ANNUAL ADDRESS.

FORCE VS. WORK: SOME PRACTICAL REMARKS ON DIETETICS IN DISEASE.

BY WILLIAM PEPPER, M. D., L.L. D.

Provost and Professor of the Theory and Practice of Medicine and of Clinical Medicine, University of Pennsylvania.

Mr. President and Gentlemen:

I have much feared, since accepting your courteous invitation to address you on this occasion, that I should wholly fail in finding a subject of interest to more than a section of your body. Absorbed as I, in common with other clinical physicians, have been in the results and applications of recent investigations, confined chiefly to the province of practical medicine, I have hesitated about entering upon a discussion of any such topic, which might have but a limited interest for an association whose very name of Medico-Chirurgical denotes its comprehensive scope. But, mindful of the thoughtful work not long since published by your distinguished President, which, I am sure, attracted the same attention and met with the same favor here as elsewhere, I was led to hope that an informal presentation of some practical remarks upon the subject of dietetics might not be without interest. I must confess, however, that, in looking ahead over what I have prepared to say, it seems as though, as often hap pens to our children, real or literary, I had chosen in advance a title sufficiently inappropriate; for it can scarcely be said to treat of dietetics in disease except in so far as it offers some desultory thoughts upon the relations of dietetic errors to the

*Health and How to Promote It. By Richard McSherry, M. D.

production of disease and upon the value of restricted diet in the treatment of some special affections.

However, imperfect and partial though my handling of the topic be, I am sure that all of us will, at least, agree upon its importance; and I believe all of us would have to acknowledge, were we to review candidly our dealings with our patients, that this important subject fails in many instances to receive at our hands the sustained and minute attention it demands.

And yet it seems to me apparent that, amid the currents and counter-currents of medical opinion during the past decade-so prolific in speculations and hypotheses and new methods of treatment, too often hastily advanced only to be abandoned speedilythere has been a constantly growing appreciation of the importance of dietetits, and of the fact that in every case requiring medical or surgical care the adjustment of the diet is one of the indispensable elements of the treatment. It is, indeed, safe to go further than this, and to assert that it is becoming recognized more clearly that, in very many conditions of impaired health and actual disease, successful treatment depends chiefly or exclusively upon proper diet and regimen. I do not, of course, refer only to the familiar facts that in typhoid fever, in diabetes, in ulcer of the stomach, in functional dyspepsia, the diet must receive close attention, and that a neglect of this will render unavailing any other treatment, however judicious. But I wish to state clearly-and even at the risk of seeming to emphasize a trite commonplace-that many other morbid states can only be successfully treated when it is recognized that diet is the most important, and, in fact the one essential, feature in their management; and further, that many other morbid states, often regarded as distinct pathological entities and vigorously combatted as such by special medication, are essentially dependent upon dietetic errors, relative or absolute, and are curable only by having first corrected these errors.

If time permitted, I should attempt to illustrate suitably the tremendous influence of diet on the normal condition of man, the wide range and varied character of the morbid symptoms resulting from the gift of food abused, and the wonderful remedial effects of special forms of diet. I believe it would appear

from such a study that the line in which, more than in any other, the greatest triumphs of therapeutics are to be won in the near future is in the direction of dietetics scientifically adapted to special morbid states.

In estimating the influence of the great factors of our physical life upon the development of the individual or of the race, I have long felt that far too much importance has been attached to climate and far too little to diet and personal hygiene. No more can the average man attain his full moral growth and the normal perception of freedom and of obligation under evil forms of government, or under the sway of gross religious superstitions, than he can attain his full physical development under the influence of bad dietetic traditions and of uneducated appetites. No weight can be attached to the fact that exceptional individuals in every community display the highest physical and intellectual health and vigor while pursuing courses of life admissibly injurious. A separate study of these exceptional cases is much needed, and would possess great interest and practical value. But, for the establishment of the laws of dietetics and hygiene, we are concerned only with the average man, and of. him we may safely make the above assertion.

No people need the diffusion of sound information on these subjects as badly as we do. In India we have had the opportunity of observing the curiously interesting results of subjecting large numbers of Anglo-Saxons, and in many instances through successive generations, to climatic conditions diametrically opposite to those familiar to that race. In Australia a similar experiment is being conducted on an even larger scale. And I believe the verdict of the best observers is to the effect that, with suitable diet and regimen the characteristic health and energy of the race will be preserved unimpaired. But in this country we see a more complicated experiment tried on vast proportions. A nation growing in numbers with unprecedented rapidity, by aid of recruiting in all quarters of the globe; a vast territory, representing wide varieties of soil and climate to be occupied and brought under cultivation by this motley multitude; a fierce contest to be

waged with strange and untried climatic, industrial and social conditions; the gift of freedom, personal, political and pecuniary, to be borne by millions, heretofore comparative strangers to these blessings: these barely hint at the transcendent difficulties encountered by the people of this country in planting and establishing permanently in full and typical health and vigor the great Anglo-Saxon race. Small wonder that during the experimental stages of this great work, many curious effects, physical as well as social, have been developed, and that pessimists have found ample food for prophecies that this race could never become permanently established and productive under climatic conditions so different from those familiar to the chief components of our people.

The so-called typical American certainly came to be something quite different from his English, Irish or German ancestor, and his pale or sallow face, with tall slender figure full of the irritable restlessness bred of nervous dyspepsia has been rendered suf ficiently familiar to us, more so in fact in the hardly good-natured or veracious pages of travelers and novelists than in actual life.* Still there he has been and there, in considerable numbers, he still is; and the interesting question arises whether his physical peculiarities are inseparably dependent upon our climatic condition or upon other and transient influences. I confess my own observation. has led me to the deliberate conclusion that it is to the latter almost exclusively that we are to attribute the results indicated. It is manifest that one must pay more attention to adapt himself successfully to the extreme features of a great continental climate like ours than is required in the comparatively uniform climate of England or Ireland. But it is equally true that malaria, damp soil and damp houses, due to defective drainage, are deadly but wholly avoidable foes to health. And it is no less certain that communities where, from earliest boyhood, the

*It is in fact to be noted that the contrasts used to heighten the effects of vivid pictares of the physical peculiarities of Americans, have been drawn from classes abroad who are living widely different lives, and that a truer description of foreign populations would show how ridiculously unfair it is to adopt the burly, ruddy yeoman farmer of the fat midland counties of England as the type of the laboring classes (civic and rural) of Great Britain and the Continent.

excessive use of tobacco in the most injurious forms is general, where bad whiskey is a staple drink between meals for the men, where for all alike, men, women and children, reeking strong tea and coffee in unlimited quantities are consumed at every meal, while beyond all this the reign of the frying pan and the soda baking-powder and the patent purgative pill is universal and undisputed, cannot be fairly expected to perpetuate the finer types of manly or womanly physique; and I repeat my opinion that it is to these latter influences that we are chiefly to attribute most of the physical peculiarities commonly assigned to the agency of the American climate. I believe myself that, with due regard to the conditions under which work must be prosecuted here, it will be found that there is no more favorable climate on earth, and I appeal to your observation of the generations now rising in support of the prediction that, with the correction of what may, and surely will, be corrected in our physical conditions and habits here, there will be a gradual advancement in our average physical vigor, until, even if a complete reversion to our ancestral type is not attained, there will be developed a new type, in no way inferior.

So, too, even at the risk of being misunderstood, I would like to call attention to the excessive share which has been attributed to overwork in the production of the many forms of nervous exexhaustion and premature breakdown which we daily meet with. Unquestionably, there is a degree of eager, ceaseless absorption in exciting work, involving immense mental, moral and physical exertion, which is capable of breaking down the strongest and best constitution. But unless my own experience is altogether exceptional, such instances are rare, and the vast majority of cases met with are those in which an amount of work and excitement entirely consistent with the maintenance of good health, if the laws of health were duly observed, is rendered destructive by reckless disregard of those laws.

The familiar instance of a man who, at five and forty, is at the head of several large businesses and is a director in a dozen companies, and who finds himself breaking down with insomnia, headache, gastralgia or some of the myriad forms of nerve suffering,