pigment, which he regards as a third variety. Practically all recent observers are agreed that the hæmofuscin and hæmosiderin represent different stages in the same process. Whether the pigment is deposited in the cells as such, or is formed within them, is still an open question. The opinion most widely accepted is that the pigment is brought to the cells in a soluble form and then precipitated out by cell action. The fact that the iron free pigment is especially likely to occur in certain types of cell, especially smooth muscle, suggests that some cells carry the process further than others. There have been various theories as to the pathogenesis of the disease. The original one of Hanot and Chauffard, that diabetes is the original lesion and that the pigmentation is due to hæmolysis from blood changes produced by this disease, has been generally abandoned. If it were accepted it would be hard to understand why, with diabetes so common, bronzed diabetes should be so rare. In recent years the current opinion has been that the hæmochromatosis was the preliminary lesion and that the secondary changes in the liver and pancreas were produced by the deposition of the pigment. According to this view cases with pigmentation of the skin and cirrhosis, but without diabetes, are simply early stages of so-called bronzed diabetes, which represents the terminal stage of the disease. Recently there has been some dissension from this view, especially by Simmonds. Looking at the question from the point of view of the pathologist, Simmonds believes that the cirrhosis of the liver and pancreas are not due to the presence of the pigment. He points out that in other conditions in which there is an excess of iron pigment in the liver, such as pernicious anæmia, cirrhosis does not take place. He therefore, believes that the cirrhosis and pigmentation, rather than being dependent upon one another, are both the result of the same underlying cause. It may be pointed out that the degree of pigmentation which is present in hæmochromatosis is never approached by that seen in pernicious anæmia. In the latter disease the pigment is in the form of fine granules and is limited almost entirely to the portion of the cell lying in immediate relation to the bile capillaries. One does not see in pernicious anæmia the crowding of cells with coarse pigment that occurs in hæmochromatosis. Furthermore, there are known forms of cirrhosis in which the condition is associated with the deposition of pigment, notably the cirrhosis anthracotica described by Welch. It has likewise been urged that the amount of cirrhosis in the pancreas is often very slight, and insufficient to produce diabetes. As to the ultimate cause of the pigment formation, it is believed by many that it is due to some toxin, or toxins, which produce a chronic form of hæmolysis. There is little clinical evidence to support this view. The blood picture in these patients is usually normal, or almost normal. Tests of the fragility of the blood corpuscles have not been made to my knowledge unless by Elmer, who states in his very brief report that there was no evidence of hæmolysis. The occasional occurrence of purpura or hæmoglobinuria appears to me rather weak evidence of a hæmolytic origin of the disease inasmuch as these manifestations occur late, i. e., at a time when so-called cachectic purpura or purpura due to terminal infection might readily occur. The comparatively small amount of pigment in the spleen is in itself a very strong argument against general hæmolysis. One must admit the possibility of a local hæmolysis confined to the portal system. The work of Ritchie seems to show that blood destruction taking place within the portal zone may lead to the deposition of pigment with its maximum deposit in the abdominal organs much as that which occurs in hæmochromatosis. The question of the differentiation of this disease brings up the whole question of cutaneous pigmentation. The differential diagnosis can be simplified by pointing out that a combination of pigmentation with an enlarged hard liver and glycosuria is not likely to occur in any other condition. In vagabonds' disease and chloasma associated with pregnancy or with cachexia the distribution and character of the pigmentation, together with the presence of the usual causal factors and the absence of hepatic enlargement and glycosuria, should make the diagnosis simple enough. Addison's disease with diabetes might be puzzling, but the association of Addison's disease with diabetes only occurs once in 800 cases of Addison's disease. Furthermore the enlarged liver would not be present. Pigmentation from various drugs, such as arsenic and silver, would likewise be unassociated with diabetes and an enlarged liver. The same is true of scleroderma, where the pigmentation occurs in advanced cases with marked skin lesions. Pigmentary syphilis is associated with areas of depigmentation, and is more patchy. Basedow's disease with diabetes and pigmentation might be hard to differentiate if the patient also had an enlarged liver, as was the case in Berg's patient. After all, while we cannot deny the possibility of the occurrence of diabetes, or of an enlarged liver, as a complication in various diseases, associated with pigmentation of the skin, the likelihood that the triad of symptoms and signs will occur outside of bronzed diabetes is very small. Note-A compilation of the cases up to 1899 will be found in the article of Anschuetz, Deutsch. Arch. fuer Klin. Med., 1899, LXII, 411. A compilation of the cases since Anschuetz' article will be found in the article of Futcher, Amer. Jour. of Med. Sci., Jan. 1907. Since then the following cases have been reported: Simmonds, Berl. Klin. Woch. 1909, XLVI, 531. (2 cases) French, Proc. Royal. Soc. Med. 1909-10, iii, Path. Sec. 94. Elmer, Weekly Bull. of the St. Louis Med. Soc. 1910, IV, 279. Bernouilli, Corespondenzbl. fuer Schweitz. Aerzte 1910, XL, 610. There is also one case in the Swedish literature and one in the French which I have been unable to obtain. DISCUSSION. DR. WILDER TILESTON (New Haven): Hemochromatosis is probably a better name than bronze diabetes for this condition, because it covers also those cases which at the time they come under observation do not show glycosuria. I saw such a case in Boston in 1899 in the wards of Dr. R. H. Fitz. The patient was an English sailor 29 years old, who, eighteen months previously, had fallen on the deck of a vessel and was unconscious for a while. Three months later he noticed pigmentation of the face and body associated with loss of strength. Although previously fair-skinned, at entrance he was the color of a mulatto. The pigmentation was diffuse and involved the face and the whole body. Contrary to the usual rule, the mucous membranes of the mouth were also diffusely pigmented; there was no enlargement of the liver and no sugar in the urine. The correct diagnosis was made by Dr. Fitz, previous observers having mistaken the case for Addison's disease. The diagnosis was confirmed by examination of a section of the skin which showed ironcontaining pigment; this never occurs in Addison's disease, nor, in fact, in any other form of pigmentation but hæmochromatosis. It should be emphasized that the skin in hæmochromatosis, as Dr. Blumer stated, may contain only iron-free pigment, in which case the microscopical examination is of no diagnostic value. The whole question of abnormal pigmentation of the skin and mucous membranes is of great interest, both from the diagnostic and the theoretical point of veiw. So far no satisfactory theory has been advanced either for the physiological or the pathological types of pigmentation, but most authorities agree that the pigment is brought to the cells of the skin by the blood, and is not manufactured locally in the skin. Marked pigmentation of the skin is usually looked upon as suspicious of Addison's disease, but in my experience, only the minority of the cases is due to disease of the adrenals. Pigmentation from itching affections, such as pediculosis and senile pruritus, and from cachectic conditions, is probably more common. Pigmentation from arsenic, though rather rare, must always be reckoned with, and the usual statement that arsenic pigmentation does not affect the mucous membranes, is not without exception; I have recently seen a case of typical pernicious anæmia with arsenic pigmentation involving the mouth as well as the skin. It should be borne in mind, moreover, that pigmentation of the mucous membrane of the mouth may rarely occur in persons who are apparently healthy. I have seen one such case-a man whose lips and cheeks showed numerous brownish-black spots of two years' duration, although the skin was not pigmented; no etiological factor could be made out. Brownish spots on the cheeks and gums of healthy negroes are not uncommon. DR. GEORGE BLUMER (New Haven): I also think that the term hæmochromatosis is more desirable than bronzed diabetes, because we do not necessarily get diabetes with the coloring of the skin. In the title of my paper, I put the word hæmochromatosis in brackets after the other name. Some Problems Connected With the Medical Inspection in Schools. EDWARD WINCHESTER GOODENOUGH, M.D., WATERBURY. This Society was organized and developed in this Land of Steady Habits to prevent disease and heal the sick. Our members lead in organizations for the care and cure of epileptics, for the prevention and cure of tuberculosis, in organizations for sexual hygiene and for the prevention of the spread of sexual disease. We have societies for mental hygiene; organizations also for the care of the criminal and the pauper. All of these touch children directly or indirectly. The most important work for medical men to-day is connected with the growth and development of the child. Thousands of children are born in this state annually without the attendance of a physician and a large percentage of these children have no medical supervision up to the time they enter school. Some have medical attendance occasionally for acute sickness, but too many enter school without the slightest conception of hygiene, and many, especially in our cities, with too little knowledge of cleanliness. The Great Physician two thousand years ago emphasized the importance of the child. "Suffer little children to come unto me," and "Whoso shall offend one of these little ones which believe in me," were said by one who fully recognized the laws of development and the power of suggestion to the young. Medical inspection in the schools is primarily for the benefit of the growing child. We raise the health average of this school generation. The State reaps the benefit in the voters of the next generation. A clean and healthy citizenship means not only less pauperism and crime, but more happiness and less discontent. The facts thoroughly fixed in the minds of our legislators will bring to pass |