which occurs almost exclusively in the Indo-Germanic race, and particularly in men.

Treatment.-The most reliable preventive measure (prophylaxis) against hereditary hemophilia is the non-marriage of the female members of hemophilic families, and, as a matter of fact, the girls in the hemophilic families of Grisons have agreed by vow to remain single. Measures for the control of existing hemophilia are unknown. Particular importance is to be attached to the avoidance of all wounds. Naturally, all dangers are thereby not averted, as life may be threatened also by spontaneous hemorrhage. Among wounds only vaccination appears to be borne by the hemophilic, while circumcision of the prepuce is dangerous. Bleeders should be exempt from military service. If traumatic or spontaneous hemorrhage occur, it should be controlled according to surgical rules by tamponade, elevation of the member, constriction or ligation of the vessels. Occasionally success will be attained by enlarging the wound with the knife, and instituting surgical treatment. Renal hemorrhage has also been controlled by nephrectomy. Nothing can be accomplished with internal hemostatics, styptics, or astringents. Calcium chlorid (2.0-30 grains daily) has been reported to exert a favorable influence through its power of increasing the coagulability of the blood. If the anemia is alarming, physiologic salt-solution (0.75 per cent.) may be infused into the veins.

PAROXYSMAL HEMOGLOBINURIA.

Symptoms, Diagnosis, and Prognosis.-In cases of paroxysmal hemoglobinuria the patients secrete periodically bloody urine, which, however, contains few or no red blood-corpuscles, but hemoglobin in solution; there thus results hemoglobinuria. This hemoglobinuria is always preceded by hemoglobinemia; that is, solution of red corpuscles in the blood first takes place, and the blood-plasma gets rid through the kidneys of the hemoglobin dissolved in it. Another portion of the hemoglobin is deposited in the spleen and the liver, and causes enlargement of both of these viscera. The occurrence of an attack of hemoglobinuria is often preceded by the operation of certain injurious influences, including especially exposure to cold and excessive physical activity. In some patients an attack may be induced with certainty by a cold bath or a long walk. The patients also occasionally suffer from attacks only during the winter; whence the name winter hematuria. Often the attack begins with chilliness, or even with a chill, which is followed by elevation of temperature to 40° C. (104° F.) and above. The patient acquires a remarkably pallid, almost earthy appearance, while not rarely the skin and the conjunctival covering of the selera are distinctly, though generally but slightly,

icteric. Occasionally urticaria is present. The spleen and the liver become increased in size, and are not rarely tender on pressure. Also, complaint is often made of a sense of tension and of pain in the region of the kidney.

On examination of the blood the plasma exhibits a bloody color, and here and there discolored red blood-corpuscles--socalled blood-shadows-are visible. The number of red bloodcorpuscles and the percentage of hemoglobin are diminished. The urine may possibly contain only a small amount of albumin, but it soon becomes conspicuous from its bloody color, which is not like that of fresh red blood, but is rather reddish brown or almost black from the presence of methemoglobin in considerable amount. If the urine be boiled, a coherent mass of albumin presenting a brownish appearance, from the presence of hemoglobin, will usually be precipitated. On spectroscopic examination of the blood either the absorption-bands of methemoglobin alone are found, of which particularly a band in the red of the spectrum between the Fraunhofer lines C and D is important; or the two bands of oxyhemoglobin in the yellow and the green between the lines D and E appear. On microscopic examination of the urinary sediment granules and filaments of hemoglobin will be found, which here and there lie close together in the form of hemoglobin-casts, and also a small number of red blood-corpuscles, mostly in the form of decolorized dises or shadows. If round cells or epithelial cells from the uriniferous tubules are present in the sediment, these also are often found discolored greenish or brownish by the hemoglobin.

The attack of hemoglobinuria is of variable duration, lasting between a few hours and a few days. Slight albuminuria often persists for a short time after the hemoglobinuria has disappeared. Abortive attacks also occur, manifested only by paroxysmal albuminuria. The disorder can be readily recognized, but not rarely proves most obstinate, although it but seldom terminates fatally, so that the prognosis is not unfavorable.

Anatomic Alterations.-Opportunities for post-mortem examination in cases of paroxysmal hemoglobinuria have as yet been exceedingly rare. The kidneys have been found abundantly filled with blood and enlarged, and they contained hemoglobin.

Etiology.-Syphilis should be mentioned as a not uncommon cause of paroxysmal hemoglobinuria; also, other infectious diseases -malaria, articular rheumatism-are occasionally followed by the disorder. Such other influences as have been mentioned as causative factors cannot be considered as such. Obviously syphilis is capable of diminishing the resisting power of the red blood-corpuscles, for it has been possible to demonstrate that in such patients constriction of a finger and immersion in cold water will

cause dissolution of the red blood-corpuscles. The disease is most common in men.

Treatment.-During an attack of hemoglobinuria the patient should be kept in bed and weak tea administered. In order to avert the occurrence of an attack, the patient should guard against exposure to cold, cold baths, and excessive physical activity, especially long walks. The general tendency to the disease will be removed by mercurial inunctions and potassium iodid if syphilis be the cause of the disorder. Quinin is to be recommended when malarial influences are operative.

PART IX.

DISORDERS OF METABOLISM.

OBESITY (POLYSARCIA).

Etiology.-Polysarcia depends upon abnormal formation and accumulation of fatty tissue in the body. Two varieties of obesity can be distinguished, namely, the plethoric and the anemic. Plethoric obesity is the result of faulty nutrition. One who indulges in larger amounts of food than are demanded by his physical activity is exposed to the danger of becoming obese. The disorder therefore occurs frequently in persons who more about but little and who engage in little physical exercise. Obesity often depends upon faulty constitution of the food, and such individuals therefore become obese who use carbohydrates (farinaceous food, sugar, alcohol) in excess. In addition, the tendency to obesity is hereditary in some families, so that in the members of such families an excessive deposition of fat takes place, even with the observance of an apparently moderate mode of life. Often several of the injurious influences named are jointly operative, and the patient, in spite of hereditary predisposition, cats generously, with a preference for farinaceous and saccharine food, indulges freely in alcoholics, and avoids all possible physical movement and activity.

From what has been said it should not be surprising that certain periods in life favor the development of obesity. Infants often exhibit abundant deposition of fat because the milk is rich in sugar and active physical exercise is wanting. Also, however, in advanced age, when it is customary to withdraw gradually from ordinary pursuits, the increased physical inactivity readily results in obesity. Rarely obesity is congenital. Protracted sleeping favors the development of obesity, as well as a moist, warm climate and sexual continence. Eunuchs readily become obese. Obesity likewise develops readily in women at the climacteric period.

Anemic obesity is observed in connection with chlorosis, progressive pernicious anemia, and allied conditions. It occurs also after loss of blood, not rarely after antecedent parturition. Even in cases of carcinoma and pulmonary tuberculosis an excessive deposition of fat not rarely takes place. Under all of these con

ditions the increased formation of fat depends upon the deficiency of hemoglobin in the blood, resulting in diminished processes of oxidation and combustion in the body. In this category belongs also toxic obesity, which is of but slight clinical significance, and, among other factors, develops after the use of arsenic.

Anatomic Alterations.—In cases of obesity the fatty tissue is deposited first in increased amount in such situations as under normal conditions are the seat of fat, and only subsequently does it appear upon unusual portions of the body. The subcutaneous fatty tissue acquires a considerable thickness; particularly in the abdominal walls it often forms a layer 10 cm. thick and even more. The mediastinal fatty tissue also is greatly increased, and represents a thick, coherent layer of fat. The great omentum, the mesentery, and the epiploic appendages of the intestine represent enormous masses of fat, between which bowel and other abdominal viscera appear in some degree squeezed. The heart is surrounded by an enormous fatty capsule, in consequence of increase in the subepicardial fat, and this often penetrates between the muscular layers of the heart. The kidneys likewise appear buried in a massive capsule of fat. Other viscera, particularly the liver and the kidneys, are enlarged, generally anemic, and infiltrated with fat. Even in the blood an excessive amount of fat has in a number of instances been described-so-called lipemia; but, it is true, all such reports do not appear trustworthy.

Symptoms, Diagnosis, and Prognosis.-Obese individuals attract attention, in the first place, on account of their increased size; the abdomen particularly becomes greatly increased in circumference. If the abdominal walls be grasped, a remarkably thick layer of fat can be felt. The umbilicus and the genitalia not rarely appear greatly retracted, while the breasts project as heavy cushions of fat. The entire shape of the body becomes rather oval, and the attitude of the body is so changed that the patients walk almost like a pregnant woman, with the upper part of the body bent backward, with the legs far apart, and with short, stumbling steps, so that they make the impression of a sprawling and bloated individual. The bodily weight increases, and not rarely attains extraordinary figures (up to more than one thousand pounds); while, on the other hand, the specific gravity of the body diminishes, so that obese persons float readily in water, particularly in salt sea-water.

The facial expression of an obese person often exhibits some thing of fatigue and dulness. The fat cheeks hang loosely downward, the eyelids overladen with fat cause narrowing of the palpebral fissure, and the fatty tissue in the submental region projeets downward as a thick cushion of fat-so-called double chinso that the chin appears retracted. The nucha is thickened and shortened, and frequently forms one or several transverse rolls of fat.