Examination showed only some exaggeration of the deep reflexes, failure of the right plantar, abdominal and cremasteric cutaneous reflexes. The motility was normal except for a slight lack of firmness in the gait. Sensibility was normal, and the pupils reacted and converged well. The heart sounds were clear, the second being somewhat accentuated. The systolic blood pressure, which a year before had been 190, had been reduced under the care of the physician who referred him, to 160 when I examined him. He exuded an unpleasant odor of sour tobacco. Physically he felt dull, as a rule, but worried much and felt very restless at times, especially after exertion.

The diagnosis was toxicotic hypertension. The prognosis was good. The treatment consisted of limitation of tobacco to three cigars a day, cure of the constipation by special diet, removal of the toxic condition by this special diet, aided by a course of baths to favor cutaneous action, and exercise in moderation to increase metabolism.

As a result, by April 18th, the systolic blood pressure was 130, and he was rarely dizzy. A favorable result, however, caused him to exceed dietically once or twice, so by April 25th several dizzy attacks had occurred. The blood pressure, however, was only 124 that day when I saw him. The instructions were emphasized, so that by June 2nd, with blood pressure 122, there had been no vertigo. On June 23rd, blood pressure was 124, constipation induced vertigo again; and it occurred once more on July 11th as a result of oversmoking. (Blood pressure was only 120 when I saw him).

His complexion had improved, his eyes became clearer, the accentuation of the second cardiac sound had disappeared, and he was able to perform his duties like a normal person. Thanks to an earnest and intelligent wife, who sees to his diet, this patient remains well October, 1916.

Psychological Factors.-I have said nothing of strain and anxiety as factors in the causation of this disease, for I believe their effects are purely secondary in that they interfere with the vegetative functions, which of course disorder the metabolism.

load do we obtain the conditions required for the disease. Innumerable cases of chronic anxiety fail to develop hypertension or its antecedent, and the disease often occurs in persons of sanguine or placid disposition and contented life as in the case of the congressman. In the case of the engineer, not only did the causes for his anxiety remain, but he was cured without any psychotherapy, merely by dietetic meas

ures.

1705 N Street.

SHALL ACUTE VENEREAL DISEASES BE REPORTED?

BY

HOWARD CRUTCHER, M. D.,

Roswell, New Mexico.

One time I knew a man who claimed to have changed his politics seven times, every time, he declared, "for the best of reasons." In like manner, I have changed my views concerning the reporting of venereal diseases one time, and shall state what I believe to be substantial reasons for so doing. As to the precise manner of reporting such infections I have no definite plan to present, but the fact that such diseases are a grievous danger to public health can not be denied by any one familiar with present day con

ditions.

The illustrations that I shall present are taken from life and every one of them is true to the last outline.

A young man applied to me for treatment for a well-defined primary syphilitic lesion involving the glans penis and sections of the prepuce. Three weeks after beginning the treatment he called with an acute gonorrhea which he freely confessed to having contracted a few days before with an unpro

tected chancre in full blast. To my intense disgust, he admitted having continued his liasons without interruption. It would not be saying a great deal to affirm that there are thousands of men now behind prison bars with far higher moral ideals than the shameless rake I have just mentioned.

A handsome young man of 26, whose physical outlines were the admiration of all who have an eye for perfection of the human figure, boasted with entire freedom of his innumerable conquests. I protested to him that he was nothing but a carrier of gonorrhea, to which he responded that "turn about was fair play," and that he supposed that he was as much entitled to give gonorrhea as he was to receive it! His known character was such that decent society shunned him as it would a venomous snake, but his power to impose his "charms" upon the unwary may be inferred from the boast that he made of having led fifteen girls astray within two years! He told me of the foregoing as tho they were events he was proud of. Notable triumphs, surely!

Another young man whom I was treating for primary syphilis called one afternoon to introduce his bride, a perfectly unsuspecting young woman whom he had married two days before. He explained to me that the girl was wealthy in her own right and that if he had postponed the nuptials he feared that she might fall into the hands of a rival whom he appeared to hate profoundly. Within a year an apparently healthy child was born, but another year revealed unmistable evidences of syphilis in the whole family. The young mother happened to learn the facts, whereupon she took her diseased baby and her bank account and left her money-loving husband to shift for himself. One of my colleagues told me some time later that he had removed two large pus

tubes from her and that she was practically a physical wreck for life.

A man of forty, as dirty a rake as ever came out of the jungles of a great city, told me that while he had contracted gonorrhea at least once a year for twenty years, he felt sure that he had never "given the disease to any woman." Certainly not, when he had gleet all the time, acute gonorrhea most of the time, and was having sexual relations promiscuously all the time. It ought to be stated that he had syphilis before he was thirty and chancroid at least once. What surprised me was that he afterwards married a woman of high character and settled down to decent living. So far as I know, his wife never became infected from contact with him, altho the couple were childless.

Al

A young man of about thirty, thru business talents of a high order, had risen to unusual prominence and influence in a well-known firm of manufacturers. tho his income was large, his fondness for an assortment of mistresses generally kept his nose to the grindstone and his feet in very hot water. One night I was summoned in great haste to the apartment of one of his lady friends and found him suffering from shock due to bleeding, the result of a pistol shot wound that had penetrated a pectoral muscle, broken a rib or two, but had not entered the cavity of the chest. It was, as a matter of course, a sheer accident, as such things usually are, and great was the rejoicing when I assured all concerned that I expected a prompt recovery. A few days later the mistress called to see me, desiring above all things to learn whether she was suffering from gonorrhea, adding most significantly, “if I am, I'll take better aim next time!"

Let it not be supposed for an instant that men are the only offenders in these lines.

Some women are as heartless and as shameless as Madam Pompadour. Knowing themselves to be the victims of venereal infection, they accept the attentions of men only to scatter broadcast diseases as deadly as any known to mankind. Not always for money, let it be understood. One day I told a little coquette that she ought to be locked up as a menace to public health, when to my disgust she justified her conduct on the ground that she did not "degrade" herself by accepting money for her promiscuous irregularities. I have known some young women, always active in social circles, who carried around under purple and fine linen a mass of filth almost beyond belief. One day I was consulted by the daughter of a man of nation-wide influence. After making an examination, I said rather haltingly, "I do not really understand your condition." To which she coolly replied, "Are you sure it is not gonorrhea?" So widespread had been the field of her operations that she could not even pretend to name a probable "suspect." She assured me that she had no thought whatever of ever getting married and meant to "have a glorious time" while. still in the bloom of youth. A few years. later I learned that she had contracted syphilis from eating from an infected spoon or fork "at some country hotel.”

A modest country girl, who had been raised in a clean home, went to a great city and obtained a creditable position. The glitter and tinsel of metropolitan life not only unsettled her mental equipoise but broke down her moral fibre as well. Within a year she was under full headway for ruin and never stopped till she had sunk to the lowest depths of debauchery. I asked her once whether she supposed that fifty years would be enough to eradicate all the disease she had set going in the world, to which she replied, with a cynical smile, "I guess not."

No, some of the most brazen, unfeeling and incorrigible disease carriers to be found anywhere are women. They deliberately abandon a life of respectability for one of boundless dissipation, expecting to return at some time between suns to the narrower paths of honest living. In the meantime they think little and care less for the terrible wreckage they leave in their wake. Heedless girls start out to "learn something of life" and to have "a good time for awhile," with no desire for pecuniary gain, become diseased and stumble and stagger till they reach total ruin.

One day I asked a neighbor how he had relished a visitation of some eruptive disease in his family.

"Oh," he replied, "we didn't mind the disease, but I do hate that infernal quarantine.”

I have heretofore opposed the reporting of venereal infections on the ground that such publicity, limited even to strictly official records, might do far more harm than good; but a tolerably mature experience has brought me to the opposite view of the situation. In the first place, such a course would be in the highest interests of the patient himself for perfectly obvious reasons. A strict quarantine against the social activities of a shameless rake would assuredly concentrate his thoughts and energies upon. immediate and ceaseless efforts for restoration to health. Meanwhile society at large would be in no danger from his usual ac

tivities in the sexual line.

From local authorities little or nothing in the way of legislation is to be expected. Gonorrhea, if not amongst the respectable ailments of mankind, possesses none of the terrors of smallpox and yellow fever. many quarters, where ignorance is densest, it is still viewed as something akin to a joke. A vestryman down with typhoid excites

In

eases.

There is, however, a means of dealing a stunning if not a decisive blow against the general and promiscuous spread of venereal diseases. The Congress of the United States has absolute and unchallenged power to

In conclusion, I would again recall to the mind of the reader the burning editorial observation of AMERICAN MEDICINE for April, 1916, the substance of which is that our management of venereal diseases stands as a serious reflection upon our character as scientific men.

Union. Who questions the power of this body of lawmakers to prohibit the carrying of infectious disease beyond the borders of any State? In the interests of public health a statute prohibiting disease carriers from leaving their own States would prove a tremendous deterrent to all spreaders of venereal disease. It goes without saying that such carriers might be excluded from all interstate lines of travel, such as railways, steamers, and vehicles of all classes carrying the United States mails. It may be observed that this drastic and wholly sensible provision would be an invasion of the rights of the several States. This is not true. On the contrary, it would emphatically prevent the invasion of one State by a most unwelcome infection from another. The whole spirit of such a law would be State protection, not State subjection. Much of course might be effected by States and cities to abate if not eradicate the glaring evils of present day conditions, which all admit are full of peril to all classes of society. Certain classes of diseased persons are excluded from our ports of entry and for valid reasons that none ever questions. It is a mere matter of time before necessity shall compel our lawmakers to adopt some course of action at once sane, thorogoing and effective for the

PENDICITIS.

BY

HARRY J. PHILLIPS, M. D.,
Louisville, Kentucky.

While it is generally conceded that appendicitis is a surgical disease, it is equally true that in the majority of instances the patient is first observed by the general practitioner whose duty it becomes to perfect the clinical diagnosis. Mistakes sometimes occur, not in making the diagnosis of appendicitis, but rather failing to make a correct diagnosis, i. e., by calling something else appendicitis in the absence of such a lesion.

In the majority of cases appendicitis is catarrhal in its incipiency, and the patient is usually seen by the practitioner while the disease is in that stage. Every case may eventually become suppurative, progressing from catarrhal to ulcerative and possibly to the perforative type before suppuration ensues.

If it were the general practice to examine the abdomen of every patient as a routine measure, practitioners would become better acquainted with normal appendices and be thus able to more readily detect pathology in this situation.

In the beginning of catarrhal appendicitis.

there is no abdominal distension, and inspection may reveal no variation in the iliac fossæ. However, pressure over the point of McBurney elicits excruciating pain, provided the appendix be acutely inflamed. The two features of greatest diagnostic importance in appendicitis are, (a) tension of the rectus muscle, and (b) induration over the site of the appendix from beginning tumor formation. Oftentimes in incipient catarrhal appendicitis no enlargement can be detected, the patient merely complaining of more or less abdominal uneasiness and discomfort. A tumor-mass may be later appreciable in the appendiceal region which gradually disappears without the invocation of surgery. This is not invariably because of failure on part of the practitioner to call a surgeon, but because the patient refuses to submit to operative intervention. The practitioner may be surprised because the mass gradually disappears, and be inclined to doubt the correctness of his original diagnosis. While the patient improves, health is not completely regained, and he is in imminent danger from recurrent attacks. Following catarrhal inflammation, ulceration, perforation, and suppuration, are likely to ensue.

When the diagnosis of appendicitis has been made, it is the imperative duty of the internist to enlist the services of a competent surgeon, who may not only confirm the diagnosis but advise operation. It is practically agreed that every diseased appendix should be immediately extirpated; in fact, any appendix may be regarded as a menace to life, since it may cause a healthy individual to become a corpse within a few hours!

It is sometimes difficult for the practitioner to make an early diagnosis of appendicitis, and be certain that he is justi

fied in calling a surgeon for the purpose of immediate operation. However, after the disease has progressed to the suppurative stage the diagnosis is easy, because the clinical picture is practically unmistakable; but early in the attack, when it is of the utmost importance that the diagnosis be perfected and a surgeon called to operate while the disease is still in the catarrhal stage, considerable difficulty is likely to be encountered.

The exact location of the pus after suppuration has ensued has an important bearing upon the question of diagnosis. Oftentimes pus pockets are located in the pelvis far below the normal site of the appendix, along the psoas muscle, or at the angle of the promontory of the sacrum, sometimes being so small that their palpation is impossible. Under such circumstances the clinical symptoms and the physical condition of the patient constitute the sole guide to diagnosis.

A few words concerning treatment may be permissible: Like every other practitioner, the writer has had to treat many cases of appendicitis without the aid of surgery, because the patient and the family objected to operation, and palliative remedial measures had to be employed. In the majority of cases where the inflammation can be checked by medical treatment, suppuration can at least be arrested. By persistent application of the ice bag, the administration of opiates and perfect rest in bed, many cases of catarrhal appendicitis do not progress to the suppurative stage, and the patient may not have a recurrence for months or years. However, it is frankly admitted that where suppuration has already ensued, the proper treatment of appendicitis is immediate surgical intervention.