Definition.--Osler says that it is a chronic disease of the joints, of doubtful etiology. Judging from my own experience, I should say that the disease is a legitimate outcome of abuse to the digestive function in those of the gouty diathesis.

   Etiology.--There is more of this disease occurring between the ages of thirty and fifty than at any other time of life. Children, and young people at or before puberty, do, however, develop it. More women than men are affected with this disease, if I am to judge from my experience.

   Predisposing Cause.--Gouty diathesis,

   Exciting Cause.--Anything that will shock the system like the loss of a friend by death, sudden fright, and injury. But, of course, for these exciting causes to precipitate a case of arthritis deformans, the patient's nutrition must be perverted, so that only the last straw, so to speak, is necessary. Some medical writers are inclined to recognize the disease as, originating in the nervous system. There is a type of arthritis deformans that has its origin in the nervous system, but it is not what is generally understood as this disease; that is, the type that distorts the joints by ankylosis (bony union). All diseases have an element of nerve derangement. Indeed, we must have enervation before any disease can develop and enervation may be brought about by anything--any influence--that uses up nerve energy.

   The nutritional disturbance that ends in the disease under consideration comes from continual overeating--eating beyond the digestive capacity. The subjects in this particular class, if they were of the scrofulous diathesis, would develop tuberculosis, or some form of tubercular disease of kidneys, brain, liver, etc.; but in the gouty diathesis the disease leads off to bursal inflammations, with deposits of lime. When the morbid state is once set in motion, it will never stop until all foods that are carrying much mineral--lime, etc.--are left out of the dietary.

   Symptoms.--Sometimes the disease will start in the hands, sometimes in the toes; there will be a development of nodes; the finger joints become sensitive, swollen, and little elevations of bony deposits take place. If the subject moves to another country--goes from north to south, south to north, east to west, or west to east--some habits will be dropped, which may favorably influence nutrition, and the disease may come to an end, leaving the finger joints enlarged. But when the disease once starts, if the cause is not removed, accidentally or otherwise, the joints become more and more deformed, and more and more of the joints become involved in the disease, extending from the hands to the wrists and elbows, and from the toes to the ankles and knees. Sometimes the disease develops very rapidly in the spinal column, and may cause complete ankylosis in a few months. Patients who have this disease develop in the hips will often in a very short time develop ankylosis of the hip joints. This disposes forever of the possibility of sitting down--the patient must either lie down or stand up. If the knees are involved, so that there is complete loss of the knee joints, it will be impossible for the person to walk. If his arms are left to him, he may go from place to place on crutches.

   No one ever has a node form on the fingers who has not had indigestion. No one will ever develop rheumatism of any kind without first having indigestion, and that indigestion must have been running along for months, and even years, before the nutrition is so perverted as to change the function of cell development. As stated above, the disease may start and come to a sudden end. Then again it may start and continue making new conquests from month to month--perhaps not so rapidly, but surely from winter to winter; each new involvement meaning a destruction of the particular joint involved. This is called the progressive type of the disease; which does not mean anything, except that nothing has been done by well-directed treatment to stop the progress of the disease by correcting the errors of nutrition.

   Diagnosis.--In the very beginning this disease may be mistaken for inflammatory rheumatism. This mistake will not be of long duration; for deposits will take place, which speak for themselves. The swelling is never so great in this disease as in inflammatory rheumatism. The inflammation never runs so high, and the general fever never reaches the height that it does in acute articular rheumatism.

   Treatment.--A lost joint is lost forever, but the disease may be checked. A complete fast should be given until the pains are all gone, and then a diet for several weeks of fruit and vegetables--fresh or uncooked fruit and non-starchy vegetables, with plenty of salad. These are the eliminating foods. Foods that are inclined to cause deposits in the system--such as meat and all forms of cereal--should be left out of the dietary, if necessary for a year, so as completely to transform the: nutrition of the victim of this disease.

   Etiology.--This disease represents a perverted state of nutrition. Its victims belong to the gouty diathesis. They are almost invariably eaters of large quantities of starch--great bread-eaters. Workers in damp places; those whose work is in basement; those who live in damp houses, on low, marshy ground, in sections of the country which are not drained, are inclined to develop this disease.

   Symptoms.--Stiff joints are always in evidence. The subjects of chronic rheumatism find it difficult to get around when they first get up in the morning. The knee joints, ankle joints, and other joints of the body complain very bitterly when they are moved; but, after being up for a few hours, the patient becomes more comfortable. if, however, he lies down during the day for a nap, or sits down for any length of time, he will get up stiff and sore.

   These people are supposed to be barometers. They can tell when there is to be a change in the weather. If they cannot tell, they think they can; so it does not matter, for they have pain in season and out of season. Some of the joints will be tender to the touch, and a little swollen, but there will not always be any redness. The rule is that more than one joint is affected, but we meet with a great many cases where the disease is confined for years to one shoulder, or one particular point in the back, or to the hip, or to one knee. The general health of such people is not badly impaired; they always have a good appetite, and are especially fond of sweets. The disease is not recognized as serious; yet some cases do develop heart complications. These patients are very inclined to develop arteriosclerosis, seldom live to be very old, yet may live to be sixty or seventy.

   After the rheumatism becomes chronic there is seldom, if ever, any fever. In the early stages fever may run very high, up to 103 or 104 degrees. A patient in this condition should not have anything but hot water until the pain and swelling are all overcome.

   Treatment.--The diet must be corrected. It is impossible to build chronic rheumatism without improper diet, improper clothing, improper bathing, improper housing, etc. No two cases require exactly the same treatment--every case is a law unto itself. If there is constipation, it must be overcome. All bad habits must be put aside; no coffee- or tea-drinking; and, of course, alcoholics are never to be thought of by those afflicted with rheumatism. The use of tobacco must stop.

   Breakfasts should never be more than an apple or an orange. Until the rheumatism has been entirely overcome, these patients get along better by using such fruits as apples, pears, and peaches, and leaving out the citrus fruits. Anything in the starch line--bread, potatoes, beans, etc,--should not be eaten oftener than once a day; meat two or three times a week; cooked, non-starchy vegetables and a combination salad always being preferred in these cases. The amount of food must be limited until the condition has been entirely overcome. At no time so long as there is any rheumatism should one eat what would be called a full meal.

   Definition.--A painful affection of the voluntary muscles and the faciae (the fat that covers muscles and dips down between them). This disease often takes hold of the periosteum (lining membrane of the bone). When it affects the muscles in the back, it is called lumbago; when affecting the muscles in the chest, it is called intercostal neuralgia.

   Etiology.--This disease follows colds and exposure. People who develop it are subject to acetous fermentation in the stomach from eating food potentially acid and low in vitamin. Their habits are very much the same as those described under the head of chronic rheumatism. The constitutional disturbance is less than in the former disease.

   Symptoms.--The affection is entirely local. The constitutional disturbance is light. There is no fever, pain being the principal symptom. People who are afraid of pain will often make a very great deal of complaint, and they make their suffering much worse than it really is, by pitying and feeling sorry for themselves. For instance, if they have pain in the shoulder, they will set the muscles to keep the shoulder from moving, and it will not be long before they have more pain from tire, because of keeping the muscles fixed, than on account of the disease itself.

   This is true whatever the location. One of the principal varieties is lumbago. When the patient gets this trouble, he will often put his muscles on guard, to keep from moving the sensitive point; and in the course of a day the muscles that stand guard will be so worn out, and so very sensitive and painful, that the lumbago, plus the muscle fatigue, will make a very large-appearing disease, when there is really nothing to do for the patient, unless he can be induced to lie down and relax. Where the disease is in the neck, known as "stiff-neck," the same distressing condition may be brought about, if the patient does not know the injurious influence of keeping his muscles set or on guard.

   Treatment.--Rest, and, if the patient is in very great pain, he should go to bed. Previous to going to bed, however, he must be told how necessary it is for him to poise--relax. Then a hot bath should be taken, the water being as hot as can be borne. The patient should remain in the bath until relieved, even if it requires an hour. Then he should go to bed, and be lightly covered. The bowels should be made to move with enemas. The patient should drink all the water possible for several days--two or three quarts during the day. Positively no food must be eaten until the pain is entirely controlled. Then meat eating must be given up, except about three times a week. Any kind of fruit (except perhaps the citrus fruits) should be given for two meals a day--morning and noon. At the noon meal a little cream or cottage cheese may be added to the fruit. Supper should consist of cooked, non-starchy Vegetables and salad, with meat added about three times a week. On the evenings when meat is not taken, one of the decidedly starchy foods may be taken with the salad and vegetables.

   Definition.--Perverted nutrition in which sugar fails to be carried through the regular digestive process and appears in the urine. It is considered that a patient has diabetes if sugar is appearing in the urine daily.

   Etiology.--This is, a disease of civilization. It is a disease that makes, itself felt in all sections of the country where the cost of high living is well known. In other words, it is a disease peculiar to leisure and luxury. It is said that men are afflicted more often than women. The reason for this is that men indulge themselves in luxuries more than women. Man smokes and drinks, and is more inclined than woman to go to excess in all kinds of stimulants. People who have a tendency to obesity are more disposed to develop this disease than thin people. Mental shocks, nerve strains, overwork, worry, anxiety, all have a tendency to favor the development of this disease. Severe injuries are frequently followed by sugar in the urine.

   Metabolism in Diabetes.--There is no question but that the foundation for this disease is laid in toxemia; and toxemia is brought on from excessive eating and eating to repletion--eating until there is a chronic state of acidosis, fermentation in the stomach and duodenum, and also putrefaction in the large intestine, with daily absorption of toxins. Just why one case of toxemia will be followed by diabetes, another by Bright's disease, and another by tuberculosis, is not apparent to the lay public; but the real cause is anatomical and physiological. In diabetic subjects there is a tendency for a derangement of the pancreas and liver. It is said that in all cases of extirpation of the pancreas permanent diabetes is established. Then it is reasonable to believe that where there is a constant state of acetous fermentation of the stomach and duodenum, this acid state prevents the enzymes secreted by the pancreas from converting the starch into sugar. Much of the starch will be worked up into alcohol, and quite a good deal will pass off by way of the kidneys as sugar in the urine. The walls of the intestine as well as the liver fail to dehydrate the sugar, and this allows it to pass into the circulation and out by way of the kidneys.

   Symptoms.--The acute form runs its course more rapidly. The patients become rapidly emaciated. In the chronic form many patients will be showing considerable sugar, without any very material change in the constitutional symptoms, running over a period of several years. The acute form may occur in the aged, but the rule is that people beyond middle life have the chronic form. There are people who have sugar in the urine a great deal of the time, and yet they are not truly diabetic. Those who eat a great deal of sugar, and those who overeat on starch, are very much inclined to have sugar in the urine.

   There is a strictly neurotic type of diabetes. Where men are employed in enterprises requiring all the nerve energy they have, and are pushed to the limit in endurance, a nervous state will be developed that will be accompanied by sugar in the urine. The disease is strictly one of perverted nutrition; and unless nutrition is brought back to normal, a permanent cure will not be made.

   Polyuria is a state where there is not much sugar in the urine, yet there is a very great quantity of urine passed--as much as a gallon or over in twenty-four hours. This particular type is of nervous origin, and, of course, there is, more or less gastro-intestinal indigestion. A tendency on the part of some cases is to drink a great deal of water or light alcoholics. In most cases the disease develops gradually, the patient not noticing the frequent desire to urinate. He will be troubled in this way not only in the daytime, but also at night. The quantity passed will attract his attention sooner or later. When measured, he will find that he is passing four, five, or six pints in twenty-four hours, instead of three; and he will also be surprised to find that it is of greater specific gravity. It will run from 1,025 to 1,040. The tongue is usually red--sometimes very silky-looking, as though it were varnished. Saliva is usually scanty. The gums are sometimes red and swollen, and sores appear in the mouth. Constipation is the rule in such cases. The appetite is usually enormous; but, in spite of this, the patients with pronounced diabetes will continue to grow thinner and become more emaciated. The skin is usually dry and puffy, and abnormally warm; in fact, the hands and feet will often be quite hot, without showing any fever.

   Sometimes there will be great quantities of urine passed in twenty-four hours, and then during the next twenty-four hours the quantity will drop to almost normal; but the patient will have a profuse perspiration, wetting the underclothing, bed-clothing, and bringing on discomfort from the amount of dampness.

   Glycogen is found in the urine, and, of course, is due to imperfect digestion. Albumin is frequently found in diabetic urine. Perhaps one-third of the cases show more or less albumin.

   Pneumaturia means the amount of gas in the urine due to fermentation taking place in the bladder. This is not met with very often.

   Blood is frequently found in the urine.

   Among people who live high, diabetes is not infrequent in children. Inasmuch as it is a disease resulting from high living, it would be natural for children of this class to develop the disease. High living usually means eating cake and puddings; food that is extravagantly dressed; food cooked with lots of butter and cream.

   Diabetic patients are frequently carried off by pneumonia. Broncho-pneumonia is said to be very common. Albuminuria is also a frequent complication. In such cases there will usually be edema of the feet. Diabetes is frequently associated with arteriosclerosis; in fact, the cause of diabetes is often the cause of arteriosclerosis.

   Diabetic Tabes.--This is a nervous derangement characterized by shooting pains in the extremities, and the patella reflex is lost. The gait of the patient is that of tabes dorsalis.

   Mental Symptoms.--Patients with this disease often become morose and despondent.

   Special Senses.--Cataract is liable to grow, also inflammation of the retina, closely resembling that which accompanies albuminuria. Hemorrhages are also common in the eye.

   Sexual Function.--Impotency is common, and may develop very early in the case. Conception is rather rare, sterility is established, and, where pregnancy takes place it is liable to be followed by abortion.

   Diagnosis.--Sugar in anything like unusual quantities, found in the urine daily, is almost diagnostic. It should be present for weeks, and it should show more three hours after a meal than before that time or after. The sugar thrown off is a true grape sugar; an albuminuria or glycosuria is temporary, and always means overeating, especially of the sweets. In such cases, by watching, the patient can soon learn to know what his limitations are in regard to starches or carbohydrates; and then he should respect his limitations. If he does not, he may bring on a real grape-sugar diabetes.

   Treatment.--The diet should be confined to fruit for one, two, or three weeks, depending upon the severity of the symptoms and the rapidity with which the amount of sugar in the urine is reduced. As soon as the amount is brought down to almost normal, the eating should be about as follows: any kind of fresh, uncooked fruit with tea-kettle tea for breakfast; Tilden salad and teakettle tea for the noon meal; and the evening meal may be fish once or twice a week, eggs (soft-boiled, scrambled, or poached) twice a week, lamb or chicken two or three times a week. With these items of food the patient is to have a Tilden salad. If the amount of urine passed increases, drop the teakettle tea at noon. After several months of absence of sugar in the urine there should be a change in diet. In the morning thoroughly dried out wholewheat bread or shredded wheat may be taken dry, followed with fresh fruit and teakettle tea. The other meals can remain the same.

   The eating must be watched. If there is any tendency for sugar to reappear, the patient should drop back to fruit. Then, when the sugar disappears, he should return to the regular routine. Baths should be given every morning, if the bathroom is warm. If not, the bath should be taken in the evening, and it should be of from two to five minutes' duration. Have the water as hot as the patient can possibly endure. Follow the hot bath with a quick cold sponge-bath. Not more than one minute should be required to get the cold water over the body. Then a dry towel-rubbing should be given. If the bath is taken in the evening, a dry towel-rubbing should be given in the morning. Rest is very necessary. The patient should retire at nine and get up late. He should avoid excitement-should stay away from picture shows, theaters, etc., and avoid reading anything that will excite the nervous system. There is no objection to a little brain work in the line of study, but the nervous system must not be overfatigued at any time.

      The underwear should be open-woven cotton or linen, and never anything heavier than medium weight in the coldest winter weather. Heavy outside wraps may be worn in cold weather. Everything must be eliminated from the daily habits that uses up nerve energy. The patient is not to use coffee, tea, chocolate, cocoa, alcoholics, or tobacco. These stimulants must positively be stopped, if the disease is to be controlled and the patient brought into a condition where he will not relapse.

   Definition.--A chronic derangement characterized by passing large quantities of urine of low specific gravity. Sometimes the urine will not be heavier than water.

   Etiology.--The disease is caused by a nervous derangement. Fear of overworked emotions are the causes in those who are very nervous. It is more common to the young than to the old. Little children at the breast are prone to have this derangement. Mothers should be cautioned to avoid everything of an exciting character.

   Diagnosis.--A low-specific-gravity urine, passed in large quantities, devoid of sugar.

   Treatment.--It is said that the treatment is very unsatisfactory. I have not had this experience. I should expect to have trouble of this kind if I should resort to opium or drugs; but, inasmuch as the disease is strictly of a nervous character, I should expect every case to get normal in a very reasonable time, by being deprived of food, and resting in bed. The feet should be kept warm by artificial heat if necessary, and a reasonable amount of water may be given if there is thirst. It is strictly a disease coming under the head of nervous dyspepsia.

   Definition.--An over-development of body; an excessive deposit of fat in all parts of the body.

   Etiology.--There are two types of this disease which have a hereditary tendency. In one type it comes from a family of fat people. It is almost impossible to keep them from taking on an excess of adipose tissue. There is nothing strange about this; for, when permitted to choose the food they like best, their choice will almost invariably be something that produces fat. The second class are those who develop obesity because of excessive indulgence in carbohydrates. The American people consume about 125 pounds of candy per capita per annum. If this habit is continued, in a few generations from now the people of this country will all be more or less obese. Fat does not mean health, in spite of the fact that the majority of people look upon those who are rotund as pictures of health. The popularity of rotundity is so great that it proves to be a serious handicap in curing women of chronic diseases. They are so afraid of losing their weight and their good looks that they would rather be sick and well rounded than to be perfectly well and slender. Obesity is not always caused by overeating, but it is always caused by imprudent or improper eating or drinking. Many persons are light eaters. They live in such a way that they bring on a perverted nutrition. Enervation accompanies the derangement; also faulty elimination. The kidneys fail to carry off the solid constituents. Many of these subjects of obesity will get into a state where they neither gain nor lose, and can almost live without any food at all without losing weight. This is due to the peculiar influence of the intoxication coming from retained excretions. The gouty diathesis is more apt to take on obesity than the tuberculosis diathesis. A great many obese people are troubled with an inherent desire for sleeping. This is peculiar to those whose kidneys are not sufficiently active.

   Treatment--It requires skill, and much more than the average judgment, to bring the obese down to a normal weight, and at the same time avoid doing them harm. No class of patients endure a long fast so badly. Long before they have the appearance of being greatly depleted, dangerous symptoms may develop. The reason for this is that nearly all the leading, vital organs of the body have been pressed upon by the accumulation of fat until they have all been weakened--enervated. When put on a fast, or a restricted diet, causing a steady reduction, in the course of three or four weeks the patients will begin to show a haggard appearance. Some of them will show a blueness or purpleness of the tissues of the face, which means oppression of the heart. To remove the pressure from the different organs is very enervating. To illustrate this point, I may say that, if patients suffering from over-distended abdomens on account of dropsy, acetous fermentation, and gas distention, or large ovarian or fibroid tumors, have the distention--the water in the dropsical tumor--drained off suddenly, or the ovarian cyst removed without preliminary preparation, they are liable to die of collapse brought on because of the sudden removal of the distention and pressure on important organs.

   In obesity, as the accumulation in the chest is absorbed, the heart begins to palpitate and the pulse will become weak. This heart weakness may be marked by sharp, acute strokes of the pulse, with a decided emptiness following immediately. This is a pulsation of weakness. The kidneys also, will suffer from sudden removal of the accumulation, by becoming very sluggish. It is almost impossible to induce them to act. In cases of rheumatic heart trouble accompanying obesity, very great care must be exercised. Sometimes the reduction of ten or fifteen pounds in two weeks will bring on a very distressed condition of the heart. Whenever the heart begins to complain, the patient must have the food increased. A very good plan to start with is to put the patient on fruit-fresh, uncooked fruit morning, noon, and night, and no other food. If all goes well, this plan of eating need not be changed for one week, two weeks, or even three weeks. A few patients can go nearly four weeks on nothing but fruit; but at the end of that time they will begin to show a little purpleness about the tissues of the face. When this symptom presents, one meal of fruit should be dropped, and a meal of meat, cooked, non-starchy vegetables, and salad substituted. This meal is to be continued daily until the sypmtoms of depression have all passed away; then the patient may return to fruit until the weight is normal. If, however, after the meat and vegetable dinner is adopted, the weight continues to drop, the dinners may be continued; and perhaps in the course of one or two weeks one meat meal can be dropped every other day, and a baked potato meal, or any other decidedly starchy food, may be given, with non-starchy vegetables and a salad. After this plan has been carried on, and the weight shows a gradual decline, without any symptoms of oppression of any of the organs of the body, this kind of eating may be continued indefinitely, unless a feeling of weakness and lack of vim sets in. Then one starchy meal a day, with fruit, may be substituted for one of the two fruit meals; and this starch is to be continued unless the weight increases; if it does, then return to the fruit. It is very largely a matter of good judgment on the part of the physician watching the case; but no accidents will occur in these cases where the physician is experienced and does not become careless.

   One or two cleansing baths a week may be used in conjunction with the treatment. Then, night and morning, dry towel-rubbing should be used--or friction mittens in place of the towel--to establish a thorough capillary circulation and a good, wholesome condition of the skin. Where the bowels are inclined to be constipated, one of the cooked, non-starchy vegetables with the dinners should be either spinach or onions. All the time a patient is taking this treatment he should avoid hard work or strenuous exercise. A very good exercise is the tensing movement. This may be taken in a recumbent position. It means tensing the arms and legs, abdomen and muscles, wherever they can be voluntarily contracted. It means making the muscles of the arm hard, then relaxing, and then hard again, etc. It is a very excellent exercise for people who are taking treatment for obesity. After the patient has been brought to the proper weight, regular eating may be resumed, leaving out the butter, sugar, cream, candies, pastries, cakes, etc.

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