778 PERCY FRIDENBERG 



inflammatory changes in the eye and that general toxic absorption is 

 shown by the frequent loss of weight and appetite, nervousness and in- 

 ability to sleep. 



Pellagra. Central scotoma for color and disturbances of the peripheral 

 fields are early signs of this affection, and in advanced cases pallor of 

 the optic nerve heads is found (Calhoun). 



Constitutional Disease and Endocrin Disturbances. In the light of 

 endocrinology and fuller knowledge of certain clinical conditions we shall 

 have to revise, at least in part, our conceptions of etiology and pathological 

 mechanism connected with rheumatism, and possibly with syphilis and 

 tuberculosis. 



Rheumatism and Arthritic States. Pemberton concludes on an in- 

 tensive study of four hundred cases that indiscriminate removal of teeth 

 has gone too far, that with chronicity the results of the removal of pus 

 foci become less important, and "in a regrettable number of chronic cases 

 and in some early instances, the removal of focal infection may be of no 

 avail whatever." He lays stress on the etiological significance of ex- 

 posure to cold and wet, and to diffuse infections as opposed to foci 

 such as dysentery, influenza, and pneumonia, while quiescent foci may 

 be made operative by a severe illness and reactions following endocrin 

 alteration by emotional stress. The beneficial effects of radium, the 

 roentgen ray, arsenic and massage indicate, as does the improvement un- 

 der thyroid administration, that agents which hasten body metabolism 

 have a good effect on arthritis. Arthritics show a lowered elimination, and 

 a lowering of sugar tolerance which, in turn, seems to be markedly de- 

 pendent on focal infections and their removal. In many cases, however, 

 this lowered sugar tolerance remained in spite of removal, or returned to 

 normal in spite of persistence of pus foci, with cure by other me>ans. Cut- 

 ting down food, particularly carbohydrate intake, and stimulating metab- 

 olism by heat and hyperemia are valuable procedures. The starvation pre- 

 ceding and following narcosis and operation has a great deal to do with 

 the beneficial effects of adenectomy and tonsillectomy usually ascribed 

 to surgical intervention in chronic arthritis, and may explain in part 

 the not infrequent relapses, of which Pemberton cites a number, when 

 these patients were again placed on full diet. The application of these 

 clinical studies to the management of rheumatic eye affections is evident, 

 particularly in iritis and the ocular manifestations of gout, such as the 

 various forms of scleritis and the hot eye of keratitis. At first, salicylates, 

 then removal of focal infections and intestinal debris, and now, stimula- 

 tion of basal metabolism via endocrin medication. The frequency of my- 

 ositis in Pemberton's series suggests the possibility, in inflammatory affec- 

 tions of the extrinsic ocular muscles and possibly in the sphincter iridis 

 and muscle of accommodation, of a more frequent agency in the form 

 of lowered metabolism dependent on a generally hypothyroid dyscrinism. 



