The third case was one of orthostatic albuminuria. I found his morning urine clear of albumen on all occasions, also his morning blood pressure about 130 mm. About II A. M. he began to pass albumen, the amount increasing as the day passed, and the blood pressure steadily lowering, until at 6 P. M., the quantity of albumen was greatest, and the blood pressure lowest- - between 100 and 110 mm.

The indications for treatment seemed clear, and the six o'clock urine now contains but a small part of the albumen it formerly yielded, and the pressure does not go so low. Yesterday, about 120 mm. at the same hour.

Some interesting work has been done in the study of the relation of arterio-sclerosis, involving the cerebral vessels, to mental diseases. I can only mention this most interesting subject, but the practical point is obvious. If high or low pressure is found, its regulation will certainly help the patient, and possibly its correction may go towards preventing the subsequent mental changes.

It is probable that some of the nervous disturbances of the menopause are due to changes in arterial tension, either a high or low pressure, bringing its discomforts. Beginning arterio-sclerosis may, of course, be present already, but we must also remember that a constantly increasing tension may in itself induce subsequent sclerotic changes in the arteries. In this class of cases also, the sphygmometer is a very practical help in diagnosis and treat

ment.

Of the use of the sphygmometer as a help in watching the effect of treatment in heart, kidney, brain or other diseases, in estimating the variation of blood pressure in valvular diseases of the heart, there is only time to suggest that it is an interesting study, with very much yet to be learned. There is not as yet much definite knowledge in regard to pressure changes in chronic diseases of the heart. In these cases, the estimation of the diastolic pressure seems especially important, the difference between that and the systolic reading being more marked than in other conditions. This is marked in cases of aortic insufficiency. As a rule, the systolic pressure is rather high. In cases of broken compensation, with high pressure, the patient is much improved by lowering the pressure. If

the pressure is already low, it should be raised. These indications. for treatment are important and helpful.

Treatment. The treatment is a large subject, in a general way. So far as possible, we must reverse our patient's manner of life. The over-worked man must work less, the lazy man must work more. The over-fed man must eat less, the under-fed man must eat more. Every possible improvement in digestion must be obtained with especial attention to the process of elimination, by kidneys, bowels, and skin. Where certain organs are markedly affected, as the heart or kidneys or brain, especial attention must be given to them. Insomnia has been mentioned as an important result, and always needs attention.

The diet should be general, but containing as large a proportion as possible of fruit and vegetables and cereals, without too much nitrogenous food.

Carbonated and other baths may be used, and as many authors might be quoted in favor of the iodine preparations as could be quoted as opposed to them. For most cases, some use of the alkaline preparations is helpful.

Really, general rules amount to but little. Each individual case must be studied most carefully, and the diet, the manner of life, the things used, must be such as careful observation shows are truly helpful. As showing the results of treatment, the sphygmometer readings are most useful.

In Conclusion.

It is admitted that blood pressure readings are not final in the diagnosis of any disease. In the prognosis, they are suggestive and helpful, and in prognosis we need every possible help. In treatment, they are more helpful. A high pressure can be lowered, a low pressure raised, and repeated observations will show just how well our treatment is working, and will help us to determine in each individual case the safest and best means of obtaining these results. But on the other hand, blood pressure changes are always suggestive and important; the use of the sphygmometer takes but little time, and its readings are at least helpful.

I would urge its more general use.

DISCUSSION.

Dr. Oliver T. Osborne (New Haven): Mr. President and Members: We have listened to a very scholarly paper, and certainly the scientific side of it has been most splendidly covered. I can but agree with the speaker that there is no question but that increased blood tension is the cause of arterio-sclerosis always. Irritants may be circulating in the blood, and, by irritation of the arteries cause increased tension. If we look through the various causes, we find that increased tension is always the forerunner, whether it be from lead, whether it be from gout, or whether it be from the irritation of alcohol, causing an opening and shutting of the blood vessels, giving them too much exercise, and the over-exercise of any structure of the gland or body sooner or later causes a sclerosis of it.

Normally, as has just been stated, we are only as old as our arteries. As we grow older our blood tension increases. The thyroid gland is the part of the body which furnishes the most vaso-dilator material. This gland begins to atrophy, and its secretions to diminish after 45. At this time then, normally, the suprarenals furnishing this vaso-pressor material with the gradual diminution of the vasodilator material give a relatively increased tension to the arteries. This, I believe, is the normal cause of old age-i. e., arterio-sclerosis.

The treatment of hypertension is the point to consider. Anything that prevents constant or recurrent high tension will prevent arterio-sclerosis. We can have arterio-sclerosis, and yet a weakened left ventricle, and a low pulse-tension of the radial arteries. Nitroglycerine is one of the most useful drugs if increased tension is present. Iodides in any form are always useful because, I think, they are stimulants to the thyroid gland.

Arterio-sclerosis is certainly on the increase, because of the tension of our lives. We are always going at full speed, competition makes us hustle and hurry, and we are keeping up that nervous tension; our electric cars and our trains must go fast, everything is a constant hustle, and all the more reason why we should take vacations. Once a week most men should have a day; at least once a month they should have two or three days, and certainly once a year a month, otherwise we keep up too much tension.

Dr. Ernest H. Arnold (New Haven): Mr. Chairman, I would like to recite a case that recently came under my observation to show what the general practitioner, who is not on the lookout, may expect. A man aged 45 years, a business man, came to me because he has become bowlegged; it commenced about a year and a half ago, and has grown to such an alarming degree that he can no longer hide the fact that he is bow-legged from the knee down. I didn't know what to make of it, there was no history of trauma, no history of anything, as far as arterio-sclerosis goes, no alcohol or syphilitic history; the man had had some business troubles for a year, he was temperate, in apparently good health, with no history of lead poison. I don't know whether I asked for it at the time, but certainly there was none in the history. The examination of the heart

was negative, the pulse was regular, the pulse near the arteries at the temple and radial normal to my touch, the urine examination was negative. I had an X-ray taken of the bone of the leg, and lying alongside of the bone was unmistakably a sclerosis of the posterior and anterior tibial artery, with great big thickened places of calcareous matter all along its course. The diagnosis of arterio-sclerosis was made. Looking up the case afterwards, I believe there was no mistake. The treatment I shall not discuss.

The next case was a young man 28 years old who had run the gauntlet of all the profession, who had been treated for neurasthenia and everything else. He went down to New York in despair (that is the place of despair of most people here who don't know where else to go when they get desperate) (Laughter) and he fortunately fell in the hands of men who diagnosed the case, because this man complained of a pain in the chest, a pericardial pain which increased on moving, especially in bending. The pain kept him awake nights. A diagnosis of the tuberculosis of the spine was made and the man was kept in a plaster jacket for two years. His condition did not get better, and he came to New Haven finally and fell into my hands. I could not make a diagnosis of tuberculosis of the spine. I had an X-ray made and the X-ray showed the spine to be absolutely sound, there was no trace of tuberculous disease there, but it showed arterio-sclerosis. The examination of the urine showed nothing, the man had no hardening of the temporal or of the radial arteries.

The third case was a man of 35, who had an injury to his knee; water on the knee followed. He was treated by splints, by massage and by heat before he came to me. It did not yield to treatment. He was in perfect health otherwise and came for relief from the knee trouble. He was in despair, and I suggested an X-ray. I felt sure there was no lesion, and when I got the picture, there was arterio-sclerosis. There was nothing in the urine, nothing in the heart, no high-tension radial or temporal arteries.

A man of 63 came with the history of an old sprain received years ago, it never gave him any trouble until lately. He seemed a perfectly healthy man and I treated him. He had been treated before with no results. Examination of the urine was negative, the history was negative, the heart was negative, the pulse of the radial and temporal arteries were negative. The diagnosis was made with an X-ray.

I want to draw your attention to the definite means that we have in the X-ray for making a diagnosis which leaves no doubt when properly performed.

The Home Treatment of Tuberculosis.

DAVID R. LYMAN, M.D., Wallingford.

There is no disease that the general practitioner is so often called upon to treat as tuberculosis, none against which he labors under so great a handicap, and none that subjects him to so much adverse and unjust criticism. The premonitory constitutional symptoms that are present before the disease is recognizable in the lungs by any known means of examination, often cause the patient to seek medical advice before the symptoms are sufficiently definite to enable the physician to make a positive diagnosis and if he frankly fulfills his duties by telling the patient that while he can find nothing in his lungs, yet the symptoms indicate that there may be trouble there, and it is essential for him to return and have his case carefully watched; the patient comforts himself with the belief that there is nothing wrong and does not come back. The chances are that he will rest up for a short while until the symptoms abate somewhat, and then return to his old habits of life the symptoms reappearing once more, he again becomes anxious and argues that if his physician did not find the cause, he is no good and goes to another the same process is repeated two or three times (only varied by the prolonged use of some patent remedy recommended by a friend), and finally the patient presents himself to physician No. 3 or 4 with a well-developed case of tuberculosis and a bitter tale of woe as to the incompetence of the physicians he had been to before; whose advice he had not thought necessary to follow and whom he had never given the asked-for opportunity of following the course of his case for sufficiently long to enable them to make a diagnosis.

Even when the physician is accorded the confidence he deserves, and by carefully following the case is able to make an early diag