our treatment must include the elimination of toxins via natural. Here again as in acne we are often confronted by the apparent contradiction that with active catharsis we are unable to favorably influence the lesion. And here again the same explanation holds. We must employ measures that tip over the cesspool and establish adequate body drainage. Mineral oil and a bandage with proper restriction of putrefiable ingesta may contribute largely to the desired result. If they fail it is in order to consider whether the annoyance and disfigurement are great enough to authorize graver measures. Insomnia, pruritus, repulsiveness form a triad of indications of a very serious character. Men have been driven to the verge of distraction by the itch that will not permit them to sleep and forces them to unseemly demonstrations in public assemblages. As suggested in speaking of acne all skin lesions look alike to the laity and spell "syphilis." "A censorious world, construing all evil." It might be faring too far afield to discuss the possibility of pemphigus and mycosis fungoides and acanthosis nigricans being related to the faulty action of a damaged gut. Still in the absence of anything but the merest surmise regarding their causation the suggestion is not utterly devoid of merit. Acnthosis is accompanied by cancer of the viscera. According to Lane, cancer of the viscera, is an occasional result of stasis. The other two diseases are of microbic origin. The microbes are unidentified. May they not be of the many generated and cultivated, harbored and nurtured in the hospitable atmosphere of the pestilential puddle? Acidosis has been firmly established as an etiological factor of importance and also as a terminal condition in many fatal affections. The diabetic dies of an acidosis, the pneumonia patient also; the victim of Bright's, likewise. Anything interfering with a proper supply of oxygen to the tissues induces an acidosis. Many ingesta act in the same way. Microbic attacks invariably have the like effect. So we can heartily subscribe to the acidosis doctrine in all of its highly instructive ramifications, and still retain our conception of chronic intestinal stasis as the ultimate source of the pathogenic agencies inducing the various phases. If you say rheumatism is an acidosis, the same is conceded. If it be due to a bacillus, it is derived from the intestine. If it be due to errors of diet they aggravate the existing intestinal disturbance. Toxins are generated and absorbed. Arthritis appears. Erythema nodosum appears. Schönlein's disease appears. Urticaria appears. A dozen cutaneous diseases may be ascribed on the one hand to acidosis and on the other to chronic intestinal stasis and with perfect accuracy in both cases. It is of little practical importance whether the germs directly bring about the pathological picture or act thru the medium of acidosis. The end result is the same. It would be possible to extend the enumeration of cutaneous diseases plausibly dependent on intestinal putrefaction to all of those not otherwise accounted for and even to many that are. But the purpose of this paper was not to frame a catalogue of reference but to stimulate a line of thought that might be fruitful of discovery. We are encouraged in this by the remarkable experience of the trustworthy men who have blazed the trail and opened up the promised land, and also by the consonance of their findings with the widespread conviction that the failure of competent peristalsis was responsible in a general way for many overt and obscure ills. We have felt much of what Lane and his coadjutors have demonstrated. Instinctively in managing our patients we have endeavored to apply the principles that they have laid down. We did not know the full menace of intestinal incapability. We frequently went off at tangents about sluggish livers and defective secretions and enfeebled musculature. But we realized vaguely the need of elimination and undoubtedly accomplished a great deal of good with a hit or miss therapeusis. But now that we have come to understand the actual conditions existing in chronic intestinal stasis, our investigations have been placed upon a rational basis and our treatment is directed with vigor and precision. Castor oil-excellent and effective in its sphere of actionhas given place to mineral oil which is the ideal lubricant for the deranged drainage system. Sagging bowels are supported by belts. Nitrogenized foods are limited rigorously. Failing with these measures we understand that we have not come to the end of our tether but that if the severity of the pathological reactions demand it operation may be resorted to, with every prospect of permanent relief. Chronic intestinal stasis therefore looms large in the domain of progressive medicine not only as a distressing local disorder accompanied by some remote annoyances, but as an anatomical distortion producing a persistent and increasing perversion of function with incalculable influences of the greatest gravity on every part of the organism. Some of these influences in the domain of dermatology have already been reviewed. It were futile to assail the applicability of others to the etiology of dermatoses for which we have no explanation. If the best we can offer in a number of perplexities is "etiology unknown" "etiology obscure," "probable cause defec tive innervation" or the like unsatisfactory banalities it were honester and wiser to turn for help to chronic intestinal stasis. It has explained many things. It may explain many more. 616 Madison Avenue. HYSTERICAL SELF INJURY WITH RESULTING AMPUTATION AT THE SHOULDER JOINTREPORT OF A CASE. BY HOWARD LILIENTHAL, M. D., F. A. C. S., Professor of Clinical Surgery, Cornell Medical Hospital and Bellevue Hospital. The following extraordinary case exemplifies the strange form of mental disorder which is accompanied by so great a desire to excite the wonder and sympathy of physicians and attendants that the patient is willing to suffer pain and even mutilation in gratifying this peculiar pathological vanity. The patient was a well nourished young girl, 17 years of age, who was admitted to Mt. Sinai Hospital on October 3rd, 1913. With the exception of the condition about to be described she was in an apparently normal physical condition. The corneal and pharyngeal reflexes were normal; the skin sensations responded to the usual tests; the deep reflexes were present and not exaggerated. She stated that about two years before admission she had been bitten by a dog and that there had been several operations. on account of infections of the left arm following the injury. There was tremendous board-like edema of the entire left upper extremity, rather sharply limited just above the insertion of the deltoid muscle. There was an ulcer-like wound perature were within the bounds of normal it was decided to explore the epitrochlear lymph nodes and this was done on the of the forearm with sluggish granulations. 4th of October, by open operation. There FIG. 2. Note great general improvement a few days after the constriction was removed and the patient prevented from reapplying it. arm and hand was that of elephantiasis, the fingers being held in the claw-like position resulting from flexion of the phalan previous operation upon the dorsum of the hand. (See Fig. 1). The progress of the healing of the wound was extremely slow. For the sake of histological examination and also in the hope of relieving the condition a strip of the entire thickness of the board-like skin was removed on February 20th, 1914, the incision extending from the middle of the upper arm to a point below the elbow posteriorly. This wound was FIG. 3. Result following amputation at shoulder. Large granulating wound in left hypochondriac region, probably self-inflicted. closed by sutures and healed with rapidity. Nothing to explain the condition was found in the specimen. When the patient had been in the hospital for some months it was decided to make a photograph of the patient. Dur ing preparation for the photograph the writer saw that she made an attempt to get rid of something near the upper part of the arm and on examination it was found that there was a narrow strip of adhesive plaster tightly encircling the extremity near the shoulder. It was then recalled that the patient had always kept her shoulders covered during examinations until she could prepare herself, and this sometimes took several minutes. The sudden termination of the pathological appearances in a groove near the shoulder had been noted but stupidly enough the cause had been unsuspected until the day of the photograph. After the discovery of the adhesive plaster strip the arm was put up in plaster of Paris and only a few days later another photograph was taken (Fig. 2) which showed a decided diminution in the size of the limb. The patient had been kept in bed following this final operation with constant improvement. When she was permitted to go about, however, the condition became almost as bad as before, probably because she surreptitiously caused constriction of some sort. She was then put to bed and kept there under close surveillance and by March 19th, about a month after the discovery of the true cause of her trouble, the hands were of equal size and the skin. practically normal. There was, however, some main en griffe due to the operation on the dorsum of the hand above referred. to. The patient was now discharged and the prognosis was thought to be good. I then lost track of the girl, but three years later in response to a letter she appeared for examination. What was my astonishment to find that a shoulder joint amputation had been performed. This operation had preceded her visit by about one year, or in March, 1916, and had been |