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The Contributions of Professor Ernst Fuchs to Ophthalmic Pathology
THE CONTRIBUTIONS OF PROFESSOR ERNST FUCHS TO OPHTHALMIC PATHOLOGY JONAS S. FRIEDENWALD, M.D., F.A.C.S. BALTIMORE
Fuchs's very numerous and comprehensive studies in pathological research were de voted especially to discovering the morphological basis of disease. A list of Fuchs's con tributions in this department of ophthalmology is appended. "Clarity, calm, and good will, com studies concerning the pterygium 2 and bined with an untiring joy in labor and the pinguecula 3 . Little has been added . . . a superb integrity, seem to me to our knowledge of these subjects in to be the characteristics which have the fifty odd years that have elapsed made Fuchs, for over a quarter of a since those studies were published. century, a leader of our art". Such is Characteristically his study of the the just tribute written fifteen years ago chalazion led him back from pathology by his colleague and friend Hirschberg. to normal anatomy, and the same Fuchs possessed an extraordinarily in period saw the publication of his work tegrated personality, so thoroughly at on the anatomy and physiology of the one with himself and his environment blood vessels and lymphatics of the that in his earliest written works there lids 4 . appear those same features which in his Among his numerous writings cer maturity and old age characterized all tain themes of recurrent interest can of his human relationships. His clini be enumerated—diseases of the cornea 5 , cal, pathological, and anatomical re intraocular inflammation 6 , sarcoma of searches are so bound together by his the choroid 7 , changes in the optic disc 8 . wide view of ophthalmological prob Again and again he comes back to one lems as to make the separate evalua or another of these major problems, tion of one phase of these contributions each time adding further construction an almost impossible task. To his upon the foundations which he had pathological researches he brought the previously built. His interest in these light of his extraordinary clinical acu fields dates from his earliest years. men and the profound erudition of his This return to problems of long con anatomical knowledge, while on the tinued interest was not conditioned other hand his clinical writings are upon any lack of completeness in the from the very first illuminated by his first studies, for each of Fuchs's writ morphological studies. Nowhere is this ings has a painstaking and meticulous more characteristically shown than in completeness in itself. Indeed the his textbook in which the morpho amount of material which he has con logical basis of the signs and symp densed in each of his numerous publica toms of disease is used through tions is almost unbelievable. Thus his out to clarify the clinical discussion. first paper on exogenous intraocular in The book serves almost equally well flammatory disease is an analysis of as a textbook of ophthalmic pathology two hundred cases of penetrating or for a textbook of clinical ophthal wounds of the eye, including thirtymology. five that were sympathogenic, and four Many of Fuchs's early studies have teen which caused sympathetic irrita become so deeply rooted in our com tion. It was on the basis of this study mon knowledge that his contribution that he was able clearly to define sym has been almost completely forgotten. pathetic ophthalmia as a disease entity, In his student days, while still an as specific in its histological and clinical sistant to Professor Arlt, he published characteristics. His first two works on the first comprehensive studies on the sarcoma of the choroid include reports pathology of the chalazion 1 . This was of first twenty-two and then one hun followed a few years later by similar dred and fifty cases, which enabled him 138
THE CONTRIBUTIONS OF PROFESSOR ERNST FUCHS to describe the whole gamut of variations seen in this condition. The time and labor required for these many studies are all the more remarkable when one remembers that at the same time Fuchs was engaged actively in teaching, and in directing large clinical institutes. To all of these studies he brought his intense clinical interest, and the Leitmotif of all of his pathological researches was the discovery of the raorphological basis of disease. Pathogenesis and etiology interested him less,
139
and he never allowed himself to be seduced into the more romantic field of experimental research, yet it is upon the firm foundation of his morphological studies that the modern edifice of experimental investigation is being raised. Future generations will remember him for these great accomplishments, but for those of the present generation who have benefited by his great kindness and wisdom the greatness of the man transcends even that of his works. 1212 Eutaw place.
List ' Ueber das Chalazion und einige seltene Lidgeschwiilste. Graefe's Arch., 1878, v. 24, pt. 2, p. 121. ■Ueber das P t e r y g i u m . Graefe's Arch., 1892, v. 38, pt. 2, p. 1. 3 Zur Anatomie der Pinguecula. Graefe's Arch., 1891, v. 37, pt. 3, p. 143. ' Zur A n a t o m i e der Blut- und Lymphgefasse der Augenlider. Graefe's Arch., 1878, v. 24, pt. 3, p. 1. 5 Ueber die t r a u m a t i s c h e Keratitis. Centralbl. f. d. medic. Wissensch., 1876, p. 113; Virchow's Arch. f. path. Anat., 1876, v. 66, p. 401. D e r m o i d der Cornea. Klin. M. f. Augenh., 1880, v. 18, p. 131. Vollstandige Sequestration der Cornea nach einfacher Linearextraction. Klin. M. f. Augenh., 1880, p. 134. Ueber die T r i i b u n g der H o r n h a u t bei Glaukom. Graefe's Arch., 1881, v. 27, pt. 3, p. 66; Deutsche O p h t h . GeselL, 1881, p. 73. Keratitis punctata superficialis. Wien. klin. Woch., 1889, v. 2, p. 837. K e r a t o m y k o s i s aspergillina. W i e n . klin. W o c h . , 1894, v. 7, p. 305. Ueber Aufhellung von H o r n h a u t n a r b e n . D e u t s c h m a n n ' s Beit. z. prakt. Augenh., 1900, pt. 44, p. 117. Ueber ringformige und scheibenformige Keratitis ( K e r a t i t i s annularis et disciformis). Klin. M. f. Augenh., 1901, v. 39, p. 513. Ueber Randsklerose und R a n d a t r o p h i e der H o r n h a u t . Graefe's Arch., 1901, v. 52, p. 317. O n keratitis. Being t h e B o w m a n lecture. T r a n s . O p h t h . Soc. U n i t e d Kingdom, 1902, v. 22. Ueber knotchenformige H o r n h a u t t r i i b u n g . Graefe's Arch., 1902, v. 53, p. 423. U e b e r Ringabscess der H o r n h a u t . Graefe's Arch., 1903, v. 56, p. 1. D y s t r o p h i a epithelialis corneas. Graefe's Arch., 1910, v. 76, p. 478. U e b e r Dellen in der H o r n h a u t . Graefe's Arch., 1911, v. 78, p. 82. Ueber knotchenformige H o r n h a u t t r i i b u n g . Graefe's Arch., 1915, v. 89, p. 337. Ueber senile R a n d a t r o p h i e der H o r n h a u t . Graefe's Arch., 1915, v. 89, p. 386. Ueber Keratitis pustuliformis profunda. Graefe's Arch., 1915, v. 90, p. 13. Zur A n a t o m i e des S t a p h y l o m a corneae. Graefe's Arch., 1918, v. 95, p. 215. A n a t o m i s c h e Befunde nach T a t o w i e r u n g mit T u s c h e . Graefe's Arch., 1928, v. 120, p. 714. Localization of pathologic changes in cornea. Arch, of Ophth., 1930, v. 3, p. 588. ' Iritis syphilitica. Graefe's Arch., 1884, v. 30, pt. 3, p. 139. Anatomische V e r a n d e r u n g e n bei E n t z i i n d u n g der A d e r h a u t . Graefe's Arch., 1904, v. 58, p. 391. U e b e r sympathisierende E n t z i i n d u n g nebst Bemerkungen iiber serose t r a u m a t i s c h e Iritis. Graefe's Arch., 1905, v. 61, p. 365. V o r d e r e Synechie und H y p e r t o n i e . Graefe's Arch., 1908, v. 69, p. 254. Ueber O p h t h a l m i a Sympathica. Graefe's Arch., 1909, v. 70, p. 465. Ueber chronische endogene Uveitis. Graefe's Arch.. 1913, v. 84, p. 201. Ueber V e r a n d e r u n g e n des S e h n e r v e n bei e k t o g e n e r intraokularer Entziindung. Graefe's Arch., 1915, v. 91, p. 1. Ueber Eosinophilie im Auge. Graefe's Arch., 1918, v. 95, p. 162. Ueber Vuetische Choroiditis. Graefe's Arch., 1918, v. 97, p. 85. U e b e r anatomische V e r a n d e r u n g e n bei chronischer endogener Iridochoroiditis. Graefe's Arch., 1919, v. 98, p. 122. Ein Fall intraokularer A k t i n o m y k o s e . Graefe's Arch., 1919, v. 101, p. 24.
140
HARRY S. GRADLE
Ueber primare Tuberkulose der Netzhaut. Graefe's Arch., 1919, v. 101, p. 14. Ueber Chorioretinitis. Graefe's Arch., 1921, v. 107, p. IS. Ueber lymphocytare Infiltration der Aderhaut. Graefe's Arch., 1924, v. 115, p. 584. Zur Anatomie der Endophthalmitis. Graefe's Arch., 1924, v. 115, p. 387. Ueber chronische infiltrierende Iritis. Graefe's Arch., 1925, v. 116, p. 168. Iritis serosa oder Cyclitis chronica? Zeit. f. Augenh., 1925, v. 57, p. 6. Ueber Exsudatbelag bei chronischer Iritis. Graefe's Arch., 1929, v. 123, p. 43. Das Sarcom des Uvealtractus. Wien, 1882. Demonstration von Praparaten eines beginnenden Melanosarkoms der Aderhaut. Graefe's Arch., 1900, v. 51, p. 197; Deutsche Ophth. Gesell., 1900, p. 197. Ueber Sarkom der Aderhaut nebst Bemerkungen iiber Nekrose der Uvea. Graefe's Arch., 1910, v. 77, p. 304. Smallest sarcoma of the choroid. Trans. Amer. Ophth. Soc, 1909-11, v. 12, p. 787. Nachtrag zur Arbeit: Ueber Sarkom der Aderhaut. Graefe's Arch., 1912, v. 81, p. 556. Beitrag zu den angeborenen Anomalien des Sehnerven. Graefe's Arch., 1882, v. 28, pt. 1, p. 139. Die periphere Atrophie des Sehnerven. Graefe's Arch., 1885, v. 31, pt. 1, p. 177. Ueber nasalen Konus. Klin. M. f. Augenh., 1919, v. 63, p. 433. Ueber senile Veranderungen des Sehnerven. Deutsche Ophth. Gesell., 1920, p. 182.
A STATISTICAL ANALYSIS OF OPHTHALMIC PATIENTS H A R R Y S.
GRADLE, M.D., CHICAGO
F.A.C.S.
A practitioner who carefully examines each of his cases and who methodically records every detail of interest will accumulate, over a period of years, a wealth of material for study. Dependable conclusions may be confidently drawn when the experiences of each year are consistent with the experiences of other years. Conclusions are drawn as to the ma terial included in this paper. The final conclusion emphasizes the inadvisability of eye examinations by persons lacking the proper expert knowledge. Read before the Michigan State Medical Society, September 16, 1930. I n the r o u t i n e of a b u s y practice or clinic it is a l m o s t impossible to c o n d u c t a s u r v e y of w o r k t h a t h a s been done, because t h e details of cases on h a n d obscure t h e m e m o r y for t h e details of cases seen last w e e k or last m o n t h . B u t it is w o r t h one's t i m e t o m a k e a s u r v e y of case records over an e x t e n d e d period of t i m e to a n a l y z e t h e c h a r a c t e r of w o r k presented, e s t i m a t e the n u m b e r of er rors m a d e , and find w h e r e m i s t a k e s h a v e occurred. W i t h t h e s e p o i n t s in mind, I s t a r t e d , some six y e a r s a g o . a critical s t u d y of cases seen in private practice and I i m m e d i a t e l y found n u m erous problems. I t w a s found n e c e s s a r y to limit t h e s t u d y to so-called n e w c a s e s ; t h a t is, cases t h a t c a m e to the office for t h e first t i m e r e g a r d l e s s of w h e t h e r t h e y had been u n d e r t r e a t m e n t elsewhere. I t w a s also found t h a t a critical s t u d y e x t e n d i n g over m o r e t h a n one y e a r in cluded too m u c h m a t e r i a l ; a h a s t y a n a l y s i s of s u c c e e d i n g y e a r s showed
t h a t p e r c e n t a g e s varied i m m a t e r i a l l y . T h e r e f o r e t h e critical s t u d y w a s limited to 1923, a n d g r o s s c o m p a r i s o n s w e r e m a d e for t h e following six y e a r s . T h e s t u d y e m b r a c e d p a t i e n t s seen in an a v e r a g e m e t r o p o l i t a n p r a c t i c e and w h o w e r e n e a r l y all city dwellers. T h e ages r a n g e d from t h e n e w - b o r n b a b e to 94 y e a r s ; 49.33 p e r c e n t w e r e m a l e s and 50.67 p e r c e n t w e r e females. T h e p e r c e n t a g e of foreign b o r n p a t i e n t s w a s c o m p a r a t i v e l y low. A n e n d e a v o r w a s m a d e to h a v e each p a t i e n t s t a t e t h e n a t u r e of his complaint in his o w n p h r a s e o l o g y . I t w a s found t h a t t h e c o m p l a i n t s could b e classified into t w e n t y - n i n e g r o u p s . M a n y p a t i e n t s h a d m o r e t h a n one complaint, a n d b y c o m p a r i n g t h e n u m b e r of pa t i e n t s w i t h t h e n u m b e r of c o m p l a i n t s it w a s found t h a t each p a t i e n t h a d 1.36 c o m p l a i n t s . T h e following t a b l e gives t h e individual p e r c e n t a g e s in t h e total n u m b e r of c o m p l a i n t s , b u t n o t t h e total n u m b e r of p a t i e n t s :
Fuchs's very numerous and comprehensive studies in pathological research were de voted especially to discovering the morphological basis of disease. A list of Fuchs's con tributions in this department of ophthalmology is appended. "Clarity, calm, and good will, com studies concerning the pterygium 2 and bined with an untiring joy in labor and the pinguecula 3 . Little has been added . . . a superb integrity, seem to me to our knowledge of these subjects in to be the characteristics which have the fifty odd years that have elapsed made Fuchs, for over a quarter of a since those studies were published. century, a leader of our art". Such is Characteristically his study of the the just tribute written fifteen years ago chalazion led him back from pathology by his colleague and friend Hirschberg. to normal anatomy, and the same Fuchs possessed an extraordinarily in period saw the publication of his work tegrated personality, so thoroughly at on the anatomy and physiology of the one with himself and his environment blood vessels and lymphatics of the that in his earliest written works there lids 4 . appear those same features which in his Among his numerous writings cer maturity and old age characterized all tain themes of recurrent interest can of his human relationships. His clini be enumerated—diseases of the cornea 5 , cal, pathological, and anatomical re intraocular inflammation 6 , sarcoma of searches are so bound together by his the choroid 7 , changes in the optic disc 8 . wide view of ophthalmological prob Again and again he comes back to one lems as to make the separate evalua or another of these major problems, tion of one phase of these contributions each time adding further construction an almost impossible task. To his upon the foundations which he had pathological researches he brought the previously built. His interest in these light of his extraordinary clinical acu fields dates from his earliest years. men and the profound erudition of his This return to problems of long con anatomical knowledge, while on the tinued interest was not conditioned other hand his clinical writings are upon any lack of completeness in the from the very first illuminated by his first studies, for each of Fuchs's writ morphological studies. Nowhere is this ings has a painstaking and meticulous more characteristically shown than in completeness in itself. Indeed the his textbook in which the morpho amount of material which he has con logical basis of the signs and symp densed in each of his numerous publica toms of disease is used through tions is almost unbelievable. Thus his out to clarify the clinical discussion. first paper on exogenous intraocular in The book serves almost equally well flammatory disease is an analysis of as a textbook of ophthalmic pathology two hundred cases of penetrating or for a textbook of clinical ophthal wounds of the eye, including thirtymology. five that were sympathogenic, and four Many of Fuchs's early studies have teen which caused sympathetic irrita become so deeply rooted in our com tion. It was on the basis of this study mon knowledge that his contribution that he was able clearly to define sym has been almost completely forgotten. pathetic ophthalmia as a disease entity, In his student days, while still an as specific in its histological and clinical sistant to Professor Arlt, he published characteristics. His first two works on the first comprehensive studies on the sarcoma of the choroid include reports pathology of the chalazion 1 . This was of first twenty-two and then one hun followed a few years later by similar dred and fifty cases, which enabled him 138
THE CONTRIBUTIONS OF PROFESSOR ERNST FUCHS to describe the whole gamut of variations seen in this condition. The time and labor required for these many studies are all the more remarkable when one remembers that at the same time Fuchs was engaged actively in teaching, and in directing large clinical institutes. To all of these studies he brought his intense clinical interest, and the Leitmotif of all of his pathological researches was the discovery of the raorphological basis of disease. Pathogenesis and etiology interested him less,
139
and he never allowed himself to be seduced into the more romantic field of experimental research, yet it is upon the firm foundation of his morphological studies that the modern edifice of experimental investigation is being raised. Future generations will remember him for these great accomplishments, but for those of the present generation who have benefited by his great kindness and wisdom the greatness of the man transcends even that of his works. 1212 Eutaw place.
List ' Ueber das Chalazion und einige seltene Lidgeschwiilste. Graefe's Arch., 1878, v. 24, pt. 2, p. 121. ■Ueber das P t e r y g i u m . Graefe's Arch., 1892, v. 38, pt. 2, p. 1. 3 Zur Anatomie der Pinguecula. Graefe's Arch., 1891, v. 37, pt. 3, p. 143. ' Zur A n a t o m i e der Blut- und Lymphgefasse der Augenlider. Graefe's Arch., 1878, v. 24, pt. 3, p. 1. 5 Ueber die t r a u m a t i s c h e Keratitis. Centralbl. f. d. medic. Wissensch., 1876, p. 113; Virchow's Arch. f. path. Anat., 1876, v. 66, p. 401. D e r m o i d der Cornea. Klin. M. f. Augenh., 1880, v. 18, p. 131. Vollstandige Sequestration der Cornea nach einfacher Linearextraction. Klin. M. f. Augenh., 1880, p. 134. Ueber die T r i i b u n g der H o r n h a u t bei Glaukom. Graefe's Arch., 1881, v. 27, pt. 3, p. 66; Deutsche O p h t h . GeselL, 1881, p. 73. Keratitis punctata superficialis. Wien. klin. Woch., 1889, v. 2, p. 837. K e r a t o m y k o s i s aspergillina. W i e n . klin. W o c h . , 1894, v. 7, p. 305. Ueber Aufhellung von H o r n h a u t n a r b e n . D e u t s c h m a n n ' s Beit. z. prakt. Augenh., 1900, pt. 44, p. 117. Ueber ringformige und scheibenformige Keratitis ( K e r a t i t i s annularis et disciformis). Klin. M. f. Augenh., 1901, v. 39, p. 513. Ueber Randsklerose und R a n d a t r o p h i e der H o r n h a u t . Graefe's Arch., 1901, v. 52, p. 317. O n keratitis. Being t h e B o w m a n lecture. T r a n s . O p h t h . Soc. U n i t e d Kingdom, 1902, v. 22. Ueber knotchenformige H o r n h a u t t r i i b u n g . Graefe's Arch., 1902, v. 53, p. 423. U e b e r Ringabscess der H o r n h a u t . Graefe's Arch., 1903, v. 56, p. 1. D y s t r o p h i a epithelialis corneas. Graefe's Arch., 1910, v. 76, p. 478. U e b e r Dellen in der H o r n h a u t . Graefe's Arch., 1911, v. 78, p. 82. Ueber knotchenformige H o r n h a u t t r i i b u n g . Graefe's Arch., 1915, v. 89, p. 337. Ueber senile R a n d a t r o p h i e der H o r n h a u t . Graefe's Arch., 1915, v. 89, p. 386. Ueber Keratitis pustuliformis profunda. Graefe's Arch., 1915, v. 90, p. 13. Zur A n a t o m i e des S t a p h y l o m a corneae. Graefe's Arch., 1918, v. 95, p. 215. A n a t o m i s c h e Befunde nach T a t o w i e r u n g mit T u s c h e . Graefe's Arch., 1928, v. 120, p. 714. Localization of pathologic changes in cornea. Arch, of Ophth., 1930, v. 3, p. 588. ' Iritis syphilitica. Graefe's Arch., 1884, v. 30, pt. 3, p. 139. Anatomische V e r a n d e r u n g e n bei E n t z i i n d u n g der A d e r h a u t . Graefe's Arch., 1904, v. 58, p. 391. U e b e r sympathisierende E n t z i i n d u n g nebst Bemerkungen iiber serose t r a u m a t i s c h e Iritis. Graefe's Arch., 1905, v. 61, p. 365. V o r d e r e Synechie und H y p e r t o n i e . Graefe's Arch., 1908, v. 69, p. 254. Ueber O p h t h a l m i a Sympathica. Graefe's Arch., 1909, v. 70, p. 465. Ueber chronische endogene Uveitis. Graefe's Arch.. 1913, v. 84, p. 201. Ueber V e r a n d e r u n g e n des S e h n e r v e n bei e k t o g e n e r intraokularer Entziindung. Graefe's Arch., 1915, v. 91, p. 1. Ueber Eosinophilie im Auge. Graefe's Arch., 1918, v. 95, p. 162. Ueber Vuetische Choroiditis. Graefe's Arch., 1918, v. 97, p. 85. U e b e r anatomische V e r a n d e r u n g e n bei chronischer endogener Iridochoroiditis. Graefe's Arch., 1919, v. 98, p. 122. Ein Fall intraokularer A k t i n o m y k o s e . Graefe's Arch., 1919, v. 101, p. 24.
140
HARRY S. GRADLE
Ueber primare Tuberkulose der Netzhaut. Graefe's Arch., 1919, v. 101, p. 14. Ueber Chorioretinitis. Graefe's Arch., 1921, v. 107, p. IS. Ueber lymphocytare Infiltration der Aderhaut. Graefe's Arch., 1924, v. 115, p. 584. Zur Anatomie der Endophthalmitis. Graefe's Arch., 1924, v. 115, p. 387. Ueber chronische infiltrierende Iritis. Graefe's Arch., 1925, v. 116, p. 168. Iritis serosa oder Cyclitis chronica? Zeit. f. Augenh., 1925, v. 57, p. 6. Ueber Exsudatbelag bei chronischer Iritis. Graefe's Arch., 1929, v. 123, p. 43. Das Sarcom des Uvealtractus. Wien, 1882. Demonstration von Praparaten eines beginnenden Melanosarkoms der Aderhaut. Graefe's Arch., 1900, v. 51, p. 197; Deutsche Ophth. Gesell., 1900, p. 197. Ueber Sarkom der Aderhaut nebst Bemerkungen iiber Nekrose der Uvea. Graefe's Arch., 1910, v. 77, p. 304. Smallest sarcoma of the choroid. Trans. Amer. Ophth. Soc, 1909-11, v. 12, p. 787. Nachtrag zur Arbeit: Ueber Sarkom der Aderhaut. Graefe's Arch., 1912, v. 81, p. 556. Beitrag zu den angeborenen Anomalien des Sehnerven. Graefe's Arch., 1882, v. 28, pt. 1, p. 139. Die periphere Atrophie des Sehnerven. Graefe's Arch., 1885, v. 31, pt. 1, p. 177. Ueber nasalen Konus. Klin. M. f. Augenh., 1919, v. 63, p. 433. Ueber senile Veranderungen des Sehnerven. Deutsche Ophth. Gesell., 1920, p. 182.
A STATISTICAL ANALYSIS OF OPHTHALMIC PATIENTS H A R R Y S.
GRADLE, M.D., CHICAGO
F.A.C.S.
A practitioner who carefully examines each of his cases and who methodically records every detail of interest will accumulate, over a period of years, a wealth of material for study. Dependable conclusions may be confidently drawn when the experiences of each year are consistent with the experiences of other years. Conclusions are drawn as to the ma terial included in this paper. The final conclusion emphasizes the inadvisability of eye examinations by persons lacking the proper expert knowledge. Read before the Michigan State Medical Society, September 16, 1930. I n the r o u t i n e of a b u s y practice or clinic it is a l m o s t impossible to c o n d u c t a s u r v e y of w o r k t h a t h a s been done, because t h e details of cases on h a n d obscure t h e m e m o r y for t h e details of cases seen last w e e k or last m o n t h . B u t it is w o r t h one's t i m e t o m a k e a s u r v e y of case records over an e x t e n d e d period of t i m e to a n a l y z e t h e c h a r a c t e r of w o r k presented, e s t i m a t e the n u m b e r of er rors m a d e , and find w h e r e m i s t a k e s h a v e occurred. W i t h t h e s e p o i n t s in mind, I s t a r t e d , some six y e a r s a g o . a critical s t u d y of cases seen in private practice and I i m m e d i a t e l y found n u m erous problems. I t w a s found n e c e s s a r y to limit t h e s t u d y to so-called n e w c a s e s ; t h a t is, cases t h a t c a m e to the office for t h e first t i m e r e g a r d l e s s of w h e t h e r t h e y had been u n d e r t r e a t m e n t elsewhere. I t w a s also found t h a t a critical s t u d y e x t e n d i n g over m o r e t h a n one y e a r in cluded too m u c h m a t e r i a l ; a h a s t y a n a l y s i s of s u c c e e d i n g y e a r s showed
t h a t p e r c e n t a g e s varied i m m a t e r i a l l y . T h e r e f o r e t h e critical s t u d y w a s limited to 1923, a n d g r o s s c o m p a r i s o n s w e r e m a d e for t h e following six y e a r s . T h e s t u d y e m b r a c e d p a t i e n t s seen in an a v e r a g e m e t r o p o l i t a n p r a c t i c e and w h o w e r e n e a r l y all city dwellers. T h e ages r a n g e d from t h e n e w - b o r n b a b e to 94 y e a r s ; 49.33 p e r c e n t w e r e m a l e s and 50.67 p e r c e n t w e r e females. T h e p e r c e n t a g e of foreign b o r n p a t i e n t s w a s c o m p a r a t i v e l y low. A n e n d e a v o r w a s m a d e to h a v e each p a t i e n t s t a t e t h e n a t u r e of his complaint in his o w n p h r a s e o l o g y . I t w a s found t h a t t h e c o m p l a i n t s could b e classified into t w e n t y - n i n e g r o u p s . M a n y p a t i e n t s h a d m o r e t h a n one complaint, a n d b y c o m p a r i n g t h e n u m b e r of pa t i e n t s w i t h t h e n u m b e r of c o m p l a i n t s it w a s found t h a t each p a t i e n t h a d 1.36 c o m p l a i n t s . T h e following t a b l e gives t h e individual p e r c e n t a g e s in t h e total n u m b e r of c o m p l a i n t s , b u t n o t t h e total n u m b e r of p a t i e n t s :