BNF Nutrition Bulletin Vol 2 I , January I996

Dr Black‘s Professor Alun Evans Department of Epidemiology and Public Health The Queen’s University of Belfast Grosvenor Road Belfast BT I2 6BJ dietary

I b advice e eminent Irish physician, Dr Samuel Black, was born in 1764 and

died at his house at Marcus Square, Newry in July 1832. He qualified T as a doctor from Edinhrgh University graduating MD in I786 and he set up practice in Newry in 1788. His reputation was established with the publication of his book Clinical and Pathological Reports in I 8 19,’ in which he described a total of 18 dissections, the first four of which involved pa- tients who had died of angina pectoris. He also turned his scalpel to drunkards, those with gout, chronic peritonitis, otitis media and diabetes, and persons who had succumbed to the typhus epidemic of I 8 17.

Proudfit has written of Dr Black‘s considerable contribution to the ischaemic hypothesis of angina pectoris. Proudfit records that ‘Black gave full tribute to Jenner and Parry but there is no doubt that his observations were origi- na1’.2 Black believed that ‘the application of chemical principles . , . may lead to the knowledge of remedies calculated to correct the diatheses, or per- haps remove the deposit.’ Proudfit commented that ‘This remarkable vision, formed when chemistry was in its infancy, has not been fulfilled, but is still viable.’ Black looked upon the problem as ‘ossific’ but certainly there are chemical means available today, at least to deplete the lipid content of atherosclerotic plaque.

Certainly Dr Black saw that chemistry was central to the unravelling of the problem of angina pectoris. He quoted Brown who considered the human body as a machine endowed with a certain essence which he named ‘excitabilit$ According to Black ‘This excitability, acted on by stimulants from without or from within, such as food, drink, heat, passions etc gives rise to the phenomena of life and of disease. Life in fact appears to be a flame supported by a constant supply of fuel.’

One of Dr Black‘s recurrent themes was ‘lifestyle.’ In Blacks words, this is variously referred to as ‘mode of living,’ ‘a full habit,’ ‘habits and modes of

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living.' The concept probably originated with Hippocrates. Dr Black spoke of Hippocrates' 'acute observation, detailed with a luminous perspicuity and elegant conciseness,' The likely source is 'On Airs, Waters and place^'^ - 'the mode in which the inhabitants live, and what are their pursuits, whether they are fond of drinking and eating to excess, and given to indolence, or are fond of exercise and labour; and not given to excess in eating and drinking.'

It is of interest that Ancel Keys first used the phrase 'mode of life' in a paper in 1948.4 Apparently he preferred this to the more modern term 'lifestyle.' 'Life-style' was first coined by Orgler in I939 from metal mined by Alfred Adler a decade earlier: Adler used the phrase 'style of life' t o denote a plan of life, ie a person's consistent movement towards a goaL5

From his dissections in angina pectoris, Black concluded that one of the factors responsible was an accumulation of fat around the heart. This was present even in 'Mr Woodney' who was 'not corpulent; accustomed in his mode of living to strict habits of regularity temperance and attention to active business.'

Dr Black made a number of important observations on the epidemiology of angina pectoris connecting it with 'a degree of obesity.' Interestingly, Dr Black was perhaps the first t o notice the relative infrequency of angina pedoris in France, and he could 'readily conceive that the French habits and modes of living, coinciding with the benignity of their climate and the pecu- liar character of their moral affections (psychological stress), may have a less tendency to favour this peculiar disorganisation than the same circumstances, considered in their application to the inhabitants of the British Islands.' Dr Black also included 'the meridional regions' (southern Europe) as being exempt. However; Dr Black did not ascribe these differences to alcohol consumption between Ireland and France or t o the possible influence of the Mediterranean diet - a title introduced by Ancel Keys and his wife in a cookery book6

For the treatment of angina pectoris Dr Black was 'inclined to propose a regimen of the most abstemious kind, exclusive, in a great measure, of animal food and fermented drink.. . I would earnestly recommend the adoption of a plan of abstemiousness and self-denial. Experience however; has taught me that it is in vain for men to begin such a system of living, unless they are endowed with a certain firmness and constancy of mind, such as are necessary to enable men to forego Sybaritic gratifications and to prefer a prospective advantage to a present enjoyment.'

Dr Black also noticed a 'tendency of paroxysms of angina pectoris t o attack after dinner' and recommended 'a small quantity of light nutrients every three or four hours, by which the inconveniences of the distended stomach will be avoided.' Elsewhere he states 'that the great majority of

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BNF Nutrition Bulletin Vol 2 I , January I996

the subjects of [sic] it have belonged to the better ranks of society, who were in the habit of sitting down every day to a plentiful table, in the pleas- ures of which they may have indulged to a greater extent than was suitable to the tendency of their constitution:’ ,.. Again, ‘These considerations ap- pear to me t o suggest the propriety of a regimen very low and abstemious.’ Judging by the phrase ‘the tendency of their constitution’ Dr Black foresaw the important genetic component of heart disease which is only now being unravel led.

He describes two cases of diabetes, one in an individual in his mid-thirties, the other in ‘an elderly gentleman.’ ‘He was a man of a broken constitution, had lived very freely and was aged about 68.’ His diabetes had been precipitated by drinking large amounts of oxymel, a concoction of vinegar and honey, which appears to have caused a crisis of the hyperosmolar non- ketotic variety. The diet recommended by Dr Black was ‘exclusively of the animal kind.’ Dr Black‘s method of assessing the severity of diabetes was simple - urine and even serum was ‘sweet to the organ of taste.’ To prove that urine contained sugar Dr Black commandeered his wife Margaret’s ‘earthen pipkin’ (a small earthenware boiler) t o evaporate the fluid ‘leaving a residuum, having the appearance of molasses with a strong smell and taste of hone$ Dr Black informs us that ‘Dr Home by adding barm to the urine of his patients, Murray and Arthur; obtained what he calls a tolerable small beeu: . ,.’ This might be of interest t o the Real Ale fraternity.

In conclusion, Dr Black made highly original observations on various dis- eases. He had very little good to say about alcohol consumption, and perhaps this reflected a strong Protestant background with a tendency to Puritanism - which would have been appropriate to the Ulster of the early nineteenth century, Elsewhere, he speaks of ‘overbearing instinct.. . which nature has implanted in the breasts of all living creatures towards their offspring, that parents look rather to the gratification of their children than to their solid and permanent advantage. They too often view their interest through the refractive and distorting medium of feeling.’ Dr and Mrs Black‘s marriage was childless.

References I Black S. Qinicol and Pathological Reports. Newry: Alexander Wilkinson, I8 19. 2 ProudfitW L. Origin of concept o f ischaernic heart disease. Br Heart] 1983; 5 0 209-2 12. 3 Hippocrates. On Airs, Waters and Places. In Foundations of Epidemiology. Lilienfeld AM, Lilienfeld DE. Oxford: Oxford University Press,

4 Keys A. Mode of life and the development 1980, 23- 24.

of heart disease: research for preventive hygiene. Chicago Heort Association Bulletin

5 The Oxford English Dictionory, Second Edition, VolumeVIII. Oxford: Clarendon Press, 1989; 9 17. 6 Ferro-Luui A, Sette S. The Mediterranean Diet: an attempt t o define its present and past composition. Eur J Clin Nutr 1989; 43 (Suppl 2): 13-29.

1948; 26: 3-6.

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