Whether the morbid matter may have been the result of bacterial infection as in rheumatism, or of excessive eating as in gout and lithemia, or of diminished vitality as in arthritis deformans, in the one case overcrowding the system with nutrition and thus preventing normal metabolism, in the other case suspending the powers of metabolism by reason of a diminished vitality, it matters little; for it is reasonable to expect that no constant anatomical changes may be observed in the tissues where nervous phenomena are the ruling cause, any more than to expect constant phenomena in an attack of hysteria or nerve storm. It would seem reasonable, therefore, to believe that the waste products retained in the system might vary in composition to some extent, and at the same time be due to a common cause. Before considering the treatment of diseases, the principal phenomena of which are waste products that have been retained by reason of abnormal function, the etiology and pathologic anatomy should be borne in mind. Preceding all anatomical changes of structure, a neuropathic inheritance or some form of neurosis appears. In gout and lithemia overeating and the use of improper articles of food are etiological factors. In rheumatism the ravages of bacteria or the retention of noxious products resulting from hardships, including the vicissitudes of season, are prime causes. Lastly, the etiology of arthritis deformans points to a wasted vitality, due to hemorrhage or excessive care. Then let us review some of the pathologic changes found in those diseases, in and about the joints, in the fibrous and serous tissues, and in the various organs and other parts of the body, and we have the physical clinical features of abnormal metabolism. Suboxidation seems to take a prominent part in the pathologic formations. It is not my purpose to consider the diet most suitable, or review the various remedies which have been employed for the cure of the foregoing disorders. I shall allude briefly only to the restoration of nerve force by the healing powers of mineral waters and pure air There are many resorts for such invalids in this country where more or less relief has been obtained. No doubt, in many instances, the relief has come from rest of mind and body more than from the use of the vaunted waters. An ideal resort would be one of uniform temperature at an altitude of from 2,000 to 3,000 feet above the sea level, to which could be added the healing powers of solvent mineral waters capable of dissolving and eliminating the retained products of a defective metabolism of cells and tissues. Hot Springs, situated in Bath County, Virginia, near the main line of the C. & O. R. R., is such a resort. It is a place of rest for the afflicted of mind or body. Surrounded by mountains whose summits reach far above the clouds of blue mist that sometimes obscure the view, nature has bestowed her richest gifts upon the environments, and man has done his full part to bring into use the pure air and healing waters. In the use of those thermal waters in that balmy atmosphere without germ or mote, beneath the mists and in the shadows of those verdant mountains, tired nature will find its truest remedy for the renewal of life's forces. LOUISVILLE. LUPUS VULGARIS.* BY JOHN EDWIN HAYS, M. D. Professor of Dermatology, etc., in the Hospital College of Medicine, Louisville, Ky. Statistics indicate that lupus vulgaris is comparatively a rare disease. It is one, however, to which much interest attaches, in view of its stubborn and rebellious nature, the great disfigurement which so often attends its progress, and in presenting features which disclose its identity as one of the forms of tuberculosis. The essential etiological factor in lupus vulgaris is the tubercle bacillus. Friedlander was the first to demonstrate the presence of this organism, and to prove by crucial tests its tubercular character. Lupus vulgaris may therefore be defined as a chronic inflammatory disease of the skin, tubercular in its nature, and characterized by the development of small elevated nodules in the corium, which tend to enlarge, coalesce, and spread, usually proceeding to ulceration. Once started, this ulceration usually continues until horrible disfigurement results from tissue loss. The disease may attack any part of the integument, but usually occurs on the uncovered portions, as the hands and face, especially the latter. The favorite point of attack on the face is the nose and the neighboring part of the cheek. The mucous membrane of the cheek, palate, pharynx, and larynx may be attacked, but, as a rule, not primarily, this condition succeeding an involvement of the skin. * Read before the Louisville Medico-Chirurgical Society, March 29, 1901. For discussion see page 346. The distinctive lesion in a patch of lupus vulgaris is a small nodule. This lupus nodule is about the size of a pin's head, is brownish-red in color and somewhat soft in consistency, and, as Hutchinson first pointed out, resembles apple jelly in its appearance. The tubercle bacilli are imbedded in these little neoplastic growths. They are scanty in number, and frequently very difficult to find. As yet very little is positively known in what way the bacillus gains access to the corium. While it is very probable in the majority of cases that it enters through an abrasion in the epidermis, it may, however, be carried into the body through some of the natural channels, and be conveyed to the skin through the blood or lymph current. The initial lesion is a single, or, as a rule, several reddish-brown papules, which may occupy a level with the skin, depressed below or slightly elevated above it. These papules eventually coalesce to form a patch, which is soon converted into an ulcerating surface. The progress of the disease is very slow, and absence of pain one of its distinguishing features. Lupus vulgaris is a disease of early life, the great majority of cases beginning before the age of twenty years. It is said to be met with more in the female sex. It is a disease which frequently leads to a very great destruction of tissue before its termination. As regards prognosis, it may be stated that in many cases it is possible to check the disease, but, unfortunately, a recurrence is very likely to take place. When complications exist, as, for instance, the presence of tubercles in other organs, they must be taken into account in forecasting the issue of the disease. In a large proportion of cases the diagnosis of lupus vulgaris presents no difficulty, the appearance of the lesions being amply sufficient to identify the nature of the trouble. In obscure cases, however, one must have recourse to a process of exclusion. The presence of the bacillus would, of course, be conclusive, but it must be admitted that its discovery, when present in the lesions, is not always easy, even to an expert. Syphilis and epithelioma are the two conditions which most closely resemble lupus vulgaris. Syphilitic lesions may be eliminated by the history of the case, traces of disease elsewhere in the body, by a much more rapid destruction of tissue, and in otherwise doubtful cases by their behavior to antisyphilitic measures. Malignant growths occur later in life, run a more rapid course, are more painful and more likely to implicate the neighboring lymphatic glands. Let us compare the principal points of the pathological anatomy of those diseases: In gout there are destructive changes in and about the joints; fibrous and serous tissues, anemia, and the blood is charged with fibrinogen and bi-urate of soda. In lithemia there are changes in the synovial and serous membranes, the blood is less alkaline, and there is arterio-sclerosis, cardiac and renal sclerosis, and vascular hepatic sclerosis and anemia. In arthritis deformans there are destructive changes in the joints, Haygarth's nodosities, and sometimes eburnation, destruction of the synovial membranes, and chalky deposits. There is anemia and an excess of fibrin in the blood. In rheumatism there are destructive changes in and about the joints, fibrous and serous tissues-flocculi in the synovial fluid and an excess of fibrin in the blood. These are the principal anatomical changes found in those diseases, and when we come to analyze them closely we are unable to discover any great discrepancy that might point out a well-defined difference in the metabolism. If from a dozen or more such cases as the foregoing, which I have seen, a final conclusion could be reached, there would be no more proof wanting to establish the common origin of arthritis. deformans, of gout, of lithemia, and of rheumatism. When we come to think of the character of the forces which are at work in the nervous system and how little we know of their real nature, the mind is forced to turn away from this trend of thought and leave to the visual sense the duty of observing results, from which alone we can logically draw deductions. The changes in normal metabolism which are present in those diseases must surely be preceded by certain disturbances in the nerve force, and as we can judge from results only, we are prepared to believe that the phenomena of arthritis deformans with its exudates, nodes, and nodosities, and destructive changes in and about the joints, does not differ materially from the pathological phenomena of gout, of lithemia, and of rheumatism. In all cases we find that the joints are involved, the synovial membrane, the fibrous membrane, and the serous membrane are involved, and, too, there is anemia, though not so pronounced as it is observed in rheumatism. There is an increase of fibrin and fibrinogen in the blood, and there are sclerotic changes in the various organs of the body, notably the blood-vessels, the heart, the liver, and the kidneys. Whether the morbid matter may have been the result of bacterial infection as in rheumatism, or of excessive eating as in gout and lithemia, or of diminished vitality as in arthritis deformans, in the one case overcrowding the system with nutrition and thus preventing normal metabolism, in the other case suspending the powers of metabolism by reason of a diminished vitality, it matters little; for it is reasonable to expect that no constant anatomical changes may be observed in the tissues where nervous phenomena are the ruling cause, any more than to expect constant phenomena in an attack of hysteria or nerve storm. It would seem reasonable, therefore, to believe that the waste. products retained in the system might vary in composition to some extent, and at the same time be due to a common cause. Before considering the treatment of diseases, the principal phenomena of which are waste products that have been retained by reason of abnormal function, the etiology and pathologic anatomy should be borne in mind. Preceding all anatomical changes of structure, a neuropathic inheritance or some form of neurosis appears. In gout and lithemia overeating and the use of improper articles of food are etiological factors. In rheumatism the ravages of bacteria or the retention of noxious products resulting from hardships, including the vicissitudes of season, are prime causes. Lastly, the etiology of arthritis deformans points to a wasted vitality, due to hemorrhage or excessive care. Then let us review some of the pathologic changes found in those diseases, in and about the joints, in the fibrous and serous tissues, and in the various organs and other parts of the body, and we have the physical clinical features of abnormal metabolism. Suboxidation seems to take a prominent part in the pathologic formations. It is not my purpose to consider the diet most suitable, or review the various remedies which have been employed for the cure of the foregoing disorders. I shall allude briefly only to the restoration of nerve force by the healing powers of mineral waters and pure air. There are many resorts for such invalids in this country where more or less relief has been obtained. No doubt, in many instances, the relief has come from rest of mind and body more than from the use of the vaunted waters. An ideal resort would be one of uniform temperature at an altitude of from 2,000 to 3,000 feet above the sea level, to which could be added the healing powers of solvent mineral waters |