[1]
Paper read before the Institution of Mechanical Engineers, July 28, 1891.
[2]
Transactions Northeast Coast Institution of Engineers and Shipbuilders, vol. 7, 1890-91, p. 179.
[3]
Transactions Northeast Coast Institution of Engineers and Shipbuilders, vol. 6, 1889-90, p. 253.
One of the highest medical authorities is credited with the statement that "nine-tenths of the diseases that afflict humanity are caused by neglect to answer the calls of Nature."
This state of affairs is generally admitted, but is usually attributed to individual indolence. That, doubtless, has a great deal to do with it, but should not part of the blame be laid upon the often unpleasant environments, which make us shrink as from the performance of a painful duty?
In social life, unless from absolute necessity or charity, people of refined habits do not call on those whose surroundings shock their sense of decency; but when they go to pay the calls of Nature, they are often compelled to visit her in the meanest and most offensive of abodes; built for her by men's hands; for Nature herself makes no such mistakes in conducting her operations. She does not always surround herself with the pomp and pride of life, but she invariably hedges herself in with the thousand decencies and the pomp of privacy.
But what do we often do? We build what is sometimes aptly termed "an out-house," because it is placed so that the delicate minded among its frequenters may be made keenly alive to the fact that they can be plainly seen by every passer-by and by every idle neighbor on the lookout. This tiny building is seldom weatherproof; In consequence, keen cold winds from above, below, and all around find ready entrance, chill the uncovered person, frequently check the motions, and make the strong as well as the weak, the young as well as the old, very sorry indeed that they are so often uselessly obliged to answer the calls of Nature. It is true, the floor is sometimes carpeted with snow, but the feet feel that to be but cold comfort, though the door may enjoy rattling its broken hasp and creaking its loose hinges.
How often, too, are the nose and the eye offended by disregard of the Mosaic injunction, found in the twelfth, thirteenth, and fourteenth verses of the twenty-third chapter of Deuteronomy! Of course this injunction was addressed to a people who had been debased by slavery, but who were being trained to fit them for their high calling as the chosen of God; but is not some such sanitary regulation needed in these times, when a natural office is often made so offensive to us by its environments that it is difficult for us to believe that "God made man a little lower than the angels," or that the human body is the temple of the Holy Ghost?
Dwellers in the aristocratic regions of a well drained city, whose wealth enables them to surround themselves with all devices tending to a refined seclusion, may doubt all this, but sanitary inspectors who have made a round of domiciliary visits in the suburbs, or the older, neglected parts of a large city, of to any part of a country town or village, will readily affirm as to its general truth.
This unpardonable neglect of one of the minor decencies by the mass of the people seems to be caused partly by a feeling of false shame, and partly by an idea that it is expensive and troublesome to make any change that will improve their sanitary condition or dignify their daily lives.
The Rev. Henry Moule, of Fordington Vicarage, Dorsetshire, England, was one of the first to turn his attention to this matter. With the threefold object of improving the sanitary condition of his people, refining their habits, and enriching their gardens, he invented what he called the "dry earth closet."
"It is based on the power of clay and the decomposed organic matter found in the soil to absorb and retain all offensive odors and all fertilizing matters; and it consists, essentially, of a mechanical contrivance (attached to the ordinary seat) for measuring out and discharging into the vault or pan below a sufficient quantity of sifted dry earth to entirely cover the solid ordure and to absorb the urine.
"The discharge of earth is effected by an ordinary pull-up, similar to that used in the water closet, or (in the self-acting apparatus) by the rising of the seat when the weight of the person is removed.
"The vault or pan under the seat is so arranged that the accumulation can be removed at pleasure.
"From the moment when the earth is discharged and the evacuation covered, all offensive exhalation entirely ceases. Under certain circumstances there may be, at times, a slight odor as of guano mixed with earth, but this is so trifling and so local that a commode arranged on this plan may, without the least annoyance, be kept in use in any room."
The "dry earth closet" of the philanthropic clergyman was found to work well, and was acceptable to his parishioners. One reason why it was so was because dry earth was ready to hand, or could be easily procured in a country district where labor was cheap. But where labor was dear and dry earth scarce, those who had to pay for the carting of the earth and the removal of the deodorized increment found it both expensive and troublesome.
But a modification of this dry earth closet, the joint contrivance of an English church clergyman and his brother, "the doctor," residents of a Canadian country town, who had heard of Moule's invention, is a good substitute, and is within the reach of all. This will be briefly described.
The vault was dug as for an ordinary closet, about fifteen feet deep, and a rough wooden shell fitted in. About four feet below the surface of this wooden shell a stout wide ledge was firmly fastened all around. Upon this ledge a substantially made wooden box was placed, just as we place a well fitting tray into our trunks. About three feet of the back of the wooden shell was then taken out, leaving the back of the box exposed. From the center of the back of the box a square was cut out and a trap door fitted in and hasped down.
The tiny building, on which pains, paint, and inventive genius had not been spared to make it snug, comfortable, well lighted and well ventilated, was placed securely on this vault.
After stones had been embedded in the earth at the back of the vault, to keep it from falling upon the trap door, two or three heavy planks were laid across the hollow close to the closet. These were first covered with a barrowful of earth and then with a heap of brushwood.
Within the closet, in the left hand corner, a tall wooden box was placed, about two-thirds full of dry, well sifted wood ashes. The box also contained a small long-handled fire shovel. When about six inches of the ashes had been strewn into the vault the closet was ready for use. No; not quite; for squares of suitable paper had to be cut, looped together with twine, and hung within convenient reaching distance of the right hand; also a little to the left of this pad of paper, and above the range of sight when seated, a ten pound paper bag of the toughest texture had to be hung by a loop on a nail driven into the corner.
At first the rector thought that his guests would be "quick-witted enough to understand the arrangement," but when he found that the majority of them were, as the Scotch say, "dull in the uptak," he had to think of some plan to enforce his rules and regulations. As by-word-of-mouth instructions would have been rather embarrassing to both sides, he tacked up explicit written orders, which must have provoked many a smile. Above the bin of sifted ashes he nailed a card which instructed "Those who use this closet must strew two shovelfuls of ashes into the vault." Above the pad of clean paper he tacked the thrifty proverb: "Waste not, want not;" and above the paper bag he suspended a card bearing this warning: "All refuse paper must be put into this bag; not a scrap of clean or unclean paper must be thrown into the vault."
This had the desired effect. Some complacently united to humor their host's whim, as they called it, and others, immediately recognizing its utility and decency, took notes with a view to modifying their own closet arrangements.
Sarah, the maid of all work, caused a good deal of amusement in the family circle by writing her instructions in blue pencil on the front of the ash bin. These were: "Strew two shuffefuls of ashes into the volt, but don't spill two shuffefuls onto the floor. By order of the Gurl who has to sweap up." This order was emphatically approved of by those fastidious ones who didn't have to "sweep up."
This closet opened off the woodshed, and besides being snugly weatherproof in itself, was sheltered on one side by the shed and on another by a high board fence. The other two sides were screened from observation by lattice work, outside of which evergreens were planted to give added seclusion and shade. A ventilator in the roof and two sunny little windows, screened at will from within by tiny Venetian shutters, gave ample light and currents of fresh air. For winter use, the rector's wife and daughters made "hooked" mats for floor and for foot support. These were hung up every night in the shed to air and put back first thing in the morning. For the greater protection and comfort of invalids, an old-fashioned foot warmer, with a handle like a basket, was always at hand ready to be filled with live coals and carried out.
The little place was always kept as exquisitely clean as the dainty, old-fashioned drawing room, and so vigilant was the overseeing care bestowed on every detail, that the most delicate and acute sense of smell could not detect the slightest abiding unpleasant odor. The paper bag was frequently changed, and every night the accumulated contents were burned; out of doors in the summer, and in the kitchen stove--after a strong draught had been secured--in the winter.
At stated times the deodorized mass of solid increment--in which there was not or ought not to have been any refuse paper to add useless bulk--was spaded, through the trap door, out of the box in the upper part of the vault, into a wheelbarrow, thrown upon the garden soil, and thoroughly incorporated with it. In this cleansing out process there was little to offend, so well had the ashes done their concealing deodorizing work.
In using this modified form of Moule's invention, it is not necessary to dig a deep vault. The rector, given to forecasting, thought that some day his property might be bought by those who preferred the old style, but his brother, the doctor, not troubling about what might be, simply fitted his well made, four feet deep box, with its trap door, into a smoothly dug hole that exactly held it, and set the closet over it. In all other respects it was a model of his brother's.
This last is within the reach of all, even those who live in other people's houses; for, when they find themselves in possession of an unspeakably foul closet, they can cover up the old vault and set the well cleaned, repaired, fumigated closet upon a vault fashioned after the doctor's plan. A stout drygoods box, which can be bought for a trifle, answers well for this purpose, after a little "tinkering" to form a trap door.
Of course, dry earth is by far the best deodorizer and absorbent, but when it cannot be easily and cheaply procured, well sifted wood or coal ashes--wood preferred--is a good substitute. The ashes must be kept dry. If they are not, they lose their absorbing, deodorizing powers. They must also be well sifted. If they are not, the cinders add a useless and very heavy bulk to the increment.
An ash sifter can be made by knocking the bottom out of a shallow box, studding the edge all round with tacks, and using them to cross and recross with odd lengths of stovepipe wire to form a sieve.--The Sanitarian.
In order to properly regulate the regimen of the obese, it is first necessary to determine the source of the superfluous adipose of the organism, since either the albuminoids or the hydrocarbons may furnish fat.
Alimentary fat becomes fixed in the tissues, as has been proved by Lebede, who fed dogs, emaciated by long fast, with meat wholly deprived of fat, and substituted for the latter linseed oil, when he was able to recover the oil in each instance from the animal; parallel experiments with mutton fat,in lieuof oil, afforded like results.
Hoffman also deprived dogs of fat for a month, causing them to lose as high as twenty-two pounds weight, then began nourishing with bacon fat with but little lean; the quantity of fat formed in five days, in the dog that lost twenty-two pounds, was more than three pounds, which could have been derived only from the bacon fat.
It has been stated, however, that alimentary fat seems to preserve from destruction the fat of the organism which arises from other sources. Be this as it may, it is a fact that the pre-existence of fat furthers the accumulation of more adipose; or in other words, fat induces fattening!
That adipose may be formed through the transformation of albuminous matters (meat) is an extremely important corollary, one established beyond cavil by Pettinkofer and Voit, in an indirect way, by first estimating the nitrogen and carbon ingested, and second the amount eliminated. Giving a dog meat that was wholly deprived of fat, they found it impossible to recover more than a portion of the contained carbon; hence some must necessarily have been utilized in the organism, and this would be possible only by the transformation of the carbon into fat! It goes without saying, however, that the amount of adipose thus deposited is meager.
Other facts also plead in favor of the transformation of a portion of albumen into fat within the economy, notably the changing of a portion of dead organism into what is known as "cadaveric fat," and the very rapid fatty degeneration of organs that supervenes upon certain forms of poisoning, as by phosphorus.
The carbohydrates, or more properly speaking hydrocarbons, are regarded by all physiologists as specially capable of producing fat, and numerous alimentary experiments have been undertaken to prove this point. Chaniewski, Meissl, and Munk obtained results that evidenced, apparently, sugar and starch provide more fat than do the albuminoids. Voit, however, disapproves this, maintaining the greater part of the hydrocarbons is burned (furnishes fuel for the immediate evolution of force), and that fat cannot be stored up unless a due proportion of albuminoids is also administered. He believes the hydrocarbons exert a direct influence only; being more oxidizable than fats, they guard the latter from oxidation. This protective role of the hydrocarbons applies also to the albuminoids.
We may believe, then, that the three great classes of aliment yield fat, in some degree; that alimentary fat may be fixed in the tissues; and that hydrocarbons favor the deposition of adipose either directly or indirectly.
It is well understood that fat may disappear with great rapidity under certain conditions; many maladies are accompanied by speedy emaciation; therefore, as fat never passes into the secretions, at least not in appreciable quantities, it probably undergoes transformation, perhaps by oxidation or a form of fermentation, the final results of which are, directly or indirectly, water and cadaveric acid. It is certain the process of oxidation favors the destruction of adipose, and that everything which inhibits such destruction tends to fat accumulation.
Since the earliest period of history, there seems to have been an anxiety to secure some regimen of general application that would reduce or combat obesity. Thus Hippocrates says:
Fat people, and all those who would become lean, should perform laborious tasks while fasting, and eat while still breathless from fatigue, without rest, and after having drunk diluted wine not very cold. Their meats should be prepared with sesamum, with sweets, and other similar substances, and these dishes should be free from fat.
In this manner one will be satiated through eating less.
But, besides, one should take only one meal; take no bath; sleep on a hard bed; and walk as much as may be.
How much has medical science gained in this direction during the interval of more than two thousand years? Let us see:
First among moderns to seek to establish on a scientific basis a regimen for the obese, was Dancel, who forbade fats, starchy foods, etc., prescribed soups and aqueous aliment, and reduced the quantity of beverage to the lowest possible limit; at the same time he employed frequent and profuse purgation.
This regimen, which permits, at most, but seven to twelve ounces of fluid at each repast, is somewhat difficult to follow, though it may be obtained, gradually, with ease. Dr. Constantine Paul records a case in which this regimen, gradually induced, and followed for ten years, rewarded the patient with "moderate flesh and most excellent health."
In Great Britain, a mode of treatment instituted in one Banting, by Dr. Harvey, whereby the former was decreased in weight forty pounds, has obtained somewhat wide celebrity; and what is more remarkable, it is known as "Bantingism," taking its name from the patient instead of the physician who originated it. The dietary is as follows:
Breakfast.--Five to six ounces of lean meat, broiled fish, or smoked bacon--veal and pork interdicted; a cup of tea or coffee without milk or sugar; one ounce of toast or dry biscuit (crackers).
Dinner.--Five or six ounces of lean meat or fish--excluding eel, salmon, and herring; a small quantity of vegetables, but no potatoes, parsnips, carrots, beets, peas, or beans; one ounce of toast, fruit, or fowl; two glasses of red wine--beer, champagne, and port forbidden.
Tea.--Two or three ounces of fruit; one kind of pastry; one cup of tea.
Supper.--Three or four ounces of lean beef or fish; one or two glasses of red wine.
At bed-time.--Grog without sugar (whisky and water, or rum and water), and one or two glasses of sherry or Bordeaux.
"Bantingism," to be effective, must be most closely followed, when, unfortunately also, it proves extremely debilitating; it is suitable only for sturdy, hard riding gluttons of the Squire Western type. The patient rapidly loses strength as well as flesh, and speedily acquires an unconquerable repugnance to the dietary. Further, from a strictly physiological point of view, the quantity of meat is greatly in excess, while with the cessation of the regimen, the fat quickly reappears.
Next Ebstein formulated a dietary that is certainly much better tolerated than that of Harvey and Banting, and yields as good, or even better, results. He allows patients to take a definite quantity--two to two and a half ounces-of fat daily, in the form of bacon or butter which, theoretically at least, offers several advantages: It diminishes the sensations of hunger and thirst, and plays a special role with respect to the albuminoids; the latter may thus be assimilated by the economy without being resolved into fat, and thus the adipose of the organism at this period is drawn upon without subsequent renewal. The following is the outline:
Breakfast.--At 6 a.m. in summer; 7:30 in winter:--Eight ounces of black tea without either milk or sugar; two ounces of white bread or toast, with a copious layer of butter.
Dinner.--2 p.m.:--A modicum of beef marrow soup; four ounces of meat, preferably of fatty character; moderate quantity of vegetable, especially the legumines, but no potatoes or anything containing starch; raw fruits in season, and cooked fruits (stewed, without sugar); two or three glasses of light wine as a beverage, and after eating, a cup of black tea without sugar.
Supper.--7:30 p m.:--An egg, bit of fat roast, ham, or bacon; a slice of white bread well buttered; a large cup of black tea without milk or sugar; from time to time, cheese and fresh fruits.
Germain See suggests as a modification of this regimen, the abundant use of beverage, the addition of gelatins, and at times small doses of potassium iodide in twenty cases he claims constant and relatively prompt results.
Whatever may be urged for Ebstein's system--and it has afforded most excellent results to Unna and to Lube, as well as its author--it certainly exposes the patient to the terrors of dyspepsia, when the routine must needs be interrupted or modified; hence it is not always to be depended upon. As between dyspepsia and obesity, there are few, I fancy, who would not prefer the latter.
Another "system" that has acquired no little celebrity, and which has for its aim the reduction as far as possible of alimentary hydrocarbons while permitting a certain proportion of fat, is that, of Denneth, which necessarily follows somewhat closely the lines laid down by Ebstein.
Oertels' treatment, somewhat widely known, and not without due measure of fame, is based upon a series of measures having as object the withdrawal from both circulation and the economy at large, as much of the fluids as possible. It is especially adapted for the relief of those obese who are suffering fatty degeneration of the heart. Themenuis as follows:
Breakfast.--Pour to five ounces of tea or coffee with a little milk; two to two and a half ounces bread.
Dinner.--Three or four ounces of roast or boiled meat, or moderately fat food; fish, slightly fat; salad and vegetables at pleasure; one and a half ounces of bread (in certain cases as much as three ounces of farinaceous food may be permitted); three to six ounces of fruit; at times a little pastry for dessert.--In summer, if fruit is not obtainable, six to eight ounces of light wine may be allowed.
Tea,--A cupful (four to five ounces) of tea or coffee, with a trifle of milk, as at breakfast; one and three-fourths ounces of bread; and exceptionally (and at most) six ounces of water.
Supper.--One to two soft boiled eggs; four or five ounces of meat; one and three fourths ounces of bread; a trifle of cheese, salad, or fruit; six to eight ounces of light wine diluted with an eighth volume of water. The quantity of beverage may be slightly augmented at each meal if necessary, especially if there is no morbid heart trouble.
Schwenninger (Bismarck's physician), who opened a large sanitarium near Berlin a few years since for the treatment of the obese, employs Oertel's treatment, modified in that an abundance of beverage is permitted, provided it is not indulged in at meals; it is forbidden until two hours after eating.
Both Oertel's and Schwenninger's methods have procured grave dyspepsias, and fatal albuminurias as well, according to Meyer and Rosenfield. It has been charged the allowance of beverage upon which Schwenninger lays so much stress in the treatment at his sanitarium has a pecuniary basis, in other words a commission upon the sale of wines.2
Thus, it will be observed that while some forbid beverage, others rather insist upon its employment in greater or less quantities. Under such circumstances, it would seem but rational, before undertaking to relieve obesity, to establish its exact nature, and also the role taken by fluids in the phenomena of nutrition.
Physiologists generally admit water facilitates nutritive exchanges, which is explained by the elimination of a large quantity of urine; the experiments of Genth and Robin in this direction appear conclusive.
Bischoff, Voit, and Hermann have shown that water increases, not alone the elimination of urine, but also of sodium chloride, phosphoric acid, etc. Grigoriantz observed augmentation of disintegration when the quantity of beverage exceeded forty-six to eighty ounces ("1,400 to 2,400 cubic centimeters") per diem. Oppenheim, Fraenkel, and Debove, while believing water has but little influence upon the exchanges, admit it certainly need not diminish the latter; and Debove and Flament, after administering water in quantities varying from two to eight pints per diem, concluded that urine was diminished below the former figure, while above the latter it increased somewhat, being dependent upon the amount ingested. It was on the strength of the foregoing that Lallemand declared water to have no influence upon the exchanges.
The results claimed by Oppenheim, Debove,et al.were immediately challenged--and it is now generally admitted, not without some justice--by Germain See. It seems certain, to say the least, that water taken during the repast does tend to augment the quantity and facilitate the elimination of urine. Abundance of beverage, moreover, presents other advantages, in that it facilitates digestion by reason of its diluent action, a fact well worth bearing in mind when treating the obese who are possessed of gouty diathesis, and whose kidneys are accordingly encumbered with uric and oxalic acids. The foregoing presents the ground upon which Germain See permits an abundance of beverage; but he also expresses strong reservation as regards beer and alcohol, either of which (more especially the former) tends to the production of adipose. In his opinion, the only beverage of the alcoholic class that is at all permissible, and then only for cases suffering from fatty heart, is a littleliqueuror diluted wine. Coffee and tea he commends highly, and recommends the ingestion of large quantities at high temperature, both during the repasts and their intervals. Coffee in large doses is undoubtedly a means of de-nutrition, and so, too, in no less extent, is tea; both act vigorously owing to the contained alkaloids, though, to be sure, they sometimes, at first, tend to insomnia and palpitation, to which no attention need be paid, however. The treatment outlined by See is:
1. A physiological regimen comprising four to five ounces of nitrogenous principles as derived from eight to ten ounces animal muscle and albuminates; three to six ounces of fat; eight to ten ounces of hydrocarbons as yielded by ten to twelve ounces of sugar or starch food.
These proportions to be modified in such manner that the musculo-albuminates shall not sensibly exceed the normal ratio, for meat in excess itself furnishes fat during transformation. The fatty substances of easy digestion may, without inconvenience, be utilized in doses of two to three ounces. The hydrocarbons should be reduced to a minimum. As for the herbaceous elements, they contain nothing nutritive.
2. Beverage, far from being suppressed, should be augmented, in order to facilitate stomachal digestion and promote general nutrition, though alcoholic liquids must be inhibited; likewise mineral waters, except, perhaps, for occasional use. Both should be replaced by infusions of coffee or tea, taken as hot as can be drank.
Henrich Kisch insists that any method which promises rapid and marked decrease of adipose must,per se, be objectionable, even if not positively injurious, since it tends to provoke general troubles of nutrition. He suggests that first the fats and hydrocarbons be reduced as little as possible; that a moderate mixed regimen is required, containing a preponderance of albumen, small quantities of hydrocarbons and gelatinous matters, with but very little fat. Certain fatty meats, however, should be generally interdicted, such as pork sausage, smoked beef tongue, goose breast, smoked ham, fat salmon, and herring in any form. Eggs, however, may be partaken of in moderation, giving preference to the albumen over the yelk. Farinaceous foods, in the main, should be rejected, even bread being allowed only in small quantities, and then preferably in the form of toast. Cheese likewise contains too much fat; and mushrooms are so rich in hydrocarbons that they should be rejected. Condiments, water, vegetable acids (vinegars excepted) may be permitted; especially pernicious is vinegar where there is any tendency to gout or gravel. All fatty beverages--bouillon, unskimmed milk, chocolate, or cacao--and all alcoholics, are hurtful; breakfast tea is undoubtedly the best beverage, but, after a little, is advantageously replaced by light white wine diluted with water.
Kisch believes in a free and abundant use of water by the obese, especially where there is a tendency to plethora, since this fluid facilitates oxidation as the result of absorption; thus he advocates the inhibition of large quantities of cold water by all, save those presenting evidence of cardiac insufficiency. In short, his regimen is based upon the administration of a large quantity of albumen, like that of Harvey-Banting.
E. Munk recommends an almost identical dietary, save that he prefers great moderation in fluids employed as beverage.
M. Robin has sought to harmonize the opposing views regarding fluids, and therefore declares obesity arises from two distinct sources: 1. Augmentation of assimilation. 2. Reduced disassimilation. In the former, he insists water must be interdicted, while in the latter it may be allowedad libitum.
Again, in order to recognize the exact variety of obesity, he divides his patients into three classes, each recognizable by the volume of urea excreted. In the first there is an increase above normal; in the second the volume of urea is stationary; in the third decreased, increased, or stationary.
When the urea is stationary, which is most frequently the case, it is necessary to calculate the coefficient of oxidation; that is, the relation existing between the solid matters of the urine and the urea. The elevation of the coefficient isprima facieevidence the obesity is due to excess of assimilation, while depression of the coefficient indicates default of assimilation. In the first case, water and liquids must be denied as far as possible, the same as if there was no augmentation of urea; in the second, the same as if there was diminution of urea, the patients may be permitted to imbibe fluids at pleasure.
For the obese from default of disassimilation, Robin recommends a regimen of green vegetables and bread chiefly--the latter in small quantities, however, and fluids as may be desired. By this means, on one occasion, he was able in the course of one month to diminish the weight of a female patient by twelve and a half pounds, her measurement around the waist at the same time decreasing 5.2 inches and across the stomach 4.8 inches.
M. De St. Germain achieved good results by combining judicious exercise with moderate alimentation, excluding wine and bread.
M. Dujardin Beaumetz, who professes to have given most close and careful study and attention to regimen for the obese, outlines the following, provided there is no evidence of fatty degeneration of heart.
Breakfast(at 8 a. m.)--Three-fourths of an ounce of bread "en flute"--that is abounding with crust; one and a half ounces of cold meat, ham or beef, six ounces weak black tea,sanssugar.
Lunch(at 1 p.m.)--An ounce and a half to two ounces of bread, or aragout, or two eggs; three ounces green vegetables; one-half ounce of cheese; fruits at discretion.
Dinner(at 7 p.m.)--An ounce and a half to two ounces of bread; three to four ounces of meat, orragout; ditto of green vegetables, salad, half an ounce of cheese, fruitad libitum.
At meal times the patient may take only a "glass and a half" of liquid--approximately ten ounces--though a greater amount may be permitted if he abstains during the intervals.
Special alimentary regimen, however, does not constitute the sole treatment of obesity. Concurrently must be employed a number of practical adjuvants which are oftentimes of the utmost assistance. For one thing, exercise is indispensable; all authorities agree on this point. The exercise taken in the gymnasium is one of the best, notably the "wall exercise," which is more particularly suited to those afflicted with pendulous and protuberant abdomens as the result of feebleness of the hypogastric muscles, to accumulation of fat under the skin and in the omentum, and to dilation of the stomach and intestines. In the "wall exercise," the patient stands erect against an absolutely straight and plumb wall, lifts his hands (carrying a weight) straight over the head, and causes them to describe a semicircle forward. Zantz particularly insists upon arm and leg exercise for the obese, especially the former, since with the same amount of effort a larger amount of oxygen is consumed than is possible by the latter.
However, of whatever character, the exercise should be continued to the point of fatigue or dyspn#oelig;a--three thousand movements daily, gradually increased to twenty-five thousand, if the system can bear it; and under such conditions, not only is there consumption of hydrocarbons, but there is provided a veritable greed for air that augments waste. The experiments of Oertel indicate that loss of weight due to fatiguing exercise arises more particularly from dehydration, which is made good by absorption of the fluids employed as beverage; the fluids are claimed by Germain See to act as accelerants of oxidation.
During exercise there is obviously more abundant absorption of oxygen, and consequently greater elimination of carbonic acid, and as a consequence (as shown by researches of Voit), the reserve fat of the economy is attacked and diminished; in intense labor there is an average hourly consumption of about 8.2 percent. of fat. Further physical activity is useful in exercising the voluntary muscles, and thus opposing the invasion by interstitial fat of the muscle fibrils. Extreme exercise also, to a certain degree, exerts a favorable influence on the cardiac muscle, augmenting both its nutrition and its capacity for labor. With the anæmic obese, however, it is necessary to be most circumspect in prescribing forced exercise; also with the elderly obese possessed of enfeebled or fatty heart.
Hydrotherapy, especially in the form of cold douches, particularly when combined with massage, is often of considerable value in relieving obesity; the method of Harmman, of St. Germain, which has in many instances induced rapid loss of adipose, is of this class. Tepid saline baths and vapor baths have many advocates, and may afford material aid when the heart and circulation do not inhibit their employment. Hot baths elevate the temperature of the body and increase the organic exchanges, hence, as Bert and Reynard have pointed out, tend to the elimination of oxygen and carbonic acid; but when employed, the patient should be introduced while the temperature is below 130° F., when it may be gradually raised in the course of thirty or forty minutes to 140° F.
It has already been intimated, the chief feature of the treatment of obesity is acceleration of the exchanges; and this is in the main true, though it must also be borne in mind that, while there are obese who excrete little urea and have a depressed central nervous temperature, many may be azoturic, and besides eliminate phosphate in excess, when an oxidating treatment will not only fail, but prove positively injurious.
The bile throws out fat, therefore, to accelerate nutritive oxidations, the liver and nervous system must be acted upon,i.e., stimulated. Everything that tends to diminish the activity of the former, or depress the latter, must be avoided. Hence intellectual labor should be encouraged, or in lieu thereof, travel advised. Exercise should be taken chiefly while fasting; the limits of sleep confined to strict necessity, andsiestasafter meals and during the day strictly forbidden; the skin stimulated by hydro-therapeutic measures, including massage under cold affusions, during warm salt baths, etc.
To increase the activity of the liver, salicylate of soda may often be advantageously administered for its cholagogue effect; or resort may be had to saline purgatives such as are afforded by the springs of Marienbad, Kissengen, Homburg, Carlsbad, Brides, Hunyadi, or Chatel-Guyon; and it is somewhat remarkable that while undergoing a course of these waters, there is often no appreciable change in weight or obesity, though the decrease becomes most marked almost immediately upon cessation of treatment.
Everything tending to increased or fuller respiration is to be encouraged, for the fats are thus supplied with oxygen, hastening their disintegration and consumption.
Direct medicinal treatment presents no very wide scope. Bouchard imagines lime water may be useful by accelerating nutrition, but this is problematical, since fat in emulsion or in droplets does not burn. Nevertheless, alkalies in general, alkaline carbonates, liquor potassa, soaps, etc., aid in rendering fat more soluble, and consequently more susceptible to attack. The alkaline waters, however, are much less active in obesity than the saline mineral waters, unless, as sometimes happens, there is a complication of diabetes and obesity.
Purgatives are always more or less useful, and often required to be renewed with all the regularity of habit. Then too, the iodides, especially iodide of sodium or potassium, as recommended by M. Germain See, frequently prove of excellent service by aiding elimination and facilitating the mutations.
According to Kisch, the cold mineral waters containing an abundance of sulphate of soda, like Hunyadi and Marienbad, are to be preferred to the hot mineral waters, such as Carlsbad, because of their lesser irritant action on the vascular system, and because they strongly excite diuresis through their low temperature and contained carbonic acid; Carlsbad deserves preference only when obesity is combined with uric acid calculi, or with diabetes. For very anæmic persons, however, the weak alkaline and saline waters should be selected; or they should confine themselves to chalybeate waters containing an excess of sulphate of soda. Water containing sulphate of soda is also indicated as a beverage where there are troubles of the circulatory apparatus; it is contraindicated only in accentuated arterio-sclerosis.
As a matter of fact, I find the suggestion of M. Dujardin-Beaumetz, that the obese should be divided into two groups, a most practical one, for some are strong and vigorous--great eaters, perhaps even gluttons--while others, on the contrary, are feeble and debilitated, with flesh soft and flaccid; and upon the former may be imposed all the rigors of the reducing system, while the latter must be dealt with more carefully.
In general, it must be noted, the regimen prescribed for the obese is insufficient, as the following table prepared by M.C. Paul abundantly proves:
There is, therefore, as Dujardin-Beaumetz asserts, autophagia in the obese, and all these varieties of treatment have but one end, viz.: Reduction of the daily ration. But the quantity of nourishment should not be too greatly curtailed, for, manifestly, if the fat disappears the more surely, the muscles (rich in albumen) undergo too rapid modification. It is progressive action that should always be sought.
The quantity of aliment may be reduced either by imposing an always uniform regimen, which soon begets anorexia and disgust, or by withholding from the food a considerable quantity of fat, or, finally, by forbidding beverage during meals. Emaciation is obtained readily enough in either way, and demands only the constant exercise of will power on the part of the patient; but unhappily, severe regimen cannot always be prescribed. When the obese patient has passed the age of forty; when the heart suffers from degeneration; or when the heart is anæmic--in all, rigorous treatment will serve to still further enfeeble the central organ of circulation, and tend to precipitate accidents that, by all means, are to be avoided. In such cases, bynottreating the obesity, the days of the patient will be prolonged. In degeneration of the heart, however, the method of Ebstein may be tried; and when there is renal calculi and gouty diathesis, that of Germain See may prove satisfactory.
[1]
Translated by Mr. Jos. Helfman, Detroit, Mich.
[2]
The sanitarium is owned by a stock company, Schwenninger being merely Medical Director.--ED.
THE FRENCH ARMORED TURRET SHIP MARCEAUSYLVAIN DORNON, THE STILT WALKER OF LANDES.
Sylvain Dornon, the stilt walker of Landes, started from Paris on the 12th of last March for Moscow, and reached the end of his journey at the end of a fifty-eight days' walk. This long journey upon stilts constitutes a genuine curiosity, not only to the Russians, to whom this sort of locomotion is unknown, but also to many Frenchmen.
Walking on stilts, in fact, which was common twenty years ago in certain parts of France, is gradually tending to become a thing of the past. In the wastes of Gascony it was formerly a means of locomotion adapted to the nature of the country. The waste lands were then great level plains covered with stunted bushes and dry heath. Moreover, on account of the permeability of the subsoil, all the declivities were transformed into marshes after the slightest fall of rain.
There were no roads of any kind, and the population, relying upon sheep raising for a living, was much scattered. It was evidently in order to be able to move around under these very peculiar conditions that the shepherds devised and adopted stilts. The stilts of Landes are called, in the language of the country,tchangues, which signifies "big legs," and those who use them are calledtchanguès. The stilts are pieces of wood about five feet in length, provided with a shoulder and strap to support the foot. The upper part of the wood is flattened and rests against the leg, where it is held by a strong strap. The lower part, that which rests upon the earth, is enlarged and is sometimes strengthened with a sheep's bone. The Landese shepherd is provided with a staff which he uses for numerous purposes, such as a point of support for getting on to the stilts and as a crook for directing his flocks. Again, being provided with a board, the staff constitutes a comfortable seat adapted to the height of the stilts. Resting in this manner, the shepherd seems to be upon a gigantic tripod. When he stops he knits or he spins with the distaff thrust in his girdle. His usual costume consists of a sort of jacket without sleeves, made of sheep skin, of canvas gaiters, and of a drugget cloak. His head gear consists of a beret or a large hat. This accouterment was formerly completed by a gun to defend the flock against wolves, and a stove for preparing meals.
The aspect of the Landeses is doubtless most picturesque, but their poverty is extreme. They are generally spare and sickly, they are poorly fed and are preyed upon by fever. Mounted on their stilts, the shepherds of Landes drive their flocks across the wastes, going through bushes, brush and pools of water, and traversing marshes with safety, without having to seek roads or beaten footpaths. Moreover, this elevation permits them to easily watch their sheep, which are often scattered over a wide surface. In the morning the shepherd, in order to get on his stilts, mounts by a ladder or seats himself upon the sill of a window, or else climbs upon the mantel of a large chimney. Even in a flat country, being seated upon the ground, and having fixed his stilts, he easily rises with the aid of his staff. To persons accustomed to walking on foot, it is evident that locomotion upon stilts would be somewhat appalling.
One may judge by what results from the fall of a pedestrian what danger may result from a fall from a pair of stilts. But the shepherds of Landes, accustomed from their childhood to this sort of exercise, acquire an extraordinary freedom and skill therein. Thetchanguèknows very well how to preserve his equilibrium; he walks with great strides, stands upright, runs with agility, or executes a few feats of true acrobatism, such as picking up a pebble from the ground, plucking a flower, simulating a fall and quickly rising, running on one foot, etc.
The speed that the stilt walkers attain is easily explained. Although the angle of the legs at every step is less than that of ordinary walking with the feet on the ground, the sides prolonged by the stilts are five or six feet apart at the base. It will be seen that with steps of such a length, distances must be rapidly covered.
When, in 1808, the Empress Josephine went to Bayonne to rejoin Napoleon I, who resided there by reason of the affairs of Spain, the municipality sent an escort of young Landese stilt walkers to meet her. On the return, these followed the carriages with the greatest facility, although the horses went at a full trot.
During the stay of the empress, the shepherds, mounted upon their stilts, much amused the ladies of the court, who took delight in making them race, or in throwing money upon the ground and seeing several of them go for it at once, the result being a scramble and a skillful and cunning onset, often accompanied with falls.
Up to recent years scarcely any merry-makings occurred in the villages of Gascony that were not accompanied with stilt races. The prizes usually consisted of a gun, a sheep, a cock, etc. The young people vied with each other in speed and agility, and plucky young girls often took part in the contests.
Some of the municipalities of the environs of Bayonne and Biarritz still organize stilt races, at the period of the influx of travelers; but the latter claim that the stiltsmen thus presented are not genuine Landese shepherds, but simple supernumeraries recruited at hazard, and in most cases from among strolling acrobats. The stilt walkers of Landes not only attain a great speed, but are capable of traveling long distances without appreciable fatigue.
Formerly, on the market days at Bayonne and Bordeaux, long files of peasants were seen coming in on stilts, and, although they were loaded with bags and baskets, they came from the villages situated at 10, 15, or 20 leagues distance. To-day the sight of a stilt walker is a curiosity almost as great at Bordeaux as at Paris. The peasant of Landes now comes to the city in a wagon or even by railway.--La Nature.