and rapid pulse seen so frequently are questions not always easily answered. Infectious and visceral diseases can of course be properly blamed for a great deal of malnutrition.

But so often the onset of the infection and more especially the onset of some visceral disease is so slow and insidious with so few positive symptoms or physical signs that the diagnosis becomes most difficult and uncertain, and often remains so for an annoying length of time. The speedy return to the former normal weight and nutrition which follows most of the acute infectious diseases is of course gratifying and frequent in the absence of any sequelae. But such is not the case with malnutrition following chronic visceral diseases, arteriosclerosis, and nervous disorders. I shall limit the further discussion to the loss of weight likely to follow any one or all of the three conditions just named, and will report a few cases typical of each. In the class of chronic cases, which I meet most frequently in private practise and hospital work, are quite a number whose loss of weight follows either some gastro-intestinal disturbance, or arteriosclerosis, which of course has its effect upon both heart and kidneys, and the so-called condition of "nervous prostration." Taking these three common causes in the order named I will first consider that loss of weight which follows gastro-intestinal disturbances.

The effect which the abnormal secretions in the stomach and bowel have upon the body nutrition can be observed most frequently. It is a very difficult thing to maintain a perfect nutrition through impaired functions of the gastro-intestinal tract. The chronic catarrh of these organs, if the term be allowable, with perhaps a hyposecretion and atrophy of the mucous membrane, as well as the occasional catarrhal or more frequent nervous condition which causes a hypersecretion, together with the pronounced acute or slightly chronic ulceration of the stomach, gradually causes slight to considerable loss of weight. The symptoms alone of gastro-intestinal diseases are often misleading and most unreliable, but when one makes a careful study of both symptoms and physical findings the reason for the malnutrition is often very clear and positive. The stimulation of a gastric hypoacidity, the removal of a diseased appendix, the surgical treatment of the gall-bladder, the cure of a chronic ulcer with a carefully selected but liberal diet, often lead to a gratifying and sometimes remarkable increase or return of weight. When, however, one begins to treat these cases after a questionable diagnosis, and when one

depends greatly upon the numerous and widely advertised digestive agents which flood the market, and leaves the selection of a diet mostly to the patient himself, the result is just as frequently very disappointing, and the patient passes out of observation. I will refer briefly to three cases as examples of some of these defects and of the satisfactory results.

CASE I: A housemaid, aet. 36, who previously had an attack of typhoid and several acute attacks of grippe, continued to lose weight and strength gradually for a whole year until she weighed 99 pounds. Her most annoying symptoms were a slight cough and gastric hypoacidity. She had a well marked atonic dilation of the stomach and two floating kidneys. The uterus and ovaries were negative. The menses had not appeared for four months. Without rest in bed and with a carefully selected diet liberal and forced in quantity, some bitter tonics, iron and arsenic and an occasional laxative, at the end of six months the menses returned, her strength improved and the weight increased from 99 to 115 pounds, which was very near her maximum weight at any time previously.

CASE II: Is that of a tall man, a broker, real estate agent, and promotor of industries, and an admirer of Venus. He has been under constant observation for the past five years. He was of neurotic temperament. His weight had been reduced from a maximum 180 to 140 pounds. He had attacks of syncope. He was alarmed about the condition of his heart, which was perfectly normal. He had constipation, insomnia, many gastric symptoms, and a marked gastric hyperchlorhydria with an occasional attack of vomiting. After trying symptomatic treatment for more than a year with only moderate improvement he was given a strict and prolonged rest cure or Mitchell treatment. The last two years his average weight has been between 190 and 210. Most of his symptoms have disappeared and his business capacity has increased remarkably.

CASE III: Is an example of chronic malnutrition, the result of perhaps more or less chronic ulceration, with dilatation, of the stomach which may have been present for years. Recently there was a very positive condition of an acute return of the ulcer. She was 27 years of age and a college student when she came under my observation in September, 1905. She is tall and has had a maximum weight of 135 when in good health. She gave a history of dyspepsia and constipation, which had existed for more than seven years. There had been attacks of vomiting. Some years before she was treated by systematic lavage of the stomach which gave considerable relief. There was no history of hemorrhages. When first seen three years ago she weighed 120. She showed upon examination considerable anemia, two floating kidneys, and a greatly dilated stomach. There was tenderness, but no rigidity over the ensiform region. The first gastric analyses gave a normal to subnormal secretion and acidity. The stomach contents were free from blood. The same condition was found in the occasional, subsequent, gastric analyses. She was treated symptomatically and with much benefit and comfort. She gained 10 pounds (weight 130) at the end of a year while at college. During her last college year however with heavier work, greater anxiety, and perhaps less care about rest, exercise and hygiene, she again began to lose weight. Her gastric symptoms became more pronounced and annoying. And upon her return in June, 1908, with a diploma from a university in the East, she weighed 110 and she had all the typical symptoms of gastric ulcer-pain, tenderness, rigidity, hematemesis, and a very constant finding of blood in the gastric secretions and feces. She was treated symptomatically with rest in bed and the Lenhardt diet for four weeks. In September she reported at my office when her weight had returned to 123, which is still rather low for a patient of her height and physique, but all her symptoms have disappeared, and she feels very well. No doubt a more

or less chronic ulceration of the stomach which I always suspected had been there at times for some years before it was diagnosed.

Cases of this kind are rather frequent, so I shall discuss the next cause of malnutrition, that following arteriosclerosis. A very convincing argument of this condition was given by Cabot two years ago in a discussion of "Two Possible Causes of Emaciation not Generally Recognized." In a series of 19 cases of arteriosclerosis which he studied he found an average loss of weight of 291⁄2 pounds in the average 11 years preceding the average age of 64. In the same paper he also made mention of several other plausible causes of malnutrition-namely excessive sexual indulgence, pain and loss of sleep. A report of three of my own cases may consequently serve well as examples at this point.

CASE I: Mr. W., aet. 60, was seen in the spring of 1904. In the preceding six months his weight had dropped from 160 to 130 pounds. He was weak and sallow, complaining of distress in his stomach after eating, with nausea. There was pain in the epigastrium with tenderness. The urine was normal in quantity, but occasionally gave a marked reaction for indican. Pus and blood-cells were found rather frequently, and small granular casts. The lungs were negative. The abdomen was scaphoid. The liver was easily palpable, hard and tender. The heart was slightly hypertrophied with a loud aortic second sound. The arteries were hard, though the blood-pressure was not high. The gastric analysis showed a hyperacidity and a hyperchlorhydria. There was no blood in the gastric contents, though there was history of former lavage of the stomach when blood occasionally appeared. The several subsequent gastric analyses showed about the same condition as the first. What now was the cause of the loss of 30 pounds in weight? Dyspepsia with previous gastric ulcer or beginning cancer was not improbable. Nephritis and cirrhosis of the liver could easily cause the same. With some hesitation the patient was put upon a treatment which was carried out quite successfully and resulted in restoring 10 pounds of weight in one year, beyond which however I could never increase his weight. He is now after four years quite well, though his former weight will probably never again be reached. During the first year of this man's treatment I was always uneasy, not knowing how soon I would be forced to diagnose cirrhosis of the liver, nephritis, or ulcer, or perhaps even cancer, of the stomach.

CASE II: Mr. O. W., aet. 47, was first seen in May, 1902. The family history was good and his previous history negative, except for the constant use for years of spirits taken daily in what was regarded as a temperate manner, no large quantities and never to excess. The weight had fallen from 180 to 150. There were symptoms of dysuria from an enlarged prostate with, however, little retention of urine. The urine contained blood and pus at times, a little albumen and a few casts. The liver was big and usually palpable. The abdomen was soft and not tenderexcept over the edge of the liver. There were few or no gastric symptoms. No gastric analysis was done The arteries were hard and firm. Heart and lungs were negative. Increased severity of symptoms was at once anticipated on account of the cirrhotic liver, and the enlarged prostate (which was handled gently). However, after four years of frequent observation with occasional treatment and advice, following a more continuous treatment for six months after the first consultation, I find him quite free from all symptoms and apparently well. His weight three years ago was 148 pounds, but six months ago was 167.

CASE III: Mr. D. K., aet. 63, a man of various occupations as a laborer, and now a foreman over laborers, came under observation during the last year. He was of good habits and 10 years ago he weighed 132 pounds, but now he weighs 90. He has gastric symptoms, anorexia, nausea, and distress after meals, and vomits occasionally. He had a slight cough with little or no expectoration, but had night sweats. He has had a fair appetite, but had artificial teeth for about 15 years, which he used only between meals as he claimed he could not get teeth well fitted. Examination showed arteriosclerosis, a negative urine, hypertrophy of the heart with mitral leakage and aortic roughening, anemia, dilation and ptosis of the stomach, and an achylia gastrica. His arteries were very firm and rigid. There was a systolic blood-pressure of 110. A diagnosis of arteriosclerosis was made as the most probable cause of the malnutrition, following a dyspepsia which might have been a factor in producing all his symptoms. Though under treatment for only a brief time the patient has gained a few pounds, and seems improving with the aid of a few drugs and carefully selected diet for achylia.

The above report of three cases of arteriosclerosis is much abbreviated. However it may be sufficiently convincing that arteriosclerosis is a general condition causing disorder in all of the organs at the same time. Defect in any one of the organs could be easily mistaken for the sole cause of all the loss of weight. All of the three cases had reached or passed middle life. And though the state of health of all of them is not at all alarming now, one can readily appreciate that the loss of weight which was so difficult or impossible to restore was a matter of no little concern to both patient and physician. Another feature of these cases of arteriosclerosis which has been emphasized by Stengel not long ago, ought to be mentioned at this place. The pallor which so many of these patients with hardened arteries show is often very conspicuous but frequently very misleading inasmuch as the cases often show on examination of the blood a hemoglobin practically normal, and a red blood-count of 6,000,000 to 7,000,000 or more, which is far above the supposed average in health. I can confirm this observation with quite a few cases. I do not hesitate to say emphatically that the premature senility and loss of weight which come on so often in people who have just passed into or beyond the middle period of life is the result of arteriosclerosis, perhaps more frequently than we appreciate.

The last of the three causes under consideration, nervous prostration, is one rather difficult to define. The term, no doubt, has been used frequently as a cloak to cover up an unrecognized condition and an inaccurate diagnosis in many patients.

Though difficult to define, this term is quite easily understood. It applies to a class of patients complaining of all kinds of symptoms of nervous origin, real and imaginary, and who have a slight, considerable or alarming loss of weight. No doubt

this loss of power and weight is frequently the result of defects in other organs rather than a defect in the nervous mechanism itself. Any careful observer need not be surprised to meet cases in which the cause of the malnutrition has been named "nervous prostration" either by the patient or the physician or both, but in which a demonstrable underlying disease of the thyroid gland, chronic disorder of the heart, lungs, kidneys, liver, stomach and bowels could be found eventually. But granting there is such a condition as nervous prostration, and that no cause for the weakness, discomfort, and loss of weight can be found in any organ, except a nervous mechanism with unnatural signs and symptoms, it is a serious condition to meet and handle. It is often closely associated with hysteria from which it is many times hard to differentiate. The misery which these patients suffer, or seem to suffer, and the discomfort and anxiety which they cause to those about them is indescribable and at times almost maddening. Its onset, though usually insidious, may be sudden. Its duration is from a few months to many years. Complete recovery is difficult until the cause is entirely removed, much rest allowed, much food prescribed, and the lost weight restored. Many patients never recover but become easy victims of other intercurrent fatal diseases. Occasionally, though, such a final positive cause of death cannot be discovered and the cause of death can be attributed to nothing else than a malnutrition from nervous prostration. The following report of a rare and fatal case deserved more study than was permitted at the time of her illness and more comment than can be given here.

A girl at the age of 15 was seen in consultation in September, 1907. The mother was living and well. Father died of typhoid. She was never seriously ill and had reached a maximum weight of 106 at the age of 14. About that time she was given a rather confining position in a store and was made the confidant of a very serious financial situation in the home of her mother and step-father. She seemed to worry greatly, began to grow weak and tired and complained of distress after meals, anorexia and belching. The bowels became more constipated and all food as well as water was said to cause great distress in the stomach. The patient no doubt magnified her symptoms, and the family and relatives were in a state of such alarm and sympathy that they advised her to partake of only a very limited amount of food and drink. Finally she claimed she could not swallow water and nothing as hard as bread, and yet in my office we succeeded in having her take the Ewald test meal, two slices of bread and two glasses of water. An aunt, who was present, could hardly believe the girl could take so much water and food. Examination revealed normal signs of the heart and lungs. The urine was negative, the blood and reflexes normal, gastric analysis showed food well digested though there was a slight hypoacidity. Her weight at that time was 68. She was sent to the hospital for a trial of the Weir Mitchell treatment, however she died a few weeks later in spite of all medical effort. A postmortem