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Reform Diet As a Therapeutic Measure in Ophthalmic Practice
REFORM DIET AS A T H E R A P E U T I C M E A S U R E IN
OPHTHALMIC
PRACTICE. GEORGE H U S T O N B E L L , M . D . , NEW
YORK
F.A.C.S.
CITY.
T h e i m p o r t a n c e of t o x e m i a of g a s t r o i n t e s t i n a l o r i g i n , a l o n g with focal i n f e c t i o n s , as a cause of o c u l a r disease is here e m p h a s i z e d . I t is held that heavy starches to be digested in the intestines should not be m i x e d with proteins, that m u s t b e d i g e s t e d in the s t o m a c h ; a n d t h e excessive use of sugar is condemned. T h e influence of diet in e t i o l o g y and the therapeutic value of its c o r r e c t i o n , is illustrated w i t h reference to corneal ulcer, keratomalacia, head ache, g l a u c o m a , c h o r o i d i t i s , a n d o t h e r o c u l a r c o n d i t i o n s . R e a d b e f o r e the M e d i c a l S o c i e t y of N e w J e r s e y , J u n e 2 2 , 1923.
In presenting a paper o n " R e f o r m D i e t , " I w i s h it to be u n d e r s t o o d that it is part of m y r e m e d y for the "three T s . " T h e ramifications o f the "three T s " (teeth, tonsils and t o x e m i a s of the intestinal tract) are so i n t e r w o v e n , that t o m y mind it is i m p o s s i b l e to dis associate t h e m . In thinking o f any one of the "three T s " in c o n n e c t i o n w i t h a patient, the other t w o invariably c o m e into m y m i n d . T h e y g o hand in hand. W e k n o w that gastrointestinal dis turbances and severe septic intoxica tion, are at times b r o u g h t on, o r ag gravated, b y oral sepsis, diseased ton sils, o r w r o n g f o o d c o m b i n a t i o n s , and n o t infrequently b y all three. I said at the A . M . A . meeting in 1 9 1 9 \ that oral sepsis w a s o n e of the greatest m e n a c e s t o the human r a c e ! I reaf firm that statement. I also said that negative e v i d e n c e d o e s not e x c l u d e the possibility of infection from the tonsil, and that b a c t e r i o l o g i c examination of all r e m o v e d tonsils w h i c h I h a v e ex amined, d e m o n s t r a t e d the p r e s e n c e o f o r g a n i s m s . I have been driven to the c o n c l u s i o n that a healthy tonsil is a scarce article. T h e r e is n o d o u b t in m y m i n d that the constant s w a l l o w i n g of infected secretions from the m o u t h and tonsils, is one o f our greatest sources of danger. Septic infection m a y b e a b s o r b e d into the circulation from b o t h , and thus diseased teeth and ton sils in t w o w a y s b e c o m e e n e m i e s o f the host and g n a w at the vitals. E . Libman,'^ in a paper o n A c u t e Bacterial E n d o c a r d i t i s s a i d : " T h e i m portant thing is t o s y s t e m a t i c a l l y rid all patients h a v i n g valvular disease, of the ascertainable foci of infection," (teeth, tonsils, e t c . ) , and he further adds that the q u e s t i o n o f p r e v e n t i o n seems to b e the m o s t pressing. 118
B e h a n , ' s a i d : — " W e see c o n t i n u a l l y in our private dispensary and hospi tal w o r k , all the c h a n g e s characteristic of albuminuric ncuroretinitis in v a r y ing c o m b i n a t i o n s . In the a b s e n c e of nephritis w e d o not hesitate to ascribe as a cause for these c h a n g e s the "three T s " of Bell, the anemias and infectious diseases." Olmstead"* s a i d : " I feel safe in s a y i n g at this time, e x c e p t i n g trauma and venereal disease, w e can, o r will eventually, p r o v e e v e r y dis eased c o n d i t i o n of the e y e due t o s o m e o n e of the three r e c o g n i z e d s o u r c e s of focal infections, v i z : "the three T s . " In the light of all this, w h a t is the sense and w h a t is the use of p u t t i n g patients on a diet, unless y o u are g o i n g to g e t rid of infected teeth and dis eased tonsils? W e m u s t attend to the h y g i e n e of the m o u t h and throat. W e c o m e n o w to m y " R e f o r m D i e t . " I hold and believe that diet is c o m m o n sense applied to living. A l l m u s t agree to that, if w e are t o m a k e a n y real p r o g r e s s in o v e r c o m i n g t o x e m i a . W e m u s t c o n s i d e r the fuel that w e put into the l a b o r a t o r y that nature maintains in the s t o m a c h . T h e d a y is at h a n d w h e n the p r o g r e s s i v e o p h t h a l m o l o g i s t must take up with his patients the question of diet. H o w m a n y oculists w a r n their patients against e x c e s s i v e c o n s u m p t i o n of sugars, s w e e t s and starches, and w r o n g food combinations. M a n y oph t h a l m o l o g i s t s are so o c c u p i e d w i t h the purely o p h t h a l m o l o g i c aspect o f a case, that t h e y p a y a b s o l u t e l y n o attention t o the practical i m p o r t a n t e t i o l o g i c fac tors. W h e n w e realize that ninety o u t o f o n e hundred p e r s o n s die f r o m s o m e s e c o n d a r y disease, the result of s o m e focal infection, it is high time that w e w e r e s t u d y i n g the causes of focal in fections. McCollum'^ c o m e s out in his
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latest b o o k o n " T h e N e w e r K n o w l e d g e of N u t r i t i o n " and says, that n o o n e will b e likely to dispute the statement that f e w p e o p l e are entirely w e l l , and that their failures, indiscretions, fits o f temper, t e n d e n c y t o c o m p l a i n , their lack of enthusiasm, their inefficiencies as creatures, are in a great measure the result o f ill health, and he adds that there can b e n o reasonable d o u b t that the diet m a y d e v i a t e f r o m the o p timal even in the U n i t e d States, t o a d e g r e e w h i c h can easily cause the re sults w e see. N o w if w h a t M c C o l l u m says b e true, and I b e l i e v e it is, and if w e h a v e b e e n l i v i n g o n a s o c a l l e d w e l l balanced diet w h i c h includes meat, bread, v e g e t a b l e s and sweets, and also meat, p o t a t o e s , v e g e t a b l e s and s w e e t s , and h e a v y starches and p r o t e i n s at the s a m e meal, it is high time w e w e r e m a k i n g a c h a n g e , and that w e tried s o m e o t h e r form o f diet, and thus e n d e a v o r e d t o p r e v e n t the factors c o n c e r n e d in the p r o d u c t i o n of this f o r m i d a b l e array of ills, of w h i c h M c C o l l u m speaks. H e n c e m y reason for p r e s e n t i n g t o y o u for c o n s i d e r a t i o n m y " R e f o r m D i e t , " as a therapeutic measure in ophthalmic practice. L e t us k e e p a f e w t h i n g s clearly in mind. H e a v y starches and proteins m u s t n o t b e eaten t o g e t h e r at the s a m e m e a l ; for the reason that starches are d i g e s t e d in the m o u t h and intestines, and proteins in the s t o m a c h . W h a t is the sense of eating f o o d s t o g e t h e r that fight in the s t o m a c h ? W h y n o t eat them separately, and at diflierent meals? W h e n m e a t is eaten it causes a flow of gastric j u i c e . T h e e l e m e n t s of a f o o d that are p e c u l i a r l y fitted t o a c e r tain d i g e s t i v e fluid, cause this fluid t o b e s e c r e t e d — s o that w h e n m e a t and h i g h l y starchy f o o d s are eaten t o gether, the meat will be d i g e s t e d in the s t o m a c h , b u t n o t the starch. N o w all the time the starch is in the s t o m ach, it is n o t o n l y not p e r m i t t e d t o b e d i g e s t e d , b u t it also hinders the di g e s t i o n o f the protein o r meat. S o w e g e t an acid fermentation in the s t o m ach from the starchy f o o d s w i t h the formation of volatile and n o n v o l a t i l e
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acids and s o m e t i m e s marsh g a s , h y d r o g e n and a l c o h o l . It is the a c i d fermentation p r o d u c e d b y these w r o n g f o o d c o m b i n a t i o n s w h i c h in the e n d leads t o t o x e m i a . S t a r c h y f o o d s , o f c o u r s e , w e n e e d for e n e r g y and heat, b u t t h e y m u s t b e eaten w i t h n o n s t a r c h y v e g e t a b l e s , sal ads and fruits, in o r d e r that they m a y all pass out o f the s t o m a c h at the s a m e time, and in that w a y w e are able t o p r e v e n t acid d y s p e p s i a and acid fer m e n t a t i o n in t h e s t o m a c h . M a t t h e w s " in the third edition o f his " P h y s i o l o g i c a l C h e m i s t r y " s a y s that starches, o r c a r b o h y d r a t e s , are di g e s t e d b y the ptyalin o f the saliva, the a m y l o p s i n , maltase and lactase of the pancreas, and the invertin o f the in testinal j u i c e s , s o that t h e y are all re d u c e d to a state o f m o n o s a c c h a r i d s . H e further a d d s that s o m e o f t h e c a r b o hydrates are further b r o k e n up b y the bacteria w i t h the resultant f o r m a t i o n of lactic acid, a l c o h o l , m a r s h - g a s , h y d r o g e n and b u t y r i c acid. S h e r m a n ' adds that a m o n g c a s e s of e x c e s s i v e bacterial d e c o m p o s i t i o n in the d i g e s t i v e tract, t h e fermentation o f carbohydrates with the production o f o r g a n i c acids, and p o s s i b l y a l c o h o l , is m o s t likely to o c c u r in the s t o m a c h ; w h i l e putrefaction o f proteins o c c u r s m a i n l y in the large intestines. Then if w h a t S h e r m a n and M a t t h e w s say b e true, w h y n o t eat c a r b o h y d r a t e s at a time w h e n t h e y w o n ' t be detained in the s t o m a c h ? Sir F r a n c i s H a r e ' comes out flat-footed, and s a y s (in " F o o d F a c t o r in D i s e a s e , " V o l . I ) that there is n o t h i n g in the s t o m a c h to di g e s t the starches. J. H . T i l d e n ' says the s a m e t h i n g and has a d v o c a t e d for a l o n g time this diet o f n o t m i x i n g starches and proteins at the s a m e meal. D e e k s " a l s o has p o i n t e d o u t that there is n o t h i n g in the s t o m a c h t o d i g e s t the sugars. I am a firm b e l i e v e r in the baneful effect of s u g a r as a s y s t e m i c p o i s o n in d i s e a s e d c o n d i t i o n s o f the eyes. W e all h a v e seen the baneful efliect o f su g a r as a s y s t e m i c p o i s o n in diseased c o n d i t i o n s o f the e y e s . W e all h a v e seen the baneful effect of c a n d y and s w e e t s in children c o m i n g to us w i t h
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e c z e m a t o u s conjunctivitis. Stay a w a y from sugars and s w e e t s and g e t the necessary sweets b y eating fresh fruits and v e g e t a b l e s . O n e hundred years a g o the total per capita c o n s u m p t i o n of sugar in the U n i t e d States w a s less than nine p o u n d s per annum. Since then it has increased b y leaps and b o u n d s , until n o w this c o u n t r y is p r o b ably the largest c o n s u m e r of sugar in the w o r l d . K e l l o g g and T a y l o r esti mated the per capita use of sugar just before the war, at close to four o u n c e s a d a y per individual. Estimates of su gar in the b l o o d are o f value in the treatment of all cases of o b s c u r e e y e c o n d i t i o n s . C h a c e said in 1920 at the annual m e e t i n g of the M e d i c a l S o c i e t y of the State of N e w Y o r k , that sugar is perhaps responsible for p r o d u c i n g m o r e h y p e r a c i d i t } ' than any other sin gle article of diet, and that the great increase in the p r e v a l e n c e of hyper acidity d u r i n g the last d e c a d e is largely due to increased sugar c o n s u m p t i o n . T h e r e is a g r o w i n g d e m a n d for a scientific supervision of the diet in health and disease, and an increasing realization of its i m p o r t a n c e . Hence m y great interest in "dietary r e f o r m s . " I w a n t to emphasize the i m p o r t a n c e of using certified raw milk, and of eating r a w fruits, g r e e n v e g e t a b l e s and sal ads. A g a i n , certain important sub stances o c c u r in animal fats w h i c h should form a part o f the diet, such as fats from meats, butter and c r e a m . W e should c o n s u m e at least o n e quart of milk o r its equivalent in dairy p r o d ucts e v e r y day, and raw food and raw fruits should be eaten as salads and desserts o n c e o r t w i c e daily to insure the required a m o u n t of vitamins. It seems that in the course of c o o k i n g or d r y i n g s o m e t h i n g essential is de s t r o y e d . W e o u g h t e v e r y day to eat freely of s o m e leafy v e g e t a b l e f o o d such as spinach, c a b b a g e , beet t o p s brussels sprouts, lettuce, dandelions, pepper-grass and S w i s s chard. They have unique properties. T h e c o n s u m p tion of these leafy v e g e t a b l e f o o d s will g o far towards o v e r c o m i n g c o n s t i p a tion. I have so arranged the " r e f o r m d i e t " that milk can be taken at the p r o p e r
time. I am a firm believer in the f o o d value o f milk, the m o s t desirable single article of f o o d for infants and children, and b e i n g m o r e and m o r e appreciated b y adults. F u n k w a s the first to sug gest the relationship b e t w e e n the c o m position of the milk, and s o m e de ficiency diseases in children. Funk stated that on heating milk certain vitamins b e c o m e m o r e or less c o m pletely d e s t r o y e d . T h e r e f o r e great ad v a n t a g e lay in a certified raw p r o d u c t , safeguarded from c o n t a g i o u s diseases and c o n t a i n i n g a m o r e or less constant fat c o n t e n t . Milk taken with the or dinary meals f r e q u e n t l y causes catarrh, because of o v e r e a t i n g and o v e r l o a d i n g the s t o m a c h . M i l k must be taken with a starch o r fruit, and not with a full meal, b e c a u s e o n e quart of certified raw milk is a meal in itself. A hearty eater, w h o drank about t w o glasses of raw milk with each meal, three times daily, d e v e l o p e d a ca tarrhal state, f o l l o w e d b y intestinal t o x e m i a and keratitis of both e y e s . I found his t o n g u e heavily c o a t e d , his breath v e r y foul and his urine loaded with indican, also he w a s a sufferer from constipation. H i s teeth w e r e ap parently healthy. I was able to extrude pus from his tonsils. Examination of his eyes s h o w e d M o o r e n ' s ulcer of right e y e and in cipient ulcer o f the left. T h e ulcer in the right e y e had d e v e l o p e d from the margin o f the cornea a b o v e , and had e x t e n d e d all the w a y a r o u n d the cornea. T h e gray, c l o u d y m a r g i n of the ulcer w a s u n d e r m i n e d and c o u l d b e elevated. M o r e o v e r , there w e r e marked inflammatory c o m p l i c a t i o n s . H e had been treated for six w e e k s b y an o p h t h a l m o l o g i s t . T h i s oculist had cauterized the ulcer with c a r b o l i c acid several times and had used the actual cautery, also hot f o m e n t a t i o n s and atropin w e r e b e i n g used. All I did for him w a s to h a v e his tonsils enucleated at o n c e , put him on m y " r e f o r m diet" with hot applications to his e y e s — b i chlorid vaseline—1-5000 in b o t h e y e s night and m o r n i n g , and atropin solu tion in his eyes o c c a s i o n a l l y ; w h i l e his colon was thoroly emptied every d a y b y means of an enema of w a t e r
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at b l o o d heat. T h i s patient m a d e a g o o d and rapid r e c o v e r y , and returned to his native state in t w o w e e k s , w h e r e he continued the treatment for four weeks more. D o c t o r H . A . Wakefield of Charlotte, N o r t h Carolina, in a let ter recently, said that M r . B . n o w had n o r m a l vision in b o t h eyes. RULE OF T H E REFORM DIET.
T h e principle of the reform diet is simple and v e r y plain. Not to mix h e a v y starches and proteins at the same meal. H e a v y s t a r c h e s—Bread, w h o l e wheat, w h i t e c o r n or rye, and crackers. P o t a t o e s , rice, m a c a r o n i , c o r n , lima beans, dry beans, and also sugar. H e a v y p r o t e i n s — M e a t s o f all kinds, fish, shell fish, chicken, d u c k , turkey, e g g s and cheese. I h a v e arranged a " D i e t S h e e t " b u t o n e m a y m a k e his o w n , if he d o e s not violate the rule and principle. This s y s t e m of diet, w h i c h I can s t r o n g l y r e c o m m e n d , is in n o respect a radical o n e . It includes the best features of several types of diet. E a t a n y kind of f o o d y o u like or c h o o s e , p r o v i d e d y o u eat it at the right time. McCollum^^ says that in the last cen t u r y c h a n g e s in the habits of the p o p u lation o f E u r o p e and A m e r i c a have b r o u g h t a b o u t c h a n g e s in diet. The c h a n g e s have been in favor of h i g h l y milled cereal p r o d u c t s , m u s c l e meats, potatoes and sugar. This diet is a failure in animal experimentation and is p r o v i n g a failure in h u m a n ex perience. E v i d e n c e that this is true is abundantly supplied in the p e r c e n t a g e o f u n d e r w e i g h t children in o u r s c h o o l s and in the prevalence of rickets, small j a w s , and teeth w h i c h are irregular, p o o r l y d e v e l o p e d and w h i c h d e c a y easily. P e r s o n a l l y , I a m c o n v i n c e d that there is s o m e t h i n g w r o n g w i t h our w a y o f living. M c C o l l u m has p r o v e d it with animals, and m y e x p e r i e n c e w i t h this reform diet o v e r a p e r i o d o f years, in m y clinics and with m y pri vate patients, c o i n c i d e s e x a c t l y with his findings. It is a never e n d i n g fer mentation in the s t o m a c h and putre factive c o n d i t i o n in the intestines, brought about b y w r o n g food c o m
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binations, bad teeth, and diseased t o n sils, that is d e s t r o y i n g the h u m a n race. W e m u s t not lose sight of the fact that t o x e m i a ranges in intensity from an o r d i n a r y c o l d t o s e v e r e acidosis. A n d also d o n o t f o r g e t that w e can h a v e e x c e s s i v e fermentation as well as e x c e s s i v e putrefaction in the same in dividual and at o n e and the s a m e time. S h e r m a n ' adds, that f r o m eating large quantities o f meat and sugar t o g e t h e r , a type o f fermentation ensues in which o x a l i c acid is p r o d u c e d and w h i c h m u s t be h i g h l y injurious and m o s t dis tinctly t o x i c . A l s o L i e b ' ^ has p r o v e n that o x a l i c acid is p r o d u c e d in the c o l o n b y the bacterial d e c o m p o s i t i o n of sugars, and that o x a l i c acid p r o d u c e s definite t o x i c s y m p t o m s even in small a m o u n t s . KERATOMALACIA. Extensive use of faulty foods which are l o w in vitamins, prevails largely a m o n g m a n y civilized p e o p l e at the present time. M c C o l l u m and S i m m o n d s have p r o v e d keratomalacia t o be due specifically t o lack o f fat soluble A vitamin in the diet o f ani mals. B l o c h " has o b s e r v e d 40 cases of keratomalacia a m o n g children fed on h i g h l y centrifuged milk, fat b e i n g g i v e n in the f o r m of v e g e t a b l e mar garine. A cure w a s obtained in m o s t cases w i t h the aid o f r a w milk, or c o d liver oil. B l o c h b e l i e v e s that this f o r m of o p h t h a l m i a o c c u r s quite frequently in D e n m a r k and m a y often b e a cause of blindness. McCarrison^* states that this disease o c c u r s not infrequently in India, from a diet of polished rice and v e g e t a b l e oils, and is curable with c o d liver oil. I have o b s e r v e d o n l y five cases o f keratomalacia, all five in y o u n g chil dren. T h e d i a g n o s i s is e a s y : all o f t h e m w e r e sufifering from severe mal nutrition. T h e skin w a s dry, shriveled and scaly. R a w milk and c r e a m , with the addition o f c o d liver oil, effected a cure in three of the cases. HEADACHES AND DIZZINESS OVZ TO FOOD INTOXICATION. T h e f o l l o w i n g is a m o s t interesting case and w a s u n q u e s t i o n a b l y d u e to
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" w r o n g f o o d c o m b i n a t i o n s . " T h i s pa tient, D r . G. F. R., c o n s u l t e d m e for occipital and frontal headaches, w h i c h c a m e o n from time to time. H e also c o m p l a i n e d o f great dizziness w i t h o u t loss of appetite. In fact, he said to m e : "I am so d i z z y that I can't p r o p erly d o m y w o r k . " U p o n e x a m i n g his e y e s I found that his glasses w e r e c o r rect. L o o k i n g him o v e r for the "three T s " I found his teeth excellent, his t o n g u e c o a t e d , and his tonsils had been r e m o v e d . T h e n I t o o k up with h i m the question of diet, and this is w h a t he w a s eating e v e r y day. Breakfast—Orange juice, cooked fruit with sugar and cream, eggs and bacon, or fish, coffee, toast o r muffins. 11:30 A . M . E g g - n o g . Luncheon—1 P. M . A big bowl o f thick s o u p , ( m e a t ) with lentils, beans and peas, black bread and butter. 4 : 3 0 P. M . — A r r o w root biscuit and two cups of tea. Dinner—7 P. M . Soup, meat, p o tatoes o r rice, o r macaroni with cheese, fresh vegetables, salad with F r e n c h dressing, and a s w e e t dessert. H e w a s especially fond of p u d d i n g s . T h e diagnosis was easy in this case. I at o n c e told him that he w a s suffer ing from intestinal t o x e m i a due to wrong food combinations—eating heavy starches and proteins at the s a m e meal, and o v e r l o a d i n g the s t o m ach. H e is a v e r y b u s y dentist and thought the more he ate, the better he could w o r k . In other w o r d s he w a s catering to his appetite. I put him on "reform diet," w h i c h he has been fol l o w i n g n o w for t w e l v e m o n t h s . His dizziness has entirely disappeared, and his headaches have been c o m p l e t e l y relieved. H e s a y s that he feels like another man, and w o r k s from 8:30 A . M . to 6 P. M . six days a week. GLAUCOMA.
W e come now to chronic congestive and noncongestive glaucoma, the cause of which is little u n d e r s t o o d . G l a u c o m a is not m e r e l y a local dis ease. It is the o u t c o m e of p r o l o n g e d c h r o n i c autotoxemia, p r o v i d e d w e can e x c l u d e s y p h i l i s ; and w e m a y have b o t h infections in the same case. Glau
c o m a cases m u s t first have the W a s sermann test. A vitiated b l o o d s u p p l y n o t o n l y acts deleteriously upon the n e r v o u s apparatus, but c o i n c i d e n t l y w i t h this, g i v e s rise t o inefficiency o f the secretion o f e v e r y e n d o c r i n g l a n d in the b o d y , the natural c o n s e q u e n c e being an absence o f healthy cell metab olism, and the dire disturbance which must f o l l o w . Chronic constipation, gout, rheumatism, arteriosclerosis or uricacidemia, o r all o f them exist in t h o s e w h o b e c o m e the v i c t i m s o f chronic glaucoma. Professor E. F u c h s " says, that the relation b e t w e e n g l a u c o m a and the t h y r o i d is s u p p o s e d to b e due to the influence o f the g l a n d on the salt m e t a b o l i s m . In g l a u c o m a cases, the salt in the b l o o d a m o u n t e d to 0 . 7 2 % as against 1.13% in healthy persons. I m r e g o t g o o d results, a c c o r d i n g to F u c h s , b y t h y r o i d treat ment in g l a u c o m a cases, and he f o u n d the tension l o w e r d u r i n g p r e g n a n c y w h e n the t h y r o i d b e c o m e s e n l a r g e d . I said at the N e w Y o r k A c a d e m y of M e d i c i n e , five years a g o , that f e w e r of o u r g l a u c o m a cases w o u l d c o m e to the o p e r a t i n g table, if w e w o u l d o n l y re m o v e their focal infections and the p r o f o u n d t o x e m i a from w h i c h they all suffer. L a g r a n g e c o m e s o u t in his lat est b o o k and lays stress on a p o i n t that is often forgotten, n a m e l y that g l a u c o m a is generally not m e r e l y a l o cal disease, but an o c u l a r disease o c c u r r i n g in an already diseased o r g a n ism. Elliot, also, in his latest b o o k o n G l a u c o m a s a y s : "It s e e m s p r o b a b l e that one of the greatest a d v a n c e s of the future in the treatment o f glau c o m a m a y lie in the direction of the early and scientific c o m b a t i n g of the source o f autointoxication." M y c o n v i c t i o n is that g l a u c o m a must b e treated constitutionally, as well as locally or surgically. I have the r e c o r d s of 4 4 cases of g l a u c o m a w h i c h I am treating a c c o r d i n g to m y m e t h o d ; and s o far not o n e of these t w e n t y - t w o cases has c o m e to the o p e r ating table. O n e of these cases has been under observation for nearly ten years. In all m y cases I use nitrat of Pilocarpin. T h e e y e stands it bet ter o v e r a period of years, and I think
DIET IN O P H T H A L M I C T H E R A P E U T I C S
it is less irritating. P o s e y first called m y attention to it, and as P o s e y says, the d r u g must be used c o n s t a n t l y and c o n t i n u o u s l y every day at least three times. T h e history of this patient w h o m I have had for ten years is v e r y inter esting. A t the time I first s a w her, she w a s 70 years of age. She c o m plained o f disturbed vision, as t h o l o o k i n g thru a f o g , and the street l a m p s had a halo of c o l o r e d rings. S h e had recently been in the hands of t w o oculists, both of w h o m had m a d e a diagnosis o f c h r o n i c g l a u c o m a . B o t h oculists wanted to operate on her. W h e n I first saw her, she had a dis tinct g l a u c o m a t o u s disc in each e y e ; her anterior c h a m b e r w a s v e r y shal low, with the pupils m o d e r a t e l y di lated. S c h i ö t z r e c o r d e d 35 m . m . o f f i g . in each eye. H e r b l o o d pressure w a s 180. H e r urine w a s loaded with in dican. U p o n l o o k i n g her o v e r for the "three T s " I found that her t o n g u e w a s heavily coated, her breath foul, and she suffered from constipation. X - r a y of teeth v^as negative. She g a v e a history o f c o n s u m i n g considerable sweets, and w a s in the habit of eat ing meat t w i c e daily and taking a great deal of coffee. I restricted the use of the eyes for close w o r k , and put the patient o n a diet. T h e e x c l u s i o n of h e a v y m e a t s and stimulants, such as tea, coffee, al c o h o l and t o b a c c o is m o s t essential in order to obviate the final need of sur g e r y in these g l a u c o m a cases. E . L y man Fisk'" says that it is a p o o r c o m pliment to the h u m a n race to say that life is unlivable w i t h o u t a l c o h o l , to b a c c o , coffee and tea. A l s o w i t h this patient I used Pilocarpin nitrat, o n e • per cent three times daily, h o t bath ing for the e y e s three times daily, and a h o t bath at bed time. I also g a v e her a vial o f bacillus bulgaricus three times daily after meals, and careful attention w a s g i v e n to evacuation of the bowels every day. In addition to this the c o l o n w a s t h o r o l y emptied o n c e a w e e k b y an enema of water at b l o o d heat. T h i s regimen has been kept up for ten years, with practically n o loss o f vision and o n l y a slight i m
123
pairment o f the fields. Is n o t such a m e t h o d as this far preferable to an o p eration on a patient o v e r 70 y e a r s of age? L e t me g i v e o n e m o r e e x a m p l e of c h r o n i c simple g l a u c o m a w h i c h is m o s t interesting. T h e patient, also a w o m a n , age 45, w a s o p e r a t e d u p o n for c h r o n i c g l a u c o m a b y o n e of o u r well k n o w n s u r g e o n s . W h e n I first s a w her three years a g o , I l o o k e d at her e y e s and s a w that she had had a p r o p e r opera tion performed, but the v i s i o n re mained v e r y p o o r . She c a m e to m e t o b e treated for headaches, and pain in her g o o d e\'e. I found the anterior chamber very shallow. T h e tension w a s up. U p o n l o o k i n g her o v e r for the "three T s " the X - r a y of the teeth revealed abscesses at the r o o t s of eight of her teeth. T h e r e is n o t h i n g that can d e s t r o y bacterial life in the pus sacs at the r o o t s of infected teeth e x cept extraction, so we had her infected teeth r e m o v e d . H e r tonsils had already been r e m o v e d . H e r t o n g u e w a s heav ily coated, her breath w a s foul and she w a s suffering from constipation. M o r e o v e r , her urine w a s l o a d e d with indican. H e r W a s s e r m a n n w a s nega tive. I placed her o n the " r e f o r m diet" and the usual treatment for glau comatous eyes. I g a v e her Bacillus acidophilus. W c k n o w that Bacillus a c i d o p h i l u s is the p r o t e c t i v e o r g a n i s m of the intestinal tract. E g g s t o n and N o r m a n ^ ' have p r o v e d that b e y o n d question. I g i v e the B. A . for o n e month at a time, and then I g i v e small d o s e s of iodin for o n e m o n t h at a time t o maintain the endocrin balance. This iodin treatment, which was first b r o u g h t to m y attention b y A . J. Q u i m b y , ' * is s o valuable that I g i v e the formula. ^ I o d i n crystals Gr X X X A m m o n i a iodid Gr X X Alcohol 7, IV Glycerin q. s. o I M i s c e et s i g n a : o n e d r o p in glassful o f water once daily. F o r patients w h o have been travel ling the road of t o x e m i a for years, and w h e r e the toxins have been accu m u l a t i n g in the b l o o d , small d o s e s o f iodin are e x c e e d i n g l y valuable. A s the
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result of this treatment this patient has normal vision and normal fields after three years. N o effort had been m a d e in this case to i m p r o v e the quality o f the b l o o d stream, until she c a m e under m y observation. O f c o u r s e I operate for g l a u c o m a when I find it is necessary—that is w h e n the treatment w h i c h I have out lined is not effective. This, however, is rarely the case. I had a chemical examination of the b l o o d made in six of these g l a u c o m a cases. In four of the six cases, the b l o o d chemistry s h o w e d uric acid c o n t e n t a b o v e normal. The uric acid ranged from 4.5 to 6 m g . per 100 c c . of b l o o d . According t o ' D ^ N i o r d and Bixb\-, when the b l o o d chemistry reveals uricacidemia, that is e n o u g h t o justify a d i a g n o s t i c finding, indicating a c h r o n i c infection s o m e w h e r e in the b o d y . I maintain that in all c h r o n i c simple g l a u c o m a s , w e should insist upon a chemical b l o o d test for uric acid. This general routine treatment which I advocate in glaucoma cases is also car ried out by me in all diseases of the eye, such as episcleritis and deep scleritis, retinitis, optic neuritis, eczema o f the lids, herpes febrilis, herpes zoster, edema of the lids, toxic amblyopia, immature cataracts, both hard and soft, choroidi tis, keratitis o f all forms, chronic con junctivitis and blepharitis, iridocyclitis, plastic iritis, chronic uveitis, recurrent hemorrhages in the \'itreous body, sym pathetic ophthalmia, migraine, a n g i o neurotic edema and papilledema. Of course, in conjunction with this general routine treatment, the necessary local remedies f o r the eyes must be used. Salvarsan and inunctions o f mercury and tuberculin are also added when indicated and necessary. In chronic conditions o f the eye, where the tuberculin test is posi tive, I find myself giving less and less tuberculin, and relying more and more upon fresh air, sunshine, exercise, my "reform diet" and the iodin treatment, as well as close attention to the sanitary con dition of the colon. CHOROIDITIS.
Several well k n o w n oculists have recently reported cases of choroiditis.
keratitis and episcleritis cured as a re sult of the diet. I have any n u m b e r of such cases a m o n g m y r e c o r d s . T h e r e is one case of exudative c h o r o i d i t i s in a y o u n g Federal B o a r d student, aged 24, of Λvhich I w o u l d like t o speak. H i s t o r y as f o l l o w s : T h e sight o f O . S. \vas lo>t in France, as a result of shell e x p l o s i o n , O . D . vision 10/200. O n e x a m i n i n g his eye with the o p h t h a l m o s c o p e there w a s a large cloud of floating opacities in the vitreous, so thick that the details of the fundus c o u l d not be seen. I ad mitted him to the U . S . P . H . Hospital N o . 38 ( N e w Y o r k P o l y c l i n i c ) w h e r e the W a s s e r m a n n was negative. L o o k ing him o v e r for the "three T . s " I found that his teeth w e r e in fine shape, but his tonsils w e r e filled with ])us. I had his tonsils enucleated, and put him on the reform diet. H o t ajiplications to the eyes for o n e h o u r at a time, three times daily, w e r e g i v e n and also a w e a k solution of atropin w a s used. Careful attention w a s g i v e n daily to c o m p l e t e evacuation of the c o l o n . T h e patient b e g a n to i m p r o v e , and left the hospital at the end o f t w o w e e k s Avith instructions in regard t o diet and enemas. Six m o n t h s later I s a w this patient, and m u c h to m y surprise he had 2 0 / 2 0 vision. O n e x a m i n i n g the vitreous n o floating opacities c o u l d be found, but several patches of c h o r o i d i tis could be seen in the ])eripheral ])οι·tion of the fundus. CONCLUSIONS.
1. After five years e x p e r i e n c e with the " R e f o r m D i e t " I feel that I stand on a firm foundation in r e c o m m e n d i n g it as a therapeutic measure in ophthal mic practice. 2. I agree with Meiler, w h o says that s y m p a t h e t i c o p h t h a l m i a m a y be p r o d u c e d b y e n d o g e n o u s infection, and he adds that the o r g a n i s m s in the b l o o d settle in the tissues of the e y e weakened b y injury, the o r g a n i s m s b e c o m i n g virulent and finally reaching the o t h e r e y e thru the b l o o d stream. I maintain that a house c l e a n i n g p r o c ess is in order in every o b s c u r e c o n d i tion of the eye.
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3. A l i m e n t a r y t o x e m i a is b e y o n d question responsible for a large percentage of diseases of the e y e . T h e relation of f o o d ingested to alimentary t o x e m i a is v e r y important. Most p e o p l e eat far t o o m u c h and m i g h t with a d v a n t a g e eat v e r y m u c h less. T h i s idea should be c o n s t a n t l y kept in mind b y every o i ) h t h a l m o l o g i s t . 4. In acute and c h r o n i c diseases of the eye, w o u l d it not help matters materially if w e adopted measures, such as a " R e f o r m D i e t " , the s y s t e m a t i c
THERAPEUTICS
12Í.
r e m o v a l of ascertainable foci of infection and the closest attention to the sanitary c o n d i t i o n o f the c o l o n , w i t h a v i e w to r e m o v i n g the t o x i c c o n d i t i o n of the b l o o d ? 5. W h e n a man like M c C o l l u m says that a diet c o m p o s e d of milled cereal p r o d u c t s , m u s c l e meats, p o t a t o e s and sugar is a failure in animal experim e n t a t i o n , and is also p r o v i n g a failure in h u m a n e x p e r i e n c e , then I think it is high time that we " S T O P — L O O K —and L I S T E N . "
REFERENCES. 1. 2. 3. 4. 5. 6. 7. 8. 9 10. 11. 12. 13. 14. 15. 16. 17.
18.
Bell, G. H . Relations of Teeth, Tonsils a n d Intestinal T o x e m i a s to Diseases of the E y e . J. A . M . Α . , October 1921, p. 1131. Libman, Ε . A c u t e Bacterial Endocarditis. Brit. M e d . J., 1920, p. 306. Behan, J. L. F u n d u s Changes in Nephritis. J. A . M . .A.., June 1922, p. 1692. Olmstead, W . D . Focal Infections in Relation to E v e Diseases. J. M e d . Soc. N . J., June 1922. M c C o l l u m , E. V . T h e N e w e r K n o u l e d g s of Nutrition, 2nd edition, p. 409. M a t t h e w s , A . P. Physiological Chemistry, 3rd edition, p. 399. Sherman, H . C . Chemistry of F o o d and Nutrition, 2nd edition, p. 97. H a r e , Francis. T h e F o o d Factor in Disease, v. I, p. 4 1 . Tilden, J. H . F o o d , v. I, p. 24. Decks, W . E . Gastric and D u o d e n a l Uc:vs. N . Y . M e d . Journal, 1912, p. 1103. M c C o l l u m and S i m m o n d s . T h e Potcncv of Commercial V i t a m i n Preparations. J. A . M. Α . , June 1922, p. 1945. Lieb, C. W . O x a l i c A c i d Production in Colon in Disease Causation. N. Y . Med. Journal and Medical Review, June 1923. Bloch, C. E . E v e Diseases and O t h e r Disturbances in I n f a n t s f r o m Deficiency of Fat in Food. Cited f r o m J. A . M . Α . , 1917, p. 1516. M c C a r r i s o n , R . Faulty F o o d in Relation to Gastrointestinal Disorder. J. A , ML Α . , Jan. 1922. Fuchs, Ε . O c u l a r Manifestations of Internal Secretions. A r c h . O p h . , Julv 1922, p. 311. Fish, E . L . Preventable Diseases of A d u l t L i f e . N . Y . State M e d . J., Dec. 1921. N o r m a n , N . P., and E g g s t r o n , A . A . A N e w Technique for Preparation of Bacillus .Acidophilus M i l k and Its Therapeutic V a l u e . N . Y . State M e d . J. and M e d . R., June 1922. Q u i m b y , A . J.
Physiological
Iodine.
N.
V . M e d . J. and M e d . R., Dec. 1922.
OPHTHALMIC
PRACTICE. GEORGE H U S T O N B E L L , M . D . , NEW
YORK
F.A.C.S.
CITY.
T h e i m p o r t a n c e of t o x e m i a of g a s t r o i n t e s t i n a l o r i g i n , a l o n g with focal i n f e c t i o n s , as a cause of o c u l a r disease is here e m p h a s i z e d . I t is held that heavy starches to be digested in the intestines should not be m i x e d with proteins, that m u s t b e d i g e s t e d in the s t o m a c h ; a n d t h e excessive use of sugar is condemned. T h e influence of diet in e t i o l o g y and the therapeutic value of its c o r r e c t i o n , is illustrated w i t h reference to corneal ulcer, keratomalacia, head ache, g l a u c o m a , c h o r o i d i t i s , a n d o t h e r o c u l a r c o n d i t i o n s . R e a d b e f o r e the M e d i c a l S o c i e t y of N e w J e r s e y , J u n e 2 2 , 1923.
In presenting a paper o n " R e f o r m D i e t , " I w i s h it to be u n d e r s t o o d that it is part of m y r e m e d y for the "three T s . " T h e ramifications o f the "three T s " (teeth, tonsils and t o x e m i a s of the intestinal tract) are so i n t e r w o v e n , that t o m y mind it is i m p o s s i b l e to dis associate t h e m . In thinking o f any one of the "three T s " in c o n n e c t i o n w i t h a patient, the other t w o invariably c o m e into m y m i n d . T h e y g o hand in hand. W e k n o w that gastrointestinal dis turbances and severe septic intoxica tion, are at times b r o u g h t on, o r ag gravated, b y oral sepsis, diseased ton sils, o r w r o n g f o o d c o m b i n a t i o n s , and n o t infrequently b y all three. I said at the A . M . A . meeting in 1 9 1 9 \ that oral sepsis w a s o n e of the greatest m e n a c e s t o the human r a c e ! I reaf firm that statement. I also said that negative e v i d e n c e d o e s not e x c l u d e the possibility of infection from the tonsil, and that b a c t e r i o l o g i c examination of all r e m o v e d tonsils w h i c h I h a v e ex amined, d e m o n s t r a t e d the p r e s e n c e o f o r g a n i s m s . I have been driven to the c o n c l u s i o n that a healthy tonsil is a scarce article. T h e r e is n o d o u b t in m y m i n d that the constant s w a l l o w i n g of infected secretions from the m o u t h and tonsils, is one o f our greatest sources of danger. Septic infection m a y b e a b s o r b e d into the circulation from b o t h , and thus diseased teeth and ton sils in t w o w a y s b e c o m e e n e m i e s o f the host and g n a w at the vitals. E . Libman,'^ in a paper o n A c u t e Bacterial E n d o c a r d i t i s s a i d : " T h e i m portant thing is t o s y s t e m a t i c a l l y rid all patients h a v i n g valvular disease, of the ascertainable foci of infection," (teeth, tonsils, e t c . ) , and he further adds that the q u e s t i o n o f p r e v e n t i o n seems to b e the m o s t pressing. 118
B e h a n , ' s a i d : — " W e see c o n t i n u a l l y in our private dispensary and hospi tal w o r k , all the c h a n g e s characteristic of albuminuric ncuroretinitis in v a r y ing c o m b i n a t i o n s . In the a b s e n c e of nephritis w e d o not hesitate to ascribe as a cause for these c h a n g e s the "three T s " of Bell, the anemias and infectious diseases." Olmstead"* s a i d : " I feel safe in s a y i n g at this time, e x c e p t i n g trauma and venereal disease, w e can, o r will eventually, p r o v e e v e r y dis eased c o n d i t i o n of the e y e due t o s o m e o n e of the three r e c o g n i z e d s o u r c e s of focal infections, v i z : "the three T s . " In the light of all this, w h a t is the sense and w h a t is the use of p u t t i n g patients on a diet, unless y o u are g o i n g to g e t rid of infected teeth and dis eased tonsils? W e m u s t attend to the h y g i e n e of the m o u t h and throat. W e c o m e n o w to m y " R e f o r m D i e t . " I hold and believe that diet is c o m m o n sense applied to living. A l l m u s t agree to that, if w e are t o m a k e a n y real p r o g r e s s in o v e r c o m i n g t o x e m i a . W e m u s t c o n s i d e r the fuel that w e put into the l a b o r a t o r y that nature maintains in the s t o m a c h . T h e d a y is at h a n d w h e n the p r o g r e s s i v e o p h t h a l m o l o g i s t must take up with his patients the question of diet. H o w m a n y oculists w a r n their patients against e x c e s s i v e c o n s u m p t i o n of sugars, s w e e t s and starches, and w r o n g food combinations. M a n y oph t h a l m o l o g i s t s are so o c c u p i e d w i t h the purely o p h t h a l m o l o g i c aspect o f a case, that t h e y p a y a b s o l u t e l y n o attention t o the practical i m p o r t a n t e t i o l o g i c fac tors. W h e n w e realize that ninety o u t o f o n e hundred p e r s o n s die f r o m s o m e s e c o n d a r y disease, the result of s o m e focal infection, it is high time that w e w e r e s t u d y i n g the causes of focal in fections. McCollum'^ c o m e s out in his
D I E T IN O P H T H A L M I C T H E R A P E U T I C S
latest b o o k o n " T h e N e w e r K n o w l e d g e of N u t r i t i o n " and says, that n o o n e will b e likely to dispute the statement that f e w p e o p l e are entirely w e l l , and that their failures, indiscretions, fits o f temper, t e n d e n c y t o c o m p l a i n , their lack of enthusiasm, their inefficiencies as creatures, are in a great measure the result o f ill health, and he adds that there can b e n o reasonable d o u b t that the diet m a y d e v i a t e f r o m the o p timal even in the U n i t e d States, t o a d e g r e e w h i c h can easily cause the re sults w e see. N o w if w h a t M c C o l l u m says b e true, and I b e l i e v e it is, and if w e h a v e b e e n l i v i n g o n a s o c a l l e d w e l l balanced diet w h i c h includes meat, bread, v e g e t a b l e s and sweets, and also meat, p o t a t o e s , v e g e t a b l e s and s w e e t s , and h e a v y starches and p r o t e i n s at the s a m e meal, it is high time w e w e r e m a k i n g a c h a n g e , and that w e tried s o m e o t h e r form o f diet, and thus e n d e a v o r e d t o p r e v e n t the factors c o n c e r n e d in the p r o d u c t i o n of this f o r m i d a b l e array of ills, of w h i c h M c C o l l u m speaks. H e n c e m y reason for p r e s e n t i n g t o y o u for c o n s i d e r a t i o n m y " R e f o r m D i e t , " as a therapeutic measure in ophthalmic practice. L e t us k e e p a f e w t h i n g s clearly in mind. H e a v y starches and proteins m u s t n o t b e eaten t o g e t h e r at the s a m e m e a l ; for the reason that starches are d i g e s t e d in the m o u t h and intestines, and proteins in the s t o m a c h . W h a t is the sense of eating f o o d s t o g e t h e r that fight in the s t o m a c h ? W h y n o t eat them separately, and at diflierent meals? W h e n m e a t is eaten it causes a flow of gastric j u i c e . T h e e l e m e n t s of a f o o d that are p e c u l i a r l y fitted t o a c e r tain d i g e s t i v e fluid, cause this fluid t o b e s e c r e t e d — s o that w h e n m e a t and h i g h l y starchy f o o d s are eaten t o gether, the meat will be d i g e s t e d in the s t o m a c h , b u t n o t the starch. N o w all the time the starch is in the s t o m ach, it is n o t o n l y not p e r m i t t e d t o b e d i g e s t e d , b u t it also hinders the di g e s t i o n o f the protein o r meat. S o w e g e t an acid fermentation in the s t o m ach from the starchy f o o d s w i t h the formation of volatile and n o n v o l a t i l e
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acids and s o m e t i m e s marsh g a s , h y d r o g e n and a l c o h o l . It is the a c i d fermentation p r o d u c e d b y these w r o n g f o o d c o m b i n a t i o n s w h i c h in the e n d leads t o t o x e m i a . S t a r c h y f o o d s , o f c o u r s e , w e n e e d for e n e r g y and heat, b u t t h e y m u s t b e eaten w i t h n o n s t a r c h y v e g e t a b l e s , sal ads and fruits, in o r d e r that they m a y all pass out o f the s t o m a c h at the s a m e time, and in that w a y w e are able t o p r e v e n t acid d y s p e p s i a and acid fer m e n t a t i o n in t h e s t o m a c h . M a t t h e w s " in the third edition o f his " P h y s i o l o g i c a l C h e m i s t r y " s a y s that starches, o r c a r b o h y d r a t e s , are di g e s t e d b y the ptyalin o f the saliva, the a m y l o p s i n , maltase and lactase of the pancreas, and the invertin o f the in testinal j u i c e s , s o that t h e y are all re d u c e d to a state o f m o n o s a c c h a r i d s . H e further a d d s that s o m e o f t h e c a r b o hydrates are further b r o k e n up b y the bacteria w i t h the resultant f o r m a t i o n of lactic acid, a l c o h o l , m a r s h - g a s , h y d r o g e n and b u t y r i c acid. S h e r m a n ' adds that a m o n g c a s e s of e x c e s s i v e bacterial d e c o m p o s i t i o n in the d i g e s t i v e tract, t h e fermentation o f carbohydrates with the production o f o r g a n i c acids, and p o s s i b l y a l c o h o l , is m o s t likely to o c c u r in the s t o m a c h ; w h i l e putrefaction o f proteins o c c u r s m a i n l y in the large intestines. Then if w h a t S h e r m a n and M a t t h e w s say b e true, w h y n o t eat c a r b o h y d r a t e s at a time w h e n t h e y w o n ' t be detained in the s t o m a c h ? Sir F r a n c i s H a r e ' comes out flat-footed, and s a y s (in " F o o d F a c t o r in D i s e a s e , " V o l . I ) that there is n o t h i n g in the s t o m a c h to di g e s t the starches. J. H . T i l d e n ' says the s a m e t h i n g and has a d v o c a t e d for a l o n g time this diet o f n o t m i x i n g starches and proteins at the s a m e meal. D e e k s " a l s o has p o i n t e d o u t that there is n o t h i n g in the s t o m a c h t o d i g e s t the sugars. I am a firm b e l i e v e r in the baneful effect of s u g a r as a s y s t e m i c p o i s o n in d i s e a s e d c o n d i t i o n s o f the eyes. W e all h a v e seen the baneful efliect o f su g a r as a s y s t e m i c p o i s o n in diseased c o n d i t i o n s o f the e y e s . W e all h a v e seen the baneful effect of c a n d y and s w e e t s in children c o m i n g to us w i t h
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e c z e m a t o u s conjunctivitis. Stay a w a y from sugars and s w e e t s and g e t the necessary sweets b y eating fresh fruits and v e g e t a b l e s . O n e hundred years a g o the total per capita c o n s u m p t i o n of sugar in the U n i t e d States w a s less than nine p o u n d s per annum. Since then it has increased b y leaps and b o u n d s , until n o w this c o u n t r y is p r o b ably the largest c o n s u m e r of sugar in the w o r l d . K e l l o g g and T a y l o r esti mated the per capita use of sugar just before the war, at close to four o u n c e s a d a y per individual. Estimates of su gar in the b l o o d are o f value in the treatment of all cases of o b s c u r e e y e c o n d i t i o n s . C h a c e said in 1920 at the annual m e e t i n g of the M e d i c a l S o c i e t y of the State of N e w Y o r k , that sugar is perhaps responsible for p r o d u c i n g m o r e h y p e r a c i d i t } ' than any other sin gle article of diet, and that the great increase in the p r e v a l e n c e of hyper acidity d u r i n g the last d e c a d e is largely due to increased sugar c o n s u m p t i o n . T h e r e is a g r o w i n g d e m a n d for a scientific supervision of the diet in health and disease, and an increasing realization of its i m p o r t a n c e . Hence m y great interest in "dietary r e f o r m s . " I w a n t to emphasize the i m p o r t a n c e of using certified raw milk, and of eating r a w fruits, g r e e n v e g e t a b l e s and sal ads. A g a i n , certain important sub stances o c c u r in animal fats w h i c h should form a part o f the diet, such as fats from meats, butter and c r e a m . W e should c o n s u m e at least o n e quart of milk o r its equivalent in dairy p r o d ucts e v e r y day, and raw food and raw fruits should be eaten as salads and desserts o n c e o r t w i c e daily to insure the required a m o u n t of vitamins. It seems that in the course of c o o k i n g or d r y i n g s o m e t h i n g essential is de s t r o y e d . W e o u g h t e v e r y day to eat freely of s o m e leafy v e g e t a b l e f o o d such as spinach, c a b b a g e , beet t o p s brussels sprouts, lettuce, dandelions, pepper-grass and S w i s s chard. They have unique properties. T h e c o n s u m p tion of these leafy v e g e t a b l e f o o d s will g o far towards o v e r c o m i n g c o n s t i p a tion. I have so arranged the " r e f o r m d i e t " that milk can be taken at the p r o p e r
time. I am a firm believer in the f o o d value o f milk, the m o s t desirable single article of f o o d for infants and children, and b e i n g m o r e and m o r e appreciated b y adults. F u n k w a s the first to sug gest the relationship b e t w e e n the c o m position of the milk, and s o m e de ficiency diseases in children. Funk stated that on heating milk certain vitamins b e c o m e m o r e or less c o m pletely d e s t r o y e d . T h e r e f o r e great ad v a n t a g e lay in a certified raw p r o d u c t , safeguarded from c o n t a g i o u s diseases and c o n t a i n i n g a m o r e or less constant fat c o n t e n t . Milk taken with the or dinary meals f r e q u e n t l y causes catarrh, because of o v e r e a t i n g and o v e r l o a d i n g the s t o m a c h . M i l k must be taken with a starch o r fruit, and not with a full meal, b e c a u s e o n e quart of certified raw milk is a meal in itself. A hearty eater, w h o drank about t w o glasses of raw milk with each meal, three times daily, d e v e l o p e d a ca tarrhal state, f o l l o w e d b y intestinal t o x e m i a and keratitis of both e y e s . I found his t o n g u e heavily c o a t e d , his breath v e r y foul and his urine loaded with indican, also he w a s a sufferer from constipation. H i s teeth w e r e ap parently healthy. I was able to extrude pus from his tonsils. Examination of his eyes s h o w e d M o o r e n ' s ulcer of right e y e and in cipient ulcer o f the left. T h e ulcer in the right e y e had d e v e l o p e d from the margin o f the cornea a b o v e , and had e x t e n d e d all the w a y a r o u n d the cornea. T h e gray, c l o u d y m a r g i n of the ulcer w a s u n d e r m i n e d and c o u l d b e elevated. M o r e o v e r , there w e r e marked inflammatory c o m p l i c a t i o n s . H e had been treated for six w e e k s b y an o p h t h a l m o l o g i s t . T h i s oculist had cauterized the ulcer with c a r b o l i c acid several times and had used the actual cautery, also hot f o m e n t a t i o n s and atropin w e r e b e i n g used. All I did for him w a s to h a v e his tonsils enucleated at o n c e , put him on m y " r e f o r m diet" with hot applications to his e y e s — b i chlorid vaseline—1-5000 in b o t h e y e s night and m o r n i n g , and atropin solu tion in his eyes o c c a s i o n a l l y ; w h i l e his colon was thoroly emptied every d a y b y means of an enema of w a t e r
D I E T IN O P H T H A L M I C T H E R A P E U T I C S
at b l o o d heat. T h i s patient m a d e a g o o d and rapid r e c o v e r y , and returned to his native state in t w o w e e k s , w h e r e he continued the treatment for four weeks more. D o c t o r H . A . Wakefield of Charlotte, N o r t h Carolina, in a let ter recently, said that M r . B . n o w had n o r m a l vision in b o t h eyes. RULE OF T H E REFORM DIET.
T h e principle of the reform diet is simple and v e r y plain. Not to mix h e a v y starches and proteins at the same meal. H e a v y s t a r c h e s—Bread, w h o l e wheat, w h i t e c o r n or rye, and crackers. P o t a t o e s , rice, m a c a r o n i , c o r n , lima beans, dry beans, and also sugar. H e a v y p r o t e i n s — M e a t s o f all kinds, fish, shell fish, chicken, d u c k , turkey, e g g s and cheese. I h a v e arranged a " D i e t S h e e t " b u t o n e m a y m a k e his o w n , if he d o e s not violate the rule and principle. This s y s t e m of diet, w h i c h I can s t r o n g l y r e c o m m e n d , is in n o respect a radical o n e . It includes the best features of several types of diet. E a t a n y kind of f o o d y o u like or c h o o s e , p r o v i d e d y o u eat it at the right time. McCollum^^ says that in the last cen t u r y c h a n g e s in the habits of the p o p u lation o f E u r o p e and A m e r i c a have b r o u g h t a b o u t c h a n g e s in diet. The c h a n g e s have been in favor of h i g h l y milled cereal p r o d u c t s , m u s c l e meats, potatoes and sugar. This diet is a failure in animal experimentation and is p r o v i n g a failure in h u m a n ex perience. E v i d e n c e that this is true is abundantly supplied in the p e r c e n t a g e o f u n d e r w e i g h t children in o u r s c h o o l s and in the prevalence of rickets, small j a w s , and teeth w h i c h are irregular, p o o r l y d e v e l o p e d and w h i c h d e c a y easily. P e r s o n a l l y , I a m c o n v i n c e d that there is s o m e t h i n g w r o n g w i t h our w a y o f living. M c C o l l u m has p r o v e d it with animals, and m y e x p e r i e n c e w i t h this reform diet o v e r a p e r i o d o f years, in m y clinics and with m y pri vate patients, c o i n c i d e s e x a c t l y with his findings. It is a never e n d i n g fer mentation in the s t o m a c h and putre factive c o n d i t i o n in the intestines, brought about b y w r o n g food c o m
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binations, bad teeth, and diseased t o n sils, that is d e s t r o y i n g the h u m a n race. W e m u s t not lose sight of the fact that t o x e m i a ranges in intensity from an o r d i n a r y c o l d t o s e v e r e acidosis. A n d also d o n o t f o r g e t that w e can h a v e e x c e s s i v e fermentation as well as e x c e s s i v e putrefaction in the same in dividual and at o n e and the s a m e time. S h e r m a n ' adds, that f r o m eating large quantities o f meat and sugar t o g e t h e r , a type o f fermentation ensues in which o x a l i c acid is p r o d u c e d and w h i c h m u s t be h i g h l y injurious and m o s t dis tinctly t o x i c . A l s o L i e b ' ^ has p r o v e n that o x a l i c acid is p r o d u c e d in the c o l o n b y the bacterial d e c o m p o s i t i o n of sugars, and that o x a l i c acid p r o d u c e s definite t o x i c s y m p t o m s even in small a m o u n t s . KERATOMALACIA. Extensive use of faulty foods which are l o w in vitamins, prevails largely a m o n g m a n y civilized p e o p l e at the present time. M c C o l l u m and S i m m o n d s have p r o v e d keratomalacia t o be due specifically t o lack o f fat soluble A vitamin in the diet o f ani mals. B l o c h " has o b s e r v e d 40 cases of keratomalacia a m o n g children fed on h i g h l y centrifuged milk, fat b e i n g g i v e n in the f o r m of v e g e t a b l e mar garine. A cure w a s obtained in m o s t cases w i t h the aid o f r a w milk, or c o d liver oil. B l o c h b e l i e v e s that this f o r m of o p h t h a l m i a o c c u r s quite frequently in D e n m a r k and m a y often b e a cause of blindness. McCarrison^* states that this disease o c c u r s not infrequently in India, from a diet of polished rice and v e g e t a b l e oils, and is curable with c o d liver oil. I have o b s e r v e d o n l y five cases o f keratomalacia, all five in y o u n g chil dren. T h e d i a g n o s i s is e a s y : all o f t h e m w e r e sufifering from severe mal nutrition. T h e skin w a s dry, shriveled and scaly. R a w milk and c r e a m , with the addition o f c o d liver oil, effected a cure in three of the cases. HEADACHES AND DIZZINESS OVZ TO FOOD INTOXICATION. T h e f o l l o w i n g is a m o s t interesting case and w a s u n q u e s t i o n a b l y d u e to
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" w r o n g f o o d c o m b i n a t i o n s . " T h i s pa tient, D r . G. F. R., c o n s u l t e d m e for occipital and frontal headaches, w h i c h c a m e o n from time to time. H e also c o m p l a i n e d o f great dizziness w i t h o u t loss of appetite. In fact, he said to m e : "I am so d i z z y that I can't p r o p erly d o m y w o r k . " U p o n e x a m i n g his e y e s I found that his glasses w e r e c o r rect. L o o k i n g him o v e r for the "three T s " I found his teeth excellent, his t o n g u e c o a t e d , and his tonsils had been r e m o v e d . T h e n I t o o k up with h i m the question of diet, and this is w h a t he w a s eating e v e r y day. Breakfast—Orange juice, cooked fruit with sugar and cream, eggs and bacon, or fish, coffee, toast o r muffins. 11:30 A . M . E g g - n o g . Luncheon—1 P. M . A big bowl o f thick s o u p , ( m e a t ) with lentils, beans and peas, black bread and butter. 4 : 3 0 P. M . — A r r o w root biscuit and two cups of tea. Dinner—7 P. M . Soup, meat, p o tatoes o r rice, o r macaroni with cheese, fresh vegetables, salad with F r e n c h dressing, and a s w e e t dessert. H e w a s especially fond of p u d d i n g s . T h e diagnosis was easy in this case. I at o n c e told him that he w a s suffer ing from intestinal t o x e m i a due to wrong food combinations—eating heavy starches and proteins at the s a m e meal, and o v e r l o a d i n g the s t o m ach. H e is a v e r y b u s y dentist and thought the more he ate, the better he could w o r k . In other w o r d s he w a s catering to his appetite. I put him on "reform diet," w h i c h he has been fol l o w i n g n o w for t w e l v e m o n t h s . His dizziness has entirely disappeared, and his headaches have been c o m p l e t e l y relieved. H e s a y s that he feels like another man, and w o r k s from 8:30 A . M . to 6 P. M . six days a week. GLAUCOMA.
W e come now to chronic congestive and noncongestive glaucoma, the cause of which is little u n d e r s t o o d . G l a u c o m a is not m e r e l y a local dis ease. It is the o u t c o m e of p r o l o n g e d c h r o n i c autotoxemia, p r o v i d e d w e can e x c l u d e s y p h i l i s ; and w e m a y have b o t h infections in the same case. Glau
c o m a cases m u s t first have the W a s sermann test. A vitiated b l o o d s u p p l y n o t o n l y acts deleteriously upon the n e r v o u s apparatus, but c o i n c i d e n t l y w i t h this, g i v e s rise t o inefficiency o f the secretion o f e v e r y e n d o c r i n g l a n d in the b o d y , the natural c o n s e q u e n c e being an absence o f healthy cell metab olism, and the dire disturbance which must f o l l o w . Chronic constipation, gout, rheumatism, arteriosclerosis or uricacidemia, o r all o f them exist in t h o s e w h o b e c o m e the v i c t i m s o f chronic glaucoma. Professor E. F u c h s " says, that the relation b e t w e e n g l a u c o m a and the t h y r o i d is s u p p o s e d to b e due to the influence o f the g l a n d on the salt m e t a b o l i s m . In g l a u c o m a cases, the salt in the b l o o d a m o u n t e d to 0 . 7 2 % as against 1.13% in healthy persons. I m r e g o t g o o d results, a c c o r d i n g to F u c h s , b y t h y r o i d treat ment in g l a u c o m a cases, and he f o u n d the tension l o w e r d u r i n g p r e g n a n c y w h e n the t h y r o i d b e c o m e s e n l a r g e d . I said at the N e w Y o r k A c a d e m y of M e d i c i n e , five years a g o , that f e w e r of o u r g l a u c o m a cases w o u l d c o m e to the o p e r a t i n g table, if w e w o u l d o n l y re m o v e their focal infections and the p r o f o u n d t o x e m i a from w h i c h they all suffer. L a g r a n g e c o m e s o u t in his lat est b o o k and lays stress on a p o i n t that is often forgotten, n a m e l y that g l a u c o m a is generally not m e r e l y a l o cal disease, but an o c u l a r disease o c c u r r i n g in an already diseased o r g a n ism. Elliot, also, in his latest b o o k o n G l a u c o m a s a y s : "It s e e m s p r o b a b l e that one of the greatest a d v a n c e s of the future in the treatment o f glau c o m a m a y lie in the direction of the early and scientific c o m b a t i n g of the source o f autointoxication." M y c o n v i c t i o n is that g l a u c o m a must b e treated constitutionally, as well as locally or surgically. I have the r e c o r d s of 4 4 cases of g l a u c o m a w h i c h I am treating a c c o r d i n g to m y m e t h o d ; and s o far not o n e of these t w e n t y - t w o cases has c o m e to the o p e r ating table. O n e of these cases has been under observation for nearly ten years. In all m y cases I use nitrat of Pilocarpin. T h e e y e stands it bet ter o v e r a period of years, and I think
DIET IN O P H T H A L M I C T H E R A P E U T I C S
it is less irritating. P o s e y first called m y attention to it, and as P o s e y says, the d r u g must be used c o n s t a n t l y and c o n t i n u o u s l y every day at least three times. T h e history of this patient w h o m I have had for ten years is v e r y inter esting. A t the time I first s a w her, she w a s 70 years of age. She c o m plained o f disturbed vision, as t h o l o o k i n g thru a f o g , and the street l a m p s had a halo of c o l o r e d rings. S h e had recently been in the hands of t w o oculists, both of w h o m had m a d e a diagnosis o f c h r o n i c g l a u c o m a . B o t h oculists wanted to operate on her. W h e n I first saw her, she had a dis tinct g l a u c o m a t o u s disc in each e y e ; her anterior c h a m b e r w a s v e r y shal low, with the pupils m o d e r a t e l y di lated. S c h i ö t z r e c o r d e d 35 m . m . o f f i g . in each eye. H e r b l o o d pressure w a s 180. H e r urine w a s loaded with in dican. U p o n l o o k i n g her o v e r for the "three T s " I found that her t o n g u e w a s heavily coated, her breath foul, and she suffered from constipation. X - r a y of teeth v^as negative. She g a v e a history o f c o n s u m i n g considerable sweets, and w a s in the habit of eat ing meat t w i c e daily and taking a great deal of coffee. I restricted the use of the eyes for close w o r k , and put the patient o n a diet. T h e e x c l u s i o n of h e a v y m e a t s and stimulants, such as tea, coffee, al c o h o l and t o b a c c o is m o s t essential in order to obviate the final need of sur g e r y in these g l a u c o m a cases. E . L y man Fisk'" says that it is a p o o r c o m pliment to the h u m a n race to say that life is unlivable w i t h o u t a l c o h o l , to b a c c o , coffee and tea. A l s o w i t h this patient I used Pilocarpin nitrat, o n e • per cent three times daily, h o t bath ing for the e y e s three times daily, and a h o t bath at bed time. I also g a v e her a vial o f bacillus bulgaricus three times daily after meals, and careful attention w a s g i v e n to evacuation of the bowels every day. In addition to this the c o l o n w a s t h o r o l y emptied o n c e a w e e k b y an enema of water at b l o o d heat. T h i s regimen has been kept up for ten years, with practically n o loss o f vision and o n l y a slight i m
123
pairment o f the fields. Is n o t such a m e t h o d as this far preferable to an o p eration on a patient o v e r 70 y e a r s of age? L e t me g i v e o n e m o r e e x a m p l e of c h r o n i c simple g l a u c o m a w h i c h is m o s t interesting. T h e patient, also a w o m a n , age 45, w a s o p e r a t e d u p o n for c h r o n i c g l a u c o m a b y o n e of o u r well k n o w n s u r g e o n s . W h e n I first s a w her three years a g o , I l o o k e d at her e y e s and s a w that she had had a p r o p e r opera tion performed, but the v i s i o n re mained v e r y p o o r . She c a m e to m e t o b e treated for headaches, and pain in her g o o d e\'e. I found the anterior chamber very shallow. T h e tension w a s up. U p o n l o o k i n g her o v e r for the "three T s " the X - r a y of the teeth revealed abscesses at the r o o t s of eight of her teeth. T h e r e is n o t h i n g that can d e s t r o y bacterial life in the pus sacs at the r o o t s of infected teeth e x cept extraction, so we had her infected teeth r e m o v e d . H e r tonsils had already been r e m o v e d . H e r t o n g u e w a s heav ily coated, her breath w a s foul and she w a s suffering from constipation. M o r e o v e r , her urine w a s l o a d e d with indican. H e r W a s s e r m a n n w a s nega tive. I placed her o n the " r e f o r m diet" and the usual treatment for glau comatous eyes. I g a v e her Bacillus acidophilus. W c k n o w that Bacillus a c i d o p h i l u s is the p r o t e c t i v e o r g a n i s m of the intestinal tract. E g g s t o n and N o r m a n ^ ' have p r o v e d that b e y o n d question. I g i v e the B. A . for o n e month at a time, and then I g i v e small d o s e s of iodin for o n e m o n t h at a time t o maintain the endocrin balance. This iodin treatment, which was first b r o u g h t to m y attention b y A . J. Q u i m b y , ' * is s o valuable that I g i v e the formula. ^ I o d i n crystals Gr X X X A m m o n i a iodid Gr X X Alcohol 7, IV Glycerin q. s. o I M i s c e et s i g n a : o n e d r o p in glassful o f water once daily. F o r patients w h o have been travel ling the road of t o x e m i a for years, and w h e r e the toxins have been accu m u l a t i n g in the b l o o d , small d o s e s o f iodin are e x c e e d i n g l y valuable. A s the
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GEORGE Η. B E L L
result of this treatment this patient has normal vision and normal fields after three years. N o effort had been m a d e in this case to i m p r o v e the quality o f the b l o o d stream, until she c a m e under m y observation. O f c o u r s e I operate for g l a u c o m a when I find it is necessary—that is w h e n the treatment w h i c h I have out lined is not effective. This, however, is rarely the case. I had a chemical examination of the b l o o d made in six of these g l a u c o m a cases. In four of the six cases, the b l o o d chemistry s h o w e d uric acid c o n t e n t a b o v e normal. The uric acid ranged from 4.5 to 6 m g . per 100 c c . of b l o o d . According t o ' D ^ N i o r d and Bixb\-, when the b l o o d chemistry reveals uricacidemia, that is e n o u g h t o justify a d i a g n o s t i c finding, indicating a c h r o n i c infection s o m e w h e r e in the b o d y . I maintain that in all c h r o n i c simple g l a u c o m a s , w e should insist upon a chemical b l o o d test for uric acid. This general routine treatment which I advocate in glaucoma cases is also car ried out by me in all diseases of the eye, such as episcleritis and deep scleritis, retinitis, optic neuritis, eczema o f the lids, herpes febrilis, herpes zoster, edema of the lids, toxic amblyopia, immature cataracts, both hard and soft, choroidi tis, keratitis o f all forms, chronic con junctivitis and blepharitis, iridocyclitis, plastic iritis, chronic uveitis, recurrent hemorrhages in the \'itreous body, sym pathetic ophthalmia, migraine, a n g i o neurotic edema and papilledema. Of course, in conjunction with this general routine treatment, the necessary local remedies f o r the eyes must be used. Salvarsan and inunctions o f mercury and tuberculin are also added when indicated and necessary. In chronic conditions o f the eye, where the tuberculin test is posi tive, I find myself giving less and less tuberculin, and relying more and more upon fresh air, sunshine, exercise, my "reform diet" and the iodin treatment, as well as close attention to the sanitary con dition of the colon. CHOROIDITIS.
Several well k n o w n oculists have recently reported cases of choroiditis.
keratitis and episcleritis cured as a re sult of the diet. I have any n u m b e r of such cases a m o n g m y r e c o r d s . T h e r e is one case of exudative c h o r o i d i t i s in a y o u n g Federal B o a r d student, aged 24, of Λvhich I w o u l d like t o speak. H i s t o r y as f o l l o w s : T h e sight o f O . S. \vas lo>t in France, as a result of shell e x p l o s i o n , O . D . vision 10/200. O n e x a m i n i n g his eye with the o p h t h a l m o s c o p e there w a s a large cloud of floating opacities in the vitreous, so thick that the details of the fundus c o u l d not be seen. I ad mitted him to the U . S . P . H . Hospital N o . 38 ( N e w Y o r k P o l y c l i n i c ) w h e r e the W a s s e r m a n n was negative. L o o k ing him o v e r for the "three T . s " I found that his teeth w e r e in fine shape, but his tonsils w e r e filled with ])us. I had his tonsils enucleated, and put him on the reform diet. H o t ajiplications to the eyes for o n e h o u r at a time, three times daily, w e r e g i v e n and also a w e a k solution of atropin w a s used. Careful attention w a s g i v e n daily to c o m p l e t e evacuation of the c o l o n . T h e patient b e g a n to i m p r o v e , and left the hospital at the end o f t w o w e e k s Avith instructions in regard t o diet and enemas. Six m o n t h s later I s a w this patient, and m u c h to m y surprise he had 2 0 / 2 0 vision. O n e x a m i n i n g the vitreous n o floating opacities c o u l d be found, but several patches of c h o r o i d i tis could be seen in the ])eripheral ])οι·tion of the fundus. CONCLUSIONS.
1. After five years e x p e r i e n c e with the " R e f o r m D i e t " I feel that I stand on a firm foundation in r e c o m m e n d i n g it as a therapeutic measure in ophthal mic practice. 2. I agree with Meiler, w h o says that s y m p a t h e t i c o p h t h a l m i a m a y be p r o d u c e d b y e n d o g e n o u s infection, and he adds that the o r g a n i s m s in the b l o o d settle in the tissues of the e y e weakened b y injury, the o r g a n i s m s b e c o m i n g virulent and finally reaching the o t h e r e y e thru the b l o o d stream. I maintain that a house c l e a n i n g p r o c ess is in order in every o b s c u r e c o n d i tion of the eye.
DIET
IN
OPHTHALMIC
3. A l i m e n t a r y t o x e m i a is b e y o n d question responsible for a large percentage of diseases of the e y e . T h e relation of f o o d ingested to alimentary t o x e m i a is v e r y important. Most p e o p l e eat far t o o m u c h and m i g h t with a d v a n t a g e eat v e r y m u c h less. T h i s idea should be c o n s t a n t l y kept in mind b y every o i ) h t h a l m o l o g i s t . 4. In acute and c h r o n i c diseases of the eye, w o u l d it not help matters materially if w e adopted measures, such as a " R e f o r m D i e t " , the s y s t e m a t i c
THERAPEUTICS
12Í.
r e m o v a l of ascertainable foci of infection and the closest attention to the sanitary c o n d i t i o n o f the c o l o n , w i t h a v i e w to r e m o v i n g the t o x i c c o n d i t i o n of the b l o o d ? 5. W h e n a man like M c C o l l u m says that a diet c o m p o s e d of milled cereal p r o d u c t s , m u s c l e meats, p o t a t o e s and sugar is a failure in animal experim e n t a t i o n , and is also p r o v i n g a failure in h u m a n e x p e r i e n c e , then I think it is high time that we " S T O P — L O O K —and L I S T E N . "
REFERENCES. 1. 2. 3. 4. 5. 6. 7. 8. 9 10. 11. 12. 13. 14. 15. 16. 17.
18.
Bell, G. H . Relations of Teeth, Tonsils a n d Intestinal T o x e m i a s to Diseases of the E y e . J. A . M . Α . , October 1921, p. 1131. Libman, Ε . A c u t e Bacterial Endocarditis. Brit. M e d . J., 1920, p. 306. Behan, J. L. F u n d u s Changes in Nephritis. J. A . M . .A.., June 1922, p. 1692. Olmstead, W . D . Focal Infections in Relation to E v e Diseases. J. M e d . Soc. N . J., June 1922. M c C o l l u m , E. V . T h e N e w e r K n o u l e d g s of Nutrition, 2nd edition, p. 409. M a t t h e w s , A . P. Physiological Chemistry, 3rd edition, p. 399. Sherman, H . C . Chemistry of F o o d and Nutrition, 2nd edition, p. 97. H a r e , Francis. T h e F o o d Factor in Disease, v. I, p. 4 1 . Tilden, J. H . F o o d , v. I, p. 24. Decks, W . E . Gastric and D u o d e n a l Uc:vs. N . Y . M e d . Journal, 1912, p. 1103. M c C o l l u m and S i m m o n d s . T h e Potcncv of Commercial V i t a m i n Preparations. J. A . M. Α . , June 1922, p. 1945. Lieb, C. W . O x a l i c A c i d Production in Colon in Disease Causation. N. Y . Med. Journal and Medical Review, June 1923. Bloch, C. E . E v e Diseases and O t h e r Disturbances in I n f a n t s f r o m Deficiency of Fat in Food. Cited f r o m J. A . M . Α . , 1917, p. 1516. M c C a r r i s o n , R . Faulty F o o d in Relation to Gastrointestinal Disorder. J. A , ML Α . , Jan. 1922. Fuchs, Ε . O c u l a r Manifestations of Internal Secretions. A r c h . O p h . , Julv 1922, p. 311. Fish, E . L . Preventable Diseases of A d u l t L i f e . N . Y . State M e d . J., Dec. 1921. N o r m a n , N . P., and E g g s t r o n , A . A . A N e w Technique for Preparation of Bacillus .Acidophilus M i l k and Its Therapeutic V a l u e . N . Y . State M e d . J. and M e d . R., June 1922. Q u i m b y , A . J.
Physiological
Iodine.
N.
V . M e d . J. and M e d . R., Dec. 1922.