modifica- 
tion of the general constitution or predisposition of 
the patient. Sometimes, even, we may fancy that 
the removal of some simple outgrowth may have 
been followed by some other ailment, by some 
rheumatic trouble, or an attack of gout, or some 
malady which suggests that the general nutrition has 
become affected. There are, again, recurring forms 181 
of what are called simple tumours, some forms 
of fibroid, for example, which recur after removal. 
When dealing with or considering these and their 
characters, we perhaps attribute more of a general 
constitutional character to them, and may think 
their occurrence not entirely explicable by purely 
local facts or considerations ; and we may even 
find ourselves doubting whether they should be 
viewed as simple or as malignant. The malignant 
growths unfortunately recur almost invariably ; 
but some of the simple growths are very apt 
to recur also ; and there seem to be inter- 
mediate forms between the so-called simple, and 
the so-called malignant growths, which shade 
off from one another by insensible gradations; 
while there are some intermediate forms of which 
we cannot for a time say whether they are simple 
or whether they are malignant. The only possible 
way in which (besides removal) recurrence of cancer 
or other growths can be prevented, must be by 
attention to causes, and by an attempt to modify 
them. But too often we hear far too little 
of causes. Obviously, however, to remove an 
effect, and to say nothing respecting its causes, 
is a proceeding altogether futile, and doomed there- 
fore to ultimate failure so far as cure is concerned. 
I cannot help thinking that I have seen quasi- 
growths or depositions of matter which threatened 
to be malignant, but which after a time became 
absorbed and disappeared. And it has seemed to me 
No real 
dividing line 
between simple 
and malignant 
growths. 182 
that if no attempt was made to modify the causes 
of these, or to alter the nutrition of the person, 
these formations have recurred, and in due course 
one of them has been pronounced to be malignant. 
On the other hand, if the patient has been seen 
soon enough, and has been able or willing to take 
the advice offered, she has been enabled to escape 
the recurrence of such alarming conditions, or may 
have been enabled to postpone them for a very 
long time. 
This seems perhaps the most suitable place to 
introduce the statement of one of the laws of the 
occurrence of disease in the body that is not 
infrequently enunciated by the lay public, or which 
seems at least to have emphatically impressed their 
minds. The remarks made in the course of these 
observations have to a greater or less extent 
implied it more than once. I mean the law that 
the hold which diseased states have on the 
economy is strong in proportion to the length of 
time during which they have been in operation. 
Perhaps a fuller statement would be to say that 
this hold is strong in proportion to the length of 
time during which the inducing causes have been 
acting, and also to the weakness or delicacy of the 
person or constitution acted upon. A more usual 
mode of expressing the last factor would be to say 
that the hold is inversely as the resistance of the 
patient. Inverse resistance we formerly saw to be 
the equivalent of predisposition, so that the law 
Diseases are 
long-lasting in 
proportion to 
the predisposi- 
tion of the 
patient, and to 
the length of 
time during 
which their 
causes have 
been in 
operation. 183 
might be expressed thus : Diseased states affect 
the organism in proportion to the length of time 
during which their causes have been in operation, and 
to the predisposition of the patient (here of course 
the term predisposition is used strictly in the sense 
already defined, not in the more or less vague or 
metaphysical sense in which the word is often used). 
From the point of view of treatment, which is the 
standpoint from which a practical public view it 
for themselves or for their friends, the translation 
of this law is that to treat affections whose causes 
have been acting slowly and insidiously for a long 
time, a long time is required. Obviously, not only 
is this the case in point of fact, but it must be 
so. To treat cancer successfully therefore, if such 
a thing were possible—which unhappily it hardly 
ever is, though it should not be overlooked that 
a very few cases recover—a very long time would 
be required. This is a reason, as before observed, 
why the mere excision of a cancerous growth can 
never of itself offer the prospect of cure ; it 
is a reason why the hope for patients suffering 
from cancer can never be in the use of the knife 
alone, although the knife may in suitable cases be 
one of the aids to cure. It has been said that 
starvation offers the only hope for relief or possible 
cure in cancer, an opinion which, so far as I can 
see, is about as near the truth as any I have seen 
enunciated. For if cancer is caused, as I have 
suggested, by the slow accumulation in the blood of 
Therefore the 
treatment of 
long-lasting 
diseases 
demands a 
lono time. 
Starvation to 
a greater or 
less extent the 
chief means foi 
the treatment 
of Cancer. As 
also for the 
treatment of 
the Chronic 
Diseases. 184 
waste and unassimilated materials mainly from the 
digestion, if cancer is the culmination of mal-nutrition 
in tissue, what so likely to afford relief (if we can 
hardly hope for cure) as the attempt to make the 
organism slowly use up its own accumulated waste 
stuff? But indeed this is our main help to cure in all 
the chronic diseases. A shrewd middle-aged man, 
who consulted me recently on account of congenital 
heart-disease, which was in course of time followed by 
kidney-disease, described how “ he had pined (starved) 
the dropsy out of him !” He had had to fight hard 
with long-continued disease during nearly the whole 
of his life, and that was his conclusion. I have no 
doubt he owed his life, and what measure of health 
he had regained, to his observant reading of the facts 
of life as they presented themselves to him. This 
is the reason why patients so often lose weight 
when being treated for chronic disease. If we 
are to cause a re-absorption of the material, 
which, by its deposition in various internal organs, 
causes chronic diseases, how are we to do this 
without causing general absorption of tissue ? 
Plainly it is in this way that we must set to work. 
But few persons will submit to this. The medical 
profession are, I believe, somewhat to blame for this 
reluctance. We have so persistently inculcated the 
view that the strength must be maintained, and that 
it must be maintained by the administration of 
abundant nutriment, and by implication have so 
persistently asserted that increase of weight is 185 
increase of strength, that when patients find them- 
selves losing weight, nothing will make them believe 
that they are not losing vitality ; and so, com- 
paratively few will submit to the only treatment 
which has any prospect of relieving them. But 
treatment which makes patients use up some of the 
waste stuff in the body (cancerous infiltrations for 
instance, or the deposits causing chronic inflamma- 
tions, or even serous effusions into natural cavities) 
causes and must coincidently cause absorption 
of some more or less sound tissue also. It is 
only through the general circulation that we can 
reach such deposits caused by long - continued 
passive congestion, and when such deposits are 
being used up by the economy, and passed into 
the general circulation, obviously, other tissues 
are liable to be absorbed also. It has been shown by 
physiologists that certain tissues are absorbed and 
used before others. Dr. Dewey, of Pennsylvania, 
with whose views I am glad to find myself in general 
accord, and who seems to have made the same 
attempt as the writer to view the facts of medical 
practice from an independent and, may I say, original 
standpoint, quotes a table of great significance from 
Dr. Yeo. Besides quoting it in the text of his 
book, “The True Science of Living,” Dr. Dewey 
places it in capital letters in the frontispiece of 
his book. He calls it Nature’s Bill of F'are for 
the Sick; and he shows that in illness, when we 
are using up the materials accumulated in our 
Decrease of the 
weight of 
patients not 
necessarily 
decrease of 
strength, and 
vice versa. 
Dr. Dewey on 
‘ ‘ Nature's 
Bill of Fare 
for the Sick. ” 186 
bodies, we may use as much as 91 per cent, 
of our fat (practically all of it), that of muscle 
we may use as much as 30 per cent., that the 
spleen may waste to the extent of 63 per cent., the 
liver as much as 56 per cent., and the blood itself 
be absorbed to the extent of 17 per cent, of its total 
amount. But even when wasting to this extent 
has occurred, the curious and significant fact is 
emphasised, that the Brain and Nerve centres may 
not have wasted at all. The controlling nervous 
system thus does not lose its power till the very 
last. Generally, however, the wasting process does 
not require to be carried to the very last, the 
chronic inflammatory deposit (and in rare cases 
even a cancerous infiltration ?) being absorbed and 
got rid of before this point is reached. Even, 
however, when it is not possible to induce healthy 
action in malignant growths in this way, some 
absorption is induced in them, and by this means 
it is often possible to reduce the terrible gnawing, 
stabbing, recurring pain of cancer, even although 
its onward fatal progress cannot be prevented. It 
is probably in this way that the frequent sipping 
of small quantities of water (pretended or perhaps 
believed ? by some of the followers of Count Mattei 
to be gifted with various electric powers and 
virtues), amounting to a pint or more in a day, 
has mitigated the terrible pain of cancer by 
relieving the capillary congestion of the viscera, 
and especially of the kidneys, so allowing them 
May even 
cancerous 
deposits be 
occasionally 
absorbed ? 187 
to act and relieve the system, even although it has 
not prevented the fatal issue. As most, if not all, of 
the chronic diseases depend upon the deposition of 
waste unassimilated materials in various situations, 
or, in other words, depend on a blocking of the local 
circulation in this way, a little wholesome starvation 
is generally of vast benefit by inducing the economy 
to use up some of its waste stuff. Nature herself 
points the way to us in this matter, because when 
things have gone as far as she can bear, and when, 
were things to go on in the same way, death must 
ensue, she generally throws the patient into bed 
with a digestive system entirely disorganised, taking 
away all appetite for food and all power of 
assimilation for the time being. We may, in such 
circumstances, do much harm by efforts, too per- 
sistently made, to feed our patients ; but generally 
they refuse all sustenance for some time. After 
a while (Dr. Dewey does not seem to be afraid 
if his patients refuse all food even for as long 
on some occasions as thirty days continuously 
or even longer) they right themselves, the tongue 
cleans, appetite returns, the power of assimilation is 
re-established, and recovery takes place. It strikes 
me as somewhat curious (and yet, if we both look at 
the facts of life candidly and impartially, perhaps it 
is not curious) that observers so wide apart, and in 
circumstances so very different as the conditions of 
human life must be in Yorkshire from what they 
are in Pennsylvania, should come to conclusions so 188 
practically similar as Dr. Dewey and the writer 
have reached. If in cancer we cannot hope for 
recovery, or if we can hardly ever do so, we may, 
perhaps, still hope for the amelioration of such 
symptoms as pain. A case recently came under my 
care, in which a woman, aged 46 years, suffered from 
a large cancerous infiltration into the pelvis. By 
and bye, cancerous nodules appeared in various 
parts of the abdominal wall, and passive effusion of 
fluid occurred into the peritoneal cavity (that last 
mark of profound illness). I recommended a very 
spare diet of milk, lime water, and white of egg, 
what was practically a starvation diet, in the hope 
that the organism would begin to use up the waste 
material deposited in the tissues, and possibly at the 
same time the cancerous growth, or some of it. I 
found the specific gravity of the urine 1030, instead 
of 1015 —1020, as it ought to have been, a fact which 
corroborated my view (went, indeed, to help to form 
my view) of the mode of onset of her disease. At 
the end of a week the urine was no less turbid, nor 
was the specific gravity any less. At the end of the 
second week there was still no change in either of 
these particulars, nor was there any improvement at 
the end of the third week. It was quite plain 
to me that the high specific gravity and the 
turbidity were being maintained at the cost of the 
woman’s body. At about that time general wasting 
became plainly visible, and at about the same time we 
were much troubled with sickness, the food becoming 189 
sour, and the stomach ejecting it. I suppose the 
milk was undergoing the lactic acid fermentation. 
The diet had to be altered. For a time she took 
for breakfast only a cup of coffee with milk. For 
dinner she had soup and a well-cooked green 
vegetable, following on with the milk and lime 
water in the evening. For a time this seemed 
to suit her. At about the end of six weeks 
the specific gravity of the urine fell to 1010, 
and the excretion itself had cleared. The end 
I had in view was being to some extent 
accomplished, and even the cancerous mass in the 
pelvis shrank somewhat, and the pressure on the 
bladder became less. But the improvement was 
not lasting. In time, sickness returned, the further 
steps in the course of the disease above mentioned 
making their appearance ; and in a short time 
the woman left the infirmary, in order to be 
among her own people when the inevitable should 
come. The predisposing causes of the cancerous 
disease were in this case also the usual excess 
of carboniferous foods, which had for years formed 
nearly the whole of her diet. When I saw her, 
nutrition had become too profoundly modified, and 
vitality had fallen too low, for the condition to be 
cured. But I cannot doubt that, had she been seen, 
say, some years before, when too great stoutness 
and some indigestion were the only things from 
which she was suffering ; and had the carboniferous 
foods which formed too great a part of her diet 190 
been diminished, something could have been done 
for her. I think indeed that her fatal illness 
might have been indefinitely postponed, and perhaps 
altogether prevented. The case seems to me to 
teach also the other lesson which I have several 
times said appears to arise in the treatment of 
cancer. The nature of the growth was not in itself 
such as to allow us to entertain at any time the 
hope of benefiting her by operation. But if it had 
been so, and if the cancerous infiltration, in place of 
occurring into the pelvic cellular tissue, had taken the 
form of, say, a cancerous enlargement of the ovary, 
which, being a well demarcated organ, might have 
been removed—if, I say, this had been so, what would 
have happened ? No doubt the growth would have 
returned either in the pedicle or in some other 
portion of the body. Even if sound advice had been 
given to the woman regarding her food, and if she 
had conscientiously followed it, even then I fear the 
growth would have returned, the general nutrition 
having been for too long a time and too profoundly 
lowered to allow of recovery taking place. The 
hope for these patients is not in the surgeon’s 
knife ; nor does it lie in this direction alone for 
potentially cancerous patients generally ; but it is, 
on the other hand, to be looked for in dietetic and 
other management at earlier stages, and lies in fact 
in the direction of preventive medicine. Preventive 
medicine must in fact enlarge her scope and aims, 
and as she has achieved noteworthy successes in 
The hope for 
Cancer not so 
much in the 
surgeon s 
knife as in 
preventive 
medicine. 191 
the domain of consumption and the fevers, must 
press on to the prevention, or at least the post- 
ponement, of the onset of cancer as well as of the 
other deadly and insidiously starting chronic diseases. 
Dr. Dewey of course knows nothing about the case 
just detailed. I can only infer from what he has 
said about his general views how he would have set 
about its treatment if he had been consulted. 
Neither are his phrases and forms of expression 
such as we should use here. By the expression 
“ Evolution of the Breakfast Table,” for instance, 
he seems to mean the abolition of the taking of 
solid food at breakfast-time. I do not know if it 
would be good American to speak of the evolution 
of slavery as having arisen out of the American 
civil war ? But it would not be good English. 
We should speak of the abolition of slavery. By the 
phrase evolution of disease again we should mean the 
production of disease ; and the use of the expression 
would imply an opinion that disease had been pro- 
duced slowly step by step, rather than created or 
produced suddenly. We should not use the ex- 
pression evolution of disease as synonymous with 
abolition of disease, which Dr. Dewey seems some- 
times to mean. But the abolition of solid food at 
breakfast-time was part of my plan of treating the 
poor woman in question who was suffering from 
cancer, and, the question of naming and of expres- 
sion apart, I gather that it would have been his plan 
also. Although that plan stopped the sickness and 192 
ejection of food for a time, its application was too 
late. Death was by that time inevitable. But what 
if it had been adopted some years before? Two 
to five years before? It seems to me, I must say, 
that had this been so (before the blood had been so 
thoroughly loaded with waste matters that nothing, 
not even absolute starvation, would have cleared it), 
the abolition of breakfast, and placing the woman on 
two suitably selected meals a day, and far enough 
apart from one another, would either have indefinitely 
postponed the onset of her fatal illness, or 
might have prevented altogether that mode of the 
termination of her life. In this particular case also, 
heredity has had nothing to do with my patient’s 
illness. Her mother was still living when she came 
under my care. It was the patient’s manner of living 
which brought on her fatal illness. And any human 
being may suffer from any human ailment, whatever 
may have been the state of constitution of their 
ancestors, or of their family. 
I have said nothing hitherto, except, indeed, by 
implication and by way of reference, regarding the 
third great modifier of health and cause of disease, 
viz., Exercises or Movements. If not so important 
as food in their effects on the body, exercises have 
still a most important influence on life and health ; 
and much might be said regarding them, much more 
than in these concluding passages I can have the 
opportunity or the space to say. Much has been 
written on the value of exercises, both in ancient and 193 
modern times ; and yet it is still almost a truism to 
say that their importance, even when theoretically 
recognised, has not received adequate practical con- 
sideration. The public school education of England 
has always laid great stress indeed on the value of 
games and exercises, the influences of which have 
been most beneficial on the health of her youth. 
But until very recent times this means of develop- 
ment has been almost wholly neglected in the case 
of girls ; and still it is so common as to be almost the 
general rule that exercises form no part of the daily 
life of adults of either sex. It seems to be thought 
that the performance of the business of life will 
provide sufficient exercise for the various muscles of 
the body. At least, nothing is so common, when 
exercises are recommended, as for the medical man 
to be told, “ Oh, I am moving about from morning 
till night. I cannot require exercise. If anything, 
I have too much.” No doubt an occupation which 
involves a good deal of movement is better than 
a sedentary one. But the muscular movements 
involved in the performance of the business of 
life are very often monotonous, and involve the 
performance over and over again of the same, and 
that a limited number of motions. There is no 
methodising of movements or of exercises. Take, 
for instance, the life of the woman doing domestic 
work. Her occupation is varied enough, certainly. 
To be one’s own cook, and housemaid, and char- 
woman, and nurse, and laundress all at once, or 194 
at short and alternating intervals, seems to imply 
the need of making a large variety of movements. 
And yet even with all these, certain muscles hardly 
get exercised at all. How stiff many of the 
women so occupied, all day long and day after 
day, become in the muscles of the back, for 
instance, is well-known to those who have to advise 
them. And how full of pain, and sore, and aching, 
and tender, are many of those women, may easily 
be discovered by any one who inquires into 
their condition. Many of them are in such a state 
that on the slightest tap or knock, their muscles 
become black and blue, extravasations taking place 
into their substance, so soft is their structure and so 
low their nutrition. It will be said that this is due 
to wrong feeding perhaps ; accumulations of such 
substances as paralactic acid, uric acid, butyric acid, 
xanthin, hypoxanthin, inosit, and so on, taking place 
in the muscles and finding their way there in great 
measure from the food. While this may be admitted, 
and while indeed from what has been said already 
in these observations, this must even be contended ; 
still it must also be argued that much of the evil is 
due to the want of methodised exercises ; and, of 
course, absence of fresh air tells on women (and men) 
who are too much confined indoors. In fact all the 
three causes of impaired health are at work, too little 
fresh air, improper feeding, and the absence of 
methodised movements. It is with the last I wish 
now to deal. People have difficulty in realising that 195 
they may be both over-worked and under-exercised 
at the same time ; yet this is literally true, it 
seems to me, not only for those who, let us suppose, 
over-work their brains with literary or other mental 
work, and who use their muscles very little, but 
even for those engaged in the continuous domestic 
occupations referred to, for which a good deal of 
muscular movement is required. It is an interest- 
ing thing also that the performance of methodised 
movements for ten, fifteen, or twenty minutes twice 
a day, not only does not add to the fatigue of 
persons so occupied, but positively diminishes it and 
enables them to do their daily work better. It is 
better to rest a little after these movements ; but if, 
for instance, they have been taken in the morning 
before breakfast, sitting down to that meal affords all 
the rest required, so that no extra time is required 
for rest by persons who are able to be up and about. 
Few persons are so much occupied that they could 
not spare the time required for exercises. What sort 
of exercises ? The ancients appear to have used 
two main sorts, what they called gestatio, and what 
was called exercitatio; or what we should now 
term passive and active movements. On the whole 
a good deal of importance seems to have been 
attached to exercises by the Roman physicians. 
I do not suppose for a moment that their advice 
would be followed by the mass of the people. The 
social condition of the population would act as 
an effectual barrier to that, as unfortunately it still 
Persons may 
be over-worked 
and under- 
exercised at 
the same time. 
Women 
especially often 
are both. 
Ideas of Celsus 
regarding 
acnve and 
passive exer- 
cises. 
Exercitatio, 
gestatio. 196 
does to a great extent to the mass of the people in 
our own day. But we find Celsus writing after this 
fashion : “ He whom either domestic or civil duties 
have occupied during the day ought to set apart 
some time for the care of his body (curationi 
corporis sui), and his first care is exercise (exerci- 
tatio), which ought always to precede food. And 
exercise ought to be more elaborate (amplior) in 
the case of him who has worked little and has 
been well supplied with food (bene concoxit), while 
it should be less in the case of those fatigued with 
labour and who may have digested less.” 
As to passive movements “ the most gentle 
gestation,” says Celsus, “ is that of a ship, either 
in a harbour or in a river ; the more violent is on 
the high sea or in a suspension-couch (lectica), more 
violent still is that of a carriage. .And indeed each 
of these may either be intensified or rendered more 
gentle. If there be none of these things within 
a man’s reach, a bed ought to be suspended and 
moved from side to side. If there be not even 
that, a prop is to be put under one foot, and by 
this fulcrum the bed is to be propelled backwards 
and forwards by the hand.” 
A rather strange, but certainly interesting, picture, 
this of the passive movements which were prescribed 
for patients in the second century of the Christian 
Era ! It is to be hoped that they were beneficial. 
The active exercises were, on the other hand, 
“ reading aloud (clara lectio;, the use of arms, the 197 
ball. Running and walking are,” he says, “ very 
convenient exercises ; the latter of which would be 
more advantageous if not on a plane, since the 
body may be exercised better by an ascending and 
descending variety, unless it be very weak. And it 
is better in the open-air than in a portico ; better 
in the sun (if the head can bear it) than in the shade ; 
better in a shade formed by walls and shrubberies 
than that which is under a roof; a straight walk is 
better than a winding. But incipient perspiration 
ought generally to terminate the exercise, or at least 
lassitude short of fatigue, and even in this itself 
it ought to be sometimes more, sometimes less. 
And indeed there ought to be no fixed rule (nec 
certa esse lex) nor immoderate labour in these 
exercises, in imitation of the athletes. Unction very 
properly follows these exercises sometimes ; either 
in the sun or before the fire; at another time a 
bath, but in a chamber as high, light, and spacious 
as possible.” . “ After these things it is 
necessary to rest a little.” 
The elaboration of the bath also is well known to 
have reached some perfection among the Romans, 
with its Tepidarium, Calidarium, and Laconicum, 
its Solium, Piscina, and Frigidarium ; besides the 
adjuncts of the Aquarium or Reservoir, the Vasarium 
or place for holding the vessels where the water was 
heated ; and the Hypocaustum or stove. 
If we set aside the somewhat fanciful arrange- 
ments and advice as to passive movements (gestatio) 
The bath 
among the 
ancients. 198 
I think we must admit that the physician who 
recommended the arrangements for active movements 
(exercitatio) knew what he was talking about, and 
gave good advice. He may not have known 
anything about oxidation, or about the accumulation 
of various waste products in the muscle-sheaths. 
Still less could he have named those products ; but 
his juxtaposition of digestion (concoquere) with 
movements (gestatio and exercitatio), and his clear 
perception of their interdependence and relations to 
one another, mark him out as possessing the insight 
required by the accomplished physician of all times. 
It is the same man who compelled our admiration 
before when we read his advice to the medical man, 
not to rush into the sick-room and seize the patient’s 
arm immediately, as he enters the chamber, “ but 
let him sit down first,” he says, “ with a cheerful 
countenance, and inquire how he finds himself; and 
if he seems alarmed he ought to soothe him with 
some suitable observations (probabili sermone lenire), 
then he may apply his hand to the body.” What 
more could the finest teacher say to-day ? And in 
what respects are we who know of the circulation 
of the blood so much superior to him who, though 
he did not know it, still felt his patient’s pulse and 
was still aware that many causes might be affecting 
it, such as exposure to the sun, the bath, exercises, 
.and emotions like fear and anger, all of which must 
be allowed for if the true condition of the pulse was 
to be known, and its meaning appreciated. 
Ancient 
physicians, 
although 
ignorant of the 
circulation of 
the blood, 
still felt the 
pulse. 199 
As to the exercises themselves the reader may 
ask of what sort should they be. They should be 
arranged so as to move in a methodic manner all 
the muscles, not, as is too often the case, to move 
some muscles to the exclusion of the rest. Games 
are of course most useful for this purpose. The 
games ought to be such as are not. too violent. For 
young people of course more freedom and rapidity 
of movement and more exertion are allowable than 
for middle-aged and elderly persons. Cricket, which 
involves both the action of running, and the many 
movements of throwing, catching, striking, and 
finding the ball, is of course an admirably contrived 
set of exercises. Football also might perhaps be 
so if it could be relieved of its present drawbacks. 
A game which involves wrestling, and struggling so 
fierce as to wrench, and strain, and sprain xmuscles 
and ligaments, fracture collar-bones, shoulder-blades, 
ribs, and legs, and do other grievous bodily injury, 
may be a good game and a well-devised exercise 
in itself, but it is in need of reform. Lawn tennis 
also is a very good game, its few drawbacks being 
comparatively easily overcome. Golf seems to be 
in all ways a most admirable game ; and no doubt 
there are others, as billiards, &c., which are suitable. 
Walking the deck on shipboard has a fascination for 
many people, providing exercise in the open air with 
the least possible fatigue, and having the advantage 
that it can be stopped at any moment that fatigue 
suggests, and can be as readily resumed. Walking, 
Games. 200 
running, leaping, fencing, boxing, the use of the 
rings and parallel bars, and the various movements 
involved in the use of arms are all useful and of 
much benefit to those who can indulge in them. 
Mention should also be made of the use of the 
bicycle and tricycle now so much in vogue. No 
doubt, most valuable exercises can be obtained by 
means of them. The writer feels strongly that they 
are very useful, particularly for women ; and it is 
even to be hoped that they may be the means of 
preventing some of those cases of chronic invalidism 
among young women, which have often in the past 
been at once the despair of the medical profession, 
and a great trouble and cause of despondency to the 
sufferers themselves and their friends. No doubt it 
is in food and exercises that the causes of these 
depressing and long-continued ailments are chiefly 
to be found ; and the bicycle offers a means of 
supplying a useful form of the one necessity, while by 
stimulating the digestive powers to greater activity, 
it will also help to supply the other aid to healthy 
life. The use of exercises without the drawbacks of 
the solitary and more or less objectless walk, such 
as is offered by the help of the bicycle, together 
with such alterations of the diet as may seem 
indicated in each particular case, offers at least 
in combination one of the best means for the 
relief and cure of such cases. Of course all 
good things must be used in moderation. Already 
there are whispers of the over-use of this form 201 
of exercise (as from time to time there are also of 
others). It is devoutly to be hoped that abuse of a 
form of exercise, very good in itself, may not justify, 
or seem to justify, a denunciation, which, even if 
merited by cases of abuse, will be likely to restrict 
its proper use. There is nothing to hinder, but every- 
thing to recommend, the prescription of the use of 
bicycle exercise (and this applies to all other exercises 
as well) for such lengths of time as patients can bear, 
whether for half-an-hour or an hour or two hours or 
more, according to the needs of each particular case. 
The marks of a well-balanced mind are that we 
should use those things which are helpful to life in 
a more or less equal and equable manner, with 
variations of less or more indeed according to the 
varying circumstances of the moment, and according 
to the varying needs of life ; but that on the other 
hand we should avoid those extremes of rush and 
torpor, of too excited use alternating with unmerited 
neglect, of too enthusiastic recommendation and too 
vehement denunciation, which are the characteristics 
of want of balance in the mind of the individual, of 
the community, or of the medical profession. 
All these modes of exercise, however, require 
much time, and many of them involve more expense 
than can be afforded by the average man and 
woman, who much miss exercises, especially now 
that so many of the board schools employ move- 
ments so admirably adapted for training boys and 
girls. It is too often a satire on those who are 202 
ill, to advise that they should resort to out-door 
exercises. However admirable the advice is in 
itself, it is too often impossible to follow it ; and, 
indeed, had it been possible to adopt and adhere to 
it, the patient might not have been ill at all. But 
there are few so poor as to be unable to afford 5, 
10, 15, 20, or 30 minutes to methodised movements 
twice a day, movements devised for the exercise 
of all the muscles of the upper limbs, of the head 
and neck, of the ribs and trunk, of the abdomen, 
of the flanks, of the thighs and legs. And every 
one who wishes can suspend a pair of rings from a 
beam in the roof, or can use light dumb-bells or 
clubs, even if he cannot find time or means to visit 
a gymnasium regularly. Of course the society found 
at a gymnasium is of great value, and must be 
recommended to all who can make the opportunity 
to visit one. For those whose time is limited, or 
who for other reasons cannot use gymnastic instruc- 
tion, nothing could be better than to read the little 
book, say, of Dr. Schreber (Leipzig, Fleischer), 
entitled “ Aerztliche Zimmer-gymnastick.” This 
little gymnastic instructor, “ made in Germany” and 
now in its 25th edition (the last edition being of 
10,000 copies), gives wood-cuts of a large number 
of muscular movements and bodily positions, most 
admirably devised, and as pictorially instructive to 
those who cannot read German as to those who 
can. It says much for our German friends that 
there should be among them so great a demand 
Literature of 
exercises. 203 
for so useful a book, and offers an example which 
all would do well to follow both in this country 
and elsewhere. I might also mention the chart 
published by Professor Dowd, of New York, as 
offering an excellent pictorial exhibition of useful 
movements. 
There are also other valuable guides to 
methodised exercises. Especially does attention 
seem to have been bestowed on these in the 
United States of America. The foundation of 
such literature in modern times is, of course, the 
Swedish system inaugurated by Ling. But as a 
development on this we have the handbook of 
school gymnastics by Baron Nils Posse (Lee and 
Shepard, Boston), a small but well-arranged set of 
progressive exercises for children. Then there is 
the physical culture of Louise Preece (C. W. 
Bardeen, Syracuse, N.Y.), which deals not only 
with systematic exercise and movements, but also 
to a considerable extent with the expression of the 
emotions by gesture. And a little book by Edwin 
Checkley, entitled “ A Natural Method of Physical 
Training” (London: 24, Bedford Street, Strand; 
and New York, 27, West Twenty-third Street, 
G. P. Putnam’s Sons), ought to be mentioned. This 
work describes exercises without apparatus. Then 
there are “ Sound Bodies for Our Boys and Girls,” 
by William Blaikie (London : Sampson Low, 
Marston & Co.), and “ Modern Gymnastic Exer- 
cises,” by A. Alexander, F.R.G.S., both of them 204 
very good books. All of these works give 
valuable information regarding exercises and the 
methods of performing them, and may be consulted 
with advantage. And no doubt there are others. 
With these representations before one, it is 
possible to avoid the verbal descriptions which 
would take up much space, and which would not 
then be so clear as the woodcuts themselves. And 
I can go on therefore to say, respecting muscular 
movements, that the best time to take them is 
before a meal, as Celsus says, or immediately after, 
before digestion has fairly begun; otherwise it is 
not wise to take them say a couple of hours after 
food, as then digestion is in full swing, and the 
economy ought not, so to say, to have its attention 
disturbed when engaged in the digestive process. 
Four or five hours after a meal, on the other hand, 
and an hour or so before the next one, is a suitable 
time, as the movements, especially if aided by the 
drinking of say half a pint of water, stimulate 
vitality, increase oxidation, improve the power and 
rapidity of the circulation for the moment, and 
stimulate the digestive viscera to complete the 
digestion of the previous meal. There is another 
thing which these movements are calculated to 
effect, viz., that, by stimulating the rapidity and 
power of the capillary circulation, they tend to 
prevent the deposition in the muscle-sheaths, nerve- 
sheaths, and periosteum, of those waste products 
which are apt to be filtered out of the blood at 
Best times for 
exercises. 
How exercises 
benefit the 
body. 205 
that time, and being laid down in these situations, 
to be the cause of much neuralgia, rheumatism, 
periostitis, &c. The increased oxidation tends to 
consume and use up many of these products, and 
so to prevent disease. The best time for exercises 
seems, therefore, to be in the morning before 
breakfast ; and the indication seems to be that they 
should form part of the act of dressing. The 
proper use of them involves getting up, say, twenty 
to thirty minutes sooner in the morning, which is 
not a bad suggestion for any of us. For very 
delicate people (who, however, in this case must 
also have the leisure which does not fall to the lot 
of all) the morning movements may be taken 
immediately after breakfast; after which the ordinary 
business of the day may be proceeded with, as by 
change of occupation what really often amounts to 
a rest is so produced. I think movements ought 
to be had recourse to once again in the day at 
some convenient time. The organism does not 
seem to retain the impress of actions of this sort for 
more than twelve hours. If the next set of actions 
happen twenty-four hours after the previous one, 
the organism forgets, so to say, the lessons of the 
previous occasion, and the work has to be begun 
afresh. The muscles do not seem to benefit so 
much by the previous exercises. Of course once a 
day is better than not at all, but, to parody the 
words of Celsus jabout food, it seems to me it is 
much better to have exercises twice than once a day, 206 
“ potius bis die quam semel exercitationem capere.” 
If this be admitted, the best time for the second 
set will be about four or five or six o’clock, according 
as people have more leisure time. The well-to-do 
have usually a toilet to perform then, and the work- 
people return from their occupations about the later 
hour. If the bath has been taken in the morning, 
there is no need for another then ; but if not, and 
if there is leisure for it, the addition of a bath to 
the afternoon exercises will add to their refreshing 
influences, and to the feeling of ease, lightness, and 
freshness which they induce. 
To briefly recapitulate what I have attempted to 
show in these observations, I should be disposed to 
state the following propositions :— 
(a) There are three great predisposing causes of 
health and of disease, viz., the relations subsisting 
between the economy and, ist, air, 2nd, food, and 
3rd, movements or exercises or work. 
(b) The improvements which have taken place 
in the public health, and which are seen in two 
directions, and in two directions only, viz., a dimi- 
nution in the incidence and mortality from fevers 
and from consumption — these improvements have 
been effected by directing attention to one of those 
causes, viz., air. Except in the case of water, 
whose influence has been studied, the general 
effects of food and of movements have hardly 
been considered at all. 
(c) The effects of improved surgery, though very 207 
brilliant and very important in individual cases, 
have exerted no appreciable improvement on the 
public health. If improved surgery has added 
thousands of years to human life in England, 
improved medicine (including under this heading 
the effects of sanitation) has added millions. 
(d) The commonest effect of improper feeding 
and the absence of exercises is to induce a condition 
which has been called triphthcemia, whose definition 
has been given. The commonest species of triph- 
thaemia, is triphthcemia carbonifera. There may be 
other species, as, e.g., triphthcemia nitrogenosa or 
triphthcemia ex olere, or triphthcemia e pomo. Triph- 
thcemia ex olere or triphthcemia e pomo are not, 
however, very likely forms to be met with, since 
neither green vegetables nor fruits contain as a 
rule the materials in their composition which are 
likely, by accumulating waste matters in the blood, 
to lead to the production of triphthaemia. True 
gout is a good and well-known representative of 
triphthcemia nitroge)iosa, but it is far less common 
than the various phases of triphthcemia carbonifera. 
(e) Triphthaemia carbonifera is largely due to an 
excess consumption of starchy and saccharine foods. 
(f) Triphthaemia carbonifera has many phases or 
manifestations, and shows itself in the occurrence 
of such diseases as herpes labialis, tonsillitis, 
bronchitis, rheumatism, eczaema and pruritus, 
caruncle, erysipelas faciei, apoplexy, influenza and 
pneumonia, Bright’s disease, diabetes, and carcinoma. 208 
(g) Attacks of disease recurring at long intervals 
of time imply causes at work in the organism acting 
at short intervals of time. Also, constant causes 
acting on the economy show themselves, not in 
constant but in periodic effects. The presence of 
stone in the kidney, for example, is shown not, as 
a rule, by the existence of constant pain and 
haematuria, but by periodic or intermittent attacks, 
with periods of more or less complete comfort 
between them. 
(h) Carcinoma is the culmination of mal-nutrition 
in tissue. Although nearly always incurable, it is 
preventable by proper attention to food and exer- 
cises ; under the age of 65 years, or even 70. 
(i) The following dicta regarding carcinoma are 
probably correct in fact in England at the present 
time (although too frequent feeding on any sort of 
food would Very likely induce cancer) :— 
i. Carcinoma in England is never, or hardly 
ever, produced by the consumption of 
green vegetables. Carcinoma ex olere 
nunquam fit. 
ii. Carcinoma is never, or hardly ever, produced 
by the consumption of fruit. Carcinoma 
e porno nunquam fit. 
iii. Carcinoma is not often, but sometimes, per- 
haps, produced by the consumption of flesh. 
Carcinoma e came aliquando sed raro fit. 
iv. Carcinoma is often produced by the too 
frequent use of bread. The use of bread 209 
five times a day for twenty or twenty- 
five years is almost certain to produce 
carcinoma, unless the patient has in the 
meantime been swept away by some other 
of the diseases named in proposition f 
But, indeed, the use of any sort of food 
five times a day for a long period of time 
will almost certainly induce fatal illness of 
some kind. Carcinoma e pane saepius fit. 
v. Carcinoma is most commonly produced by 
the too frequent use of starch and sugar 
in the diet. Carcinoma ex amylo et 
saccharo saepissime fit. 
(j) No disease occurs in the body unless the 
material or pabulum therefor is first found in the 
blood. Morbns mil ins in corpore cujus mate vies non 
prius in sanguine. 
(k) There is nothing in the blood of an adult 
which has not been introduced by the food or by 
the air. Nihil in sanguine quod non prius aut in 
cibo aut in aere. 
(l) The other diseases mentioned in proposition 
f are for the most part curable and preventable by 
attention to diet and exercises; and the carrying 
out of a few simple suggestions regarding food and 
exercise would probably make a great difference 
for the better in the health of the people. 
(m) Heredity is of far less importance as a 
predisposing cause of disease than are the habits of 
the individual. The effects of heredity are stronger 210 
in early life. Those of personal habits increase as 
life advances. The main law of heredity in disease 
is the following:—“ Like causes acting on like 
organisms in succeeding generations induce like 
effects.” In point of fact, we are far too prone to 
attribute to our ancestors diseases which are the 
effect of our own conduct. 
(«) The influence of germs on the organism is 
of far less importance than is the state of the 
organism which they influence. The best sort of 
a-sepsis is the a-sepsis of a healthy body; and a 
body is made healthy by abundant air, proper food, 
and exercises or work. In this healthy condition 
the body, if exposed to the influence of germs, will 
oxidise them off and take no harm. 
(o) Predisposition to disease is inversely as the 
resistance of the organism. In other words, pre- 
disposition is inverse resistance. Resistance is 
increased or diminished, or, on the other hand, 
predisposition is diminished or increased, by proper 
relations between the economy and air, food, and 
movements. The exciting causes of disease are 
such things as cold, heat, wetness, dryness, storm, 
fatigue, &c. The resistance of the organism to 
these is increased by proper management of it in 
relation mainly to air, food, and movements. As 
the causes of disease have always been considered 
to be the combined influence of the two sets of 
agents, viz., the predisposing and the exciting 
causes, it follows that a main part of the problem 211 
of medicine is to express the predisposing causes 
of disease in terms of the influence on the 
economy of air, food, and movements. In other 
words, predisposition ceases to be dependent on 
metaphysical considerations, and we see on the 
other hand how it may be possible to define it 
in scientific terms. 
(p) The interests at stake dependent on these 
simple considerations are vast and, indeed, almost 
incalculable. An addition of five years to the 
average duration of life of the forty millions of 
people living in the United Kingdom would mean 
the addition of two hundred millions of years to 
the active lifetime of a generation. Already it is 
computed that something like 125 millions of 
years have been added to the early periods of the 
lifetime of this generation by the sanitary improve- 
ments connected with the efforts to provide an 
abundant supply of pure air. While we shall not 
go back on this policy, much improvement may 
further be effected by attention to food and exer- 
cises. If the latter were done, the gain would 
accrue to the more important middle periods and 
to the early-old-age periods of life. It is our 
duty as a community to press forward to attain 
this. The medical profession can interpret the 
law, but it is for the whole people to obey the 
law or otherwise. We shall reap the consequences 
in either case. 
Sunt qui volunt, et sunt qui no hint. INDEX. 
A 
Abscess, pelvic, 161 ; peri-nephritic, peri-hepatic, 162 
Accident, Death-rate from, 19 
Acid, Carbonic, caused by starch, 158; uric, 34, 35-7, 41 ; lactic, 35, 
41, 189 
Acne, Formation of, 161 
Acute, 69-73. Not the logical opposite of chronic but of mild. 
Definition of, 70 
Ages at Death : see Death-rate. 
Air, a predisposing cause of disease, 9 ; effects of, 6 
Anaemia, Predisposition to, due to carboniferous foods, 101-3 ; con- 
nected with rheumatism, 104; might be called triphthsemia 
chlorotica, 104-7 ; comparative uselessness of iron in, 109 
Angina, 38 
Anthrax, 114 
Apoplexy really a disease of the circulation, 17, 18; diagnosis of, 
24 ; why commoner among women than men, 127 ; proportional 
number of increasing, 23 
Army, Consumption in, 21 
Arthritis, 42 
Arthritic Tenonitis, 42 
Asclepiades, 69, 70. Division of diseases (into acute and chronic) 
by a retrogression 
Asthma, an inflammatory disease, 17. Is there a pure spasmodic 
nervous asthma ? 
Atavism : see Heredity 
B 
Bacilli : see Micro-organisms and Germs 
Birth-rate affects death-rate, 6, 7 ; affects also fever or zymotic 
rate, 8, 9 ; of towns, 7; of England and Wales, 6 ; of West 
Riding of Yorks., 6 214 
Blood, Nothing in, which was not first in food or air, 207 ; waste 
matters in, 198, 162, &C. 
Bovinity inherited, 98 
Bradford : Birth-rate of, 7 ; death-rate of children, 8 
Bread emasculated, 86, and “ colds,” 87 ; five times a day, 89; 
“ the staff of life,” 171 ; evils of too much, 172; causes 
dyspepsia, 174; too often for twenty or twenty-five years causes 
cancer, 209 ; and causes many other diseases, 172 
Breakfast, Abstinence from solid food at, 170, 171 ; evolution of, 
191 
Bright’s Disease, 28, 30; causes of, 143-5 
Bristol : Birth-rate of, 7 
Bronchitis : The commonest cause of death in England, 16 ; accounts 
for about a tenth of mortality. Proportional number increasing, 
20 ; caused by food rather than weather, 16, 52-4, 85 ; heredity 
of, 55 ; causes of, 55-60, 90; treatment of, 109; why commoner 
among men than women, 28 ; heat an exciting cause of, 53 
c 
Cancer, or Carcinoma : Proportional number increasing, 23 ; not 
one of the commonest causes of death, 25 ; loss from, much less 
than gain from diminution of consumption, 25 ; not appearing 
at earlier ages than before, 25 ; is culmination of mal-nutrition 
in tissue, 26 ; generally preceded by long succession of minor 
ailments, 27 ; terminates often with passive effusion into natural 
cavities, 26; often follows rheumatism, 28; seldom attacks 
children, 47; is it hereditary? 47, 150-5, 192; former propor- 
tions between men and women not maintained in increase 
of, 50; causes of require time to act, 51 ; conundrum of sphinx 
regarding, 51 ; answer to conundrum, 149 ; due to triphthsemia 
carbonifera, 135 ; proofs, 136-141 ; how caused by carboniferous 
foods, 158, 207 ; by a blow, 163 ; cachexia of, 141 ; prevention of, 
164 ; absorption of cancerous deposits, 165, 186 ; postponement 
of, 165 ; attempt to deal with causes of, necessary, 181 ; 
recurrence after removal, 177, 178 ; predisposition to, 150-5 ; 
starvation in treatment of, 183-7 ; hope for, not in surgeon’s 
knife alone but in prevention by food and exercise, 190 ; dicta 
regarding, 208, 209 
Caninity inherited, 98 
Carbonic : see Acid 
Carboniferous Foods, Effects of excess of, 86-90, &c. 215 
Causation of disease, 60-5 
Causes continuing will re-induce removed disease, 178 
Celsus on exercise, 204; on food, 166, 196-8 
Chronic, 69-73—not logical, opposite of acute; definition of, 71, 
chronic diseases recurrent before becoming chronic; treatment 
of, 76 
Circulation, Diseases of, 17; in muscles, 32, 35, 102 
Cold. Taking cold dependent on food, hi. Bronchitis and cold, 
16, 53, 85. An exciting cause of disease, 210 
Constitution, Definition of, 93 
Consumption (or Phthisis) diminished by attention to air, 4-6; 
mortality from, 18; bacillus of, 114 ; still as fatal as before but 
much diminution in number of cases, 117 ; is it hereditary? 21 ; 
in army, 21 ; prisons, 22 
Country Dwellers and disease, 45 
D 
Death-rate, Low, caused by low birth-rate, 6, 7 ; death-rates, 2-25 ; 
comparison at different ages and different periods of history, 
11 -13 ; in country, 10; town, 7; between twenty-five and sixty- 
five years of age, 13, 14; from accident, 14-19; between 
twenty-five and sixty-five, 146; ought to be prevented, 16; death 
over sixty-five occurs only to one-fourth or so of population, 10 
Deposition of Cancer, 165 
Dewey, Dr., on “True Science of Living,” 185; decrease of 
weight, 185 ; bill of fare for sick, 185 ; on refusal of food by 
patients, 187 
Diabetes : Proportional number increasing, 23 ; diagnosis of, 24 
Diarrhoea : Mortality from, 119 ; not so much diminished as from 
fevers, 119; due to food conditions rather than air, 117-9 
Diathesis : Definition of, 98 
Disease: Predisposing causes of, 9; nexus of, 28-30; origin of, 30; 
causation of, 60-5; acute and chronic, 69-73; per-acute, 71; 
tests of skill in treatment of, 75-77; disease one, 142-147; 
inference from this opinion, 145; law of parcimony in, 29; 
family disease often due to family habit, 129, 155-7; sex disease 
due often to habit, 129; property and accident in, 129; treat- 
ment of recurrent disease, canon for, 77; recurring disease 
implies constant cause, 81, 209; long-lasting disease requires 
long treatment, 182; periodicity of, 64, 65 216 
E 
Eczema, 106 
Effusion, Passive, the most striking mark of profound illness in 
general, 26 ; in carcinoma, 26 
Erysipelas, Faciei, 104; connection with triphthremia carbonifera, 
104, 105 
Exercises : Dangerous to potential apoplectics, 127 ; remarks on, 
192-206; literature of, 202, 203 ; times for, 204; not sufficiently 
provided by occupation, 193 ; Celsus on, 195, 196, 204 ; how they 
benefit, 204; overwork compatible with under-exercise, 193; 
not sufficiently attended to, 10; no instructions from Health 
Officers as to, 9 
F 
Faintness and Indigestion, 168 
Fallacies, Medical, 61 ; post hoc ergo propter hoc, 61, 82, 83 ; 
fallacy of fallacies, 62-5 ; of intermittent effects, 63, 73 
Family Disease often due to family habits, 155-7 (see Heredity 
and Disease) 
Fevers due to bad air, 6; predisposition to, due to food, 121 ; 
reduction of, by sanitation, 4-6 ; might be abolished by attention 
to air and food, 126 ; suggestion to include rheumatic fever 
among, 112 
Fibroid Tumours, 181 
Food : Not sufficiently attended to, 9 ; no instructions from Health 
Officers regarding, 9; no agreement as to effects of, 166 ; mixed 
food best, 166 ; times of taking and number of meals, afternoon 
tea, Celsus on food, European habits as to, frequent feeding, 
recommendations as to, 166-176 
G 
Galen, 77, said, “ Recurrent attacks of illness should be treated in 
intervals”; on acute and per-acute diseases, 71 
Germs: Suggestions as to, 133-5; of influenza, 111 ; fevers or zymotic 
diseases due to, 112; of consumption, 114 (see bacillus and 
micro-organism); of anthrax, 114 
Gymnastics, 9: see Exercises. 217 
H 
Headache in a wind, 126 
Heat an exciting cause of bronchitis, 53 
Heredity of disease, 48, 49, 150-5, 191 ; of cancer, 48; of syphilis, 
48; law of in disease, 50, 156; of bronchitis, 55; definition of, 
96 ; determines organisation, 97 
Hippocrates, 69-73, J45 
Hot Water before breakfast helps to relieve thirst for day, 173 ; 
taking of may help to postpone fatal illness, 173 
Hull, Birth-rate of, 7 
Humanity, Inherited, 98 
I 
Infection and infectiousness from case to case, or as successive 
effects of common cause, 99 
Infiltration : see Abscess ; see Cancer ; simple and malignant, 164 
Inflammation: Not discussed, 3t; is generally the local expression 
of a general state, 180 
Influenza : How infection carried, 91, 92 ; connection with food, 92 ; 
prevention of, 92; incidence of, among medical profession, 111 ; 
connection with pneumonia, HO; bacillus of, 112; probably 
should be classified among fevers, 112 
K 
Koch: Treatment of consumption, 114 
L 
London, Birth-rate of, 7 
Lonu continued diseases require long continued treatment, 183 ; long 
and short diseases, 70 
Lymphatic Glands, Inflammation of, 159 
M 
Macro-organism, Relation of, to micro-organisms, 116 
Malignant: Circular reasoning regarding malignant diseases, 179; 
malignant and simple diseases shade off into one another, 164, 
179 218 
Mal-nutrition, 194 
Mattei, Count, 186 
Meat, Increased consumption of, not the cause of cancer, 88 
Medicine, Progress of, in what it really consists, 1, 2; fashions in, 
74 ; preventive medicine must enlarge her scope, 190, 191 
Megrim, 38 
Meningitis, Passive : Symptoms of, 41, 42 ; after operations, 42, 43 
Micro-organisms : Growth in body dependent on nutrition, 112-116, 
210 (n); see Germs 
Muscles, Mal-nutrition of, 194; muscle tenderness, 101, 102; muscle- 
sheaths relieve blood of waste, 102, 108; deposit of unassimilated 
food-stuff in muscle-sheaths, 32, &c. 
Myalgia, 36 ; often confounded with neuralgia, 37 
N 
Names, Functional and pathological, 38, 39 ; anatomical, 40 ; scientific, 
4° 
Neuralgia, 36; ovarian N., 36; abdominal N., 36; spinal N., 36; 
suboccipital N., 38; not the name of a disease, 40 
Neuritis, 40 
Nottingham : Birth-rate, 7 
o 
Organisation inherited, 96-8 
P 
Pelvic Abscess, 161 
Perimysitis, 35, 36 
Perineuritis, 38-40 
Periodicity of Disease : A particular case of a general law, 65 ; 
a movement in spirals, 65-9 
Periostealgia, 43 
Periostitis, 42. P. sterni and bronchitis 
Pneumonia, Deaths from, 17 ; proportional number increasing, 22 
Predisposition, 16, 17 ; dependent more on acquired than inherited 
characteristics, 78 ; definition of, 94 ; due to food rather than to 
ancestors, 125 ; to cancer, 150-5 
Progress : see Medicine 219 
Pruritus commoner among women than men, 129; treatment of, 
129; case of, proving causation, 131, 134 
R 
Recapitulation, 206-11 
Recovery not continuous, 64 
Recurrent Disease: see Disease and periodicity; recovery from 
even when causes persist, 73 
Registrar General, Returns of, 2-26 
Resistance, 94, 210 
Rheumatism : IIow connected with carboniferous foods, 101 ; often 
precedes carcinoma, 28 
Rheumatic Fever : Suggestion to include among zymotic diseases, 
112 
s 
Sanitation, Effects of, 3, 4 ; is without drawback, 3 ; has diminished 
fevers and consumption, 4, 5, &c. 
Sarcoma, Causes of, 47 
Sciatica, 38 
Sex-Diseases often habit-diseases, 129; property and accident in 
sex-disease, 129 
Simple : see Malignant 
Starch : Excess of, in diet, 172, 209, 86-92 ; aids to digestion of, 
189 
Starvation in treatment of cancer and chronic diseases, 183-5 
Sugar, 87-89 ; consumption of at different periods of time, 87-89 
Surgery excluded from inquiry, 1, 2 ; has not increased length of 
life, or hardly, 3, 74, 75 ; not lowered death-rate—not without 
drawbacks, 3 
Surgeon’s Duty not fully performed unless he points out causes of 
tumour that he removes, 178 
Surgeon’s Knife not the hope in cancer, 74, 75, 190 
T 
Tea, Afternoon, 168, 169, 172; strong, 176 
Tenonalgia, 43 
TONSI LITIS, 16l 
Town-Dwellers, 45; towms, birth-rates of, 7 220 
Treatment, good or bad, 75, 76; in chronic disease, 76; of 
comparatively small moment in acute diseases, 76; canon for 
treatment of recurrent disease, 77 ; of recurrent disease apt to 
be followed by severe attack, 79-81 
Triphthaemia, 41 ; carbonifera, 103 ; pallida, 105 ; nitrogenosa, 103 ; 
rubra, 104, 105; chlorotica, 105; treatment of, 109; dauses 
headache in a wind, 126 
Typhoid Fever, Mortality from, 119; is its predisposing cause 
mainly air or food? 118, 120 
u 
United Kingdom, Birth-rate of, 7 
Urine: Too acid state of, what it causes, 35; specific gravity of, 
188 
V 
Varicose Veins, 106 
w 
Weariness after meals, 34; in morning, 34 
Weight : Body weight in disease, 184 
Wens, 180 
West Riding, Birth-rate of, 6 
Whitlow, 161 
Wool-sorter’s Disease, 114 
Women eat too often rather, perhaps, than too much, 130; cancer 
in, 50; sex-disease often habit-disease, 129 
X 
Xenaemia, 41 
WILLIAM BYLES AND SONS, PRINTERS, BRADFORD.