Dr. That's right, but how would you get it? S.-You might try hot applications. Dr.-Enemas have already been tried. S.-You might try some more. Dr.-Would you suggest any different kind of enema? Could you think of any other kind that could be given? S.-You might give a high enema, with a stimulant, such as turpentine. Dr.-It is occasionally worth while to try the high enema with oil, but it seems to me as if they had given a pretty fair trial to enemata here. They got in 51⁄2 quarts. How high would that go. S.-I should think that would go through the descending and transverse colon. Dr.-Yes, one can tell by that fact that the cbstruction is not low down. Would blood examination help you any? S.-I think so. Dr. What would you do? S.-Look for a leucocytosis. Dr.-How would that help you? S.-In a case of malignant disease anemia would be present. Dr.-I don't think it would be likely to help you; malignant disease might have produced an anemia, but his previous history was stated as excellent, so he would not be likely to be anemic. Would the urine examination help you any? S. Indican. Dr. What would that tell? S. It would show that there was intestinal obstruction. Dr. What else beside intestinal obstruction will give you an increased amount of indican? Aren't there a good many other conditions where indican is increased? S.-It might be due to constipation. Dr.-What kind of intestinal obstruction increases indican? S.-When you have any putrefactive changes. Dr. -And if intestinal obstruction, what kind would be most likely? S.-It would be far down in the intestine. Dr.-What do you think about that? You think it is usually obstruction high up? How many think it is low down. How many high up? The majority seems to be for low down. That is wrong. Usually it is high up; obstruction high up is much more. likely to give rise to an increase of indican than obstruction low down; it is due, also, to many causes where there is no obstruction at all. I don't think the estimation of indican would be likely to help us much in this case. Some writers have laid stress on it, but I don't think the majority have found it of any use in diagnosis. Practically one can't go farther in this case without laparotomy. It was done in this case, and a very small tight cancerous stricture was found, not much bigger than a signet ring, in the region of the hepatic fixture. The hernia was practically reduced and did not count. Given these facts, what is the prognosis? S.-That would depend upon whether there were secondaries or not. Dr.-Where would you look for them? S.-In the retro-peritoneal region. Dr.-Certainly. What else would it depend on? S.-The extent of the growth. Dr.-Anything else? S. The condition of the patient. Dr.-What else? S.-The length of time. Dr. Yes, every day makes the prognosis worse. But there is another element,-who does the operation. That is one of the personal elements we cannot eliminate in a case like this. If it is done by a man of experience it is of greater value than if done by a greenhorn. We have recently published in Boston some stomach statistics of operations gathered from 150 cases, and one is appalled at the mortality. The average was about four cases to an operator. Everybody was getting his experience on those cases, and consequently there was a very high mortality. On the next 150 cases in Boston, it won't be so high. So the things to be considered are the general condition of the patient, the length of time, the presence or absence of metastases, the man who does the operation, and, of course, the after treatment and nursing. We have nothing especial to say about the treatment in this case other than surgical. The medical treatment of intestinal obstruction is not a subject that one is inclined to dwell on with pride. 191 Marlboro St. THE DIFFERENTIAL DIAGNOSIS AND TREATMENT OF THE WILLIAM E. BLODGETT, M. D., The object of this paper is to offer for your consideration a simple outline of the results thus far of the work of Dr. Joel E. Goldthwait and his associates in Boston on the general subject of chronic non-tubercular joint diseases. These results are based on careful clinical and laboratory study of a very large number of cases, many of the cases being followed for a number of years, and cover the group of joint diseases confusedly called chronic rheumatism, gouty rheumatism, arthritis deformans, gout, rheumatoid arthritis, and a variety of other names. The continued study of these indiscriminate cases leads to classification of them into (1) Simple Villous Arthritis, (2) Atrophic Arthritis, (3) Hypertrophic Arthritis, (4) Infectious Arthritis, and (5) Chronic Gout. The classification does not provide for certain rare chronic joint disorders, as, for instance the neuropathic joint lesions in tabes, commonly known as Charcot's joints, or for traumatic derangements of joints, or for joint disturbances due to adjacent neoplasm, or for other articular disturbances which are not dependent on any disease, primary or secondary, of the joint itself. Thus, to illustrate, the knee may be permanently flexed owing to muscle contractures dependent on infantile paralysis, but the restriction of mobility could not properly be referred to a disease of the knee itself. It may, moreover, become necessary to add to the classification in order to provide for types of joint disease not yet recognized. But with the limitations given above, and excluding, of course, the large group of tubercular arthritis, indiscriminate cases of chronic joint trouble as they present themselves for treatment naturally fall under one or another of the five types: (1) simple villous arthritis, (2) atrophic arthritis, (3) hypertrophic arthritis, (4) infectous arthritis, (5) chronic gout. As in any group of conditions that are similar to each other, as, for instance, in the group of acute abdominal lesions, so in the group of chronic non-tubercular diseases, immediate diagnosis is not infrequently impossible; furthermore, in rare instances, the same patient may show evidence of two types of joint disease, though in such cases the onset of one type is usually found clearly to have preceded that of the other, so that the patient himself has recognized the two types as distinct; but, while it is not possible entirely to disprove all connection between the *Read before the Wayne County Medical Society, Feb. 28, 1905. several types, their continued distinctness in clinical course, total pathological complex, and response to treatment appear to indicate that they represent separate diseases. Simple Villous Arthritis. This type is variously called chronic synovitis, or hyperæmic, relaxed, or dry joint. It may arise from any cause that induces a congestion of the synovial membrane, as trauma, general loss of tone, or interference with the return circulation. The inducing trauma may be single from without, or constantly repeated from within, as in the faulty weight-bearing and constantly repeated strain that results from flat or pronated foot, or from such corpulence as, in order to maintain upright equilibrium, requires standing with the knees slightly flexed. This type of joint trouble is met with also after parturition when there has been no suspicion of puerperal infection, dependent apparently on general reduction of tissue and vascular tone. The synovial membrane, for one or another of these causes starting to become congested, cannot spread at its margins on account of its attachments, or laterally outward on account of the fibrous capsule; it must therefore, as it swells, fold inward into the joint cavity, thus forming villi and fringes. These fringes are rubbed over each other in the movement of the joint, or may be squeezed between the articulating bones; irritation and congestion are thus increased, and large pedunculated tabs may be developed, which, on account of deficient blood supply, are liable to undergo fatty degeneration, with production of intraarticular lipomata-the so-called lipoma arborescens. Microscopically such a fringe is likely to show a pedicle carrying vessels that are undergoing obliterative endarteritis; a peripheral endothelial layer continuous with that of the synovial membrane, overlying a fibrous mesh filled with small round cells that represent the product of the chronic inflammation; and an interior showing the lipomatous metamorphosis. Rarely the fringe is subject to metaplasia into cartilage or bone. Fringes getting free from the synovial membrane form loose bodies in the jointjoint mice. The same general development of intra-articular villi is likely to result from any chronic arthritis, including the tubercular form; but, in the type under consideration, simple villous arthritis, the fringe formation is not a manifestation of a general disease, but represents a purely local process, and is unaccompanied by any considerable alteration of cartilage or bone. The symptoms and treatment of simple villous arthritis are largely implied by its aetiology and pathology. The process is most commonly found in the knee, and, being dependent on the formation of villi, naturally results symptomatically in swelling and tenderness of the synovial membrane, crepitation and pain on motion, and a tendency to mechanical limitation of mobility. Muscle spasm, strong adhesions, and actual locking of the joint so that it cannot be fully extended, as seen in cases of dislocation of a semilunar fibro-cartilage, are not to be expected. The joint fluid is normal, or, if there be great irritation, excessive. The villi may often be palpated on either side of the patella as soft masses, and seen by radiography beneath the patella. If the process has gone on to lipomatous formation, the lipoma may not infrequent be felt as a more or less distinct body on one or the other side, and slightly above, the patella. When the patient stands, the normal fossae on on either side of the patella are likely to be obliterated. The process does not naturally extend to the other joints, bone and cartilage are practically unaltered, and there is no constitutional reaction. In treatment, any joint strain, as from pronated foot, pendulous abdomen, or excessive or abnormal use, which we have seen are aetiologic, should as far as possible be eliminated. The joint should be steadied, its motion limited, and its circulation supported, as by a snug flannel bandage which serves all these purposes. Local stimulation without increase of irritation is indicated, as by alternate hot and cold douches, and, if the general circulation is deficient, it would seem reasonable to treat this factor as well. This sort of treatment may be expected to avail for the early stages of the process; if, in the more advanced or obstinate cases, such non-operative measures, which it would seem conservative and wise always to try first, fail to relieve, and if the symptoms warrant it, the joint should be opened under the most perfect asepsis, and the offending villi removed. A large series of such operative interference has proved satisfactory and effective. Atrophic Arthritis. Atrophic arthritis has been called also rheumatoid arthritis, and is undoubtedly identical with the arthritis chronica ankylopoetica of Janseen and other German observers. Dr. Goldthwait has given to it the name of atrophic arthritis because the essential feature of the process is atrophy. The aetiology is unknown. Pathologically the disease consists of a beginning villous synovial process, soon succeeded by fibrillation and disintegration of the articular cartilages, and progressive atrophy of cartilage and bone, so that the whole length of the bones adjacent to affected joints becomes osteoporotic; in the last stage, cancellated bone grows through the former joint, so that a true synostosis results in the deformed position. This type of joint disease is slowly progressive, and, unless arrested, involves practically all the joints, and is a frequent cause of complete disability and residence in our alms-houses. The proximal phalangeal joints of the fingers are usually early attacked, and present at first spindle-shaped swellings with the overlying skin white and often moist with cold perspiration, succeeded soon by contractures and an annular constriction around the middle of the joint. This constriction is a manifestation of the atrophy of the cartilages, which is shown also by radiography. Other affected joints present similar signs, subject to alteration dependent upon the location of the particular joint. The spine is usually spared in the early part of the disease. The process is attended during acute exacerbations by pain even when the joint is at rest, and is subject to recrudescence and remission. The course may cover many years. The subject is usually a woman, young or old, and, as the disease progresses, becomes emaciated and pale, although the blood shows no changes except a tendency to increase of red corpuscles. The lymphatic nodes are not enlarged. The urine shows nothing important. As the essential feature of this type is atrophy, the appropriate principle of treatment is thorough stimulation local and general-locally by such means as hydrotherapy, faradism, hot air, massage, mechanical vibration, and encouragement of use. Pain is combated by immobilization for a few days, if necessary, and small doses of the salicylates or allied compounds for a few days only. While in many cases the salicylates will prove of much value in subduing the pain, it is to be remembered that any of the drugs allied to salicylic acid are more or less depressing and disordering to digestion, and that a prolonged use of these drugs, therefore, especially in this condition that calls for forced nutrition, is distinctly contraindicated. Large doses, moreover, are to be avoided, for, if the drug in a given case is to have any effect at all, five grains two to four times per day will be usually as effective as more. The drug is at best simply analgesic-in no way specific. After using the drug two or three days, a simple alkali, such as phosphate of sodium, or potassium or sodium bicarbonate, or any other, with copious ingestion of water, will usually suffice. The eliminative organs in general should be kept active. Contractures and adhesions should be overcome by manipulation under an anaesthetic, with due regard to the bone atrophy and the produced liability to fracture. A marked villous condition indicates incision. The general treatment is the same as for incipient pulmonary tuberculosis, although this type of joint disease bears no known relation to tuberculosis of any kind-forced feeding on a general mixed diet, in which meat, red or white, forms an indispensable part, fresh air, and general roborant measures. Hypertrophic Arthritis. Hypertrophic arthritis has been called indiscriminately arthritis deformans, gout, or gouty rheumatism. As its name implies, the essential features of this process is hypertrophy of bone and cartilage. The specific aetiology is unknown, but excessive use, trauma, advanced age, and exposure to damp and cold are factors. It occurs more commonly in the male sex and the latter half of life, but is not confined to this sex or to this period. The process consists of thickening of the articular cartilages at their edges, with formation of ridges or nodes, and metaplasia of these ridges and nodes into bone, thus mechanically interfering with joint mobility. The bone hypertrophy is both palpable and demonstrable with the Roentgen rays. The central parts of the cartilages, subjected to special pressure, are absorbed, and the bone underneath becomes sclerosed or "eburnated." The joint, however, is never obliterated, as is the case in atrophic arthritis, interference with motion is mechanical, and marked deformities do not result. The symptoms depend on mechanical interference with motion, and on pressure irritation of neighboring nerves, producing referred pain. Occuring in the fingers, the process leads to the well-known Heberden's nodes; these nodes involve the terminal finger joints, in contradistinction from the lesions of atrophic arthritis which occur in the proximal finger joints, and, unlike the deposits in chronic gout, are composed of hard bone and are attached to the phalanges. In the spine, the process leads to stiffness, commonly in the lower half, usually more marked in one lateral flexion than in the other, without kyphosis, and causes referred pain due to nerve-root pres |