better. They love and honor him still, but when the critical time comes, he may be left and the other taken, and woe to him who has blinded himself to this possibility, and failed to realize the inexorable law of human nature and of fashion, and woe to him who has not anticipated just such a crisis and prepared himself to meet it.

Notice how the United States Government goes about it in one of the most important branches of its service. Arbitrarily it informs its Army and its Navy officers that on their sixty-second birthday they are old, no longer fitted to follow their careers. On the day they become sixty-two years of age they step from their tents or the bridge and become private citizens, old men. Our patients are more polite about it, they say nothing, and the doctor who has become old sits and wonders what has happened. Sits and wonders? Not so if he has prepared himself, if he has watched the signs of the times, seen something, whether it be a great white light or a little cloud no bigger than a man's hand. Let us suppose, for example, that sixty-two is the age limit for a physician, the age limit for him as a professional man, the time that an Osler might want Kilmer to get out his apparatus for gas and ether. That would leave him eight years according to Biblical authority, considerably less by insurance tables, for getting out of the harness and having one grand long vacation, the opportunity to spend what years remained in doing exactly as he pleased.

The other evening four of us sat around a table and in comparing notes discovered we were all born in 1862, the poetry of which consisted in the fact that if we were in the government service, but twelve years remained to carry on our work. 1900

seems only a little while ago, and 1924 is no further distant in the future, only it seems longer. Then of those eight yearsI have no delusions as to the possibilities contained therein, I can picture the stiff knees, the bent back, the macaroni sticks which have supplanted the arteries. I know the handicaps which are likely to put vinegar in the general sweetness of a life's work completed, but need such things take away the best feature of an early happiness, its anticipation? Is it not true that about one-half of happiness in this world consists in the anticipation of it? What man in this room when he rolls in under the covers at night does not think of the big fish he is going to haul in, of the little garden he is to tend, of the swish of water and the joyous flaps of the sails?

So never mind what happens, we have already had half the pleasure if perchance the realization fails us in the end, if actually when the time comes to lay aside the strain we find ourselves unable to carry out the day dreams of younger days.

It has always seemed to me one of the marks of genius to be able to step off the stage of glory at its zenith, to gracefully make one's bow while the applause is still heard, and one of the saddest things is the effort to continue that glory or renew the applause.

How infinitely better to be forgotten gracefully than be remembered with scorn or pity! But just as one must prepare for the beginning of life's work, just so must he prepare for its close-to simply stop and say "Tomorrow I go hence," is impossible, such a change of life would be as unphysiological as the operative change of life would be in a woman. The thirty or forty years of daily routine tends to form habits, and like the old dog, new tricks are

, 1913

Vol. VIII

difficult to learn. There is where the far sighted man has made his little preparation-gotten ready when the time has come to step right into the new harness and take the home turn. The getting ready for this species of menopause involves two absolute essentials; one of them being enough of an income to live upon after the office door is closed, the other the possession of an incentive, let us call it a hobby, to occupy the mind with as great or even greater an interest than the work one is handing over to others. The financial part of it may spoil the whole programme, for it is almost a byword among the people at large that a medical man's ability to lay by for rainy days is about the worst feature of his otherwise generous supply of good qualities, and the reasons for this are abundant even if it be more or less true. I might specify as among these reasons the necessity of living on a scale which requires a fairly good income, and the further notorious reason that so many people regard the doctor as a man who scorns to receive money for his services to suffering humanity, and who might feel offended if the offer were made, hence they think it safer not to make the offer. Doctors are apt to have nice little families also, girls and boys, who are at school and college, and need pretty clothes and are right in the middle of the social whirl, and perhaps the Frau doctor herself is quite content to let matters go on in the smooth even tenor of their ways and might be inclined to exercise her right of suffrage to vote against any programme which would involve a shifting of the scenes. Here is where the idea of long sighted preparation comes in, the education of one's household that there is a limit to a professional man's ability to keep things going at the

same rate and on the same basis as existed when he is at his best in years and strength. A hard hearted and selfish household it would be which would exact from its breadwinner his maximum until the end.

It is part of the very trouble with things that the doctor himself wants to see his wife, his sons and his daughters have the best of everything, and his happiness, his joy in life is his ability to maintain their standard and yet no man with his family dependent upon him, can do otherwise than recognize the order of nature that the time will come when his sons and his daughters will have homes of their own, and have become independent component parts of the world's makeup, and that ultimately he and she will be left alone again to look at each other across the table and wonder what they are going to do now, and when that moment comes it is the psychological one. If he has, with long foresight, put aside that from which he can now live, without the hours of confinement in his office, without being the slave of that monopolistic corporation, the telephone company, without the necessity of trying to think daily of some new remedy for that gas forming bacillus, old Mrs. Welland Strong, and if, with all he has had to meet and contend against, he has managed to lay aside a fund that will now do a little work for him, then will come the second and great commandment, his occupation, his hobby, for unless one has a hobby, he is in the words of old Kaposi, of Vienna, a "verlorener mensch." He would better stay on at his work, stay on as did two of our honored confreres, whom I mention with all reverence, J. Lewis Smith, and Janeway, both of whom made a lasting impression on me. The last time I saw either of them was to see poor old Dr. Smith

being helped into the house from that old buggy he went about in, and a few months before his death, holding on to Dr. Janeway, for fear he would fall down stairs from the sick room of the patient. Their hobby was medicine, and they were consistent to the last.

Not all of us are gifted like Weir Mitchell who is spending his declining years in literature, in works which will probably make his name more enduring than anything he did as a physician, nor like old Thomas Addis Emmett. But Weir Mitchell has his hobby and Emmett has his, and we all can have our own. Fortune might arrange it for us that the little farm up in the hills of Connecticut or down in Maryland by the shores of the Chesapeake, little farms where the chickens and ducks and the cows and the gardens, with the open air and sunlight could wake up in its various coloring, the picture of a hobby. those of us who love the sea and its rivers, either the great steamship to carry us to lands of our dreams, or the trim little yacht, listing gently to leeward in the evening breeze, with our hand on the tiller, the other holding the pipe, and eyes looking out at the evening of day and of life with all the happiness and contentment that comes from knowing that our work is done.

301 W. 88th St.

And

Many, if not most, of the cases of shoulder pain variously diagnosed as circumflex neuritis, rheumatism, etc., are instances of subacromial or subcoracoid bursitis. With involvement of the former bursa there is usually tenderness just beyond the acromion, usually somewhat anteriorly; in the latter there is marked tenderness just external to the coracoid tip. Pain on rotation of the arm may be present in either; it is most constant in subcoracoid bursitis.-Amer. Jour. of Surgery.

JANUARY, 1913

, Vol. VIII

OBSERVATIONS ON AN INTERESTING CASE OF RHEUMATOID ARTHRITIS.1

BY

ORRIN S. WIGHTMAN, B. A., M. D., Clinical Professor of Medicine, N. Y. Polyclinic; Visiting Physician, Workhouse Hospital; Ass't. Visiting Physician, City Hospital. Rheumatoid arthritis has been described as an inflammatory joint disease-acute, sub-acute, or chronic-which under certain conditions is apparently of an infectious nature and origin, and under other conditions of unknown cause.

Its slow and insidious progress often masks its real seriousness, and cases are frequently in a condition of helplessness, before the real danger is appreciated.,

The case which suggested this paper, is most instructive, and rather than speculate upon the etiology of which we know so little we will endeavor to draw conclusions from facts.

The patient, Mrs. H, a married. woman of 27 years of age, with no children, has a family history of rheumatism on both sides. As a child she had scarlet fever, and later adenoids were removed, otherwise she has been perfectly healthy.

In April, 1910, her right knee would occasionally become hot and painful, and later became swollen. The greatest annoyance was in the weakness she experienced in it while, or after walking. It would "give out" as she expressed it, and after a while she developed a slight limp.

At the suggestion of friends, she tried osteopathy, taking a full course of treatment, but manipulation seemed to make it worse, and the family becoming alarmed insisted on her seeing a surgeon. She went

1 Read before the Clinical Society of the New York Polyclinic Medical School and Hospital, February 5tn, 1912.

to a distinguished orthopedic man who suspected that fluid might be present. He aspirated without result. Rather surprised he then used galvanic needles in the joint. This after several weeks merely aggravated conditions, and becoming skeptical as to the true state of affairs he had X-ray pictures taken, and became convinced that neither tuberculosis, nor malignancy was present, but placed the joint in a metal brace from hip to ankle, completely immobilizing the knee. After two months of this treatment, the orthopedic surgeon sent the woman to a physician, who at that time having no other joints to guide him, pronounced it gout and promptly started treatment accordingly.

The patient was placed upon a restricted diet, and given alkalis, salicylates and iodides. She did not seem to improve, and was advised to go South, which she did, but not until after she had had two rigorous months of cold, changeable, winter weather in New York. By this time the inflammatory changes had involved the other knee, and both shoulders, which were very swollen and painful. After the baths at Hot Springs, Virginia, she seemed to get slight relief from the pain but was losing weight and appetite. She then went further south to Florida and becoming alarmed went out to Hot Springs, Arkan

sas.

Another course of baths was taken, a restricted diet assumed, and large doses of salicylates and iodides given. She returned to New York in May, 1911, weighing 85 pounds, having lost 45 pounds, and was a bedridden invalid.

On our first examination of the patient we found extreme emaciation, a slight diarrhea alternating with constipation: her elbows, shoulders, knees, ankles, wrists,

hands and feet and even the sterno-clavicular articulations were tender and sore. Some joints were very much reddened, but the hip joints seemed to have escaped the invasion. The hands were particularly interesting the small joints, especially the carpophalangeal in the index fingers of both hands, were enlarged and showed outward deflection. The distal ends of the phalanges had exostoses, and flexion of the hands and fingers was impossible. Her temperature at this time was 101.3 and her pulse 124. Her heart showed a mitral insufficiency, with a haemic murmur carried well into the vessels of the neck. Her blood pressure was 90 m/m.

A blood examination showed 6,000 white cells, with a distribution of 40% lymphocytes, and 46% polynuclear, 4% esinophiles, Hb. 65% by Talquist. No: malarial organisms found. The urine was 1.010 sp. gv. No albumin or sugar and urea .8 of 1%.

Our treatment to be rational had to aim at three things: First, rest; second, nutrition; third, removal if possible of the products of metabolism which were causing the chronic toxemia. A most competent nurse was secured at once, and in this connection, I may say that the cooperation, tact, and forbearance of an intelligent and resourceful woman, is absolutely necessary in these cases, if we are to hope for any results. The family are well disposed but not tireless, they are sympathetic under all conditions; which is not always desirable, and more than that, order and routine can rarely be obtained, other than through the authority of a trained nurse.

We were dealing with a disease, which though acute and unusually sudden in this case, had become sub-acute and chronic. The case, moreover, especially exemplified