Health at Fifty [Reprint 2014 ed.] 9780674429215, 9780674428171

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HEALTH AT FIFTY

LONDON : H U M P H R E Y

MILFORD

OXFORD UNIVERSITY PRESS

HEALTH AT FIFTY Edited by

WILLIAM H. ROBEY

CAMBRIDGE, MASSACHUSETTS HARVARD UNIVERSITY PRESS 1939

COPYRIGHT,

1939

BY THE PRESIDENT AND FELLOWS OF HARVARD COLLEGE

PRINTED AT THE HARVARD UNIVERSITY PRESS CAMBRIDGE, MASS., U.S.A.

PREFACE

T

HE TITLE of this book should not be misleading, for health at fifty and beyond holds implicit the fact that there must be conservation and promotion of physical and mental vigor during childhood and adolescence, early attention to remediable impairments, and prevention of disease and disability through adequately applied knowledge. The average duration of life has steadily increased and will be further increased not only by advances in the science of medicine but also by a more general utilization of the means and methods which are most important in raising the standard of health. The dissemination of accurate medical knowledge should lead to more prompt recognition of the initial symptoms of disease and an earlier institution of good care; correlatively, there may result a freedom from undue apprehension over conditions of little importance. Delay in recognizing the significance of an acute abdominal pain and its treatment with home remedies may result in death from a ruptured appendix; an irregularly beating heart may indicate disease of that organ or merely a quite unimportant functional disturbance. Health problems often involve economic and social factors to a degree that makes them matters of momentous family concern, and whatever con-

vi

PREFACE

tributes to their solution has far-reaching effects. The widespread and misleading advertising of purely commercial remedies, the unwarranted use of the nomenclature derived from scientific discoveries, and the fraudulent claims of charlatans are responsible for untold physical harm and financial loss. Accredited and authoritative guides can divert the more intelligent of the laity from such pitfalls and indicate right methods of diagnosis and treatment, thereby preventing unnecessary, possibly fatal, delays. The aim of the lectures which make up this book, therefore, is to clarify, explain, and interpret the recent developments in various departments of medicine and medical research, to warn of unsuspected dangers, and to stress the necessity of seeking sources of skilled advice rather than temporizing, depending on personal interpretation of symptoms, or tampering with drugs, techniques, or cults which have neither efficacy nor scientific basis. ' The Faculty of the Medical School of Harvard University inaugurated in January 1907 a series of free Sunday afternoon lectures making available to the public the current knowledge of the causation, treatment, and prevention of disease. The plan was put into execution because the laity was becoming increasingly health-conscious and the time seemed opportune. The response fully justified the procedure, and the lecture courses have since been offered without interruption except during 1919. Clinical and laboratory experts through a sense of civic responsibility

PREFACE

vii

willingly gave of their time and energy to the preparation of material culled from their particular fields, and the enthusiastic reception by the laity proved that a constructive, timely, and effective service was being offered to the community. The lecture courses have attained an established place in the city's program of events and have maintained large, usually capacity, audiences. Many requests have been received by the committee in charge of this undertaking for copies or abstracts of various lectures. To aid in meeting this demand and in the hope of reaching a wider public, selections for inclusion in book form have been made from the most recent courses. The subjects that have been chosen are those which were found to have a wide general interest and appeal. Thanks are due to Dr. Charles F. McKhann, Chairman of the Committee on Public Lectures, for valuable contributions in the matter of selection, arrangement, and revision; and to the authors for their interest and cooperation. W I L L I A M H . ROBEY

CONTENTS H E A R T DISEASE

3

HERRMAN L. BLUMGART Associate

Professor

of Medicine,

Harvard Medical

School

BLOOD PRESSURE-LOW AND HIGH

16

SOMA WEISS Associate

Professor

of Medicine,

Harvard Medical

School

UNDERWEIGHT AND OVERWEIGHT

3J

F. DENNETTE ADAMS Instructor

in Medicine,

Harvard Medical

School

PROGRESS IN T H E CANCER PROBLEM

64

WILLIAM T. SALTER Assistant Professor of Medicine,

Harvard Medical

School

RHEUMATISM

88

WALTER BAITER Associate Professor of Medicine, NORMAL

AND

ABNORMAL

Harvard Medical

School

MENSTRUATION,

AMENORRHEA, AND THE

MENOPAUSE

.

.128

JOHN ROCK Research

Associate

in Obstetrics

cology, Harvard Medical

and Assistant

in

Gynae-

School

CARE OF T H E EYES

163

T . L . TERRY Instructor

in Ophthalmology,

Harvard Medical

V I T A M I N S A N D V I T A M I N DEFICIENCIES

School .

.

.

.

S. BURT WOLBACH Shattuck Professor of Pathological cal School

Anatomy,

Harvard

Medi-

185

X

CONTENTS

THE

G L A N D S OF I N T E R N A L HUMAN ACTIVITY

JOSEPH C. AUB Associate Professor of Medicine,

SECRETION

AND 218

Harvard Medical

School

T H E FAMILY MEDICINE CABINET REGINALD FITZ Lecturer on the History School; Wade Professor School of Medicine

of Medicine, of Medicine,

233 Harvard Medical Boston University

SOCIAL STRESS A N D M E N T A L H E A L T H

.

.

.

.

250

C. MACFIE CAMPBELL Professor

of Psychiatry,

Harvard

Medical

School

PREPARING FOR A COMFORTABLE OLD A G E .

.

WILLIAM H . ROBEY Clinical Professor School

of Medicine,

Emeritus,

Harvard

Medical

.281

HEALTH AT FIFTY

H E A R T DISEASE Herrman L. Blumgart STRUCTURE AND FUNCTION OF THE N O R M A L H E A R T

N T H I S age of machines and science the glories of the achievement of man often are praised. The most perfect machine in our world has, however, been silently performing its work for many thousands of years without the conscious control of the individual who is its possessor. Approximately seventy times a minute, a hundred thousand times a day, thirty-seven million times a year, the heart pumps the blood contained within its cavities to the various body organs, which would succumb within several minutes were this continual supply interrupted. Beginning to contract during the very first months of prenatal life and continuing after birth until, presumably, threescore years and ten, the heart contracts at least 2,800,000,000 times, and pumps more than 40,000,000 gallons of blood. The automaticity of the heart, which is still in many important aspects beyond our comprehension, is not, however, its most extraordinary attribute. Of even greater wonder is its swift adaptability to rapidly changing needs. While a person is at rest, the heart pumps blood at the rate of approximately six quarts per minute or ninety gallons per hour. With the onset of violent exercise or emotion, the heart immediately

I

4

HEALTH AT FIFTY

increases its rate and force of contraction, and within a few seconds may be pumping blood at the rate of thirty to forty quarts per minute, or 450 to 600 gallons per hour. The heart not only supplies the rest of the body with the essentials for life, but also pumps the blood to itself for its own sustenance. What is this extraordinary organ which Harvey called "a foundation of life from whence all vigor and strength does flow"? The heart is a muscular organ about the size of the fist, situated in the left side of the chest near the breastbone. It contains four cavities; two of these, the auricles, are mainly receiving cavities; the other two, the ventricles, are pumping chambers. The receiving cavity on the right side of the heart, the right auricle, receives the blood that comes to the heart from the various organs of the body; the left auricle receives the blood which has flowed through the lungs. Within a given time the blood escapes from the receiving cavities into the two pumping chambers, the ventricles. The right pumping chamber propels the blood through the lungs. In the fine vascular network of the lungs the blood comes in contact with the inhaled air, unloads some of its contaminations in the form of carbon dioxide, and takes on oxygen with which to supply the vital processes of the body. This blood flows into the left receiving chamber or auricle, then escapes into the left pumping chamber or ventricle and, following the contraction of the latter, is propelled through elastic tubes to the various parts of the body.

HEART DISEASE

5

The tubes that lead to the heart are called veins. Some of these can be seen on the back of the hand and along the sides of the neck. They are blue because they contain blood from which a large part of the oxygen has been extracted by the tissues through which this blood has flowed. The tubes that lead from the heart are called arteries. When a physician counts the pulse he palpates the radial artery which expands following each contraction of the heart. One may wonder why, when the chambers of the heart contract, they do not force blood backward into the veins, as well as forward into the arteries. Were this to occur, the results would be catastrophic within a minute. The blood is prevented from escaping in a backward direction by a system of one-way valves, situated between the receiving and pumping chambers and at the roots of the large arteries leading from the right and left ventricles. The extraordinary effectiveness of the heart derives in part from the fact that it does not work uninterruptedly. After each beat the healthy heart pauses and replenishes its strength, at the same time affording blood an opportunity to flow into the receiving and pumping chambers. The rest period after each beat is almost twice the duration of the cardiac contraction itself. In a heart beating seventy-two times per minute, each squeezing period is three-tenths of a second, while five-tenths of a second are spent resting. Applying this ratio to the twenty-four-hour day we find that for many thousands of years the

6

HEALTH AT FIFTY

heart has believed in the nine-hour day, resting completely for fifteen hours daily. There is another significant lesson to be drawn from the periods of work and rest of the heart. If the heart increases its rate, as it does during emotion or exertion, we find that the proportion of the time it is actually contracting in each minute is greatly increased. Under such circumstances the heart may be working not at the rate of eight or nine hours a day but at the rate of twelve, fourteen, or even sixteen hours a day. In brief, the heart is not only working more of the day but has less ample time to rest. It is small wonder, therefore, that we find in this world of increased pace, anxiety, stress, and strain that the heart, working more hours and having fewer hours to rest, suffers from the wear and tear of life more than it has in previous centuries. ABNORMAL STRUCTURE AND FUNCTION

Palpitation, one of the most common symptoms of heart disease, signifies consciousness of the heartbeat. Palpitation due to increased rate of contraction may be a consequence of disease elsewhere, such as overactivity of the thyroid gland. It is, of course, also experienced by healthy persons as a result of emotion or exercise, or even on lying down in bed on the left side in the quiet of the night. Some people experience occasional extra beats of the heart throughout their lives, feeling a "skipping" of the heart. This irregularity is due to the play of nervous impulses and in such individuals has been observed to occur from

HEART DISEASE

j

early life to a ripe old age without causing any further difficulty. Occasionally, however, and particularly when appearing for the first time in middle life, it may constitute a warning sign of some structural abnormality or of an increased irritability due, perhaps, to excessive smoking. Another manifestation of "the nervous heart" may be paroxysms of rapid heart action. The individual, without warning, suddenly feels an extraordinary pounding of the heart which may last for minutes, hours, or even days. He experiences a sense of impending disaster and frequently suffers from breathlessness, dizziness, or fainting. Such attacks, though most disconcerting, are rarely perilous, and fortunately the physician possesses effective remedies with which to terminate and to prevent such paroxysms. It is a great tribute to the heart that in spite of this excessive work it does not wear out during such an attack or suffer any permanent aftereffects. Nevertheless, people should not disregard such disorders of the heartbeat, for they may sometimes be the result of disease processes which require treatment. Hearts showing disorders which are due to nervous impulses may be structurally normal. A more serious form of heart disease is that due to actual anatomical damage of the muscle or valves. The heart's worst assailants are rheumatic fever, syphilis, and, occasionally, certain acute infections such as diphtheria, scarlet fever, tonsillitis, pneumonia, and gonorrhea. In addition, the natural deterioration of old age, which in

8

HEALTH A T FIFTY

present-day life frequently occurs prematurely in the middle years, causes hardening and narrowing of the arteries which supply the heart with blood. This leads to weakness or even failure of the muscular power of this organ. Of the various infectious diseases, rheumatic fever is first in importance, most frequently afflicting children after the age of five and young adults. While the age of affliction with this disease is most commonly before twenty years, 70 per cent of individuals whose hearts are affected by the disease live beyond forty years of age. Rheumatic fever is often associated with tonsillitis, and is characterized particularly by migrating pains in the joints and muscles, "growing pains," and sometimes by redness, tenderness, and swelling of various joints, nosebleeds, fever, and malnutrition. In some individuals the heart may be spared; in others, however, rheumatic fever causes weakening of the heart muscle and permanently scarred and distorted valves, allowing the escape of some blood backward with each contraction of the heart. In middle adult life we encounter not only those who have suffered from rheumatic fever but those who, having acquired syphilis in earlier years, have felt so well that they have disregarded treatment of the disease or have not been cognizant of the infection. Syphilis is most commonly contracted between the ages of twenty and thirty but gives rise to symptoms usually only fifteen to twenty years after the initial infection. During the years of neglect, the infection

HEART DISEASE

9

may cause the destruction of the root of the large vessel leading from the left pumping chamber, and of the heart valve closely adjacent. The individual may feel perfectly well for many years, until he suddenly becomes aware of symptoms such as breathlessness, pain, palpitation, and weakness. The treatment of such patients is discouragingly unsatisfactory in comparison with the striking efficacy of modern remedies in the early stages of the disease. Pain may be an important warning sign of disease of the heart. Not infrequently, however, the patient may describe his symptoms as a vague sense of oppression below the breastbone or as a dull, heavy sensation in the shoulders or arms, precipitated by exertion, emotion, overeating, or exposure to cold. One should remember, however, that skin, muscles, ribs, and lungs are also situated within this region, and may give rise to similar counterfeit symptoms in the absence of heart disease. Pain in these areas may also be due to irritation of nerves or even to diseases of the stomach or gall bladder. Contrariwise, symptoms arising in the heart may be experienced only in a distant area such as the fingers, the shoulders, or the upper part of the abdomen, or by belching or burning sensations. In any event, such symptoms, particularly when they occur in people of middle age, necessitate consulting a physician; for not only may heart disease be indicated by symptoms in other parts of the body, but disease elsewhere may be discovered because of sensations experienced in the region of the heart.

IO

HEALTH AT FIFTY

The causes of cardiac pain are numerous, but almost all have as their common denominator an inadequate blood supply to the heart muscle. With hardening and narrowing of the arteries of the heart, the amount of blood which can be pumped through these vessels may be adequate for the work of the heart while a person is resting, though inadequate for sustaining the increased requirements of the heart during exercise or emotion. The appearance of the pains due to this inadequacy should be regarded by the patient as a red light or danger signal which, if heeded, will prevent an accident, but which, if disregarded, may lead to disaster. Individuals who forego the strenuous activity which precipitates such attacks of pain and lead a life of moderation and equanimity frequently live for many useful decades. In certain instances one of the arteries may be completely occluded and give rise to severe, crushing pressure or pain; as a consequence, degeneration of the muscle supplied by such a vessel takes place. Even under such circumstances, after a part of the heart is lost, the remainder of the heart may compensate for this defect, and twenty to thirty years of comfortable life have been observed in patients after such an occurrence. H E A R T F A I L U R E VERSUS H E A R T D I S E A S E

The fact that a person has a structural deformity of his heart does not necessarily signify that he is seriously sick or that his life is endangered. Much of the important work in this world is accomplished by

HEART DISEASE

11

people with heart disease who live at a moderate tempo. To use the parable of the automobile, there may be knocks and squeaks in the engine, but, used discreetly and skillfully, it may provide its owner with entirely adequate service for many years, and may actually survive many more smoothly running engines subjected to reckless abuse. Every physician sees numerous individuals who are cardiac cripples, not because of the structural deformity of the heart but because fear and anxiety have paralyzed them. Such patients might have greater tranquillity were they to realize that many individuals enjoy happy and useful lives for seventy years or more without symptoms of heart failure at any time although they have had loud murmurs of heart disease for thirty or forty years. As Osier remarked, "The way to live forever is to acquire a chronic disease and take care of it." Many people with heart disease, undertaking more exertion than the capabilities of their hearts permit, experience signs of heart failure. The inability of the heart to pump an adequate amount of blood in a forward direction causes an accumulation of blood in the veins and consequent congestion of the various organs, skin, and underlying tissue. Breathlessness, chronic cough, with whitish or pinkish sputum, congestion of the liver, giving rise to pain in the upper right portion of the abdomen, swelling of the legs, and inability to lie flat in bed because of a sensation of breathlessness are frequently due to cardiac weakness. With adequate rest of the heart achieved by rest in

12

HEALTH AT FIFTY

bed and the skillful use of drugs, made possible by the extraordinary advances in scientific knowledge, these evidences of failure usually disappear. Such individuals may lead full, happy, and successful lives by limiting bodily activity somewhat, by securing adequate sleep and rest periods, by reducing the heart rate, and by reducing the body weight. Digitalis and such powerful therapeutic adjuncts as the diuretics which remove unnatural accumulations of fluid are important aids in treatment. In the therapy of heart disease, extraordinary advances have also been made in surgical treatment. Despite the sensitivity of the heart to injury and the situation of this organ within the bony cage of the chest, removal of accumulations of fluid surrounding the heart can be accomplished with safety. In certain instances the heart becomes encased in a tough fibrous sac which interferes with normal contraction; surgeons are now able to enter the chest and release the heart from this constricting, almost bony encasement. The injection of nerves with alcohol to relieve the pain of angina pectoris and the removal of the normal thyroid gland to lessen the work of the heart are other means by which increased comfort and longevity may be provided for certain individuals. PREVENTION OF HEART DISEASE

While extraordinary advances have been made in the diagnosis and treatment of heart disease, even more important progress has been made in regard to

HEART DISEASE

13

its prevention. Diphtheria, once so prevalent, has been successfuly controlled. The causative agent of rheumatic fever is unknown, but it is recognized that overcrowded living conditions, malnutrition, and neglected infections, particularly of teeth and tonsils, predispose to this infection. Rising standards of living and more adequate medical care have led to a definite diminution in the incidence of rheumatic heart disease. The scientific advances in medicine are nowhere better portrayed than in our knowledge of syphilis. The infecting organism has been identified, the various methods of transmission are recognized, thé clinical manifestations of the disease are accurately known, exact diagnostic tests are available, and effective methods of treatment have been evolved. All this, together with the increasing public health efforts, should lead to even greater reduction in syphilitic cardiovascular disease. Yet, despite such progress, an alarming increase in the incidence of heart disease has been reported by many observers. There are currently over two million in this country suffering from some type of heart disease, and statistics indicate that one out of seven dies of cardiac involvement. Heart disease as the cause of death is more frequent than cancer, pneumonia, and tuberculosis combined. Careful appraisal of these statistics, however, yields conclusions which are reassuring. Great progress has been made in the prevention and treatment of many infectious diseases, such as diphtheria, pneumonia, and tuberculosis, and

i4

HEALTH AT FIFTY

in combating diabetes and the nutritional and communicable diseases of infancy and childhood. The effective control of these diseases, the phenomenal advances in surgery, the careful supervision of water, milk, and other food supplies, the successful development of public health measures even during the past twenty-five years, have extended the average duration of human life in this country by approximately fifteen years. Many people who formerly died of diabetes or one of the infectious diseases now attain old age, with its tendency toward hardening of the arteries and consequent heart disease. The reduction in death from other causes because of the prolongation of life inevitably raises the proportion of deaths from heart disease. The heightened incidence of heart disease reported by many observers is not due only to the fact that more people live to an advanced age, with a natural deterioration of the heart and blood vessels. The decreasing birth rate has resulted in a larger proportion of elderly individuals in the population. Further, the greater acumen of physicians has led to the diagnosis of heart disease in many cases in which symptoms were formerly ascribed to other causes. One aspect of this problem, the increased incidence of heart disease from premature hardening of the arteries in the prime of life, particularly among men between forty and sixty years of age, is receiving concerted study and effort. Increased knowledge regarding the treatment of the most common single cause of such

HEART DISEASE

I5

heart disease, high blood pressure, and greater emphasis on the avoidance of stress and fatigue may well achieve significant results. As long ago as 1832 the eminent English clinician, James Hope, stated, "We may say on the grounds of incontestable experience, that, in their early stages, the diseases of the heart are, in a large proportion of instances, susceptible of a perfect cure; and that, when not, they may in general be so far counter-acted as not materially, and sometimes, not at all, to curtail the existence of the patient." The experience of physicians of the last hundred years has been in accord with this optimistic opinion. The great strides which have been made in our knowledge of the causes and treatment of heart disease during the past century and the concerted efforts of medical scientists of today permit us to look confidently for continuing progress in the control of these diseases.

BLOOD P R E S S U R E - L O W AND HIGH

Soma Weiss H E P U B L I C hears a great deal about "blood pressure." Medical examinations, insurance policies, medical lectures, and newspaper reports — all bring this term to the ears of the layman. But, frequent as its use is, the phrase remains vague and indefinite in meaning. What, then, are the essential facts regarding the significance of "blood pressure"? When the vague term "blood pressure" is used it usually means pressure within the larger arteries — that is, arterial pressure. This pressure is familiar to almost everyone through the powerful and rhythmical spurts of blood that occur when an artery is severed in an animal or in man. Most laymen do not know, however, that the pressure varies in different types of blood vessels as well as in the different chambers of the heart. Thus one may speak of "arterial," "arteriolar," "capillary," and "venous" pressure, as well as of "auricular" and "ventricular" pressure. As in the piston of a pump, the initial pressure within the circulatory system is generated within the ventricle of the heart during its phase of contraction (systole). This systolic discharge elevates the pressure within the overfilled and normally elastic tubes of the arterial system. The pressure within the arteries is highest at

BLOOD PRESSURE-LOW AND HIGH

17

the end of the contraction of the ventricle, and this maximal pressure is called the systolic arterial pressure. Following the contraction and during the period of relaxation of the ventricle of the heart, there is a progressive fall in the pressure in the arteries until a minimum level is reached. This minimum level is called the diastolic arterial pressure. The arterial pressure is usually expressed in millimeters of mercury. When the "blood pressure" is measured by a physician, the pressure is expressed in two numbers, such as 120 "over" 70, usually written as 120/70. This indicates that the systolic or "maximal" pressure is 120 millimeters of mercury (120 mm. H g ) and the diastolic or "minimal" pressure is 70 millimeters of mercury (70 mm. H g ) . Some of the factors which determine the systolic and diastolic arterial pressures are interrelated; others affect mainly either the systolic or the diastolic pressure. Hence, while elevation or fall in both systolic and diastolic pressures frequently occurs simultaneously, under certain types of physiological stress and in certain diseases the systolic pressure rises and the diastolic falls, or vice versa. The arteries may be considered as accessory reserve organs of the heart. Part of the energy generated in the heart is temporarily stored in the arterial system as pressure energy. This energy is subsequently reconverted into kinetic energy for maintenance of blood flow. The more elastic the arterial system, the more efficiently it functions. This interrelation between the physical properties of the arteries and the

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pressure within them is of considerable significance in health and in disease. It should be remembered that the cardiac ventricles and the arteries are constantly under more severe physical stress than other organs. The maintenance of the normal or at least adequate functioning of these organs during life is, therefore, not an easy biological task. W e know that from birth there is a progressive decrease in arterial elasticity, a change that becomes accentuated as one approaches old age. Thus there is a normal, or physiological, tendency to vascular changes and degeneration with advancing age. The pressure within the various arteries is not the same. First of all, the arterial pressure is under the influence of gravity. Even in the horizontal position there is a certain amount of pressure gradient between the large and small arteries; for example, the pressure in the aorta (the largest of the arteries) is higher than that in the small arteries. This difference is about 10 to 20 mm. Hg. The greatest drop in pressure occurs between the smallest arteries (arterioles) and the capillaries. While in the smallest arteries the pressure may be 80 to 90, in the microscopic-sized capillaries it is but 8 to 12 mm. Hg. The protection of the capillaries against high arterial pressure is accomplished by the arterioles. These small vessels play a fundamental role in the physiological activities of the body. It is their sensitivity to nervous influences and to chemical agents which makes possible the delicate local regulation of the blood flow through the capillaries. These

BLOOD PRESSURE-LOW AND HIGH

i9

arterioles act as thousands of small dams. When the tissues need more nourishment and oxygen, the sensitive arterioles, stimulated mainly by waste products of the metabolism, dilate and thereby make possible a six- to eightfold or even greater increase in the local blood flow. During rest, when the tissues need relatively little blood, or, on the other hand, when there is an emergency in certain parts of the body, the arterioles "shut down" in the inactive parts. By constricting in the inactive area, they indirectly help the active areas. Were it not for this fine local regulation of the blood flow through changes in the caliber of the arterioles, whenever there was an increased demand for blood in a small organ the heart would have to respond with increase in work and in output. Regulation of the blood flow primarily by the heart would be extremely wasteful, and eventually would be harmful to the heart as well as to the arteries. The physiological function of the arterioles is therefore of considerable significance in relation to the function of the heart. The better understanding of the normal and morbid functions of the arterioles and of the reciprocal relationship existing between the heart and the circulation in the tissues is one of the important advances made in medicine during recent decades. From the foregoing remarks, and from the consideration of certain elementary principles of hydraulics as applied to the heart and to the circulation in general, it follows that there are five main factors which determine the level of the normal arterial pressure.

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HEALTH AT FIFTY

1. The "pumping" action of the heart. It is obvious that the more blood the heart pumps into the arteries per unit of time, the higher the arterial pressure will be. The level and the fluctuation of the arterial pressure depend not only on the total volume of blood pumped out by the heart per minute (the cardiac output), but also on the heart rate per minute at which the total volume is pumped into the arteries. With an unchanged output of blood per minute, the higher the heart rate, the smaller is the volume of blood thrown into the arteries with each beat (small stroke volume), and vice versa. On the whole, if the same volume of blood is pumped into the arteries with a slower heart rate (high stroke volume), there is an increase in the maximal (systolic) and a decrease in the minimal (diastolic) arterial pressure. This is well demonstrated by the characteristics of the circulation in patients who have an abnormally low heart rate, such as 30 to 35 per minute (heart block). 2. The resistance of the arterial system. As has already been indicated, the resistance of the arterial system is determined mainly by the small terminal arteries (arterioles), which act as dams in a continuously subdividing river. Other factors being equal, the greater the resistance the higher the arterial pressure, and vice versa. As a rule, as the resistance increases, the pressure is adjusted to a new level until the flow through the tissues again becomes normal. This normal flow is about 3.5 liters of blood per minute. The delicate mechanism of the body that

BLOOD PRESSURE-LOW AND HIGH

2i

maintains this constant blood flow through the tissues in the presence of diseased arterioles is but partially understood at present. 3. The volume of the arterial system and (4) the elasticity of arteries. These two factors are closely related in their effect on arterial pressure. It is clear that the larger the volume of the "arterial tree" and the more elastic the wall, the lower will be the pressure, provided there is no change in the "pumping effect" (minute volume output of the heart and stroke volume) of the heart, and vice versa. It is probable that there is a considerable degree of variation in the total volume of the arteries in normal persons. In other words, some persons inherit a "spacious," others a "small" arterial system. 5. The "consistency" (viscosity) of the blood. Lay persons often speak of "thin" and "thick" blood. If there were much variation in the physical consistency of blood in health or in disease the difference in the frictional resistance between the particles of blood would also be an important factor influencing the level of the arterial pressure. In reality, however, this factor plays at most a minor and usually a practically negligible role. In severe anemia the viscosity of the blood is lowered, while in the opposite condition, called polycythemia (a condition characterized by an abnormally high number of red blood cells), the viscosity is high. Even in these extreme conditions, however, the consistency of the blood exerts but little influence on arterial pressure.

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HEALTH AT FIFTY

I have discussed these somewhat technical aspects of arterial pressure because I believe that the average lay person will be able to follow and appreciate them. This knowledge will then enable him to formulate a better and more "dynamic" concept of the nature of the arterial pressure; it will make clear to him that "blood pressure" is not a rigid function. In various normal and abnormal states of the body the functions affecting the arterial pressure change in various directions and combinations. Furthermore, an appreciation of these factors will bear on the understanding of the nature and development of an abnormal type of arterial pressure, such as occurs in certain diseases we shall discuss. Measurement of the arterial pressure is a relatively simple procedure. The indirect method used today is based on an apparatus proposed by the Italian physician Riva-Rocci in 1896. In order to measure arterial pressure, a cuff to which the instrument is attached is placed around the arm at about the level of the heart. The pressure within the cuff is then raised above the expected maximal (systolic) arterial pressure — that is, until the arterial pulsation below the cuff is completely obliterated. The pressure is then slowly decreased. The first palpable arterial pulsation or the first sound heard with the aid of the stethoscope placed over the artery below the cuff indicates the maximal pressure. A change in the sounds over the arteries indicates the minimal or diastolic pressure. The average systolic arterial pressure in man is

BLOOD PRESSURE-LOW AND HIGH

23

about 120 mm. Hg, and the diastolic, 80 mm. Hg. These values, however, are quite arbitrary, for there are several bodily states which influence the level of the arterial pressure even in normal persons. Among these, age, sex, weight, digestion, emotional factors, physical exertion, and posture are the more important. A t birth the arterial pressure may be as low as from 30 to 50 mm. Hg. Within two to four weeks, however, it rises to an average of about 40 to 80 mm. The change from the first year to puberty is relatively slight, usually not more than 20 to 30 mm. From puberty to young adult age there is a somewhat abrupt rise, and in young adults it is not unusual to find an appreciable fluctuation of the arterial pressure, particularly under emotional stress. Female patients may show somewhat lower arterial pressure than males. During pregnancy, the blood pressure of healthy persons does not usually change, although in some pregnant women the pressure may be lowered. There is a slow rise both in the systolic and in the diastolic pressure with advancing age. The rate of rise is not so great, however, as is often claimed. The general statement that the average normal systolic blood pressure corresponds to 100 plus the age of the subject is not correct, for after the age of twenty-five such an estimation would be too high. Thus the average arterial pressure at the age of twenty-five is estimated to be 122/81, while at the age of sixty it is only 135/89 mm. Hg. Heavy and particularly obese persons have some

24 HEALTH AT FIFTY tendency toward a relatively elevated arterial pressure. During digestion there is but a very slight elevation of the arterial pressure. Emotional factors, on the other hand, may exert considerable effect. Normal persons have different types of organ responses to emotional stress. Thus fear, anger, or joy causes constriction of the vessels in some, dilatation in others. Some persons respond with increases in cardiac rate, others with changes in the function of the intestinal canal. In certain young adults emotional stress can cause an elevation in the systolic pressure as great as 30 to 60 mm. H g or more. It is of interest that such an emotional elevation of the arterial pressure can occur even during sleep in certain imaginary activities. Thus MacWilliam has observed during sleep in normal subjects a pressure as high as 200/105 mm. Hg. Usually, however, in restful sleep there is a fall of 10 to 20 mm. in the systolic pressure. Change from the horizontal to the upright position usually causes a slight fall, 5 to 15 mm. Hg, in the systolic pressure and a very slight rise in the diastolic pressure. Strenuous physical exercise is associated with an appreciable elevation in pressure. Thus during bicycle exercise it is not uncommon to find the systolic pressure at 180 to 200 mm. Hg. Following the cessation of exercise the pressure rapidly returns to normal or, at first, falls below the normal level.

BLOOD PRESSURE-LOW AND HIGH L o w BLOOD P R E S S U R E

25

(HYPOTENSION)

There are individuals whose blood pressure is always lower than the normal level for their age. If the level of the systolic pressure in adults is below 1 1 0 both in the horizontal and in the upright position, and if there is no diseased state present, the condition is called "essential hypotension." Thus there are healthy adults whose systolic blood pressure is only between 90 and 95 mm. Hg. Not infrequently such a tendency to low blood pressure is inherited, and it may be present in several members of the family. The condition is caused by the fact that the arterial tree is spacious, the arterioles are relatively relaxed, and the heart rate is low. The vascular resistance in these persons is low. Hence there is less strain on the heart and on the arteries, and the condition is usually not associated with degenerative diseases of the heart and of the arteries. Individuals with essential hypotension frequently live long lives. Because of the low arterial pressure they often suffer from lassitude, fatigue, giddiness, and headaches, and at times they may have a tendency to faint. Elderly persons with low pressure are particularly apt to suffer from these annoying symptoms in the morning soon after rising. There are a number of special types of low pressure. There are individuals whose pressure is normal when they are in the horizontal position but low when they are in the upright position. In rare instances the pressure may even be high when lying horizon-

26

HEALTH A T FIFTY

tally, but low when standing. Relaxed abdomen, large varicose veins, disturbances of the glands of internal secretion, or diseases of certain nerves may be responsible for this condition. Some of these patients are apt to faint if they change too abruptly from the horizontal to the upright position. Transient or periodic low blood pressure develops in many conditions. The most frequent and most dramatic example of the effect of sudden lowering of blood pressure is the common "fainting spell," such as occurs under emotional stress. During such fainting, owing to the relaxation of the minute vessels, a considerable volume of the blood is pooled in various organs. As a result of the withdrawal of an appreciable portion of the blood from the active circulation the "pumping effect" of the heart rapidly decreases, and the arterial pressure falls progressively. Finally a level is reached at which it can no longer be measured. When the drop in the blood flow and the arterial pressure reach a critical level, the circulation in the brain becomes insufficient and unconsciousness ensues. Before and during unconsciousness there are numerous changes in the body that are indicative of lack of adequate circulation in the brain. There are numerous conditions associated with loss of blood, severe injury, general wasting and loss of strength which are also associated with low blood pressure of shorter or longer duration.

BLOOD PRESSURE-LOW AND HIGH

27

H I G H BLOOD P R E S S U R E ( H Y P E R T E N S I O N )

In the preceding discussion of normal blood pressure it has been emphasized that variations in the level of the arterial pressure exist in normal persons. Under the stress of daily activities this normal pressure may show a considerable degree of elevation. There are many persons in whom, in spite of apparent health and normal capacity for daily work, the arterial pressure is considerably higher than normal. Indeed, moderate elevation of the blood pressure occurs so frequently that sharp demarcation between normal and high blood pressure is difficult. Somewhat arbitrarily we speak of "high blood pressure" or "arterial hypertension" if at rest the maximal (systolic) pressure is higher than 150 mm. H g and the minimal (diastolic) pressure is higher than 90 mm. Hg. High blood pressure is not a disease; it is merely a symptom, which may be caused by a number of different conditions. It is not necessarily permanent, and frequently may subside. If a person is said to have "high blood pressure" it does not follow that his blood pressure will progressively increase. In young persons who are emotional and intense it is particularly common to find that a moderately high blood pressure may eventually subside. If we examine the responses of the heart and of the circulation in subjects with high blood pressure, little deviation from the normal is observed. The majority of persons with high blood pressure look

28

HEALTH A T FIFTY

healthy and vigorous, and they carry on their daily activities with ease. The elevation of the heart rate in response to standard exercise is usually the same as in normal persons. If we undertake more elaborate measurements we find that the heart pumps the same amount of blood per minute as in persons with normal arterial pressure. If an organ needs more blood because of increased activity, the degree of increase in the local blood flow is the same as in normal persons. The blood supply of the tissues in persons with uncomplicated high blood pressure is good. Patients with high blood pressure show normal pressure in the capillaries and the veins. The essential difference between the state of the blood vessels in persons with normal and in those with elevated blood pressure is that in subjects with high pressure the resistance of the arterial vessels is increased. In other words, the minute arteries (the arterioles) are narrower than in normal persons. The dams of the small rivers are set on a higher level, and this in turn causes an elevation of the arterial pressure until the flow of blood through these dams again becomes normal. Generally speaking, the narrower the arterioles (the greater the resistance) the higher is the arterial pressure. The interrelation between the state of the arterioles and the level of arterial pressure is such that the pressure becomes elevated until a normal amount of blood flows through the tissues. Thus in persons with high blood pressure, with the exception of the elevated arterial pressure and narrowed arterioles, there is normal function of the circulatory system.

BLOOD PRESSURE-LOW AND HIGH

29

What, then, causes this narrow state of the arterioles — that is, the increased resistance against the work of the heart? In spite of the considerable amount of investigative work done in this field, our knowledge of this aspect of the problem is meager, although we possess some significant facts. W e know, first of all, that in different persons the cause of elevation of pressure varies. High blood pressure is not caused by one mechanism only. In some instances inheritance plays a role, as indicated by the fact that a certain type of elevation of the arterial pressure is a dominant characteristic in several members of the same family. It is possible that such individuals are born with a "smaller" or "narrower" arterial tree. This group, then, presents just the opposite condition from that of persons with inherited "low blood pressure" (essential hypotension). In another group, narrow arterioles are the result of disease or of some inherited defect which renders them incapable of withstanding "normally" the wear and tear of life. Consequently these minute vessels "degenerate." This "degeneration" manifests itself in loss of normal elasticity and in gradual "clogging" with substances which accumulate during hardening of the small arteries (arteriolosclerosis). Diseases of the kidneys also bear a close relation to high blood pressure. It is well known that patients with Bright's disease of long standing are apt to have high blood pressure. W h y diseases of the kidneys should be associated with high blood pressure is not entirely clear. Judging from experiments on animals,

3o

HEALTH A T FIFTY

interference with the blood supply to the kidney is associated with formation of a chemical substance. The nature of this hypothetical substance is not well defined at present, but one can assume that after entering the circulating blood it constricts the arterioles and thereby narrows their lumen. As a result, the arterial pressure becomes elevated in order to insure normal blood flow through the tissues. Interference with the blood supply, which in experimentation with animals has been shown to cause elevation of arterial pressure, is frequently present in several types of kidney disease. Some persons develop high blood pressure during pregnancy. This condition, too, is often caused by an underlying, usually previously unrecognized, kidney disease. In certain disturbances of the functions of the glands of internal secretion, substances which have a constrictor effect on the small arterial vessels enter the blood stream. Thus disturbances in the function of the pituitary and of the adrenal glands may cause high blood pressure. Other "toxic" extrinsic substances may also cause high blood pressure. Faulty nutrition is responsible for high blood pressure only when it is excessive enough to produce obesity. Various food substances have without justification been accused of being responsible for the development of kidney disease and of high blood pressure. It is important to appreciate that meat and alcohol do not cause high blood pressure. Excessive use of tobacco, on the other hand, by increasing the irritability of the

BLOOD PRESSURE - LOW AND HIGH

3r

minute vessels, may, in persons with a tendency to high blood pressure, accentuate the condition. Mental worry and strain are often held responsible for high blood pressure. This is true only in so far as fatigue and any sort of stress or strain, particularly emotional strain, are apt to accentuate or to bring to the surface high blood pressure in persons who are predisposed to the condition. Thus it is not so much that persons with high blood pressure are unusually intense or emotional, but rather that in such persons the small arteries are irritable, and therefore a degree of strain which is ineffective in normal persons will produce a considerable elevation of pressure. It is of interest that, while the normal blood pressure falls but slightly under bed rest, high blood pressure not infrequently returns to normal after mental and physical relaxation associated with such rest. The intensity of modern life has been held responsible for the causation of high blood pressure, but the importance of this factor is probably exaggerated. W e must realize that, whereas in certain respects wear and tear is greater, in other respects social and economic advances have provided an ever-increasing degree of mental and physical security. I believe, therefore, that we are inclined to overestimate the importance of this factor on the blood pressure. It is true that the incidence of degenerative diseases of the heart and of the vessels is increasing, but this is due primarily to an increasing span of life. The more elderly persons there are in a community, the greater is the

32 HEALTH AT FIFTY number of persons with degenerative diseases of the heart and of the arteries. N o w that life expectancy has been increased to sixty years, degenerative diseases of the heart and vessels are naturally also on the upgrade. The majority of persons with high blood pressure have no complaints for many years. When symptoms develop they consist mainly in weakness, headaches, hot flashes, nosebleeds, dizziness, and generalized aches in various parts of the body. In female patients the sensations are not unlike those experienced at the menopause. At times persons who have a severe degree of elevation of the blood pressure find mental concentration difficult, and in conversation they wander from one topic to another. At times they become intensely emotional. This emotional state is often held responsible for the high blood pressure, but a careful analysis reveals that the opposite is actually the case. Many of the symptoms of these patients depend on the daily and sometimes severe fluctuations of the blood pressure (vasomotor instability). Other complaints are caused by the presence of complications. Fortunately these are not frequent in persons who lead normal, well-regulated daily lives. In some patients the strain of high blood pressure is apt eventually to affect the heart and the vessels of the brain and of the kidneys. Thus hardening of the arteries (arteriosclerosis), "angina," coronary thrombosis, heart failure, "strokes," and vascular Bright's disease, conditions of which much is heard

BLOOD PRESSURE - LOW AND HIGH

33

these days, bear a certain relationship to high blood pressure. The combined presence of kidney disease and high blood pressure acts as a vicious circle; kidney disease can cause high blood pressure, and high blood pressure, if severe and of long duration, can in turn affect the kidney or aggravate a preexisting Bright's disease. Whether or not high blood pressure eventually affects the function of various organs of the body and causes generalized deterioration depends not only on the degree and the duration of the elevated pressure but also on the individual capacity of the tissues of the arterial wall and of the heart to withstand the constant strain. In this respect tissues of different persons show considerable variation. There are persons who inherit a "vulnerable" heart and vascular system, in whom failure of the function of the heart and of the blood vessels occurs even if the arterial pressure is normal. There are still other persons who reach a comfortable old age in spite of the fact that they have had a rather severe degree of high blood pressure since early adult life. In several respects "hardening of the arteries" (arteriosclerosis) can be considered as a response of a failing arterial system to normal or to exaggerated wear and tear. Through examinations and tests the physician can obtain evidence as to the type of high blood pressure he is dealing with and the amount of damage, if any, that has been done to the heart and to the arteries by the high blood pressure.

34

HEALTH AT FIFTY

Whereas in the majority of instances of high blood pressure eradication or "cure" of the condition may not be possible with measures at present available, nevertheless much can be accomplished by following the advice of a physician. The details and the critique of the therapeutic measures which may be employed are outside the scope of this discussion. By leading a normal, rhythmic life of daily activity with periodic rest, and by using symptomatic remedies, complications can be avoided and life can be prolonged.

UNDERWEIGHT AND OVERWEIGHT F. Dennette

Adams

T

IME W A S when the veil of privacy mercifully shrouded such intimate matters as the pinkness of one's toothbrush, the efficiency of one's digestive apparatus, and the condition of the skin on one's feet. But that era of delicacy has passed, gone the way of linen dusters, mustache cups, and peg-top trousers. A certain amount of good, to be sure, has come of the present-day publicizing of our maladies, thanks to campaigns of health education launched by qualified agencies and authorities. W e are infinitely more alert than were our grandparents to the hidden dangers of a persistent cough, a lump in the breast, or bleeding from the rectum. But evil has been sown, too, by the misleading, inaccurate, high-sounding nonsense handed out by the sponsors of certain proprietary products. For much of this commercialized publicity, built as it is on a shaky foundation of pseudo-authority and quackery, has fostered hypochondria and ill-advised self-medication to an alarming degree. Among others, the subject of weight has received its full measure of attention. What you eat, how much, when, where, and why, has been for some time now the topic of intelligent discussion by in-

36

HEALTH AT FIFTY

formed and qualified writers and lecturers and, less happily, the not entirely disinterested concern of a host of beauty experts, advertising agencies, women's page editors, and a company of dubious gentlemen with Vandyke beards styling themselves Viennese savants. The public has, as a consequence, acquired an impressive vocabulary of words and many erroneous ideas concerning nutrition and diets. How often are bridge-table and luncheon conversations devoted to discussions of milk diet, banana diet, eighteen-day diet, and similar fads! How widespread the use of such terms as calorie, vitamin, acidity, and glandular disorder by people who scarcely know their meaning! My purpose in this paper is to present the basic facts underlying the subject of weight, to dissipate the murk of misconception and misinformation which surrounds it, and to outline the principles of sound dietary regulation. FACTORS INFLUENCING W E I G H T IN THE NORMAL PERSON

It is common knowledge that the weight of any individual depends to a large extent on height, age, sex, and race. These are factors over which we have no control. The figures given on weight charts merely represent an average of the weights of normal persons of the same age, height, sex, and race. No allowance is made for individual differences in the size of the bony framework. It is therefore customary to allow a leeway of 10 to 15 per HEIGHT, AGE, SEX, AND RACE.

UNDERWEIGHT AND OVERWEIGHT

37

cent above and below the chart figures in estimating what any given person should normally weigh. For example, the standard weight usually given for a thirty-year-old man, five feet nine inches tall, is 156 pounds, but he might weigh as little as 145 pounds or as much as 165 pounds and still be considered normal. The figure given for a woman thirty years old and five feet five inches tall is 134 pounds, but a weight between 125 and 140 pounds may not necessarily be abnormal. Human bodies are not, like some particular model of automobile, turned out on an assembly line according to identical specifications. Some persons have large, rugged, sturdy frames; others smaller, narrower, more fragile ones. The weight the frame will or should carry is in proportion to this underlying pattern. A normal person of large frame would obviously weigh more than one of smaller build. THE BASIC FRAME.

RELATIONSHIP B E T W E E N FOOD INTAKE AND ENERGY

This is one of the most important factors controlling body weight. The relationship between intake and output can be explained in simple terms by comparing the human body to a steam engine. The engine is supplied with fuel in the form of coal or oil, which combines with oxygen to produce heat. Some of this is dissipated; the remainder is converted into power, or work. A given unit of fuel is transformed into a specific unit of heat. Any increase of OUTPUT.

38 HEALTH AT FIFTY work that may be required cannot be obtained without a proportionate increase in the amount of fuel used; conversely, an idling engine requires less fuel. The human machine operates on exactly the same principle. Its fuel is food. Life can no more be maintained without food than power can be produced in a fuel-less engine. In the body, food is converted by a complex series of digestive processes into certain simple substances, such as sugar. These combine with oxygen and, like fuel in the engine, are converted into heat, which keeps the body warm, and into energy or driving power, which is utilized as bodily activity. W h e n activity increases, or when more heat is being generated — as, for example, in an acute fever —more food is required. The less muscular activity or heat required, the less the amount of food necessary. Here the analogy ceases. If an engine is fed more fuel than is needed for the work to be done, the extra fuel is wasted. In the normal body, more food than is necessary for immediate need is stored in the form of fat and a substance known as glycogen, which are available for use later on when additional heat or energy might be required. This is clearly shown in the case of the hibernating animal, which eats more than it needs during the summer months and stores the extra food in the form of fat. W h e n winter comes, activity is reduced to the minimum, the animal eats nothing, and keeps warm by burning up the stored fat. In the human body, moreover, food, besides be-

UNDERWEIGHT AND OVERWEIGHT

?9

ing used for heat and muscular power, has two other functions: it promotes growth and replaces tissues destroyed by daily wear and tear. These, however, do not concern us in this discussion. The complex chemical changes by which food is converted into energy are technically referred to as metabolism. Mathematically, this process of transformation is expressed in the number of units of heat liberated in a given unit of time. The standard unit of heat is the calorie, and food is measured in terms of the number of calories it can produce. For each calorie expended by the body, an equivalent amount of food must be taken in. Daily requirements are governed by the amount of energy the body uses up in the twenty-four hours. Broadly speaking, an adult of average size who leads a life of ordinary activity requires for daily consumption approximately 12 to 14 calories per pound of body weight, or a total of 1800 to 2100 calories in twenty-four hours. An active business man might require somewhere in the neighborhood of 2500 to 3000 calories per day; a laborer, 3500 to 4500. When more food is eaten than is needed for dayto-day activity, gain in weight results. If the body does not take in sufficient food to meet the daily requirements or, because of some digestive disturbance or other disorder, cannot convert the ingested food into energy, it will consume stored fat or, when this is exhausted, other body tissue. The result is weight loss.

4

o

H E A L T H A T FIFTY

Several explanations have been offered for the fact that two healthy individuals of identical age, height, sex, and race, and of similar build may eat the same type and amount of food, yet one is heavy and the other light, one gains weight easily, the other with difficulty. The most plausible explanation is difference in temperament. The person who gains readily is characteristically of a placid, easygoing disposition. He is more stable emotionally. The food he consumes is not all used up in activity and "nervous energy" but some of it stored, so that weight increases. It is generally accepted that fat men are jolly. The popular belief is that a man is jolly because he is fat. More likely, he is fat because he is jolly. The other type of person, the one who does not gain readily, has a vastly different temperament. His mechanism is keyed to a higher pitch. He is quick, alert, restless, squanders his energy in useless or accidental motion and constant fretting. What he eats is burned up; none remains to be stored. TEMPERAMENT.

Nowhere is this relationship between temperament and physical characteristics better expressed than in the words of Julius Caesar to Antony, with which most readers are doubtless familiar: Let me have men about me that are fat; Sleek-headed men and such as sleep o' nights: Yon Cassius has a lean and hungry look; He thinks too much. . . .

UNDERWEIGHT AND OVERWEIGHT

4i

Inheritance is undoubtedly of some importance in determining what an individual weighs. But the widespread belief that the actual tendency to be stout or slim is inherited is probably incorrect. True, we often find several members of a family showing the same weight pattern. But it is not the tendency which is inherited; it is the temperament which controls that tendency. INHERITANCE.

Here is an important but too often disregarded cause of similarity of weight pattern in members of the same family. In their eating habits children generally follow the example set by parents. In homes where large, rich meals are served and heavy eating is encouraged, one finds children, like their parents, much too fat. Where the family diet is scant, leanness prevails.

ENVIRONMENT.

A favorite excuse of overweight or underweight persons is that their condition is caused by "gland trouble" and is therefore beyond their control. Disturbance or disease of the pituitary, thyroid, or possibly some other gland of internal secretion undoubtedly accounts for lack or excess of weight in some instances. But this is true in only a small fraction of cases. We have no definite proof at present that the weight of presumably normal persons is to any great extent influenced by glandular disorder. INTERNAL SECRETORY GLANDS.

42

HEALTH AT FIFTY UNDERWEIGHT

Let us now consider the problem of underweight. To those who wish to learn the cause of their thinness and the remedy for their failure to gain weight, I suggest this: You are perhaps violating the simple rule of a unit of food intake for every unit of energy output. Increase your food intake and reduce your output of energy. But before taking either step make sure that there is not present some other remediable cause of your low weight. Remember that loss of weight or abnormally low weight, as distinct from constant but not abnormally low weight, often means serious disease. Its cause must be determined and corrected by a physician. ( W e shall return to this aspect of the problem later.) Those who have always been thin but have shown no recent loss of weight and those who have been assured by a physician that no disease is responsible for their deficient weight might profit by studying the accompanying diets, A and B.* DIETS A AND B BREAKFAST

Orange Toast Butter Coffee Cream

A juice, small glass . . . . i slice • i square • i cup i tablespoon ....

TOTAL CALORIES

48 77 77

30

.. 232

B Orange juice, small glass . . . • Toast 2 slices . Butter 1 square • Coffee 1 cup Cream j tablespoons . . 1 Egg • Cereal small dish • TOTAL CALORIES

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