which ordinarily would yield to treatment in a short time, drags on indefinitely-months, and even years. Finally, the picture changes, and, what was formerly a simple anemia, with low blood index and well-shapen cells, gradually, but inevitably, develops into the pernicious type, with high blood index and mal-formed corpuscles.

Of intestinal conditions that must be considered as causing a progressive anemia, are the intestinal parasites. These are of many types, too numerous to permit of discussion. However, we may take the anemia such as is caused by the Uncinaria Americana, or hook worm, an example. The report of Dr. Ashford and his assistants on the anemia of Porto Rico, covering nearly 5,000 cases, amply illustrates this point.

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Another class of intestinal diseases which are found antecedent to pernicious anemia, are the diarrheas. I can do no better than cite an example of such a

case:

The patient under discussion has been watched since the fall of 1904, when he came to the clinic of Prof. Dock, at the University Hospital, complaining of diarrhea and inability to digest his food. His stools, examined at that time, were as numerous as nine per day, and contained large quantities of mucus-often a pint at a time. The diarrhea yielded slowly to treatment. No parasites were found. When the enteritis was finally checked, the patient was much improved. Belching of gas, distress in the abdomen, and poor appetite persisted, despite rigorous treatment for these conditions. The patient, however, gained to such an extent as to be able to do light work. At that time, the patient was suffering from severe anemia, and, although the blood did not present the picture of a primary form, this type was strongly suspected. The patient was discharged, but returned in October, 1905, complaining this time of diarrhea, eructations, and of general discomfort. His legs showed some edema, for the first time, and his anemia was more marked. He had not lost much weight, although his strength had waned perceptibly. On examination, his condition was found to be much the same as before, except for the nervous symptoms

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that had developed. The blood examination showed nothing definite, and, as treatment for the gastritis and the enteritis soon improved the patient's condition, it was faithfully pursued. three months he returned to his home. March, 1906, found him with us again. Diarrhea in a very mild form and a few gastric symptoms remained, but it was now the general languor, fatigue, shortness of breath, and the swollen extremities that were foremost of the patient's complaints. His blood, too, was altered, not so much in the total number of cells, and the amount of hemoglobin, for his power of regeneration seemed good, as the shape and kinds of his cells, and the relative number of the white elements. Cord changes now seemed to be contributing to the panorama of symptoms, for his tendon reflexes have disappeared, and, lately, incontinence of urine and feces have developed.

I might cite other similar cases, less striking, perhaps, in their evolution, but exhibiting gastric and intestinal stigmata of this disorder. It will suffice, however, to state, briefly, that of 53 cases, 54% complained of loss of appetite; 38% of bad taste in the mouth, due largely to poor teeth; 46% of nausea and vomiting; 54% of epigastric distress; 24% of diarrhea, and 10% of constipation. It must not be understood, that these were the only symptoms, but in the great percentage of cases, they were the chief complaints for which the patients sought relief. In a very few cases, no such disturbances were described. In nearly every instance, general weakness and shortness of breath on exertion were complained of. 32% of cases, numbness in extremities, with often times change in color, loss of weight or languor, formed a group of symptoms whose insidious onset and persistency brought these patients to our care. For the past few years, careful gastric analyses, and examination of feces, have been the routine in these cases, while treatment was being instituted. The results are striking in their uniformity, and of value in suggesting a plan for treatment.

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Out of 35 cases, examined for free

hydrochloric acid, a small quantity was present in but one instance, after a single test meal, and absent in all others. Hydrochloric acid in combined form was rarely met with. Pepsin was tested for in 33 cases. Six gave slight evidence after a long period of time, but none of the remaining showed any degree of digestion. Chymosin was absent in every case examined. The excess of mucus found in the gastric contents was quite constant. Eighty per cent of the cases showed an excess, sometimes to such an extent as to suggest a mucous gastritis.

The microscopic examination usually reveals various kinds of bacteria. In addition red blood cells and leukocytes are frequently found, due, probably, to a diapedesis of these elements into the stomach. In a few instances, bits of mucous membrane have been withdrawn with the tube. They present, in each case, the picture of an atrophic gastritis,, with some interstitial change.

One of the most interesting of these analyses is the motor power of the stomach. In observing 34 cases, but one showed signs of retention. In 9 of the

cases, the motility was normal. In the remaining 24, the motor power was increased, varying from cases with but slight hypermotility to stomachs that emptied themselves completely in 20 minutes.

Time forbids me to go into the indications for the treatment of these cases. I should have liked to have called your attention to the excellent results that can be obtained from treatment on a rational basis, carried out along lines suggested by the symptomatology. I am content at this time, however, to interest you in these few facts:

1. The uncleanliness of the mouth and teeth in many of these cases.

2. The danger of persistence of gradually progressing gastritis, with periods of nausea, eructations, and vomiting.

3. The outcome of the various diarrheas that resist treatment.

4. The seriousness of repeated small matter from what hemorrhages,

source.

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5. The value of gastric analyses, and the examination of intestinal contents.

Dr. C. D. Aaron, Detroit, in opening the discussion, said that in pernicious anemia it is impossible to determine the chief etiological factor; for this reason, it is very important to know the state of the gastric secretions. Although these elements are usually diminished, Dr. Aaron said he had seen cases with an increase of acid and ferments. As a result of the extra work usually put upon the pancreatic digestion, there frequently is a complicating diarrhea. Under such circumstances it has been the custom to give dilute hydrochloric acid and pepsin. Usually it is better practice to start the pancreatic digestion in the stomach. At first this method did not succeed, because, as we now know, it is necessary for the pancreatic secretions to come in contact with the intestinal secretion to be made active. Some new preparations have recently been put upon the mar

ket which give an activated pancreatin. A patient, a physician, on this preparation was considerably improved for a time but died about two weeks ago.

Dr. George Dock, Ann Arbor: One of the most important points in the care of a case of pernicious anemia is to make a thorough examination of the gastro-intestinal tract. It is necessary, however, to make an examination of all the organs.

Dr. Dock has observed that the best results come when the treatment is begun early. In regard to the point made by Dr. Aaron, he thinks it is still an unsettled question and will probably turn out about like the experience with pepsin a few years ago. Dr. Aaron's statement about the physician reminds Dr. Dock of what happened to

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that same patient some two years ago. ports were circulated that he had been cured by giving large doses of hydrochloric acid. Dr. Dock predicted relapse at the time. He hoped that experience with intestinal products mentioned by Dr. Aaron, would prove more valuable but thought it very doubtful.

Dr. Hugo A. Freund, Ann Arbor, stated in conclusion that in none of the 56 cases studied was there hyperchlorhydria or an increase of the digestive ferments. One point he wished to emphasize is that we should not attempt to, work for specific cures, but try to determine the causative factors.

In accordance with the suggestion of Dr. W. L. Bower, secretary of the Montcalm County Medical Society, to whom I am indebted for the courteous invitation to appear before you, I am presenting for your consideration a few of the

common diseases of the skin in which the sense of itching plays an important role. So much confusion exists as to the weight to be attached to the sense of itching in the recognition of the true character of a dermatologic lesion, and both the profession and the laity have so popularized the term "itch," that your worthy secretary thinks it may be of interest to you if I briefly analyze and differentiate these various pruriginous affections. .

To make the analysis more clear it will be well to divide this group into

1st-Verminous parasitic diseases2d-Vegetable parasitic diseases3d-Bacterial parasitic diseases4th-Secondary bacterial infections5th-Pruriginous papular dermatoses6th-Pruriginous sensory neuroses— Itching is common to most animals,

*Delivered by invitation before the 11th Councilor District Meeting, at Greenville, October 26, 1906.

most marked in the hairy and feathered, at times being apparently spontaneous and physiologic. It seems to be allied to the sense of tickling, pricking, creeping, crawling, and to convey a suggestion of something extraneous to the body, as if provoked by an external irritant.

It would seem that the sensation must have to do with the free nerve terminals in the epidermis, as evidenced by the fact that itching occurs only when the epidermis is involved in the pathologic process. Deep seated affections do not itch, only those the lesions of which are superficial; and diseases of the connective tissue do not itch, even though superficially located. But we have all witnessed the intolerable itching of scabies, of pediculosis, of lichen planus, and the scratched skin of some of the stages of eczema, in which the itching has been so intense that the nail has denuded the skin to the retemucosum, has torn asunder the follicular prominences and the skin consists of a mass of excoriated, denuded, infiltrated tissue with secondary pustular formations, enlarged neighboring lymphatic glands, and, where the itching and the inflamma

tion have been of long standing, is thickened and pigmented.

Often the itching is a reflex phenomenon from an internal organ or from a mechanical or chemical irritant, as the ingestion of certain foods and medicines, weather changes, exposure to cold or heat, the application of certain drugs and plants, the change of clothing. It is often the accompaniment of jaundice, of dyspepsia, of the gouty state, of albuminuria and chronic Bright's disease, of lithemia and rheumatism, of diabetes mellitus, of fermentative processes of the bowels, of ovarian and uterine diseases, of pelvic tumors and of pregnancy, and may often be due to a central disease and may accompany anxiety, mental troubles and depressing mental influences.

Thus we see that disturbance, through the sense of itching, is common to many diseases, but in the affections under consideration it plays so important a role as to affix the term to the disease, irrespective of the true condition.

To the first group would belong the Human Itch,-Scabies-a dermatozoosis caused by a sarcoptes, the Acarus Scabiei. The irritation is due to the presence in the skin of the female parasite, which has burrowed into its folds for the double purpose of nutrition and the laying of her eggs. Contamination usually takes place during nocturnal contact and this mode of infection is accepted today as more probable than by contact in handshaking. As it is more liable to occur among those who segregate and as foreigners, coming into this country, are apt to live together in close quarters, it often goes by the name of the Italian, Hungarian or Polish Itch. Among the poor in European countries, in Norway, scant attention is often paid to cleanliness; the disease becomes very chronic, scales, crusts and other debris are permitted to accumulate. The retention of this mass of debris leads to almost uncontrollable itching and the dis

ease goes by the name of the "Norwegian Itch," the seven-year itch.

Again, when large bodies of men livetogether for any length of time, as in a military camp, the affection is apt to become rampant and the boys will attach the name of the country in which they are sojourning to the disease and thus we hear of the Texan itch, the Mexican itch, the Cuban itch and even, in lumber camps, of the Michigan itch.

The Cuban itch might easily be disposed of, by stating that there is no such disease per se, were it not a word made so prominent by recent history and so easily conveyed as to become popularized and that it will be used for years after by the laity and indeed often by members of the profession to cloak their ignorance or to satisfy their patients. Thus we hear of the Cuban itch eight years after the Spanish-American War.

In this country, except in large cities. where the poor are bundled together in unhygienic surroundings, and except among the old and miserable, the broken down and cachectic, or among large bodies of men encamped togetherphthiriasis of the body is not common. But in severe cases it presents a picture not easily forgotten. The lesions are due to irritation produced by the body. louse (known to the boys as the "gray back"), which inhabits the clothing, not the body, but feeds upon the body, especially upon the back. Even in the recent case the long striated, parallel lesions along the back produced by scratching are so characteristic as to be pathognomonic and when the louse and eggs are found in the seams of the clothing, the diagnosis is clear. And when severe the skin becomes thickened and discolored, especially on the back between the shoulders, on the hips and over the hypogastric region and the clothes exhale a musty odor. The itching is more intense than in scabies.

The Dhobie itch, imported from the Philippines by returning soldiers, is a

vegetable or bacterial parasitic infection, occurring among those forced to march and to live in marshy and damp grounds. These men show upon the lower extremities a brownish copperycolored pigment not unlike an old syphilitic lesion, which may be due to secondary bacterial infection. Many of these cases have I observed among soldiers, who have seen service in the Island possessions, when applying for re-enlistment into the United States Army.

What is known to dermatologists as barber's itch-tinea sycosis vel tricophytinae barbae-is a rare affection in this part of the country. At St. Mary's Hospital Free Dispensary only three cases have presented themselves to the department of diseases of the skin in 15 years,

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and two of these were in brothers. is due to fungi, the microsporon audouini and the tricophyton megalosporon and is characterized by two distinct types, one of which remains superficial, and the other of which is of a deepseated nodular form, the latter being generally acquired from contact with a domestic animal suffering from the dis

ease.

What is called by many members of the profession and is known to the laity as barber's itch is of very common occurrence, a bacterial infection, impetigo contagiosa, due to pus-cocci, the staphylococcus aureus, streptococcus and possibly the staphylococcus albus. It is an acute, contagious, inflammatory disease of the skin, noted for the superficiality of the lesion, which is usually discrete, flattened, at first serous, then sero-purulent, dying into thin yellowish crusts, found upon the face of man or woman. It is not infrequently in the case of the man, contracted during a shave in a public place-hence the name. It is the same disease which is so common among children, upon whom it may be found upon almost any part of the body.

Baker's itch, tradesman's, grocer's, washerwoman's, bricklayer's, paster's, bookbinder's, printer's, dyer's, chemist's itch are chronic, indurated, pruriginous patches of eczema with a tendency to fissures, found upon the palms of the hands and aggravated by, if not due to, the exposures of the hands, as the case may be, to the flour and yeast, to soapsuds and water, to mortar, or to the ingredients incident to the other occupa

tions.

Lumberman's, prairie or swamp itch may be indurated pruriginous patches of eczema found upon persons, especially on the lower extremities, who work in the woods, in the prairie or the swamps, due to dampness and the retention of wet clothing and aggravated by repeated scratching, or may be unrecognized cases

of scabies, or cases of autumn or winter itch.

in October or November, there comes With the beginning of cool weather, tremities, the inner surface of the thigh to not a few an itching of the lower exand the anterior and lateral surfaces of the leg below the knee. It is not constant, but is usually more aggravated as one disrobes for the night. It goes by the name of autumn or winter itch, frost itch (Pruritus Hiemalis), and is apt to continue until the warmer weather of early spring, to recur the following fall with unvarying regularity.

The Ohio scratches, the Texan mange, as found in the western and northwestern states are usually examples of this frost itch.

The itching prevalent among those who work among poultry, the fowl's itch, the itching accompanying the bites of mosquitoes, fleas, bedbugs, has an urticarial element which accounts for its severe character.

In the higher walks of life many persons bathe so frequently, once or twice a day, as to rob the skin of its natural oiliness. As the result, they complain of an irritable skin, which scratching