cases although not specific for this disease. There were many clear instances, in the army studies, in which this lowered tolerance promptly returned to normal after removal of the causative foci and recovery from the arthritis. This return to normal, however, also followed the use of nonspecific protein therapy and also a diet of limited caloric value. On the basis of these studies of the sugar tolerance and many clinical observations it is important to appreciate that in some instances a restricted caloric intake may afford the only means by which recovery from arthritis will take place. This work has been coroborated by Fletcher of the University of Toronto in two series of 150 cases in toto. It is further of interest to note that the favorable influence of a low caloric diet can be appreciated and sometimes carried to the point of recovery, in the presence of gross focal infection. In Fletcher's cases the foci were deliberately left untouched as an "experimentum crucis" though such a procedure should not of course be made the basis of clinical practice. These facts are mentioned to show that other measures are of profound influence and that removal of focal infection thus constitutes, frequently, merely the restitution of the first of a long row of bricks which have been made to topple over, the residual bricks still remaining flat on the ground. Recovery from disease after the removal of apparently causal infection must, therefore, depend in large part also upon attempts to improve and restore the disturbed physiology concerned. Neglect of this consideration is very widespread within the medical profession. Fortunately

nature has her own ways of meeting insults as is clearly evidenced in the recovery of soldiers in the army, as above mentioned. Commercial advantage has been taken of this truth upon a very wide scale and made the basis of exploitation in countless Sanatoria, Spas, and Hydrotherpeutic institutions. While such places are for the most part not discriminating in their methods of procedure, their undoubted success depends fundamentally upon the fact that much can be done to help nature meet these difficulties, often indeed, even in the presence of the removable focal infections which have caused them. In many cases of functional disease, and in selected cases of organic disease, the influence of massage, hydrotherapy, exercise and arsenic upon the local and general blood flow and metabolism is adequate alone to restore the subject to at least temporary health. Nothing in these remarks is to be interpreted as justifying neglect of focal infection and it is our invariable practice to investigate each case exhaustively and, whenever practicable, to remove foci when found. It would be worse than futile to treat nephritis, due to removable foci, by accessory or expectant measures alone. The lax manner, however, in which the removal of supposed foci has been carried out has resulted in the mutilation of countless sufferers; the removal of even causative foci has resulted in countless failures; and the surest way to approximate the truth is through an understanding of both sides of the equation. I have now under observation three cases in which definitely diseased tonsils, under consideration for removal, have so improved under broad

medical procedures that the three laryngologists concerned, Drs. Fetterolf, Geo. Wood and Geo. Coates, do not now advise operation. In two of these an important part of treatment was the removal of other foci; in the third it was a restricted diet. We must be careful not to get the cart before the horse and fail to realize that foci may be the result of metabolic or other errors as well as the cause of them. Not without interest in this connection is the work of Howe of the Forsythe Dental Infirmary in Boston who seems to have produced dental caries in experimental animals as the result of feeding a scorbutic diet. Finally, it is a duty to point out that the untimely removal of even causative foci of infection may result in an exacerbation of the original condition such that the secondary result may be worse than the first. This is particularly true in regard to radical operations on the sinuses though it may apply of course to any operative site.

SUMMARY

Focal infections, including dental, may be the undoubted cause of disease in almost any tissue of the body.

They should be removed from healthy as well as sick individuals,

when this is practicable and not contraindicated by the balance of health or severity of the surgical procedure.

Focal infections may act by disseminating bacteria to the part involved, or they may act by the intermediation of changes in basal physiology, probably in the finer vascular channels.

Recovery often fails to follow removal of foci because of this dislocation of physiology which may persist long after the cause is removed. Consideration of this secondary disturbance is often necessary before recovery occurs.

Recovery from functional disturbances may take place even in the presence of causative foci if nature's own measures of defense are aided and intensified.

Removal of focal infections at an improper time, in some cases at any time, may result in an exacerbation of the original condition which leaves. the patient worse than before.

There is indubitable evidence that some of the functional syndromes induced by focal infection can be perpetuated and caused by other mechanisms. A balanced viewpoint is necessary to determine what the cause of illness may be, to achieve a betterment, and even to avoid causing further injury.

The male patients were particular offenders in this regard, and quite often it took a female member of the family to remind the patient of his forgetfulness. The third reason is that a great many of our 300 cases were children and consequently did not have a chance as yet to develop the various manifestations of allergy, but will surely develop them at some future date. The general impression that asthma and hay-fever occur frequently together is borne out by our statistics. Thus we see that out of 82 cases of hay-fever, 56 had asthma (75.5 per cent). How many of the remaining will develop asthma at some future date of course cannot be accurately stated The occurrence of 77 cases who suffered from severe headache, 69 from frequency of urination (2), and 82 cases from arthritis (3), among the 300 cases, leads me to believe that these are allergic manifestations, as all other causes were excluded.

now.

One hundred cases of our series showed definite stigmata which pointed to endocrine disturbance. These comprised non-descended testicle, missing teeth, no axillary hair, moustaches in females, infantile uterus, irregular menstruation, sterility, enlarged thyroids, and other symptoms of hyper- and hypothyroidism, etc. It is my belief that this frequency is not mere coincidence, but the endocrines (4) together with an unstable autonomic nervous system and not merely the allergic substance, are at the bottom of allergy (5). It is surprising to see how many patients suffer from skin diseases which are really of allergic origin. It

to recognize this, because it points to the therapeutic indications. Not only do they present eczema, hives, rhus toxicodendron poisoning, but also angio-neurotic-oedema, the various occupational forms of dermatitis, miliaria, pruritus, psoriasis, and various bizarre forms of skin diseases which do not lend themselves readily to classification.

I am convinced from my studies that there is no such disease entity as asthma, hay-fever, etc., but that these are only manifestations or symptoms of an underlying disease called allergy.

Puberty and Sex. I divided arbitrarily both the male and female patients in two groups those above 16 and those below. The reason for this is that by this time puberty, as a rule, is well established. I have not infrequently noticed that puberty influences allergy, especially asthma and hay-fever. In some this influence is for the better, and even a complete cure occurs, in others it is for the worse. Some date the onset of their allergic manifestations with the onset of menstruation.

Menopause. The influence of menopause is variable, while some cases are improved, others are aggravated, and some date their asthma with the onset of menopause. On the whole menopause affects allergy unfavorably.

Age. In my series there were 50 more female patient than males above sixteen years of age, whereas below sixteen years of age there were 16 more males than fernale patients. Since puberty seems to reverse the figures, to my mind it