4400,

DEC. 28, 1907.

An AddressON

THE PERSONAL FACTOR IN DIET.Delivered before the Liverpool Medical Institution

on Oct. 24th, 1907,

BY CHARLES J. MACALISTER, M.D. EDIN.,M.R.C.P. LOND.,

LECTURER ON CLINICAL MEDICINE, UNIVERSITY OF LIVERPOOL;PHYSICIAN TO THE LIVERPOOL ROYAL SOUTHERN HOSPITAL

AND TO THE COUNTRY HOSPITAL FOR CHILDREN.

MR. PRESIDENT AND GENTLEMEN,-A greal deal ofsplendid work has been done by physiologists and experi-menters to determine the proportions of the food con-stituents and of the kinds of foods which are requisite forthe sustenance of the human being, and our knowledge ofthe problems of metabolism has during recent years beenadvanced considerably by the work of the bio-chemist ; but,notwithstanding the valuable information with which wehave been furnished, it would still puzzle the most ex-perienoed worker in the realms of practical medicine todefine what may be regarded as a normal diet for a normalman, because we know that among any considerable numberof people in perfect health, of approximately the same agesand body-weights and doing the same amounts of work, thefood which is necessary to sustain them varies greatly inkind as well as in amount. We find that, although thegeneral principle holds good that given quantities of meat,bread, milk, butter, sugar, and salts (representing in con-stitution what are considered to be the essential proportionsof proteids, carbohydrates, fats, &c., and their caloric foodvalues) are necessary for the average man, yet the fact isconstantly being witnessed that a large man may be a verysmall eater and that a small one may require a huge amountof food to keep him going; and, furthermore, we cannothelp observing that whereas one person will live mainly uponproteid-containing vegetables together with starches andfats but very little meat, another regards the beefsteak asthe foundation of strength and looks with compassion andconcern upon his brother who cannot or does not take it.Whoever wrote the old nursery rhyme-

"Jack Spratt could eat no fat, his wife could eat no lean "-

evidently recognised the personal factor in diet which is thesubject of my remarks on this occasion, and I have no doubtthat the writer of the rhyme also recognised that, althoughso different in their dietetic tastes and requirements, Jackand his wife were both perfectly healthy individuals.The ordinary diets of the soldier and sailor, of the

prisoner, of the school and hospital have all been based

upon the general principles and facts which the physiologisthas taught us, but if we observe any one of these groups inrelation to their feeding we soon learn that collective dietingwith its stereotyped proportions of food materials is notabsolutely satisfactory. We cannot study this questionanywhere better than in an industrial or reformatory schoolwhere we have, say, a couple of hundred boys to cater forevery day. The lads are all active; they all do similar workboth physically and mentally, regulated according to theirages, and they play hard, so that what food they take shouldpresumably be made good use of. None of the children areeither underfed or overfed. The noticeable point about theseboys when thus fed on similar lines is this : the majority ofthem digest and metabolise their food well but a certainsmall number do not thrive ; they get headaches and biliousattacks, they tend to be off colour and lacking in the energyand happiness of boyhood and in the winter they sufferseverely from the cold and are apt to have chilblains. Nowthese children require some individual attention and wehave found that by giving them less meat and more of thevegetable proteid foods together with milk and fats theirhealths have been immensely improved and since this planof looking after the boys individually with reference to theirdiet has been adopted there have been practically none ofthe disorders to which I have referred. In one of these schools15 years ago there was a great deal of ill-health ; most ofthe boys were below par and ansemic. Their skins wereunhealthy and their powers of resistance to disease weresmall. The sick ward invariablv had spvfral 1YIM2fPC anr)

the services of a permanent nurse were required.’ Aninvestigation of the diet at that time showed that there’wasan excess of carbohydrate food and very little animal food.A revision of the diet scale and the introduction of moremeat and milk and green vegetables was followed by greatimprovement in the general health. The majority werebenefited and the small minority representing those whodo not thrive on meat were adversely influenced by thechange.

It is thus evident that all children (and the same appliesto adults) cannot live healthily on the same kinds of food,some having idiosyncrasies of metabolism. It is possiblethat they digest all right, but their metabolic chemistryvaries, and while some manifestly require a full allow-ance of meat or flesh, others can only take limitedquantities of it, and there are those who are better withoutany at all. I am anxious to approach this subject of idio-syncrasy in diet in such a way as to avoid any imputationthat I have any cranks in rega-d to it, because my belief isthat the investigator who gets an idea into his head aboutthe relationship between what he considers to be faulty feed-ing and certain forms of ill-health is apt to conclude thatbecause certain persons have been made ill by certain foodsthese foods are bad for all humanity. Nobody can readHaig’s excellent work without being struck by the apparent

reasonableness of his arguments about uric acid as a causeof disease. He says: "Uric acid is a poison for all, andthough some suffer in one way and some in another all whoswallow it have sooner or later reason to regret that they didso " ; and again he says : " Uric acid disease is only uric acidtoxaemia; the poison is swallowed and poisoning and itssigns and symptoms result as a matter of course."Now, I have carefully put Haig’s hypothesis to the test

and am convinced that his mistake consists in his applica-tion of what results in cases of a special idiosyncrasy to allpeople. There are those who cannot take the purin-contain-ing group of foods, such as meat, tea, coffee, and cocoa,without suffering, but in reality this depends upon a meta-bolic idiosyncrasy or an idiosyncrasy of elimination. Manypeople are quite capable of taking these foods, of abstractingwhat is good from them, and of metabolising and eliminatingthe purins without detriment to their constitutions, whereasothers are poisoned by them and accumulating the uric acidor other toxic bodies in their systems are periodically orpermanently made ill by them. I might instance- here as atype of this condition the case of a woman who from girl-hood had been a martyr to bilious attacks accompanied bysevere headaches which entirely prostrated her at intervalsof a week or ten days, so that she was on the point ofabandoning the attempt to carry on her business, which was-that of a professional nurse, at the time she consulted me. 1

placed her upon a purin-free diet and since then, for a period,of 12 months or more, she has remained perfectly normal.

I was at a public dinner in Liverpool last winter and.happened to be placed between two gentlemen, neither of-whom was known to me personally. On my right was athin, evidently gouty man, ascetic in his habits, who care-fully scrutinised every dish presented to him and let most,of them pass untouched. On my left was a healthy lookingand jolly parson who took all that was going and evidentlyenjoyed it. By way of starting conversation I said to myascetic neighbour, "I I am afraid, sir, you do not eat verymuch." He replied : ’ My dear jsir, you know the answer tothe question, Is life worth living?" " "Oh, yes," said I; ;"it depends upon the liver." "Well," said he, "it is a

perfectly true answer in my case and I have to be mostcareful what I eat, otherwise I suffer for it." Presently myclerical neighbour addressed me thus : "Will you pardon me,sir, if I give my answer to the question which has just beenasked ? " I responded that I should be delighted to hear it.Then said he : " should say that the proper answer to thequestion, ‘Is life worth living ?’ is that it depends upon theliving." The pun was pardonable but the answer was truein both its senses and you will see presently that my con-tention is that the art of living in a condition of health andhappiness, so far as the results of feeding are concerned,depends in many cases upon a careful study of the individual’with reference to his digestive and metabolic capabilities.and furthermore that I do not regard those people whorequire to give special attention to the kinds of fuel whichthey consume as being in themselves necessarily abnormalor diseased until they are rendered so by their endeavoursto live upon foods which may suit the majority butare entirely unfitted for themselves. The ascetic man

nn 1"’1

1808

to whom I referred no doubt represented a type of meta-bolism requiring careful adjustment, so far as the intake offuel in quantity and quality was concerned, the other fearingno ill consequences whatever he might eat. The class ofpeople to whom Haig’s attention has mainly been directed,those who suffer from headaches, bilious attacks, and thesymptoms of collaemia, are undoubtedly immensely benefitedby leaving the purins out of their food. I have had numerousexamples of this and have seen lives of misery and incapacityfor work entirely revolutionised by abstention from meat andother purin-containing foods. But the converse holds good.There are those who cannot do without meat and who shownone of the symptoms which have been ascribed to meateating when they take it ; no evidences of uric acid poison-ing or kidney block which is so common in those who geturic acid toxaemia; they have no abnormal blood tensionand live active and healthy lives in every particular. Iknow a case in point in a professional man who livedhabitually for some time on a largely carbohydrate diet withvery little meat. He became fat, although it was foreign tohis nature to be so, but his mental acumen as well as hisphysical well-being failed. He became sleepy, unable togive attention to his work, and his urine came to containtraces of sugar. He had a carbohydrate limit and discover-ing this he reduced his carbohydrates until he found theextent of the limit and he shortly became a thinner but ahealthy man in every respect. His nutritional equilibriumis maintained and he lives in a condition of healthful.activity.

If experimental work on metabolism is going to be really.useful it appears to me that several types of people will haveto be the subject of the research. I do not mean by thisthat we shall have to group men according to their occupa-tion and habits of life as is commonly done by those whowrite upon the subject. The soldier, the clergyman, andthe athlete if of average metabolic habits and capacitieswill surely show similar terminal phenomena of metabolismin their urines, &c., but there are those whom we see in the

hospitals, and so commonly in our consulting rooms, thosewho suffer because they attempt to live upon foods whichdo not suit them, whose ill-health, whether temporary orpermanent, is due to the ingestion of foods which disagreewith them but suit most people admirably.

In a lecture on diet by an eminent physiologist I observedthat under the heading "The Ordinary Diet for a NormalMan he details the average amount of foodstuffs such asmeat, fish or fowl, bread, &c., which should be allowed, butthe question at once presents itself, "What is to be ourstandard of a healthy individual from a dietetic point ofview 2 " Is he the one who assimilates those quantities of,foods and requires them to keep him in health and if so are- those who require a larger or smaller proportion of one type-of food than another to be regarded as being outside the paleof perfect health ’2 The fact is that healthy people varygreatly in their metabolic activities ; the potential energyof the food which they take is transformed in such varyingdegrees and ways into kinetic energy by the chemicalchanges which it undergoes after absorption. Combustion isso much more rapid and complete with some than with othersthat it is not difficult to understand that different qualitiesof fuel are required to keep the various types and tempera-ments of human machines running smoothly and sweetly andwe cannot regard the person whose metabolism requires foodwith more or less of one element than another as strictlyspeaking abnormal or unhealthy. He only becomes diseasedwhen his chemistry is rendered faulty by his endeavouring tolive on stereotyped and conventional lines for which he isphysiologically unsuited.

In early life instinct guides many children into the linesof diet which are most suitable for them. Herbert Spencer ’,pointed out this fact long ago in his work on Education,where he speaks of the normal love which children have forsweet things, and he points out that this marked desire forthe valuable heat-producing sugar has to be joined with thefact that they have usually an equally marked dislike to thatother food which gives out the greatest amount of heatduring oxidation-namely, fat-and that there is reasonfor thinking that the excess of the one compensates for thedefect of the other-that the organism demands more sugarbecause it cannot deal with much fat ; and he comments uponthe discord which often exists between the instinctive wants ofchildren and their habitual treatment. We find some childrenwho dislike meat and others who have the greatest objection tostarchy foods such as tapioca and sago, and although it does

not always fall in with the parent’s views I consider it a

great mistake to make children eat those things for whichthey have a natural distaste. Sometimes we see themvomit after taking foods forced upon them and which theyinstinctively dislike, and it is best not to insist upon them

taking them. Children, of course, are often enough trainedand taught to take foods which are really unsuitable for themand no doubt many of the so-called diathetic diseases, suchas gout and rheumatism, might be avoided if a proper dietarycould be instituted early enough. Even the infant some-times manifests an idiosyncrasy in the matter of diet whenit is brought up by hand, for while it is generally an easymatter to regulate the food satisfactorily instances not

infrequently occur where wasting will take place with a milkmixture which suits the majority absolutely, and so the

personal factor manifests itself in the infant as it does inthe adult, and for your peace of mind let me advise youhaving got an infant into a thriving condition upon a milkmixture which suits it to hold fast to that which is goodand be careful how you depart from it.

In the aged or those advanced in life idiosyncrasy is lesseasy to follow. Many of those who might have survived butwho lived in a perpetual state of error in diet have paid thepenalty and passed away, the remainder representing thosewho have been able to live healthily on all the kinds of foodsand drinks which they have been accustomed to; but thereis an interesting point in this connexion. It is undoubtedthat many old folks are rendered ill by being made to takewhat are considered to be highly nutritious foods in the wayof meat, whereas they would live far more healthily on thevegetable proteid types ; I feel certain that there would belower blood tension and lorger life were this rule observed.The two ends of the curve of life are by experienceadmitted to be best supplied with the carbohydrates and thesimpler vegetable proteids together with milk. The childnormally takes a larger proportion of these than the adultand this type of food is again best suited when, " sans teeth,sans eyes, sans everythirg," the passive, unemotional periodof life is reached.

I was at the funeral of an old friend last winter, a manwho died at 87 years of age, and who had had a capacity formetabolising every kind of food that was placed before him,although in his latter years he ate far too much meat and gotgout and gouty eczema. His younger brother, a man aged 80years, who looked exceedingly well, came up to me after theservice and said : "Doctor, do you know the real secret ofkeeping health when you are old?" Thinking that I was goingto get a tip for attaining to a green old age I begged him totell me, and he replied : ’’ Live on milk. Look at me," hesaid ; " I was very unwell some time ago but since drinkingand practically living on milk and milk food I have beena different man: " and he certainly looked and looks to thisday the picture of a healthy old gentleman. It is quitelikely that this old man had really found a secret oflongevity. All his life he had been a strong and activeman and had probably, like his brother, lived on whateverwas placed before him, but with advancing years, as I feelsure must be the case with many old people, the simplest ofproteids are required, and he had found them in milk andthose things usually included in a milk diet. The very factthat the teeth come out is an indication that a simpler fuel isnecessary than was the case in the days of active work andenergy ; indeed, I feel suspicious that the dentist has donesomething to promote the metabolic diseases of thoeeadvanced in life by providing them with grinders whichenable them to take foods unsuited for them. Thus we seethat the curve of life is normally associated with a corre-sponding dietetic curve, the quality of the fuel varying fromtime to time according to the changes which take place inmetabolic activity ; first in the period of growth and develop-ment, then in that of simple repair when metabolic wasteand repair are equalised, and last of all in the period ofdecline when the tendency to repair is less active. As a

point of interest one might in passing note here what isso often overlooked-namely, the curious seasonal variationswhich take place in many people and which are difficult ofcomprehension. Sydenham recognised how apt gout is tobecome active during the spring and it is undoubted thatmany diseases not so far as we are aware dependent onfxtcrral conditions find the bodily resistance less in evidencethen and in the autumn than at other times. Children oftenhave skin eruptions in the spring and adults also suffer fromdisorders ascribed to some change in the chemistry of thebody. There had evidently been some sound fcundation for

1809

the old custom of giving spring medicines which is probablya descendant of the practice of older times still, when folkwere blooded to relieve them of noxious humours at thattime of the year. I cannot pretend to explain this fact butthese seasonal variations remind one of the more evident

changes seen in the lower animals at these times when theircents are changed and when they are often enough manifestlydepressed in health and spirit,3. One day in May I was walk-ing through Childwall Churchyard and noted that the grave-digger’s business seemed very brisk. There were severalrecent graves and I commented on the fact that many peoplewere dying to an old man employed in this way. His laconicand curt reply was, "The sap is rising," and he seemedsatisfied that this explained the whole matter.From what I have said it is evident that metabolic

phenomena will have to be studied on new lines if we areto discover the meaning of the fine distinctions whichexist between individuals. My impression is that thewhole question is one of evolution. Man, unlike thelower animals, is a mixed feeder-partly carnivorous,partly graminivorous and herbivorous, but it would appearthat there is not a constant balance in every individual ofthe species between the amounts of animal and vege-table foods necessary to sustain him, and that while there isan average, in some cases the one type prevails, in some theother, and although the bio-chemist tells us that certainmetabolic phenomena are constant, in the species clinicalexperience proves that there are distinctions and that unlessthese individual peculiarities are met disease and disorderwill prevail. We have only to think of gout to see the truthof my contentibn. It is a disease of metabolism and Ibelieve that if the proper lines of diet could be establishedearly enough this and its associations and numerous other

_Ikindred disorders might be avoided and that even more Ipeople would live to old age than is at present the case. I

It is no part of my present thesis to enter upon thecausation of gout; to do so would involve me in a very widefield for discussion, and, furthermore, it is not my intentionto go into the question of proteid or purin metabolism. Onecan only bring to your remembrance the exceedingly complexcharacter of the changes which these latter undergo and theindirect nature of the oxidation which ends in their completetransformation and the production of the normal terminalproduct urea, but I would like to mention an interestingexperiment which I made some time ago upon an exceedinglygouty man whose urine invariably contained a large depositof uric acid and who had had a calculus removed from his

kidney by operation. I got him to inhale pure oxygen atshort intervals for a couple of hours, commencing an hourafter his meals, and it was noteworthy that this measuredistinctly lessened the output of uric acid. The experimentwas performed a number of times and always with the sameresult but with no permanent benefit to his condition, and, ofcourse, the only way of dealing with him radica,lly consistedin the exclusion from his diet of the uric acid producing 1factors.With reference to the influence to evolution which I have

mentioned I was much impressed some years ago with acurious anatomical condition bearing upon this point. A manwho had been suffering from some gastric disorders consultedme with reference to his diet. He informed me that he hadthe greatest aversion to meat and was by instinct a vege-tarian. For some months he had been taking very littleflesh food and that only in deference to the wishes of hisfriends, who considered that his strength could not be main-tained without it, but he desired to ask me whether in myopinion he could safely give it up altogether. I advised himto do so but to take abundance of milk in addition tothis vegetable dietary, and from that time until now he hasnever shown the slightest tendency to waste and only oncehas had indigestion. He is a strong, athletic man, a par-ticularly fine swimmer, and full of physical and mental energy.He certainly thrives without flesh of any description. Theanatomical peculiarity to which I have referred is thepresence of a pair of adventitious mami1Jae symmetricallyplaced opposite the seventh intercostal space on either side.

I could not help thinking that this condition of polymastiashowed that there might be in this man a reversion to someancestral type of vegetable feeder indicated not only by thisanatomical anomaly but also by the physiological peculiaritywhich characterised his metabolism. Polymastia andpolythelia appear in themselves to be indications of imperfectdevelopment or of failure on the part of the embryo to getbeyond what remains as a normal condition in some of

the lower animals. Schmidt 1 has pointed out in a paper onsupernumerary mammas the interesting fact that "in thehuman embryo of about 15 millimetres in length a line ofelevated epithelium 1 0 to 1’ 5 millimetres in breadth is tobe found on the side of the thorax and abdomen as well ason the shoulder and pelvic girdles, at the boundaries betweenthe trunk and the extremities." This line he calls the milkstreak. Within or along this streak are to be found in thenormal positions the anlagen of mammae of a conical or-

lenticular form. In the region of the same streak appear inlonger embryos of from 26 to 60 millimetres in lengthepithelial anlagen of various sizes and positions which must.be looked upon as the earliest stages of supernumerary milkglands. He has found these anlagen in the region of theaxilla, on the anterior and lateral walls of the thorax, and in-the irguinal region; in fact, in those places where hyper-thelia and hypermastia most frequently occur in the adult.The condition of the normal hypertheliain the human embryo-disappears in the process of development. This observationof Schmidt has been confirmed by Dauthvilel who con-cludes that "(1) mammary structures arise in the humanembryo from the mammary line, a common epithelial anlagewhich extends from the root of the embryonic upperextremity towards the caudal end and terminates atthe inguinal fold ; and (2) at a certain stage of evolutionof the mammary line besides the normal mammary anlagenthere are other supernumerary anlagen throughout the entireextent of the line-i.e., embryonic hyperthelia and hyper-mastia exist. In the course of the development of theembryo these supernumerary formations disappear withoutleaving any trace behind." We must, therefore, not regardthese conditions of polymastia and polythelia as being dueto an excess of development but rather to its stopping shortand leaving the individual in this particular more like one ofthe lower animals than a perfectly developed man or woman.Dr. Teizo Iwai, in the interesting statistical study on thepolymastia of Japanese which he published in THE LANCET,3points out the probable relationship between polymastia andplural births (which I believe to be another evidence ofreversion to a lower type), and he also concludes that theseplural births are found more among people of the lower classand especially among those of a low order of intelligence.If this be so, does it not seem to be reasonable to supposethat the personal factor in diet may be influenced by develop-mental peculiarities kindred in character and perhaps co-existent with anatomical as well as physiological evidencesof their existence such as were present in the case whichinitiated the train of thought expressed in this paper, and ofwhich numerous other examples have come to my notice ? ’tIt seems to me likely that the appendix is another vestigialorgan functionless in the wholly developed but which maybe very useful to those perhaps less perfect people in whomit is long and well developed, and I think it quite a feasiblehypothesis that not a few cases of appendicitis may resultfrom the constant introduction of unsuitable fuel into the

furnace of the economy. One has seen appendices of greatlength-one recently 9 inches long-resembling strongly theorgan as found in the herbivorous anthropoid apes, and Iwould like very much to be able to discover whether thesepeople with large appendices should be mainly vegetarian ornot. I have had little opportunity of going into this ques-tion but would just note as a point worth mentioning that inseveral cases of appendicitis which I have seen polytheliahas been present.4

Before leaving this-what to me is a very suggestive aspectof the subject in hand-may I venture one very interestingfact which was elicited when examining a large number ofboys in an industrial school with reference to the question ofpolythelia-viz., that in the dormitory devoted to boys whosuffer habitually from incontinence of urine no less than 15out of 25 of them-i.e., 70’83 per cent.-presented thispeculiarity, whereas in the other dormitories the pro-portion was much less. This confirms an observationwhich I made a year ago and mentioned in a paper readbefore the Liverpool Medical and Literary Society in con-nexion with an investigation concerning incontinence of

1 H. Schmidt: Quoted from Eighth Report on Recent TeratologicalLiterature, by Bertram C. A. Windle, D.Sc., &c., Journal of Anatomyand Physiology, vol. xxxii.

2 G. Dauthvile : Eleventh Report on Recent Teratological Literature,ibid., vol. xxxv.

3 THE LANCET, Sept. 14th (p. 753) and 21st (p. 818), 1907.4 Since writing the above I have seen a post mortem examination on

a man who had a long, well-developed appendix, 8 inches in length,and having a funicular entrance from the cæcum. He also had a well-marked adventitious mammilla in the left seventh intercostal space.

1810

urine-viz., that it depends ill a large number of its habitualcases upon an imperfect development or backwardness of thechild.

This allusion to the evolutional explanation of some

idiosyncrasies in diet brings me back to the question of theperfect man-the fortunate who can digest and metaboliseeverything and perhaps drink everything too ; the man whosedigestive organs are capable of dealing with every kind offood and whose chemistry is perfect. The flesh foods areneeded by him and like the carnivorous animal he hasnothing to fear from their contained purins. From this typethere are variants who so long as they live on foods composedof constituents proportionate to their needs must be regardedas healthy and normal individuals, but the very fact thatmetabolic diseases are almost peculiar to the human subjectshows how common these departures from the perfect typeare and how frequently those presenting them suffer inconsequence of their efforts to live on the lines which arenecessary to the average man. The proportion of animalversus vegetable food required by them is different fromthat found in the perfect man and the effort to live on con-ventional lines results in imperfect metabolism of one orother of the food factors and eonsequent disease. These

people remind one somewhat of the anomaly of a herbivorousanimal trying to live on animal food or vice versa.Perhaps the day will come when anybody presenting thesedepartures in whatever degree or suffering from the initialstages of the diseases which result from them will consultthe physician not so much for the purpose of being treatedwith drugs as to have their metabolic capabilities experi-mentally and scientifically investigated in order that theymay be guided with reference to their general dietetic habits,this being perhaps one of the directions in which empiricismin medicine will give place to precision in the treatment andprevention of disease. " _

I trust, gentlemen, that you have followed my point.My observations have been purely of a clinical character andhave been based not on one case alone but on many whichhave proved to me that there is more than a hypotheticalassociation between these developmental anomalies and theanimal chemistry, and my object has been to show that thepersonal factor in diet is often connected with theseanatomical peculiarities in addition to those which are

physiological. Does it not occur to you, as it does to me,that one of the missing links in the chain of evolution maybe found in those individuals who bear anatomical re-

semblances, rudimentary or vestigial it may be, and havingalso alimentary requirements and metabolic similarities towhat we see in the animal kingdom a step lower in the scalethan ourselves ? " Cunningham has shown how the humanbrain occasionally retains the ape-like characters and I havetried to indicate that there are other similarities explanatoryof, and associated with, idiosyncrasies in metabolism

accounting in fact for the personal factor in diet.

CONSTITUTIONAL DEVELOPMENT ANDSOCIAL PROGRESS OF BOYS AND

GIRLS FROM INFANCY.1BY FRANCIS WARNER, M.D. LOND., F.R.C.P. LOND.,

F.R.C.S. ENG.,SENIOR PHYSICIAN TO THE LONDON HOSPITAL.

I WANT to put before you certain facts concerning thelife-history of boys and girls, showing their physical, mental,and moral progress from infancy upwards and the greatdifferences observable between the sexes. I shall avoid anyattempt at statistical analysis, though a few figures will bequoted from public records and from reports on the physicaland mental conditions of children in support of my state-ments and conclusion. 2

The Census Report, 1905 gives the number of births as472,886 males and 456,407 females, showing a larger numberof boys than girls born. It is our object to learn whatbecomes of these infants in advancing life. Many die in thefirst year and as many as 25 16 per cent. die before they arefive years old, for we find that of 1,000,000 males and

1 A paper read before the Child-Study Society, London, on Dec. 12th,1907.

2 Report of a Committee of the British Medical Association, 1893;published at the Parkes Museum.

1,000,000 females born there survive at theage of five years734,068 males and 762,622 females. This heavy infant mor-tality carries off a much larger proportion of boys thangirls. Referring again to the Census of 1905 we find that 57per cent. of the births were boys, while of the five-year-oldchildren only 43’3 per cent. were boys. Thus we have a

larger number of girls than boys to be educated and thisnumerical inequality between the sexes is maintainedthroughout life and has important bearings on many socialand political matters.

I shall pass over the consideration of the commoner

diseases which very largely account for deaths at this

early age, because I want specially to direct your atten-tion to the importance of congenital defect as a factorin this heavy and unequal mortality of infant boysand girls. For it is my conviction that these congeni-tally defective children are predisposed to early death,or if the child survives to school age to bodily and brainweakness. The Registrar-General draws attention to thisquestion and says:3 "Developmental diseases accounted inthe aggregate for 47,359 deaths, or 1593 in a million personsliving. As was mentioned in the last report, the mortalityfrom premature birth and congenital defects has shown inrecent years a constant tendency to increase. The mortalityin 1893 from premature birth was equal to 18’88, and thatfrom congenital defects to 3’ 9 per 1000 children born,showing a still further increase on the high rates prevailingin recent years." It has further been just stated thatcongenital defect, besides being a considerable factor ininfant mortality, usually predisposes the survivors tobodily and mental weakness. Clinical experience in medicalpractice shows that a large proportion of "delicate children"are more or less defective in development, the numberof boys being larger than that of the girls, but the latterbeing of lower vitality. In the children’s medical wards ofthe London Hospital, where boys and girls up to six years ofage are admitted, very few are of a normal standard indevelopment, most of them being small-headed. Themajority come under treatment for marasmus, lung diseases,&c. In one of these wards last year there were admitted 265boys and 228 girls; practically all were subnormal in

development. Of the boys 67 died and of the girls 65,representing a percentage mortality of 25 and 28 respectively.Thus there were more boys ill, but the mortality was

higher among the girls, while, as has already been pointedout, the total infant mortality of the nation is

higher for boys than girls. Coupled with these factsis the very significant one that congenital defective-ness is more common among boys than girls. Thus

it would seem that defectiveness in development pre-disposes to disease in both boys and girls, but that suchgirls have less power of resistance to disease than the boysin similar conditions. Hence the higher mortality amonggirls than boys in the children’s medical wards where

practically all are in some respect of defective constitutionfrom birth.We pass on to consider the children of school age. I will

state a proposition and not trouble you with any statisticalstatement of the detailed observations upon which theevidence is founded ; it has been published elsewhere.’ 5

" Girls with any degree of developmental defect or braindisorder are more apt to receive harm and less good fromtheir environment than boys." Children with any degreeof subnormal development are more frequent among boys,but girls of this type tend to acquire brain disorderliness,ill health, and mental dulness in larger proportion thanboys of the same status. On the other hand, amongnormal children there are fewer dull girls than dull boys,and delicate girls are not more frequently met with thandelicate boys. It is the girl who has some developmentaldefect who is delicate, not all girls. Good health andstrength are quite as frequent among normal girls as amongnormal boys but the girl who is in some degree subnormalsuffers for it more than the boy in like case. Thus in a highschool, for example, I think the well-made girls may workhard at lessons and in the gymnasium, playing vigorousgames with advantage, but on the average there are about7 per cent. of the girls with some degree of subnormaldevelopment. These should be known to the mistress andspecially watched, for under mental and physical stress they

3 Report, 1893. Eng., p. 16.4 The Study of Children, Macmillan and Co., see Tables VII. an

VIII.5 Study of Children, chapter xiii.