Benedict, F. G.: The Factors Affecting Normal Basal Metabolism, Proc. Nat. Acad. Sc., 1915, I, p. 105.

Benedict, F. G., and Smith, H. M.: The Influences of Athletic Training upon Basal Metabolism, Proc. Nat. Acad. Sc., 1915, I, p. 102.

Benedict, F. G., and Emmes, L. E.: A Comparison of the Basal Metabolism of Normal Men and Women, Proc. Nat. Acad. Sc., 1915, I, p. 104.

Benedict, F. G., and Cathcart, Edward P.: Muscular Work, Carnegie Institution of Washington, D. C., 1913.

Bryce, Alexander: Modern Theories of Diet, New York, Longmans, Green & Company, 1912; London, Edward Arnold, 1912.

Cannon, Walter B.: Bodily Changes in Pain, Hunger, Fear and Rage, D. Appleton & Company, New York and London, 1915.

Chittenden, Russell H.: Physiological Economy in Nutrition, Frederick A. Stokes & Company, New York, 1904.

Chittenden, Russell H.: The Nutrition of Man, Frederick A. Stokes & Company, New York, 1907.

Editorial: Newer Aspects of Metabolism, Jour. A. M. A., 1915, LXIV, p. 1327.

Fisher, Irving: A Graphic Method in Practical Dietetics, Jour. A. M. A., 1907, XLVIII, pp. 1316-1324.

Fisher, Irving: The Effect of Diet on Endurance, Transactions of the Connecticut Academy of Arts and Sciences, 1907, XIII, pp. 1-46.

Fisk, Eugene Lyman: A Sensible Diet for the Average Man and Woman, New York Medical Journal, July 4, 1914.

Gephart, F. C., and Lusk, Graham: Analysis and Cost of Ready-to-Serve Foods, Press of the American Medical Association, Chicago, 1915.

Gouraud, F. X.: What Shall I Eat? Rebman Company, New York, 1911.

Hall, Winfield S.: Nutrition and Dietetics, D. Appleton & Company, New York and London, 1910.

Higgins, Robert: Is Man Poltophagic or Psomophagic? The Lancet, London, 1905, I, pp. 1334-1337.

Hindhede, M.: What to Eat and Why, Ewart, Seymour & Company, Ltd., London, 1914.

Hutchison, Robert: Food and the Principles of Dietetics, William Wood & Company, New York, 1911, third edition.

Kinne, Helen, and Cooley, Anna M.: Foods and Household Management, The Macmillan Company, New York, 1914.

Lusk, Graham: The Elements of the Science of Nutrition, W. B. Saunders & Company, Philadelphia and London, 1909, second edition.

Mendel, Lafayette B.: The Relation of Foodstuffs to Alimentary Functions, Amer. Jour. of Med. Sciences, 1909, CXXXVIII, pp. 522-526.

Pavlov, I. P.: The Work of the Digestive Glands, Charles Griffin & Company, Ltd., London, 1910, second English edition, translated by W. H. Thompson.

Rose, Mary Swartz: A Laboratory Hand-Book for Dietetics, Macmillan & Company, New York and London, 1914.

Sherman, H. C.: Chemistry of Food and Nutrition, The Macmillan Company, New York, 1913.

Sherman, H. C.: Food Products, The Macmillan Company, New York, 1914.

Stiles, Percy Goldthwaite: Nutritional Physiology, N. B. Saunders Company, Philadelphia and London, 1912.

Tigerstedt, Robert: A Text-Book of Human Physiology, D. Appleton & Company, New York and London, 1906, third German edition, translated by John N. Murlin.

Taylor, Alonzo Englebert: Digestion and Metabolism, Lea & Febiger, Philadelphia and New York, 1912.

Von Noorden, Carl: Metabolism and Practical Medicine, William Heinemann, London, 1907.



SECTION II

NOTES ON OVERWEIGHT AND UNDERWEIGHT

How many people after age 35 have a conformation of body that is in accord with proper ideals of health and symmetry? The average individual, as age progresses, gains weight until he reaches old age, when the weight usually decreases.

This movement of weight is so universal that it has been accepted as normal, or physiological, whereas it is not normal, and is the result of disease-producing and life-shortening influences.

The standards for weight at the various ages and heights have been established by life insurance experience, but these standards, which show an increase in weight as age advances, by no means reflect the standards of health and efficiency. They merely indicate the average condition of people accepted for life insurance, whose death rate—while covered by life insurance premiums—is yet far above that obtaining among people of the best physical type, who live a thoroughly hygienic life.

MEN OVER AVERAGE WEIGHTS Experience of 43 American Companies 1885-1908.[G] Number of Policyholders 186,579 - - - - - Ages Overweight Overweight Overweight Overweight at 5 to 10 lbs. 15 to 20 lbs. 25 to 45 lbs. 50 to 80 lbs. Entry - - - - - Death Death Death Death Death Death Death Death Rate Rate Rate Rate Rate Rate Rate Rate Below Above Below Above Below Above Below Above Std.[H] Std. Std. Std. Std. Std. Std. Std. - - - - - - - - - 20-24 4% ... 4% ... ... 1% ... 3% 25-29 7 ... 10 ... ... 12 ... 17 30-34 1 ... 14 ... ... 19 ... 34 35-39 0 ... ... 1% ... 31 ... 55 40-44 6 ... ... 10 ... 40 ... 75 45-49 ... 3% ... 9 ... 31 ... 51 50-56 ... 2 ... 21 ... 24 ... 49 57-62 ... 2 ... 25 ... 12 ... 38 - - - - - - - - -

The heaviest mortality (75 per cent. above the standard), is found among those aged 40 to 44 who are 50 to 80 pounds overweight.

[G] Medico-Actuarial Mortality Investigation, Volume II, page 13, compiled and published by The Association of Life Insurance Medical Directors and The Actuarial Society of America.

[H] The standard death rate is that experienced by average insurance risks of the same age, according to the Medico-Actuarial Committee.

It seems reasonable to deduce from these figures that the usual gain in weight with advancing years is not an advantage but a handicap. We should endeavor to keep our weight at approximately the average weight for age 30, the period of full maturity, as experience shows that those so proportioned exhibit the most favorable mortality. This weight, for the various heights, is shown in the following table:

AGE 30 MEN Height. Pounds. Height. Pounds. Height. Pounds. - - - Ft. In. Ft. In. Ft. In. 5 126 5 7 148 6 1 178 5 1 128 5 8 152 6 2 184 5 2 130 5 9 156 6 3 190 5 3 133 5 10 161 6 4 196 5 4 136 5 11 166 6 5 201 5 5 140 6 172 .......... ......... 5 6 144 ....... ...... .......... .........

AGE 30 WOMEN Height. Pounds. Height. Pounds. Height. Pounds. - - - Ft. In. Ft. In. Ft. In. 4 8 112 5 2 124 5 8 146 4 9 114 5 4 127 5 9 150 4 10 116 5 4 131 5 10 154 4 11 118 5 5 134 5 11 157 5 120 5 6 138 6 161 5 1 122 5 7 142 .......... .........

In fat people, the number of working cells is relatively less in proportion to the weight than in thin people, as fat cells do not work. Also, there is less body surface exposed in proportion to the body weight, and consequently less heat loss. Likewise, fat people are less active, and their little cell-engines do not call for so much fuel; but in most cases the fuel is furnished right along in the ordinary diet, and what is not burned up is stored up.

[Sidenote: Diet for Overweight]

For extreme overweight, diet should be prescribed accurately by the physician to suit the needs of each individual case. Certain general principles may be stated, however, as applicable to the average case.

Meals should be light and frequent, rather than hearty and infrequent. A little fruit may be taken on rising and a glass of hot water.

A light breakfast is advisable; one or two poached eggs, no sugar, bread and butter in small quantity.

For dinner, choice may be made of chicken, game, lean meat, fish not cooked in fat, in moderate portions, and of such vegetables as celery, spinach, sea-kale, lettuce, string beans, cucumbers, carrots, tomatoes, cabbage, Brussels sprouts, turnips, bulky vegetables of low food value. Tapioca or similar pudding may be used for desserts, and melon, and other cooked unsweetened fruits.

A glass of hot water on retiring is advisable.

It is surprising what an enormous fuel value certain foods have which are eaten very carelessly, and what a very low fuel value others have which are quite satisfying to hunger. For example: One would have to eat $9.00 worth of lettuce and tomato salad to furnish 2,500 calories, the amount of fuel for the day's requirements (Lusk), while about 30 cents' worth of butter, or 10 cents' worth of sugar would furnish the same amount of energy. No one would think of feeding exclusively on any one of these foods, but it is easy to see how the elimination of butter and sugar and the introduction of such foods as lettuce, tomatoes, celery, carrots, spinach and fruits, all of which have a low fuel value, would enormously reduce the available energy and therefore the fat-forming elements in the diet, yet fill the stomach and satisfy the hunger-craving. Hunger is largely dependent upon the contractions of the empty stomach and not upon a general bodily craving for food.

[Sidenote: Fat Forming Foods That Should, as a Rule, be Avoided by Overweights]

Foods to avoid, in cases of overweight, are sugar, fats, milk as a beverage, salmon, lobster, crabs, sardines, herring, mackerel, pork and goose, fat meats, nuts, butter, cream, olive oil, pastry and sweets, water at meals. Alcohol, which is not a food, although often so called, should be avoided, as it is a fuel. It is good to burn in a stove, but not in the human body.

[Sidenote: Exercise for Overweight]

Walking, swimming, golf, billiards, hill-climbing, are all beneficial forms of exercise for the middle-aged and elderly, who are chiefly affected by overweight.

Irksome and monotonous forms of exercise, while difficult to follow regularly, are usually of more benefit, as they are less likely to create an appetite. Simple exercises, if repeated from twenty to forty times, night and morning, will accomplish much. No apparatus is required, and any movements that bring into play the entire muscular system, and especially the muscles of the trunk, with deep breathing, are sufficient. (See "Setting-up" exercises described in the "Notes on Posture," page 221.) The main reliance should be upon dietetic regulation rather than upon exercise. A very moderate increase of exercise and a persistent adherence to a proper diet will work wonders in weight reduction.

[Sidenote: Avoidance of Sudden Reduction]

It is unwise to attempt a sudden reduction in weight. Profound nervous depression may be caused by too rapid reduction in people of nervous temperament, especially if they have long been overweight. By gradually modifying the diet and moderately increasing the exercise, the results can be obtained with mathematical precision and without undue hardship. It may be necessary to forego certain pet dietetic indulgences, but such indulgences, are, after all, a mere matter of habit and a liking for new forms of food can usually be acquired. One can not have the cake and penny too. One can not safely reduce one's weight by any mysterious method that will leave one at liberty to continue the indulgences, whether of sloth or of appetite, that are responsible for its accumulation.

[Sidenote: Summary]

The reduction of weight is really a very simple matter. No mysterious or elaborate "systems" or drugs are needed.

If a reduction in the amount of energy food and an increase in the amount of exercise is made, no power on earth can prevent a reduction in weight.

Even a sedentary worker uses up about 2,500 calories a day. By reducing the food to 1,200 calories (this can be done without decreasing its bulk) and increasing the exercise to the point of burning up 3,000 calories, the tissues are drawn upon for the difference, and a reduction in weight must be experienced just as surely as a reduction in a bank account is made by drawing checks on it.

MEN—UNDER AVERAGE WEIGHT

Experience of 43 American Companies Duration of Experience, 1885-1908 Number of Policyholders, 530,108[I]

+ - Underweight, Underweight, Underweight, 5 to 10 lbs. 15 to 20 lbs. 25 to 45 lbs. Ages - -+ - -+ - at Death Death Death Death Death Death Entry. Rate Rate Rate Rate Rate Rate Below Above Below Above Below Above Std.[J] Std. Std. Std. Std. Std. + -+ - -+ - -+ - 20-24 ... 7% ... 15% ... 34% 25-29 1% ... ... 8 ... 16 30-34 ... 4 ... 0 ... 8 35-39 9 ... ... 3 ... 2 40-44 15 ... 13% ... 3% ... 45-49 3 ... 1 ... 11 ... 50-56 10 ... 8 ... 9 ... 57-62 7 ... 18 ... 19 ... + -+ + + -

[I] Medico-Actuarial Mortality Investigation, Volume 11, page 10.

[J] The standard death rate is that experienced by average insurance risks of the same age, according to the Medico-Actuarial Committee.

The most favorable mortality (19 per cent. below the average) is found among those aged 57 to 62 who are extremely light in weight, compared with the average weight for those ages. The next lowest mortality in any other age group (15 per cent. below the average) is among those aged 40 to 44 who are 5 to 10 pounds under the average weight.

[Sidenote: Diet for Underweight]

Thin people lose heat more readily than stout people, as they have a larger percentage of active tissue and expose more skin surface in proportion to the body weight. They require, therefore, an abundant supply of energy food, or fuel foods, fats, starch and sugar. Butter and olive oil are better than other fats and less likely to disturb the digestion. Sugar is a valuable fuel food, but should not be taken in concentrated form into an empty stomach. Sweets are best taken at the end of a meal, but in such cases the teeth should be well cleansed. Fruit at the end of a meal tends to prevent any injury to the teeth from sugar and starches.

Potatoes, cereals, bread and all starchy vegetables are fattening, but should be well chewed and tasted before swallowing. Thin, anemic people derive much benefit from egg lemonade or egg-nogs (without alcohol) made from the yolks, which contain fat, iron and other valuable elements.

[Sidenote: Exercise for Underweight]

Overfatigue and exhausting physical exertion should be avoided.

Moderate systematic exercises, with deep breathing, and sleeping out of doors, or approaching as near to it as one can, are advisable. At middle life and after, underweight, unless extreme or accompanied by evidence of impaired health, should not give any concern. Other things being equal, the old motto "A lean horse for a long race," holds good.



SECTION III

NOTES ON POSTURE

[Sidenote: Corrective Exercises for Faulty Posture]

Among simple exercises recommended for strengthening the abdominal muscles and restoring the organs to normal position are the following:

Lie flat on the back and rise to a sitting posture; squat until the thighs rest upon the calves of the legs. Lie flat on the back, head downward on an inclined plane (an ironing board, uptilted, will do) and make a bridge at intervals by arching the abdomen and resting on shoulders and heels.

From the fundamental standing posture described in this section, a number of exercises can be developed.

1. Yard-arm.—While deeply inhaling (through the nose) slowly raise the arms to horizontal position, straight out from the sides; let the arms fall slowly to the sides while exhaling. The chest should be well arched forward, hips drawn backward and arms hung back of thighs while performing this exercise.

These movements should be performed at the rate of about 10 per minute.

3. Tree-swaying.—While in the standing position, thrust the arms straight above the head, then sway from side to side, moving from the hips upward, the arms loosely waving like the branches of a tree. (Sargent.)

4. Leg-lifting.—Assume the standing position, but with hands resting on the hips. Raise the right thigh until at right angles with the body, leg at right angles with thigh, thrust the leg straightforward to a horizontal position, then sweep the leg back to standing posture. Repeat with the left leg. (Sargent.)

5. Signal Station.—Assume the standing posture with hands on hips. Thrust the right arm straight upward, while lifting the left leg outward and upward and rigidly extended. Lower the limbs and repeat on other side. (Sargent.)

6. Crawling Position.—Rest on hands and knees, thighs and arms at right angles to the body, spine straight. Reach forward with arm and follow with thigh and leg of same side; repeat on other side. Knee protectors can be worn during this exercise.

[Sidenote: Corrective Exercises for Flat Foot]

Draw two parallel chalk lines about three-fourths the length of one foot apart and practise walking on them until the habit of toeing straight is acquired.

When standing, do not keep the heels together and toes out, as in the ordinary attitude prescribed by athletic manuals, and the military attitude of "attention." Correct posture is more like the military attitude "at rest"—namely, heels apart, toes straight forward, the sides of the feet forming two sides of a square. This attitude gives stability and poise and insures a proper distribution of the weight of the body upon the structures of the feet.

This straightforward direction of the feet with heels apart is also noted in Spartan sculpture.

Those who stand a great deal should avoid distorted positions, such as resting the weight on the sides of the feet, or on one foot with the body sagging to one side. The body weight should be kept evenly supported on both feet.

[Sidenote: Consult Specialist]

When the condition of flat foot is found, the advice of an Orthopedic surgeon (specialist on bone deformities, etc.) should be sought, as often a plaster cast of the foot is required in order that a proper brace be adjusted to assist in the cure. In some cases, operative treatment may be needed.

The condition is one which should be treated by a physician or surgeon, and not by a shoemaker. The ordinary arch supports supplied by shoemakers do not cure flat foot. Shoes for such feet should be made to order, and have a straight internal edge.

All such measures must be supplemented by proper exercises, and the correction of faulty position of the feet while walking.

Unless "toeing out" is corrected by exercise and a proper shoe, an arch brace will do more harm than good.

The disturbances of health due to weak feet are manifold, just as are those due to eye-strain. Pain in the feet, legs and back, often mistaken for rheumatism, and improperly treated with drugs and liniment, chronic general fatigue and nervous depression are often due to this rather common affection.

[Sidenote: Detecting Weak Feet]

To detect weak feet, note whether there is a tendency to toe out when walking, and a bending inward of the ankles when standing or walking, or a disposition to walk on the inner side of the feet, as shown by the uneven wearing of the shoe. This condition may be present with a high instep, and no evidence of flat foot. As flat foot develops the inward bend of the ankle is easily apparent. The inner hollow of the foot disappears and the entire sole rests flat upon the ground when the shoes are removed.

The earlier in life this condition of weak feet is detected, the better for the individual. After middle life, a cure, especially in extremely heavy people, may be difficult or impossible, if the arches are completely broken down. Much relief, however, can be afforded by proper braces, fitted scientifically, by means of a plaster cast.

In young people, a cure can almost invariably be effected, and after a time braces and supports are not needed.

It is a very grave mistake to suppose that in such cases so-called arch supports will either cure flat foot or that people with weak feet are necessarily condemned to wear such supports throughout life.

The cure is sometimes effected in a short time, but it may take a year or two, and with proper management it can usually be accomplished, unless there is some unusual complication.

The prevention of flat foot consists largely in affording due exercise of the leg and foot muscles and tendons by plenty of walking and running, especially in childhood, and especially on rough ground. Flat pavements are, indirectly, one cause of flat foot.



SECTION IV

NOTES ON ALCOHOL

The influence of alcohol on longevity can be most satisfactorily determined by the records of life insurance companies wherein the death-rates among those abstaining from alcohol have been computed as compared to those of the general class of insured lives. In considering such figures it is well to bear in mind that the general or non-abstaining class comprises only those who were accepted as standard healthy risks and so far as could be determined were moderate in their use of alcohol. Such experiences have been carefully compiled by the following companies:

United Kingdom Temperance and General Provident Institution of London;[1][K] The Sceptre Life;[2] The Scottish Temperance Life of Glasgow;[3] The Abstainers and General Life of London;[4] The Manufacturers' Life of Canada;[5] Security Mutual Life of Binghamton, N. Y.[6]

[K] The notes ("[1]" etc.) refer to the publications listed at the close of the section.

[Sidenote: Comparative Mortality Among Abstainers and Non-Abstainers]

The comparative mortality among abstainers and non-abstainers in several of these companies is shown in the charts exhibited in this section.

It is probable that the heavier mortality among non-abstainers as compared to abstainers is not wholly due to the chemical effect of alcohol on the tissues, but in some degree to collateral excesses (especially those resulting in infection from the diseases of vice) and a more careless general manner of living engendered by alcoholic indulgence; that, furthermore, those who indulge in so-called moderation are open to greater temptation to increased indulgence and final excess than those who abstain altogether.

It has often been alleged, however, that the lower mortality among abstainers was due solely to a more conservative habit of living, and that this class is largely composed of people in favorable or preferred occupations, such as clergymen and teachers.

The experience of the Security Mutual of Binghamton, N. Y., does not support such a postulate. During a twelve years' experience the mortality among the abstainers was one-third that of the tabular expectation, and their occupations were classified as follows:

Clergymen 4 per cent. Farmers 19 " " Clerks 15 " " Miscellaneous (earning $15 to $25 per week) 62 " "

Mr. Roderick McKenzie Moore, Actuary of the United Kingdom Temperance and General Provident Institution,[7] has this to say regarding the abstainers' class in that company:

The total abstainer class was not "nursed" or favored to produce a low mortality. So far as could be determined (and many of the risks came in personal contact with the officers) they were of the same general class as the non-abstainers. They were written by the same group of agents, for the same kind of policies, for the same average amounts, and were in the same general walks of life, and of the same general financial condition. They were almost equal in numbers to the general class and did not form a small high grade section of the policyholding body. On the contrary, greater care was exercised in the selection of the non-abstainers because of the less favorable experience anticipated on them, and many borderline risks were accepted in the abstaining class because of a feeling that their abstinence would neutralize some unfavorable factor.

UNITED KINGDOM TEMPERANCE AND GENERAL PROVIDENT INSTITUTION OF LONDON HEALTHY MALES—WHOLE LIFE POLICIES 1866-1910



EXPECTED MORTALITY_______100%

NON-ABSTAINERS, RATIO ACTUAL TO EXPECTED MORTALITY........ 91%

[L]ABSTAINERS, RATIO ACTUAL TO EXPECTED MORTALITY—.—.—. 66%

MORTALITY AMONG NON-ABSTAINERS—STANDARD RISKS—37.7% HIGHER THAN AMONG ABSTAINERS

[L] THAT IS, WHERE—ACCORDING TO THE MORTALITY TABLES UPON WHICH PREMIUMS ARE BASED—100 WERE EXPECTED TO DIE, ONLY 66 ACTUALLY DIED.

* * * * *

SCEPTRE LIFE ASSOCIATION OF LONDON WHOLE LIFE POLICIES 1884-1911



EXPECTED MORTALITY_______100%

NON ABSTAINERS, RATIO ACTUAL TO EXPECTED MORTALITY........ 80%

ABSTAINERS, RATIO ACTUAL TO EXPECTED MORTALITY—.—.—.—. 52%

MORTALITY AMONG NON-ABSTAINERS—STANDARD RISKS—51.8% HIGHER THAN AMONG ABSTAINERS

THE LIFE EXTENSION INSTITUTE, INC.

* * * * *

THE SCOTTISH TEMPERANCE LIFE ASSURANCE CO. OF GLASGOW HEALTHY MALES—WHOLE LIFE POLICIES 1883-1912



EXPECTED MORTALITY_______100%

NON-ABSTAINERS, RATIO ACTUAL TO EXPECTED MORTALITY........ 66%

ABSTAINERS, RATIO ACTUAL TO EXPECTED MORTALITY—.—.—.—. 48%

MORTALITY AMONG NON-ABSTAINERS—STANDARD RISKS—43.5% HIGHER THAN AMONG ABSTAINERS

* * * * *

COMPARATIVE MORTALITY AMONG USES OF ALCOHOL 43 AMERICAN LIFE INSURANCE COMPANIES 1885-1908

DEATH RATE AMONG INSURED LIVES GENERALLY MEDICO ACTUARIAL TABLE 100

DEATH RATE AMONG POLICYHOLDERS USING 2 GLASSES OF BEER OR 1 GLASS OF WHISKEY DAILY 118

DEATH RATE AMONG POLICYHOLDERS GIVING HISTORY OF PAST INTEMPERANCE, BUT APPARENTLY CURED 150

DEATH RATE AMONG POLICYHOLDERS USING MORE THAN 2 GLASSES OF BEER OR 1 GLASS OF WHISKEY DAILY, BUT, REGARDED AS TEMPERATE & STANDARD RISKS 186

* * * * *

Now that accurate laboratory evidence is available regarding the physiological effect of alcohol in so-called moderate doses the insurance experience seems consistent, and the higher mortality among so-called moderate drinkers is only what we would naturally expect to find in the light of the most recent knowledge regarding its effects upon the human organism, not only in the direct causation of disease, but in lowering the defense to disease and increasing the liability to accident, and the tendency to careless living.

[Sidenote: Medico-Actuarial Mortality Investigation]

In the recent medico-actuarial investigation[8], including forty-three American life insurance companies, the combined experience on users of alcohol has been compiled, with very interesting results. It may be subdivided as follows:

First: Those who were accepted as standard risks but who gave a history of occasional alcoholic excess in the past. The mortality in this group was 50 per cent. in excess of the mortality of insured lives in general, equivalent to a reduction of over four years in the average lifetime of the group.

Second: Individuals who took two glasses of beer, or a glass of whisky, or their alcoholic equivalent, each day. In this group the mortality was 18 per cent. in excess of the average.

Third: Men who indulge more freely than the preceding group, but who were considered acceptable as standard insurance risks. In this group the mortality was 86 per cent. in excess of the average. In short, we find the following increase of mortality over the average death rate among insured risks generally:

Steady moderate drinkers but accepted as standard risks 86 per cent. Having past excesses 50 " " Very moderate drinkers 18 " "

This means that steady drinkers who exceed two glasses of beer or one glass of whisky daily are not, on the evidence, entitled to standard insurance, but should be charged a heavy extra premium.

In these groups, the death rates from Bright's disease, pneumonia and suicide were higher than the normal.

[Sidenote: Consumption of Alcohol]

The per capita consumption of alcohol has greatly increased in the United States in recent years, while in the United Kingdom it has materially decreased, as shown in the following table. This factor must be considered in assigning a cause for the increasing mortality from degenerative diseases in this country as compared to a decreasing mortality from these maladies in Great Britain.

ANNUAL PER CAPITA CONSUMPTION (IMPERIAL GALS.) OF ALCOHOL IN VARIOUS COUNTRIES[9] 1896-1912

1896-1900. 1908-1912. - - Beer. Wine. Spirits. Total. Beer. Wine. Spirits. Total. - - Germany 25.4 1.37 1.66 28.43 22.4 1.09 1.29 24.78 U. K. 31.6 .39 1.05 33.04 26.65 .26 .71 27.62 France 5.5 19.9 1.7 27.1 8.6 24.7 1.42 34.72 U. S. 13.01 .30 .81 14.12 16.62 .52 1.02 18.16 - -

Laboratory and Clinical Evidence Relating to the Physiological Effects of Alcohol

To interpret correctly the mortality statistics relating to moderate drinkers and total abstainers, one must have some knowledge of the physiological effects of alcohol in so-called moderate doses, a knowledge which is often lacking in those who assume to interpret such statistics.

For example: If it could be shown that small doses of alcohol produce no ascertainable ill effects upon the human organism, the higher mortality among the moderate drinkers as compared to total abstainers might have to be explained as due to some as yet unrecognized cause or causes other than alcohol. But if laboratory and clinical evidence shows that alcohol in so-called moderate quantities (social moderation) produces definite ill effects, such as lowering the resistance to disease, increasing the liability to accident and interfering with the efficiency of mind and body and thus lessening the chances for success in life, to say nothing of any toxic degenerative effect upon liver, kidneys, brain and other organs, the excess mortality that unquestionably obtains among moderate drinkers as compared to total abstainers must be ascribed chiefly to alcohol.

It is not possible here to give all the evidence, but the following items will serve to clarify these questions.

[Sidenote: Effect on Brain and Nervous System]

Kraepelin[10] and his pupils have contributed most extensively to our knowledge on this subject. According to such authorities, a half to a whole liter of beer is sufficient to lower intellectual power, to impair memory, and to retard simple mental processes, such as the addition of simple figures. Habitual association of ideas, and free association of ideas are interfered with.

As far back as 1895, Smith demonstrated the influence of small doses of alcohol in impairing memory, and these results have been confirmed by Kraepelin and quite recently by Vogt[11] in experiments on his own person—15 cc. (about 4 teaspoonfuls) of whisky on an empty stomach, or 25 cc. with food, being sufficient to distinctly impair the power to memorize.

Careful and exact experiments have shown the influence of moderate doses of alcohol in lessening the amount of work performed by printing compositors. There has also been shown a disturbance in the sequence of ideas. The time that elapses between an irritation and the beginning of a responsive movement can be measured within one one-thousandth of a second. According to Aschaffenburg,[12] under the influence of even very small doses of alcohol this reaction period is disturbed and shortened. It is below the normal, the acceleration being attained at the expense of precision and reliability. Indeed, the reaction is often premature, and constitutes a false reaction—"the judgment of the reason comes limping along after the hasty action."

It is now conceded that alcohol is not a real brain stimulant, but acts by narrowing the field of consciousness. By gradually overcoming the higher brain elements the activities of the lower ones are released, hence the so-called stimulation and the lack of judgment and common sense often shown by those even slightly under the influence of alcohol. The man who wakes up under alcohol is really going to sleep, as far as his judgment and reason are concerned. Complete abolition of consciousness is brought about by sufficient doses as when ether or chloroform is taken.

Under moderate doses, muscular efficiency is at first increased a little and then lowered, the total effect being a loss in working power, as shown by the experiments of Dubois, Schnyder,[13] Hellsten,[14] and others.

[Sidenote: Influence on Bodily Resistance to Disease]

Muller, Wirgin and others[15] have shown that alcohol restricts the formation of antibodies (the function of which is to resist infection in the blood) in rabbits, and Laitinen[16] has shown that the prolonged administration of small doses in men (15 cc.) is sufficient to lower vital resistance, especially to typhoid fever.

Rubin[17] has demonstrated that alcohol, ether and chloroform, injected under the skin, render rabbits more vulnerable to streptococcus (blood poison) and pneumnococcus infection (pneumonia); Stewart,[18] that small amounts lower the resistance to tuberculosis and streptococcus infection; Craig and Nichols,[19] that moderate doses of whisky were sufficient to cause a negative Wassermann reaction in syphilitic subjects; Fillinger[20] found the resistance of red blood cells much reduced after the administration of champagne to healthy human subjects. Similar results were found in dogs and rabbits.

Weinburg[21] confirmed these results by the same methods, showing that 20 per cent. of the red cells lose their resistance after the administration of 450 cc. of champagne.

Parkinson,[22] in a series of careful tests, failed to establish any influence on phagocytosis (capacity of the white blood cells to destroy bacteria), except when large doses or continuous moderate doses were taken.

[Sidenote: Effect on Circulation]

On the heart and circulation, alcohol acts as a depressant, increasing the rate, but not the force, of the pulse. It causes depression of the nerve center controlling the blood vessels and thus lowers blood pressure. Large doses cause paralysis of these nerves and of the heart.

Miller and Brooks[23] found from small doses (6 to 12 cc. absolute alcohol) an increase in blood pressure in conscious (unanesthetized) animals, contrary to the findings of Crile,[24] Cabot,[25] Dennig,[26] Hindelang and Gruenbaum, Alexandroff[27] and others, in man; but the amounts were small and variable, according to individual susceptibility, thus showing the drug to be, even on such evidence, uncertain and unserviceable as a heart stimulant.

[Sidenote: Food Value]

Atwater and Benedict,[28] and Beebe[29] and Mendel,[30] have shown that alcohol is a "protein sparer," and can, to some extent, take the place of fats and carbohydrates. This is what is meant by calling alcohol a "food." Always, however, it fails to pass some test by which true foods are measured. Apart from its effect on the nervous system, among which must be figured its action on the blood vessels which causes a loss of body heat, Mendel has shown that in moderate doses (96 cc. daily) it increases the output of uric acid and allied (purin) bodies derived from the tissues, a fact which distinguishes it from all other foods. These poisonous or drug effects must always be considered, together with any alleged nourishing effects. Alcohol is still used by some as a rapidly available fuel-food in fevers, and when ordinary foods cannot be readily digested and made available. But this is done to a much less degree than formerly, now that its narcotic and poisonous effects are more fully understood. Sugar and water often serve quite as useful a purpose.

It seems reasonable, on the evidence herein presented, to class alcohol among the narcotic or "deadening" drugs, such as ether or chloroform. Indeed, Aschaffenburg[31] has recently called attention to the growth of the ether habit in eastern Germany, where this drug is used as a so-called stimulant, while in reality the effects are well known to be narcotic, or deadening.

The laboratory and the life insurance records simply give exact expression to what has long been a matter of common knowledge to the employer of labor and to leaders and commanders of men; to wit, that the influence of alcohol on any large group of men, whether they be artisans or soldiers, is harmful and lowers the efficiency of the group. Individual susceptibility varies, but the man who thinks he is an exception and can indulge with safety may find that he is mistaken only after serious damage to the body has been done and perhaps a definite loss sustained in happiness and achievement.

[Sidenote: Effect on Offspring]

Stockard,[32] in his experiments on animals, has demonstrated conclusively that the germ cells of males can be so injured by allowing the subjects to inhale the fumes of alcohol that they give rise to defective offspring, although mated with vigorous untreated females. The offspring of those so treated when reaching maturity are usually nervous and slightly undersize. These effects are apparently conveyed through the descendants for at least three generations. Such evidence establishes at least the probability of the transmission of serious ill effects to human offspring through alcoholic indulgence of the male parent.

Much of the statistical evidence that has been produced on both sides of this question of the transmissibility of the effect of alcohol is misleading unless very critically analyzed, but the results of exact laboratory experiments can hardly be gainsaid.

Those who trifle with alcohol should at least take the precaution to be periodically examined in order to detect the earliest signs of ill-effect. One's own feelings are not safe guides, and may fail to warn of danger until serious damage has been done.

In 1914, at the annual meeting of the National Council of Safety, at which there were present representatives from several hundred large industries, the members unanimously voted to abolish liquor from their plants. It has been well stated by Quensel[33] that "work and alcohol do not belong together, especially when the work demands wideawakeness, attention, exactness and endurance."

The restrictive and prohibitive measures of the French and Russian governments, the well known opposition of the Kaiser to alcohol and the warnings uttered by Lord Kitchener and leading British statesmen, are sufficient evidence that the condemnation of alcohol represents the deliberate judgment of the world's strong men.

REFERENCES

[1] United Kingdom Temperance and General Provident Institution of London, Annual Report, 1910.

[2] Sceptre Life Association, Annual Report, 1912.

[3] Scottish Temperance Life Assurance Company, Annual Report, 1912.

[4] The Abstainers and General Insurance Company, Ltd., Annual Report, 1912.

[5] McMahon, T. F.: The Use of Alcohol and the Life Insurance Risk. Proceedings of the Association of the Life Insurance Medical Directors of America, 1911, Twenty-second Annual Meeting, p. 473; Medical Record, LXXX, p. 1121.

[6] Lounsberry, R. L.: Proceedings of the Life Assurance Medical Directors. October, 1913.

[7] Moore, Roderick McKenzie: On the Comparative Mortality Among Assured Lives of Abstainers and Non-Abstainers from Alcoholic Beverages. Transactions of the Institute of Actuaries, 1913, XXXVIII, pp. 248-272.

[8] Report of Medico-Actuarial Mortality Investigation, IV, pp. 11-13.

[9] Statistical Abstract for the United Kingdom, Sixty-first Number, 1809-1913 (Wyman & Sons), London, 1914, p. 173; Statistical Abstract for the Principal and Other Foreign Countries, 1901-1912, Thirty-ninth Number, pp. 505, 506, 507; Statistical Abstract of the United States, Thirty-sixth Number, 1913, p. 516.

[10] Kraepelin, Emil: Ueber die Beeinflussung einfacher psychischer Vorgaenge durch einige Arzneimittel, Verlag von Gustav Fisher, Jena, 1892; Aschaffenburg, Gustav: Praktische Arbeit unter Alkoholwirkung, Psychologische Arbeiten, 1896, I, pp. 608-626; Kurz, Ernest, and Kraepelin, Emil: Ueber die Beeinflussung psychischer Vorgaenge durch regelmaessigen Alkoholgenuss, Psychologische Arbeiten, 1901, III, pp. 417-457; Mayer, Martin: Ueber die Beeinflussung der Schrift durch den Alkohol, Psychologische Arbeiten, 1901, III, pp. 535-586; Rudin, Ernst: Ueber die Dauer der psychischen Alkoholwirkung, Psychologische Arbeiten, IV, pp. 1-44.

[11] Vogt, R.: Om virkningen af 15-50 cm3 koncentrert spiritus paa erindringsevnen, Norsk. Mag. f. Laegevidensh., 1910, LXXI, pp. 605-626; The Lancet (London), 1910, II, p. 1040.

[12] Aschaffenburg, Gustav: Crime and Its Repression, Little, Brown & Company, Boston, 1913, p. 84.

[13] Schnyder, L.: Alkohol und Muskelkraft, Archiv fuer Physiologie, 1902-3, XCIII, p. 451.

[14] Hellsten, A. F.: Ueber den Einfluss von Alkohol, Zucker und Thee auf die Leistungsfaehigkeit des Muskels, Munchen Med. Wchnschr., 1914, LI, pp. 18-94.

[15] Bastedo, Walter A.: Materia Medica Pharmacology and Therapeutics, W. B. Saunders Company, Philadelphia and London, 1913, p. 333.

[16] Laitinen, T.: The Norman Kerr Lecture on The Influence of Alcohol on Immunity, Med. Rec., LXXVI, 1909, pp. 445-446. Read before the Twelfth International Anti-Alcoholic Congress, held in London, July, 1909; Uber die Einwirkung der kleinsten Alkoholengen auf die Widerstandsfaehigkeit des tierischen Organismus mit besonderer Beruecksichtigung der Nachkommenschaft, Ztschr. f. Hyg. u. Infections-krankheiten, LVIII, 1907-8, p. 139.

[17] Rubin, George: The Influence of Alcohol, Ether, and Chloroform on Natural Immunity in its Relation to Leucocytosis and Phagocytosis, Jour. Infct. Dis., 1904, I, pp. 425-444.

[18] Stewart, Chas. E.: The Influence of Alcohol on the Opsonic Power of the Blood, Mod. Med., 1907, XVI, pp. 241-246. Read before the American Society for the Study of Alcohol and Drug Neuroses, Atlantic City, June 4, 1907, and published in the Jour. of Inebriety.

[19] Craig, Chas. F., and Nichols, Henry J.: The Effect of the Ingestion of Alcohol on the Result of the Complement Fixation Test in Syphilis, Jour. A. M. A., 1911, LVII, pp. 474-76.

[20] Fillinger, F. V.: Weitere Mitteilungen ueber Resistenzverminderung der Erythrozyten nach Alkoholgenuss, Deutsch. Med. Wchnschr., 1912, XXXVIII, p. 999.

[21] Weinburg, W. W.: The Lowering of Stability of Erythrocytes in Alcoholic Intoxication, Russky Vratch, 1912, II, p. 1324; New York Med. Jour., 1912, XCVI, p. 1040.

[22] Parkinson, P. R.: The Relation of Alcohol to Immunity, The Lancet (London), 1909, VII, pp. 1580-82.

[23] Brooks, Clyde: The Action of Alcohol on the Normal Intact Unanesthetized Animal, Jour. A. M. A., 1910, LV, pp. 372-73. Read in the Section on Pathology and Physiology of the A. M. A. at the Sixty-first Session, St. Louis, June, 1910.

[24] Crile, George W.: Blood Pressure in Surgery, J. B. Lippincott Company, Philadelphia, 1903. Cartwright Prize of the Alumni Ass'n of the College of Physicians and Surgeons, New York City.

[25] Cabot, Richard C.: Studies of the Action of Alcohol in Disease, Especially upon the Circulation, Med. News, LXXXIII, 1903, pp. 145-153. Read before the Association of American Physicians, May 13, 1903.

[26] Dennig, Hindelang und Gruenbaum: Uber den Einfluss des Alkohols auf den Blutdruck und die Herzarbeit in pathologischen Zustaenden, Namentlich beim Fieber, Deutsch. Arch. f. klin. Med., 1909, XCVI, pp. 153-162.

[27] Alexandroff, Emilie: Ueber die analeptische Wirkung des Alkohols bei pathologischen Zustaenden, Cor. Bl. f. schweiz. Aerzte., 1910, XL, pp. 465-475; Action of Alcohol During Febrile and other Pathologic Conditions, Jour. A. M. A., 1910, LV, p. 174.

[28] Atwater, W. A., and Benedict, F. G.: An Experimental Inquiry Regarding the Nutritive Value of Alcohol, National Academy of Science, 1902, Sixth Memoir.

[29] Beebe, L. B.: The Effect of Alcohol and Alcoholic Fluids Upon the Excretion of Uric Acid in Man, Amer. Jour. Physiol., 1904, XII, pp. 13-37.

[30] Mendel, L. B., and Hilditch, Warren W.: The Influence of Alcohol Upon Nitrogenous Metabolism in Men and Animals, Amer. Jour. Physiol., 1910, XXVII, pp. 1-23.

[31] Aschaffenburg, Ibid.

[32] Stockard, C. R.: A Study of Further Generations of Mammals from Ancestors Treated with Alcohol, Proc. Soc. Exper. Biol. and Med., 1914, XI, p. 136.

[33] Quensel, Ulrik: The Alcohol Question from a Medical Viewpoint—Studies in the Pathology of Alcoholism, Year Book, United States Brewers' Association, 1914, p. 168.

* * * * *

Bastedo, Walter A.: Materiel Medico, Pharmacology and Therapeutics, W. B. Saunders Company, Philadelphia and London, 1913, p. 318.

Bertillon, Jacques: On Mortality and the Causes of Death According to Occupations, Proceedings of the Fifteenth International Congress on Hygiene and Demography, Washington, 1912, I, p. 345.

Boos, William F.: The Relation of Alcohol to Industrial Accidents and to Occupational Diseases, Proceedings of the Fifteenth International Congress on Hygiene and Demography, Washington, 1912, I, p. 829.

Cabot, Richard C.: The Consumption of Alcohol and of Other Medicines at the Massachusetts General Hospital, Boston Med. Jour., CLX, 1909, pp. 480-81.

Dixon, W. E.: Alcohol in Relation to Life, The Nineteenth Century, 1910, LXVII, pp. 516, 523.

"Ethyl Alcohol," The Dispensatory of the United States of America, J. B. Lippincott & Company, Philadelphia, 19th edition, p. 102.

Ewald: Alcohol in Relation to Infectious Diseases, Med. Rec., 1913, LXXXIV, p. 75. Read before the Fourth National Congress on Physiotherapy, Berlin, March 26, 1913.

Horsley, Sir Victor: Discussion on Alcohol in Therapeutics, Med. Rec., 1912, LXXI, p. 951. Read before the Hunterian Society.

Hunter, Arthur: Can Insurance Experience be Applied to Lengthen Life? Proceedings of the Association of Life Insurance Presidents, Eighth Annual Meeting, 1914, pp. 27-37.

Kelynak, T. M.: The Drink Problem, London, Methuen & Company, 1907.

Landau, Anastazy: Beitrage zur hehre vom Purinstoffwechsel und zur Frage ueber den Alkoholeinfluss auf die Harnsaureausscheidung, Deutsch. Arch. f. klin. Med., XCV, 1908-9, pp. 280-328.

Miller, Joseph L.: The Physiologic Action, Uses and Abuses of Alcohol in the Circulatory Disturbance of the Acute Infection, Jour. A. M. A., 1910, LV, pp. 2034-2037. Read in the joint session of the Sections of Practice of Medicine and Pharmacology and Therapeutics of the A. M. A., Sixty-first Annual Session, held at St. Louis, June, 1910.

Neff, Irwin H.: The Problem of Drunkenness, Proceedings of the Fifteenth International Congress on Hygiene and Demography, Washington, 1912, IV, p. 510.

Phelps, Edward Bunnell: The Mortality from Alcohol in the United States, Proceedings of the Fifteenth International Congress on Hygiene and Demography, Washington, 1912, Vol. I, p. 813.

Proceedings: Association of Life Insurance Medical Directors, October, 1911.

Report of the Committee of Fifty on: Physiological Aspects of the Liquor Problem, Houghton, Mifflin & Company, two volumes, 1903.

Togel, O., Brezina, E., and Durig, A.: Ueber die kohlenhydratsparende Wirkung des Alkohols, Biochem. Ztschr., 1913, I, 296; Editorial, Jour. A. M. A., 1913, LXI, p. 967.

Williams, Henry Smith: Alcohol, How it Affects the Individual, the Community and the Race, The Century Company, New York, 1909.

Woods, Robert A.: The Prevention of Inebriety: Community Action, Proceedings of the Fifteenth International Congress on Hygiene and Demography, Washington, 1912, IV, p. 517.

Additional Notes on Alcohol

[Sidenote: Nutrition Laboratory Experiments]

There has lately been undertaken at the Nutrition Laboratory of the Carnegie Institution at Washington a very broad and comprehensive study of the effect of moderate doses of alcohol on the healthy and normal human body. The immense scope of the investigation planned may be judged by the fact that under the physiological division of the research, as laid out by Professors Raymond Dodge and E. C. Benedict, there are seven main sections and one hundred and sixty subdivisions. The program has been arranged after conferences, either in person or by letter, with the leading physiologists of the world, and may take ten years to complete.

[Sidenote: Psychological Effects]

The psychological program, carried out with the co-operation of Dr. F. Lyman Wells, has already been completed and the results recently published.[34] These results must be accepted as the testimony of pure science, free from all bias or even remote suggestion of propaganda. They were based upon experiments with moderate doses of alcohol (30 cubic centimeters, or about 8 teaspoonfuls, and 45 cubic centimeters) upon ten normal subjects, very moderate users of alcohol, and may be summarized as follows:

[Sidenote: Lower Levels Spinal Cord]

A very simple reflex act, the "knee-jerk," a nervous mechanism controlled by a center at the lower level of the spinal cord, was markedly depressed, the time of response being increased 10 per cent. and the thickening of the muscles concerned in the act decreased 45 per cent. In some subjects the larger dose, 45 cubic centimeters, practically abolished the knee-jerk.

The eye-lid reflex, elicited by a sudden noise, showed the next largest effect, the time of response being increased 7 per cent. and the degree of movement decreased 19 per cent.

[Sidenote: Higher Levels]

Other nervous mechanisms, or reflex arcs, at the higher levels of the cord, were next investigated: (1) eye-reaction to suddenly appearing stimulus, and (2) speech reaction to visual word stimuli. Dose A (30 cubic centimeters), accelerated the eye-reaction, while dose B (45 cubic centimeters) positively depressed it, agreeing with the simple reaction experiments of Kraepelin. This was the only instance of acceleration of movement of the voluntary muscles through alcohol, all the other tests showing it to be a consistent depressant. The speech reaction showed a positive depressant effect of 3 per cent.

[Sidenote: Memory]

Free association of ideas and memory tests were also made, and showed practically no effect from alcohol, but, unfortunately, the smaller dose only was used in these tests.

The sensitiveness to electrical stimulation was decreased 14 per cent.

Motor co-ordination, as evidenced by eye-movements in fixating seen objects, was next investigated. The velocity of these movements was decreased 11 per cent. Finger-movements, measured in an exceedingly delicate way, were reduced in speed 9 per cent.

[Sidenote: Heart and Pulse]

The effect on the pulse while these tests were made was observed, and electrocardiograms taken. The pulse was found to be accelerated, but not increased in force, that is, the "brake" was taken off the heart, but no driving force supplied by alcohol. The condition of the circulation was impaired by the narcotic effect of alcohol on the cardio-inhibitory center which holds the heart action in check.

[Sidenote: Decreases Organic Efficiency]

According to the investigators, the effect is to "decrease organic efficiency." This should shut off such little debate as still persists with respect to alcohol having any value as a heart stimulant.

[Sidenote: Always a Depressant]

While these investigations only confirm in part the contention of the Kraepelin school that alcohol first acts by depressing the higher centers, and tend to show that its first and most profound effect is on the lower levels of the spinal cord and the simpler nervous mechanisms, it confirms the view of these and other investigators, that the total effect of alcohol is that of a narcotic, depressing drug, even in the smallest doses usually taken as a beverage.

[Sidenote: Resistance of Higher Brain Function]

The possible reactions are more complex than those supposed by Kraepelin, and there is evident in the higher centers (the effect on highest brain functions, were not measured by Dodge and Benedict) a power of "autogenic reinforcement," which is well exemplified by the ability of a half-intoxicated person to sober up under some shock or strong incentive. When social conditions do not stimulate this reinforcement, but, on the contrary, dull and retard it, as in convivial company, there is reinforcement of the lower, more animal mechanisms of the nervous system, and we have exhibited revolting and foolish reactions to alcohol, which are consistent with these findings.

[Sidenote: Explanation of Memory Effects]

The slight effect on memory and free association is explained partly by the methods used in the laboratory (difference in time of recognizing words suddenly exposed a second time), which are more in the nature of "short cuts" and perhaps not so accurate a reproduction of normal memorizing as those employed by Kraepelin and Vogt (memorizing numbers and verse), and partly by the power of "autogenic reinforcement," which it is difficult to eliminate in a laboratory test.

This, the latest contribution of science to the study of alcohol, gives added proof that the higher mortality among so-called moderate users of alcohol is largely due to the unfavorable effect on the protective mechanism of the body.

[Sidenote: Lower Resistance]

This has been further emphasized by the studies of Reich[35] at the University of Munich, who found that the resistance of blood cells to salt solution and to typhoid bacilli was less among alcohol users than among total abstainers.

Konradi[36] has found that comparatively few antibodies against cholera germs develop in persons who consume alcohol daily in fairly large quantities and who had been inoculated against cholera. Pampoukis[37] has observed that alcoholics are not favorable subjects for inoculation against rabies. The Pasteur Institute in Budapest has made similar observations, based on twenty-five years' experience.

Additional References

[34] Benedict, E. C.: The Psychological Effects of Alcohol, The Carnegie Institution, Washington, D. C., 1916.

Benedict, E. C.: The Psychologic Effect of Alcohol on Man, The Journal A. M. A., 1916, lxvi, p. 1424.

[35] Reich, H. W.: Ueber den Einfluss des Alkoholgenusses auf Bakterizidie, Phagozytose und Resistenz der Erythrocyten, beim Menschen, Arch. f. Hyg., 1916, lxxxiv, 337.

[36] Konradi: Ueber den Wert der Choleraschutzimpfungen, Centralbl. f. Bakteriol., I. O., 1916, lxxvii, 339.

[37] Alcohol and Immunity, Jour. A. M. A., 1916, lxvi, p. 962, p. 1122.



SECTION V

NOTES ON TOBACCO

It is the purpose of this section to present as fairly as possible the evidence relating to the effects of tobacco on the human body, so that those who smoke may correctly measure the probable physical cost of the indulgence. The extremes of opinion on this subject are well expressed in the following verses:

"Hail! Social Pipe—Thou foe to care, Companion of my elbow chair; As forth thy curling fumes arise, They seem an evening sacrifice— An offering to my Maker's praise For all His benefits and grace." DR. GARTH.

"A custom loathsome to the eye, hateful to the nose, harmful to the brain, dangerous to the lungs, and the black stinking fume thereof nearest resembling the horrible Stygian smoke of the pit that is bottomless." JAMES I.

[Sidenote: What it Is]

Tobacco is a plant, Nicotiana Tabacum of the order Solanaceae, which includes Atropa Belladonna, or "Deadly Nightshade," Hyoscyamus, or "Henbane," Solanum Dulcamara, or "Bitter Sweet," all powerful poisons, and likewise the common potato and tomato, which are wholesome foods. The cured leaves are used for smoking and chewing, or when powdered, as snuff.

[Sidenote: History]

Prior to the middle of the 16th Century, the use of tobacco was confined to the American Indians. In 1560 the Spaniards began to cultivate tobacco as an ornamental plant, and Jean Nicot, the French Ambassador at Lisbon, introduced it at the court of Catherine de Medici in the form of snuff. Smoking subsequently became a custom which spread rapidly throughout the world, although often vigorously opposed by Governments. In the 17th Century, smoker's noses were cut off in Russia.

[Sidenote: Composition]

Tobacco contains a powerful narcotic poison, nicotin, which resembles prussic acid in the rapidity of its action, when a fatal dose is taken.

The percentage of nicotin present varies according to the brand and the conditions under which it is cultured.

The following figures have been given by the various authorities.

London Lancet[38] .64 to 5.3 per cent. French Dept. of Agriculture[39] .22 to 10.5 " " Connecticut Agricultural Experiment Station[40] 2.89 " " (Home grown—after fermentation.) U. S. Dept. of Agriculture[40] .94 to 5. " " (Domestic.)

Aside from nicotin it also contains small quantities of related substances—nicotellin, nicotein, a camphoraceous substance termed nicotianin, said to give tobacco its characteristic flavor, and likewise a volatile oil developed during the process preparation. On heating, pyridin (a substance often used to denature alcohol), picolin, collidin, and other bases are formed, as well as carbolic acid, ammonia, marsh gas, cyanogen and hydrocyanic acid, carbon monoxide (coal gas) and furfural. Furfural is a constituent of fusel oil, which is so much dreaded in poor whisky. The smoke of a single cigaret may contain as much furfural as two ounces of whisky.

The complex constitution of tobacco and the smoke from its combustion has caused much debate as to the substances that are responsible for its charm and its ill effects, which are to be described. No one can doubt the serious injurious effects from such a powerful poison as nicotin if taken in any but the most minute quantities (one to three milligrams have produced profound poisoning in man).

It has been maintained by some that nicotin is practically destroyed in the process of smoking, and that the effects of tobacco are limited to the decomposition products resulting from the burning tobacco, especially pyridin. But pyridin is also formed in the burning of cabbage leaves, and cabbage leaves do not possess any attractions for smokers, neither do they produce the well-known effects that smoking and chewing tobacco produce. No doubt pyridin and furfural are factors in the drug effects of tobacco, but recent painstaking experiments by high authorities have shown the presence of nicotin in tobacco smoke, and when we reflect that there is sometimes sufficient nicotin in an ordinary cigar to kill two men, it is not strange that enough of it may be absorbed from the smoke passing over the mucous membranes of the nose, throat and lungs to produce a distinct physiological effect.

Investigators who claim to show by experiments the absence of nicotin from tobacco smoke must explain why the palpable effects of smoking, in those who have not established a "tolerance," are those of nicotin poisoning, and why the symptoms produced by chewing tobacco are identical with those following the smoking of tobacco, which are: mild collapse, pallor of the skin, nausea, sweating, and perhaps vomiting, diarrhea, muscular weakness, faintness, dizziness, and rise in blood pressure followed by lowered blood pressure.

Nicotin is undoubtedly decomposed by burning, but it may become volatilized by heat and a certain amount absorbed before decomposition takes place.

Lehmann,[41] in 1908, found in tobacco smoke the following percentages of the nicotin contained in the tobacco:

Cigaret smoke 82 per cent. Cigar smoke 85 to 97 " "

The London Lancet[42] (1912) gives the following figures:

Cigaret smoke 3.75 to 84 per cent. Pipe mixture smoke, smoked as cigarets 79 " " Pipe smoke 77 to 92 " " Cigar smoke 31 to 63 " "

The United States Department of Agriculture[43] found in tobacco smoke about 30 per cent. of the nicotin originally present in the tobacco.

Contrary to general opinion, Havana cigars contain less nicotin than the cheaper brands, which augurs ill for the large class of people who cannot afford to smoke higher priced brands. Many of the cheaper grades do, however, show a low percentage of nicotin.

[Sidenote: Effects on Animals and Man]

By means of an ingenious apparatus, Zhebrovski,[44] a Russian investigator, compelled rabbits to smoke cigaret tobacco for a period of 6 to 8 hours daily. Some died within a month, and showed changes in the nerve-ganglia of the heart. Others established a tolerance similar to that exhibited by habitual smokers, but upon being killed at the end of five months, degenerative changes similar to those produced by the injection of nicotin were found, viz., hardening of the blood vessels. There is, indeed, no difficulty in producing the characteristic effects of nicotin by administering tobacco smoke, either in man or in animals.[45]

Nicotin causes brief stimulation of brain and spinal cord, followed by depression. There is an increased flow of saliva, followed by a decrease (large doses diminish it at once) and often nausea, vomiting and diarrhea. The heart action is at first slowed and the blood pressure increased. Subsequently there is a depression of the circulation, with rapid heart action and lowered blood pressure. In habitual smokers, this preliminary stimulation may not occur. The stimulating effect on the brain is so brief that tobacco can not properly be termed a stimulant. Its effect is narcotic or deadening. Those who fancy that their thoughts flow more readily under the use of tobacco are in the same case with any other habitue whose thoughts can not flow serenely except under his accustomed indulgence. That a sound healthy man, who has never been accustomed to the use of tobacco, can do better mental or physical work with tobacco than without it has never been shown. Indeed, such experiments as have been made on students and others show to the contrary.[46]

The statistics presented by Prof. Fred. J. Pack are of interest in this connection.

In six educational institutions the students competing for places on the football team were grouped as follows:

+ -+ -+ Number Number Per Cent. Institution. Competing Successful. Successful. for Places. + -+ -+ Institution A. Smokers 11 2 18.2 Non-smokers 19 11 57.9 Institution B. Smokers 10 4 40 Non-smokers 25 17 68 Institution C. Smokers 28 7 25 Non-Smokers 17 14 82 Institution D. Smokers 28 11 39.3 Non-smokers 15 10 66.6 Institution E. Smokers 10 7 70 Non-smokers 15 12 80 Institution F. Smokers 6 0 0 Non-smokers 26 15 57.7 + -+ -+

SCHOLASTIC STANDING

- - - - Institu- Smoker. Non- Institu- Smoker. Non- tion. smoker. tion. smoker. - - - - A 65.2 69.8 G 74.0 75.0 B 64.7 74.6 H 75.2 79.4 C 78.8 81.1 I 81.6 88.4 D 75.8 77.6 J 78.5 81.3 E 84.6 84.8 K 74.0 84.6 F 69.6 71.3 L 77.3 77.6 - - - -

The following table shows the relative scholastic standing of smokers and non-smokers:

+ + -+ - Number Total Average of Men. Mark. Mark. + + -+ - Smokers 81 6,034 74.5 Non-smokers 101 8,021 79.4 + + -+ -

Twelve institutions reporting:

+ + -+ - Number Highest Lowest of Men. Marks. Marks. + + -+ - Smokers 81 4 12 Non-smokers 101 11 6 + + -+ -

- - - Number of Highest Lowest Men. Marks. Marks. - - - 101 non-smokers furnish 11 6 101 smokers would furnish 5 15 - - -

+ + + Number Total of Men. Conditions Average. and Failures. + + + Smokers 82 70 .853 Non-smokers 98 48 .439 + + +

[Sidenote: Tobacco Smoking Athletes]

Prof. Pack's conclusions were as follows:

1. Only half as many smokers as non-smokers are successful in the "try outs" for football squads.

2. In the case of able-bodied men smoking is associated with loss of lung capacity amounting to practically 10 per cent.

3. Smoking is invariably associated with low scholarship.

There have of course been many notable instances of high scholarship and prodigious mental achievement by heavy smokers. Such exceptions, however, do not affect conclusions derived from the study of average groups.

Hitherto figures on smoking and athletics have been open to question because comparisons were made between groups that are not of necessity of the same physical and mental type, having no important difference except in the use of tobacco. But Prof. Pack has sought to avoid this objection. As he points out, the football squad is probably as nearly a homogeneous group as it is possible to find. It seems reasonable to account for the inferior physical and mental work of these particular groups of smokers on the theory that in the main the well known toxic effects of tobacco are sufficient to create this difference.

Dr. George J. Fisher,[47] in a series of careful tests found:

1. Cigaret smoking caused an increase in the heart rate.

2. Cigaret smoking maintained a blood pressure which, under the circumstances of the experiment, would otherwise have dropped.

3. Cigar smoking caused a considerable increase in heart rate and blood pressure.

4. In a number of instances, in the cigar test, the heart was unable to maintain, with a vertical position, the increased blood pressure found in the horizontal position, showing a disturbance of the control of the blood vessels. This latter effect was more pronounced in tests taken on non-smokers.

5. It was also noted that smoking was not conducive to concentration upon the reading, which the men attempted during the tests.

Bush,[48] in a series of tests on each of 15 men in several different psychic fields found the following conditions among smoking students immediately after the period of smoking was completed:

1. A 101/2 per cent. decrease in mental efficiency.

2. The greatest actual loss was in the field of imagery, 22 per cent.

3. The three greatest losses were in the fields of imagery, perception and association.

4. The greatest loss, in these experiments, occurred with cigarets.

Bush ascribed these effects to pyridin, claiming that his experiments failed to reveal nicotin in the tobacco smoke, except in a very small proportion in that of cigarets.

Tests for nicotin in smoke are beset with many difficulties and possible fallacies which have in the past misled investigators into apparently determining that tobacco smoke contained no nicotin, but simply decomposition products.

Pyridin is unquestionably present in tobacco smoke, and is a poisonous substance, although less so than nicotin. It is not found, however, in chewing tobacco, and as the clinical effects of chewing tobacco are apparently identical with those of smoking tobacco, very strong and universally accepted chemical proof of the absence of nicotin from tobacco smoke must be awaited before accepting such a conclusion. (See([41]), ([42]), ([43]) in bibliography.)

Cigaret smoking is a time waster; that is, it breaks up the power of attention, as few smokers are satisfied with one cigaret and the mere physical act of lighting a fresh cigaret disturbs the continuity of thought and work. Dr. W. J. Mayo[49] calls attention to the fact that according to his observations research scholars who smoke cigarets have not done well.

[Sidenote: Insurance Experience on Tobacco Smokers]

Only one insurance company, the New England Mutual,[50] has published any experience on tobacco users. This covered a period of 60 years and a body of 180,000 policyholders, as follows:

RATIO OF ACTUAL TO EXPECTED MORTALITY.[M]

- ABSTAINERS. RARELY USE. TEMPERATE. MODERATE. - - Tobacco, 59% 71% 84% 93% Alcohol, 57% 72% 84% 125% -

[M] The standard here used is the American Experience Table, which is largely an artificial table upon which premiums are based, but which provides for a much higher mortality than the average companies sustain. For example, the actual mortality of the New England Mutual in 1913 was 57 per cent. of the expected.

[Sidenote: Interpretation]

Fifty-nine per cent. of the expected mortality means that where, according to the premium tables, 100 were expected to die, only 59 actually died.

The general class of risks in this company were of excellent quality, as the figures show. Nevertheless, the abstainers exhibited a far lower mortality than that experienced by the general class.

Dr. Edwin Wells Dwight, who presented the figures, urged caution in their interpretation, suggesting that the low mortality among abstainers, both from alcohol and tobacco, might well be due to a more conservative habit of living. Furthermore, as the abstainers from alcohol were not separated from the abstainers from tobacco in this analysis a perfect comparison can not be made; but our knowledge of the toxic effects of both these narcotics and the preceding statistics of Doctor Pack justify us in assigning to tobacco a positively unfavorable effect.

[Sidenote: Poisonous Effects]

Experiments on animals with nicotin extracts from tobacco and inhalation of tobacco smoke have produced hardening of the large arteries. Clinical observation by some of the world's best authorities indicates that the same conditions are brought about in man by heavy smoking.[51]

Disturbance of the blood pressure, rapid heart action, shortness of breath, palpitation of the heart, pain in the region of the heart, are important effects. Tobacco heart is often lightly spoken of because the abandonment of the habit will often restore the heart to its normal condition, but tobacco heart sometimes causes death, especially under severe physical strain or in the course of acute disease, such as typhoid or pneumonia. Surgeons[52] have noted failure to rally after operation in tobacco users, who are, of course, deprived of their accustomed indulgence immediately before and after operation. It is probable that many such cases pass unrecognized, although the alcoholic is usually supplied the narcotic his system demands.

Cannon, Aub, and Binger[53] have also shown that nicotin stimulates the adrenal glands, small organs adjacent to the kidneys, which secrete a substance that in excess powerfully affects the blood vessels, constricting them and temporarily increasing the blood pressure. This influence may be partly responsible for the change in the blood vessels noted in heavy smokers.

Excessive smoking is often an important factor in causing insomnia.

Blindness or tobacco amblyopia, a form of neuritis, is not an uncommon affection among smokers. There is also often an irritant effect on the mucous membranes of eyes from the direct effect of the smoke.

Catarrhal conditions of the nose, throat and ear have also been noted.

Acid dyspepsia is a common affection among smokers.

Few people realize that so many ingredients in tobacco and tobacco smoke are deadly poisons. Few people know that one drop of nicotin on the unbroken skin of a rabbit will produce death.[54] Two drops on the tongue of a dog or cat will prove fatal; moreover, fatal poisonings have occurred in man from swallowing tobacco and even from external application of strong solutions. A case was recently reported from New Haven of fatal poisoning in a baby,[55] who had been fed from a milk bottle and milk-mixture in which some tobacco had been accidentally spilled.

SUMMARY

From the mass of evidence and opinion with which medical literature is loaded, a few salient facts stand out:

First: Tobacco and its smoke contain powerful narcotic poisons.

Second: It has never been shown to exert any beneficial influence on the human body in health, and it is not even included in the United States Pharmacopoeia as a remedy for disease, notwithstanding the claims that are made for its sedative effects and its value as a solace to mankind. If these benefits are real and dependable, they should be made available in exact dosage and applied therapeutically. If they are not real and dependable in a medical sense, they are not real and safe as a mere drug indulgence.

Third: The symptoms following tobacco-smoking are identical with the effects of tobacco-chewing among those not accustomed to its use; hence, any collateral psychic effect, such as the sight of smoke, the surrounding, etc., are of minor importance in establishing the habit. The main charm to the smoker is the drug effect, as in any other similar indulgence. Nicotinless tobacco is not popular, notwithstanding the efforts of the French and Austrian Governments to make it so.

Fourth: Fortunately, the sedative drug effect is so slight, as compared to that of other narcotics—opium, alcohol, cocaine, etc.—that the tobacco habit is less seductive and may be broken with comparative ease and is therefore less harmful morally. Men who have smoked or chewed steadily for 40 years have been known to give up the habit without experiencing much physical discomfort. Like any other habit, however, there is a tendency to increasing indulgence, and this is a risk that the smoker takes, just as does the alcohol user or the opium habitue who begins with so-called moderate indulgence.

Fifth: The well-known effects of tobacco on the heart and circulation should lead one to pause and consider the possible cost of this indulgence, especially as—

Sixth: It is difficult to determine, years in advance, whether or not one is endowed with sufficient resistance to render so-called moderate smoking comparatively harmless.

Seventh: The vital statistics show that diseases of the heart and circulation are rapidly increasing in this country in which—

Eighth: The per capita consumption has rapidly increased in recent years, while—

Ninth: In the United Kingdom, where these diseases are decreasing, there has been no material increase in the use of tobacco, and the per capita consumption is less than one-third that of the United States.

[Sidenote: Increase of Smoking]

In 1880 the annual per capita consumption of tobacco in the United States was about 5 lbs., while in 1914 it had risen to more than 7 lbs. In the United Kingdom the per capita consumption is about 2 lbs., and there has been no material increase in recent years.

The cigaret bill, in particular, has grown enormously, having more than doubled in the past five years, while there has been a slight increase in the consumption of cigars, smoking tobacco, chewing tobacco and snuff, as shown in the following table:[56]

Fiscal Tobacco, Year Cigars Cigarets Chewing and Snuff Smoking + + + -+ - 1910 8,213,356,504 7,884,748,515 436,608,898 31,969,111 1911 8,474,962,786 9,254,351,722 380,794,673 28,146,833 1912 8,350,119,103 11,239,536,803 393,785,146 30,079,482 1913 8,732,815,703 14,294,895,471 404,362,620 33,209,468 1914 8,707,625,230 16,427,086,016 412,505,213 32,766,741 + + -+ - Total 42,478,879,326 59,100,618,527 2,028,056,550 156,171,635

Tenth: The poetic effusions of the lovers of the weed are no safer guide than the exaggerated and intemperate denouncements of people who have idiosyncrasies against tobacco and simply hate it.

Eleventh: Those who now smoke should have a thorough physical examination to determine the condition of the heart and blood vessels. This examination should be repeated at least annually, in order to detect any adverse influence on the circulation.

REFERENCES

[38] The Toxic Factor in Tobacco, The Lancet (London), 1912, I, p. 944.

[39] French Department of Agriculture, Compt. Rend. Acad. de Science, CLI, p. 23.

[40] Garner, W. W.: The Relation of Nicotin to the Burning Quality of Tobacco, U. S. Department of Agriculture, Bureau of Plant Industry, Bulletin No. 141, Sept. 30, 1909, p. 15; A New Method for the Determination of Nicotin in Tobacco, U. S. Department of Agriculture, Bureau of Plant Industry, Bulletin No. 102, July 6, 1907, p. 12.

[41] Lehmann, K. B.: Untersuchungen ueber das Tabakrauchen, Munchen, med. Wchnschr., 1908, LV, pp. 723-25; The Physiological Action of Tobacco Smoke, Med. Rec., 1908, LXXIII, pp. 738, 739.

[42] The Toxic Factor in Tobacco, The Lancet (London), 1912, II, pp. 944-947.

[43] Garner, W. W.: The Relation of Nicotin to the Burning Quality of Tobacco, U. S. Department of Agriculture, Bureau of Plant Industry, Bulletin No. 141, Sept. 30, 1909, p. 15.

[44] Zhebrovsky, E. A.: The Effect of Tobacco Smoke upon the Blood Vessels of Animals, Russky Vratch, 1907, VI, p. 189; 1908, VII, pp. 429-431; Med. Rec, 1908, LXXXIV, pp. 408, 409.

[45] John, H.: Editorial, Jour. A. M. A., 1914, LXII, pp. 461-2; Ueber die Beeinflussung des systolischen und diastolischen Blutdrucks durch Tabakrauchen, Ztschr. f. exper. Path. u. Therap., 1913, XIV, pp. 352-365; Pawinski, J.: Ueber den Einfluss unmassigen Rauchens (des Nikotins) auf die Gefaesse und das Herz, Ztsch. f. klin. Med., Berl., 1914, LXXX, pp. 284-305.

[46] Pack, Frederick J.: Smoking and Football Men, Popular Science Monthly, 1912, LXXXI, p. 336.

[47] Fisher, George J. [Monograph not yet published.]

[48] Bush, Arthur D.: Tobacco Smoking and Mental Efficiency, N. Y. Med. Jour., 1914, XCIX, pp. 519, 529.

[49] Mayo, Wm. J.: Personal communication.

[50] Dwight, Edwin Wells: Proc. Assoc. Life Ins. Med. Dir., Oct., 1911, II, p. 474.

[51] Favarger, Heinrich: Experimentelle und klinische Beitraege zur chronischen Tabakvergiftung, Wien. klin. Wchnschr., 1914, XXVII, pp. 497-501; Experimental and Clinical Study of Chronic Tobacco Poisoning, Jour. A. M. A., 1914, LXII, p. 1764; Pekanovits. Effects of Tobacco Smoking, Jour. A. M. A., 1914, LXXII, p. 1907.

[52] Bangs, L. Bolton: Some Observations on the Effects of Tobacco in Surgical Practice, Medical Record, LXXIII, March 4, 1908, pp. 421-23-51.

[53] Cannon, Aub. Binger: Effect of Nicotin Injection on Adrenal Secretion, Jour. Pharm. and Exper. Therap., 1912, p. 381; Editorial, Nicotin and Adrenals, Jour. A. M. A., 1912, LXIII, p. 1287.

[54] Hare, Hobart Amory: Fiske Prize Dissertation, No. 34, p. 1884. Dixon, A. S.: Proceedings of the Academy of Natural Sciences, Philadelphia, Nov. 11, 1884.

[55] Reynolds, H. S.: Jour. A. M. A., May 30, 1914, LXII, p. 1723.

[56] Annual Report of the Commissioner of Internal Revenue, 1914, p. 34, Government Printing Office, Washington, D. C.

* * * * *

Bamberger, J.: Hygiene of Cigar Smoking, Abstr. Jour. A. M. A., 1904, XLIII, p. 706; Zur Hygienie des Rauchens, Munchen. med. Wchnschr., 1904, LI, pp. 1344-1345.

Current Comment: Some New Evidence on the Tobacco Question, Jour. A. M. A., 1912, LIX, p. 1798.

Editorial: The Pharmacology of Tobacco Smoke, Jour. A. M. A.. 1909, LII, p. 386.

Editorial: The Use of Tobacco, Jour. A. M. A., 1910, LX, p. 32.

Editorial: Tobacco-Smoking and Circulation, Jour. A. M. A., 1914, XLII, p. 461.

Hochwart, L. Von Frankl: Die Nervoesen, Erkrankungen der Tabakraucher, Deutsch. med. Wchnschr., 1911, XXXVII, pp. 2273, 2321.

Index Catalogue of the Library of the Surgeon-General's Office, second series, XVIII, pp. 297-306.

Larrabee, R. C.: Tobacco and the Heart, Abstr. Jour. A. M. A., 1903, XLI, p. 50. Read before the Massachusetts Medical Society, June, 1903.

Pel: Un cas de psychose tabagique, Ann. med. Chir., 1911, XIX, p. 171.



SECTION VI

AVOIDING COLDS

[Sidenote: Infection]

Bacteria play a part in most colds. In some cases there is a general infection, with local symptoms, as in grippe; in others there is a local infection, with mixed classes of bacteria. It is probable that these various forms of bacteria are constantly present in the nasal secretions, but do not cause trouble until the local resistance or the general resistance is in some way lowered.

[Sidenote: Nasal Obstruction]

In many, the susceptibility to colds is due to abnormalities in the nose or throat. Nasal obstruction is a very common condition. The nose, like the eye, is usually an imperfect organ. These obstructions are often the result of adenoids in childhood, which interfere with the proper development of the internal nasal structures. Malformation of the teeth and dental arches in childhood are frequent and often neglected causes of nasal obstruction. Such malformations are caused by the arresting of the growth of the upper jaw and nasal structures. Correction of the deformity of the arches often renders nasal surgery unnecessary. Such conditions not only predispose to colds, but increase their severity and the danger of complicating infection of the bony cavities in the skull that communicate with the nose. They also increase the liability to involvement of the middle ear and of the mastoid cells which are located in the skull just behind the ear. The importance, therefore, of having the nose and throat carefully examined, and of having any diseased condition of the mucous membrane or any obstruction corrected must be apparent. All who suffer from recurrent colds should take this precaution before winter sets in.

[Sidenote: General Resistance]

If the nasal passages are put in a healthy condition, strict obedience to the rules of individual hygiene will almost wholly prevent colds. In fact, except where actual nasal defects exist, the frequency of colds is usually a fair indication of how hygienically a person is living. The following points need especial emphasis, though they repeat in some cases what has already been said in the text.