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We have seen in the first chapter of this book that we may find the symptoms of old age, in quite early years, in persons whose ductless glands (the thyroid, ovaries, testicles, liver, kidneys, pancreas, adrenals, pituitary body) are degenerated by disease; nervous affections; alterations of the mind: grief, sorrow, etc.; chronic infections; numerous pregnancies, etc., or by faulty hygienics: excesses in food, alcohol, sexual pleasures, etc. We have also seen in the third chapter that the immunity of an individual against infections—be it by bacterial invasion or by poisonous food or drugs, etc.—is dependent upon the correct functionating condition of these glands. We have seen that those in whom these glands are degenerated fall easy victims to all manner of infections, and the previous chapter on heredity shows that the same happens to children, the offspring of parents suffering from alcoholism, tuberculosis, or malaria, as the children of these parents are born with a congenital degeneration of the thyroid, and thus remain backward in growth, both mentally and physically, and, especially, fall easy victims to tuberculosis. Their life is generally short. While such a sad cloud hangs over the head of persons whose glands are damaged, either congenitally or by disease, much more favorable is the lot of those who have inherited healthy glands and by careful living have preserved them intact, or who, though born with ductless glands not entirely normal, and possibly bordering on a condition of congenital myxœdema, have, by suitable treatment and hygiene, succeeded in improving the condition of their glands.

We have seen that the thyroid influences powerfully the production of those safeguards of our body against infections—the anti-bodies being, as shown by Prof. Sajous (1903-1907), beyond a doubt products of ductless glands—and the better the condition of the glands, the more protective substances will be produced in order to fight down the murderous microbes, or organic poisons, which continually threaten us with destruction. In this fight, a person with healthy ductless glands will always attain a longer life than one with ductless glands of inferior quality. The better the condition of the thyroid the greater will be the activity of those organs that are under its direct command (e.g., the kidneys, liver, skin, and intestines), and by the increased activity of the main emunctories of the body poisonous products will be eliminated by means of a greater flow of urine, an abundant perspiration, and thorough purging. Also the myriads of toxic products that are brought from the intestine to the liver will be promptly destroyed, or transformed into less dangerous combinations.

Thus there can be no doubt that a person with healthy ductless glands, especially the thyroid and testicles or ovaries, will live long provided, of course, no other vital organ be irreparably diseased.

The question now arises, by what means can we ascertain whether the ductless glands are in good condition or not? We will now try to answer this important question.

We can diagnose a healthy condition of the ductless glands either directly, by the examination of those glands which are available for a digital examination, as the thyroid, sexual glands or liver, or indirectly, by the examination of the state of those functions which are governed by these glands; e.g., the heart’s action, the pulse, regulation of temperature, defæcation, diuresis, digestion, activity of the skin and its glands, condition of the nervous system, etc.

Before entering upon the examination of these glands we must first ascertain whether our patient comes of a long-lived stock, or, if not, whether diseases that are particularly harmful to the ductless gland, and are commonly hereditary, like tuberculosis and syphilis, have occurred in the family. According to our observation boys more frequently look like their mothers, and girls like their fathers, and also inherit their qualities. After having ascertained the family history, we must inquire whether the patient has had any diseases that are specially harmful to the ductless glands: e.g., infectious diseases—scarlet fever, diphtheria, typhoid, etc.—and also ascertain his usual diet and habits, keeping in mind the bad effects of abundant meat food upon the thyroid, as well as of certain stimulants like alcohol and tobacco. As these, if of bad quality and taken in quantity for a long time, have the most damaging influence on the ductless glands, our prognosis of a long life will be duly influenced, and in particular unfavorably for those who come of a short-lived stock, or who have been weakened by previous infectious diseases. If some persons, otherwise healthy and of good family history, can with impunity indulge till old age in wine and tobacco, yet this is not a general rule. Individuals are known who drank and smoked till over one hundred years of age, but such cases are rare, and we may quote the Latin proverb: “Quod licet Jovi, non licet bovi.” Everybody will admit that the expectation of life in those who are moderate in the use of wine and tobacco and also, let us insist, of tea and coffee, is much greater than in the immoderate. We will further deal with this question in our chapters on alcohol and tobacco.

After having given an exhaustive history of the persons whose probable lifetime we are trying to determine, we next proceed to the examination of those ductless glands which are available for direct examination, and first of all, the thyroid.

The examination of the thyroid gland by palpation is a very difficult undertaking and necessitates a thorough knowledge of the anatomy and physiology of the gland. We must bear in mind the fact that, in men, we generally find only two lobes, the lateral ones, which lie on either side of the trachea, as the median lobe is generally undeveloped in the male. The right lobe is usually larger than the left. In women the median lobe is often well developed and can be distinctly seen in enlargement of the gland, for instance, during puberty, menstruation, pregnancy, etc., and especially when a goiter exists which, for reasons we have mentioned previously, is more common in the female.

When the thyroid shows a considerable swelling, as in goiter, it can be seen and felt easily, but not always, for cases certainly exist where in life no thyroid could be felt, and yet at the autopsy a large goiter has been found. Thus, in a case of acromegaly a thyroid of about 130 grammes was found by Holsti,^[119] though during life nothing could be discovered by palpation. When a large thyroid can be seen and felt, we are justified in diagnosing a swelling of the gland; but in cases where we neither see nor feel it, we are not always justified in stating that it is not enlarged.

When palpating the thyroid we must note whether it is soft or hard. If soft, the tissue present is probably parenchymatous in nature and so, probably, entirely secreting tissue, while a goiter that feels hard may denote excess of connective tissue, and thus, apparently, an inactive gland. The presence of cystic formations raises the possibility of a large quantity of colloid substance, either healthy or degenerate.

Thus, inspection and palpation of the thyroid can give us, to a certain extent, valuable information; we must, however, not rely entirely upon the results of this external examination but, especially in cases where no thyroid can be felt, we must add to the external examination an inquiry into the condition of those functions which are governed by the thyroid—we must, in fact, examine the condition of those organs whose function is dependent upon the internal secretion of the thyroid.

Thus, we must examine the skin and note whether it is dry or moist, and whether the sweat glands are acting normally. A dry skin, with diminished perspiration, denotes an inactive thyroid, especially when excess of subcutaneous fat is present. Excess of fat, of the consistence of bacon, is characteristic of a greater degeneration of the thyroid—i.e., myxœdema,—and indicates a great loss of function of the thyroid gland. Pallor of the face, with round red patches on the cheeks, and dilated capillaries, are also characteristic signs of such a condition in its early stages, and so are a wrinkled forehead, especially with two perpendicular folds, and puffy eyelids. Wrinkling of the skin of the hands, taken in conjunction with other signs, is also a point of diagnostic value.

The condition of the musculature can also give us some valuable information. The thyroid and other ductless glands, as the sexual glands, govern the tonicity of all the muscles. In children, especially about the age of puberty, the muscles are firm and elastic, but in later years, or even in young women, consequent upon various conditions which are harmful to the ductless glands, such as sexual excesses or numerous pregnancies, the muscles lose their tonicity and become lax and flabby. This also occurs in myxœdema arising from other causes. The viscera, deprived of their muscular support, become displaced, and in this way arise the various forms of visceroptosis.

Premature grayness is an indication of probable changes in the thyroid. This is confirmed by the fact that, as a rule, such persons are also very nervous. Premature grayness constitutes a typical symptom of myxœdema and hypothyroidia, and as such has been described already by Hertoghe.^[120] Falling out of the hair is also a symptom of importance, if it appears in early years, especially if it is accompanied by falling out of the eye-brows and the hair on the back of the head. On the other hand, Sajous found that in appropriate cases, thyroid extract promotes the growth of hair, while adrenal extract encourages, besides, the growth of the eye-brows.

In examining the circulatory system we must bear in mind the powerful influence of the ductless glands upon the circulation, especially that of the adrenals, thyroid, and pituitary body. As shown by Oliver and Schäfer, the thyroid secretion diminishes blood-pressure, whereas the adrenal secretion increases it. Thus, these two glands are antagonistic and it can easily be understood that if there is not sufficient thyroid secretion to counterbalance that of the adrenals, the blood-pressure will increase. If this lasts for some length of time, very serious effects will follow. Atheroma and arteriosclerosis may ensue, both of which conditions tend to shorten life. The adrenals can be stimulated to such over-secretion by mental emotions, which act upon the sympathetic (splanchnic) nerves. Besides mental emotion they can also be stimulated by various poisons, such as alcohol, tobacco, or infectious diseases (see Chapter III). We must keep these facts in mind when we examine the circulatory system, and we must ascertain the condition of the arteries, whether soft or hard, and of the blood-pressure. Tortuosity of the temporal artery in young persons is also a sign of some value. The condition of the coronary arteries is of the utmost importance. We must also not forget the fact, that even in severe cases of arteriosclerosis the pulse may be found soft. Everything will depend upon the examination of the heart, and special attention must be paid to the second sound at the aortic orifice, and to any accentuation of that sound.

In the examination of the digestive organs we must pay special attention to the state of the appetite. Very often with a degenerated thyroid this may be wanting. The appetite, as shown by Pawlow, is under the influence of the mind as we will see. With a sad melancholic disposition, as is often found in persons with a degenerated thyroid, there is insufficient or no secretion of gastric juice. Besides, in myxœdematous conditions all glandular secretions are more or less checked. Thus food passes into a stomach with insufficient gastric juice, remains there in stagnation and causes fermentation. The stomach makes vain efforts to drive the food into the intestine. Slowly an atonic condition of the gastric walls arises, and later dilatation of this organ. The fermenting foodstuffs in the stomach set up a chronic intoxication of the organism.

Concerning the condition of the intestines we should consider the chances of long life greater in those persons whose bowels act regularly and who are never constipated. Such persons are able to eliminate toxic products much better than those who are suffering from chronic constipation. The function of the intestines is powerfully influenced by the thyroid gland, chronic constipation being a typical symptom of all conditions in which this gland is degenerated, whereas in the opposite conditions, such as Graves’s disease (exophthalmic goiter), diarrhœa is common. By giving thyroid gland we can treat successfully those obstinate cases of constipation, which are based etiologically on such grounds. Besides the thyroid gland, the ovaries also influence, to a large extent, the intestines, constipation occurring, as a rule, in diseased conditions of the female sexual organs.

Flatulency and distention of the bowels are very frequently met with in women with diseased thyroids or ovaries, and are due to an irritated condition of the nerves of the intestines.

When examining the nervous system we must inquire for headaches, especially in the occipital region, migraines, and the previous occurrence of neuralgia, these being very frequent symptoms in persons with athyroidia or hypothyroidia. Most characteristic are alterations in the mental condition. Thus, memory for recent events may be gone. There may be apathy, with hesitation before every movement, such persons disliking to move about. They may sit indefinitely in the same position. As already mentioned in the chapter on the influences of the ductless glands upon the nervous system such people are frequently somnolent. Therefore we must inquire about the hours of sleep. Besides sleeping long, such persons are apt to awake in the night after dreams of a terrifying nature. Our diagnosis of a condition of athyroidia or hypothyroidia has often been helped, by inquiring whether such persons have seen little animals (rats or mice) creeping through the room while sitting quiet, or before going to sleep. Such a symptom has been described by Murray,^[121] in his book on myxœdema, in the early stages of this disease; the mind being then so much altered that even manias of persecution and suicide may arise.

Neurasthenia is a disease which, as we have tried to show, is very often based upon changes in the ductless glands, especially the thyroid, sexual glands, and pituitary body. The same holds good for hysteria. Therefore the presence of such conditions will influence us in our judgment as to the future of such persons. In cases of great nervousness, especially when associated with mental depression, there is less resistance to infection, for causes already mentioned (see Chapters III and L). Great mental excitability may predispose to certain diseases which shorten life, like diabetes, and in people in whom, owing to an unstable nervous system, there is a frequent increase in the blood-pressure, the possibility of apoplexy is to be feared, if such persons are of a plethoric build. The wear and tear of life is certainly far more felt by persons whose minds are very easily impressed and excited by events of little importance; and, considering the great influence of mind upon body, persons, who like a weak tree are easily beaten down by the smallest storm, will have less chance of long life than persons who have a better control over themselves and stronger will-power (see “Hygienics of the Mind,” Chapter L).

Having thus briefly described the principal functions governed by the thyroid gland: shown how, by observing changes in these functions, we can judge as to the healthy condition of this gland, let us now see if any means exists by which we can ascertain the functionating condition of the other ductless glands.

After the thyroid the sexual glands claim our attention, as these glands are of the utmost importance on account of their enormous influence upon the processes of metabolism and the maintenance of life (see Chapter V). We must first call to mind that their work is essentially under the influence of the thyroid, changes in which invariably produce changes in the sexual glands. Thus, in degenerated conditions of the thyroid, we find impotency in men and sterility in women. In such conditions atrophy of the testicles, or of the ovaries, can often be found. These clinical observations can be confirmed by experiments. Thus Lanz^[122] found sterility common in goats whose thyroids had been extirpated. In cretins an atrophic condition of the testicles, or of the ovaries, is present as a rule, and such patients very frequently show lack of sexual desires.

Direct examination of the sexual glands can be more easily carried out in men than in women.

The presence of varicose veins is of great importance, as varicoceles are generally accompanied by great disturbances of the nervous system, sometimes even going as far as insanity. Suicide is not unfrequently committed in such a condition.

After the testicles the prostatic gland must be examined. As direct examination of this gland is only possible by a painful examination through the rectum, we shall have to inquire into the condition of the functions of this gland. We must find out whether there is a flow of prostatic liquid and semen (frequency of pollution). It must be remembered, however, that the flow of a little semen in constipation and sexual abstinence has no importance.

We must specially inquire about previous attacks of gonorrhœa. Examining the urine in two fractions, we must ascertain whether the first fraction is as clear as the second. The presence of a few filaments tells a tale of previous gonorrhœa, but is of no consequence for the prognosis. It may be, however, that they possibly indicate the presence of gonococci in the deeper lying glands of the urethra which, after sexual excesses, can again come to the surface even after years.

Inquiring for gonorrhœa in the past, we must find out whether the patient was treated by local applications with instruments to the posterior part of the urethra, this being the only radical treatment of chronic gonorrhœa. As a rule, every chronic gonorrhœa invades the posterior part of the urethra and, usually, inflammation of the posterior part of the urethra involves also the prostatic gland.

The presence of strictures and hypertrophy of the prostate, unless they occur in connection with a gonorrhœa, are indicative of a faulty activity of those glands which influence the formation of fatty or connective tissue in the body, as will be shown. It may indicate changes in the thyroid, after extirpation or degeneration of which the connective tissue in the body is increased, to which fact is also largely due the occurrence of prostatic hypertrophy.

We must inquire as to the passage of urine. An interrupted stream with pain on micturition may indicate, in elderly persons, a hypertrophy of the prostate, especially if these pains are more frequent in cold weather. The bladder must be examined for the presence of stone. The presence of stone, as also of long-standing gleet and strictures that are not cured, lessen the chances of a long life, the dangers of cystitis, and ascending pyelonephritis, and nephritis, hanging, as the sword of Damocles, over the heads of their unfortunate possessors.

Gonorrhœa, if it occurs frequently and attacks the prostate, is a great danger both to the mental stability and sexual powers. The presence of great sexual desires, with more or less impotence, must also be taken into consideration when we are collecting evidence to find out the chances of long life in an individual.

Regarding the examination of the female sexual organs and of their functions, it cannot be the object of these lines to describe how to conduct a thorough gynæcologic examination. We must limit ourselves to those points by which we can ascertain the condition of those functions which are under the control of the ovaries, with special reference to their internal secretion. Thus, we need merely observe whether the external sexual characteristics (e.g., breasts, hips, etc.) are well developed, since these are under the direct influence of the internal secretion of the ovaries.

A chlorotic condition allows us to draw the inference that a faulty condition of the ovaries exists (ovarian origin of chlorosis—v. Noorden), and also of the thyroid, as this gland often shows change in chlorosis. The extirpation of these glands is followed by a diminution in the number of red blood-corpuscles and in the percentage of hæmoglobin. Both of these elements of the blood can be increased by the use of thyroid or ovarian extracts, as has been noted by several authorities.

The condition of menstruation can give us valuable information. The late appearance of the first menstrual period, irregularities of menstruation, its appearance at irregular intervals, and frequent disappearance for months, will give us an unfavorable idea of the ovarian activity, especially when each menstrual period is accompanied by pain. So will sterility, as this condition is common, not only in association with ovarian inactivity (if not due to malpositions of the uterus or impotency of the husband), but also with thyroid deficiency. On the other hand, too frequent pregnancies or miscarriages will also unfavorably influence our judgment, as these agencies have, as a rule, a deteriorating effect upon these important glands, causing their exhaustion and, at the same time, that of the thyroid. In women with thyroid insufficiency and general loss of muscular tone, prolapse of the uterus may be frequent, and also metrorrhagia. As Hertoghe found, we can stop uterine hæmorrhages in women with thyroid insufficiency by the administration of thyroid extracts. The history of previous gonorrhœal infection must be specially investigated, as this disease, if not treated, which is unhappily so often the case, will always involve the ovaries, causing their destruction and often their obliteration. Gonorrhœa in women is far oftener overlooked than in men, as it so often passes for a simple discharge, until by microscopical examination gonococci are found, and the ovaries already injured. It is a sad fact that a large majority of the cases of pelvic disease in married women are due to infection by the husband, for an enormous number of men enter upon marriage with gonorrhœa that is imperfectly cured, or not cured at all. Let us hope that there will come a time when a law will be passed obliging every man to be examined thoroughly before entering upon marriage, especially for gonorrhœa and syphilis. Such legal precautions would soon check the transmission of these diseases to the wife and of syphilis to the innocent descendants. It may be that thus, to a large extent, the propagation of some of the greatest scourges of humanity can be checked, viz.: of tuberculosis, alcoholism, and crime^[123] which, as shown previously, flourish on the soil prepared for them by hereditary syphilis.

A total lack of sexual desire in women is not normal, and may indicate changes in the ovaries. On the other hand, there is an increase of sexual desire at the period of augmented ovarian activity, as in the days preceding menstruation. We have had the opportunity of hearing praise of ovarian treatment from husbands of women with tendencies to sexual frigidity.

Very valuable information about the activity of the ovaries can be gained from the examination of the breasts. It must be borne in mind that the ovaries and the breasts stand in very close relation. Changes in the ovaries are always followed by changes in the breasts, and it is a very interesting fact that cases of cancer of the breast have been cured by extirpation of the ovaries.

Comparing the breasts of an innocent young girl between sixteen and twenty years with those of women of the same age leading an immoral life, or of women after many pregnancies or in advanced age, we notice at once the great difference between the large flabby breasts and the firm tissue of a young girl leading a moral life. According to our observations we have described^[124] cases of fatty enlargement of the breasts, following all those agencies which are hurtful to the ovaries, as masturbation, sexual excesses, many pregnancies, etc. On the other hand, in degenerated conditions of the ovaries and thyroid, especially if these conditions are congenital, we may find the breasts quite undeveloped.

After the thyroid and ovaries we will direct our attention to the pituitary body. Direct examination of this ductless gland being out of question, owing to its position on the base of the skull, in the sella turcica, we have to judge of its vitality by indirect methods. We know that by the alterations of this gland a condition is produced, called acromegaly, characterized by enlargement of the toes, fingers and nose, prominence of the lower jaw, sinking in of the temple and of the fossa canina in the cheek-bones, prominence of the occipital bone, etc. As with all diseases of the ductless glands, besides the extreme form just described, which constitutes the highest degree of such a degeneration, there are also marked cases where all of the above deformities are only slightly pronounced. We must inquire whether the features of such persons have changed, or the nose, hands, and feet become larger. This is best determined by comparison of old and recent photographs.

A history of headache, especially nocturnal, of mental change, e.g., great susceptibility or symptoms of neurasthenia, taken together with the external appearances, may aid our diagnosis. The simultaneous discovery of an ocular lesion (hemianopsia) will confirm our suspicions beyond doubt.

The pancreas, also, can only be examined by indirect evidences of its activity. A history of frequent or occasional epigastric colic, of large quantities of unformed shapeless stools of a yellow or yellow-gray color, containing undigested fat, together with loss of weight, will make us think of the possibility of disease of the pancreas. The most exact proof of such change can only be obtained by microscopical examination of the fæces.

Examination of the urine for sugar can also tell us whether there is disease of the pancreas, especially of those parts of the pancreas which constitute a ductless gland, independently of the rest of the viscus, namely, the islands of Langerhans.^[125]

As Mering and Minkowski^[126] first showed, every dog whose pancreas is extirpated invariably becomes diabetic, and this diabetes is similar to that of man. In many cases of diabetes changes in the pancreas have been found at autopsy; and although a good number of cases without any apparent change in the pancreas have been recorded, the cause of these has been revealed by an American author, Dr. Opie,^[127] then of the Johns Hopkins University in Baltimore. This author has found in a few cases of diabetes alterations in the islands of Langerhans in the pancreas. This fact has been confirmed by a good many authors, of whom I may mention Sobolew,^[128] Weichselbaum^[129] and Stengel, Sauerbeck, and others. As is invariably the case, the statements of these authorities have been attacked by others, as Hanseman, who have found no such changes in the islets in diabetes. We must, however, state here, that an apparently perfect anatomical condition of glandular structure after death need be no proof of a perfect secretory activity during life. Every epithelial formation, and the islands of Langerhans are of this nature, must furnish a secretion, and this flows in every gland only under a nervous stimulation. As Pawlow has shown, the pancreas secretes under nervous impulse. Therefore the findings of pathological anatomy cannot show us whether these glands have been secreting properly during life or not, especially in a nervous disease such as diabetes.

According to the experiments of Diamare and Kuliabko, the islands of Langerhans furnish a secretion which aids in the inversion of grape sugar. We have shown at meetings of the Biological Department of the Hamburg Medical Society (Germany), and of the London Pathological Society, specimens of the pancreas of diabetic persons where there were changes only in the islands of Langerhans and none in other parts of the pancreas while, in one case, nearly the whole of the pancreas was destroyed by cirrhosis, but without any diabetes, for in this case the islands of Langerhans were not changed at all. It is interesting to note that these changes in the islands of Langerhans were also present in mild cases of diabetes.

Thus, the finding of sugar in the urine usually indicates the probability of changes in the pancreas. Even small quantities of sugar, such as appear only after starchy meals (alimentary glycosuria ex amylo) may be brought into connection with changes in the pancreas; for Wille^[130] found in Hamburg from a large series of autopsies, that in a considerable number of cases with alimentary glycosuria, there were also changes in the pancreas.

We must not forget the very important fact, that even when we find no sugar we cannot at once exclude diabetes. There are many cases of mild diabetes which do not show any sugar on an ordinary diet. To recognize these cases we must give them a test meal of either about three ounces of grape sugar two hours after a light breakfast of coffee and a roll, or, as we have recommended in our book on the rational treatment of diabetes,^[131] we must give a test meal of much starchy food, such as rice and cakes, and examine the urine two hours later. If then no sugar is found, or not exceeding 0.2 per cent., diabetes may be excluded. Persons with 0.1 per cent. to 0.3 per cent. of sugar after such a starchy test meal may be considered as on the border line of diabetes. Such persons show a diminished tolerance of carbohydrates, and they have lost the power to consume all the sugar they introduce into their body. Therefore, especially if they come of diabetic parents, they should avoid eating much starchy food so as not to develop further this dangerous tendency.

Diabetes, in the majority of cases, considerably shortens the patient’s life. Mild cases of diabetes may however live for fifteen or twenty years, or often even longer. In predicting the chances of longevity in diabetic subjects everything depends on the question whether diacetic acid has been found in the urine or not. This can be easily ascertained by putting a few drops of a solution of perchloride of iron into a test tube with the diabetic urine. If diacetic acid is present, the liquid will become Burgundy red in color, and the deeper this red color, the greater is the percentage of diacetic acid present. In such cases the chances are very bad, such patients living on an average for only one to two years. Exceptions to this rule, however, are not infrequent, and we know of a case of acromegaly with severe diabetes, who has passed large quantities of diacetic acid for the last fourteen years.

Cases of severe diabetes, with diacetic acid, can often be easily recognized by their appearance. They are thin, the cheeks are often flushed, and they show nearly all the signs of a myxœdematous condition, as already described, whereas cases of mild diabetes present often symptoms of hyperactivity of the thyroid gland, as in exophthalmic goiter. As we have shown, diabetes is often due to an overactivity of the thyroid gland,^[132] as well as to degeneration of the pancreas, these glands being antagonistic to one another. This is confirmed and amplified by Sajous, who ascribes one form of diabetes to overactivity of the adrenal system, which includes the thyroid gland. Overactivity of the latter organ may also be followed by its exhaustion, with symptoms of myxœdema, as is the rule in severe diabetes.

Patients with mild diabetes often have a fresh look and a rosy face, and very frequently look much younger than they are. We believe that the healthy working condition of their thyroids has something to do with this fact.

The pancreas is a very important organ for the maintenance of life as it produces certain bodies (enzymes) which are of enormous importance in the assimilation of food. One of these bodies (they are three in number), helps the assimilation of albuminous products and is called trypsin. It also plays an important rôle in the treatment of cancerous growths. Besides this the pancreas produces an enzyme that helps the assimilation of the carbohydrates (amylopsin) and another that is indispensable for the perfect assimilation of fat (steapsin).

As we have shown by experiments made in the laboratory of Professor Minkowski (then in Cologne), the pancreas stands in definite relation to the thyroid. These two glands seem to be antagonistic to one another, for on extirpation of the pancreas of three dogs, thus rendering them diabetic, in every case the thyroid showed a condition of hyperactivity, whereas in one case, after previous extirpation of the thyroid, the pancreas showed an enormous number of islands of Langerhans—(thirty-six to forty in one field).^[133]

It was also of great interest, that each diabetic dog ceased to eliminate sugar two days after extirpation of the thyroid.

As with the thyroid, the pancreas has also very important relations with the liver. Dr. Steinhaus found, in a research conducted in the laboratory of Professor Minkowski, that in a large number of cases of hepatic cirrhosis there were also similar changes in the pancreas. Similar observations have also been made by Opie, Amato, Kliffel and Lefas,^[134] and others. This may be the reason that in diseases of the liver we have had good results from the administration of pancreatic extract. In every case we have found a better assimilation of food, and especially a better appetite. This stomachic effect of pancreatic extracts we have found in nearly every case and even when the patients were not suffering from pancreatic or hepatic disease. (See also Chapter LIV.)

Still more than the pancreas is the liver indispensable for the maintenance of life. It destroys the deadly poisons which are conveyed to it by the portal vein for neutralization. Besides this it produces certain bodies which help to destroy poisons arising from the decomposition of albuminous food. (See also Chapter XIII.)

The liver also produces certain bodies, as urea, which play a very important part in metabolism, and it also serves as a large depot for glycogen, the stored sugar of the body. The liver forms a large amount of glycogen, and stores it up for the wants of the body. By a ferment, also produced by the liver cells, the glycogen is transformed into sugar, and in this form is given off to the body. If the liver were extirpated the blood would contain no more sugar, as was found by Minkowski through experiments on animals.

Besides sugar, the liver also produces, as just mentioned, another very important substance, and this is urea. This body is produced in the liver from ammonia, which, as the final product of decomposition of albuminous substances, is brought to the liver by the blood. From carbamic acid, also, the liver forms urea. Ammonia and carbamic acid are poisonous products which arise from the decomposition of albuminous material, and, by transforming them into urea, the liver saves our body from continuous intoxication. Thus we can see that in diseases of the liver the quantity of urea falls and the elimination of ammonia increases. A normal man eliminates about thirty to forty grammes of urea in a day. Much smaller quantities per diem would thus indicate diminished activity of the liver.

Besides glycogen and urea, the liver also produces another substance, which is indispensable to the perfect process of digestion and assimilation. This is the bile. The bile transforms fat in the intestine into an emulsion, and thus makes it possible for the fat-splitting ferment of the pancreas to act upon it, and to split it up into glycerin and fatty acids, and thus make it serviceable for the uses of the organism. The bile augments the action of the pancreatic ferments; it stimulates the movements of the intestine, and is a powerful antiseptic to the contents of the intestine, as it hinders to a certain extent their putrefaction. Another important action is that it increases the water content of the fæces, and thus materially helps an easy evacuation of the bowels.

After having thus briefly passed in review the important functions of a healthy active liver, let us now say a few words about its examination. The liver is one of the few ductless glands which are available for manual examination by percussion and palpation. We must ascertain if it extends considerably below the costal margin, and by palpation we must ascertain whether the enlarged liver is soft or hard and cirrhotic. In the former condition we can diagnose hyperactivity of the liver, probably due to its efforts to safeguard the body against a long-continued intoxication, as may be the case in those who overeat, and also in long-continued digestive troubles, especially with dilatation of the stomach, chronic constipation, etc. Following on this hyperactivity, as is the case with all organs, there may come an exhaustion, more especially after long-continued intoxications. Thus in chronic alcoholism a simple hypertrophy of the liver may go on to cirrhosis, and later the hypertrophy may be followed by an atrophy, with all its harmful consequences, as ascites, etc.

On examining the liver we must not forget the sclerotics, and must note whether, on looking upward, there is any yellow discoloration.

While palpating the liver we must specially note whether it is tender, and also if the gall-bladder is tender. This is a typical symptom of chronic inflammation of the gall-bladder, or cholecystitis, which is so frequently associated with gall-stones. We find such a tender gall-bladder very frequently in elderly women, in whom gall-stones are particularly common. In fact, they occur so frequently that Halck^[135] in Copenhagen, found them in 29 per cent. of 4140 autopsies on persons above 50 years of age. However the mere presence of gall-stones does not constitute gall-stone disease, the essential point being an inflammation of the gall-bladder and bile-ducts. Such an inflammation of the gall-bladder is revealed by tenderness on pressure with the examining hand. It is a frequent symptom of all those conditions (as we have found and communicated to the French Congress of Medicine, 1905) in which the thyroid or sexual glands are diseased. For instance, after pregnancies, after infectious diseases in old age, etc., it is often accompanied and preceded by obesity, which is also a consequence of inactivity of the thyroid and sexual glands. Frerich, many years ago, observed enlargement of the liver and a tender gall-bladder in women at the climacteric, and many other authors have made similar observations. Hertoghe found such conditions common in women suffering from inactivity of the thyroid or hypothyroidia.

It has been found by experiments, made by Blumenthal and Jacobi, that extirpation of the thyroid is followed by a dilation of the gall-bladder, and many authors have noted the presence of biliary constituents in the urine of animals whose thyroid has been extirpated.

We can readily understand why women with changes in the thyroid and sexual glands are so often attacked by gall-stone disease. In these women there is, as a rule, atony of the intestines, with habitual constipation. This intestinal atony is also accompanied by an atony of the gall-ducts, and so the bile is more or less stagnant in these ducts.

As shown by Morat and Doyon,^[136] the gall-ducts contract rhythmically every ten to twenty seconds, and the bile is thus expressed. The periodical compression of the liver by the diaphragm at each inspiration also helps this expression of the bile. Thus it flows under a certain pressure through the choledochus, and it is easy to understand that the billions of microbes which infest the intestines, will have great difficulty in passing the narrow and tortuous passages of the bile-ducts through which bile is circulating at great pressure. And this is of the utmost importance, for if microbes are able to pass the common duct and thus enter the bile-ducts, they will set up inflammation, as was shown by several French authors: Gombault, Charcot, Gilbert, etc.

Inflammation of the bile-ducts plays a most important part in the origin of gall-stone disease, for, as Naunyn and his pupils have shown, inflammation of the bile-ducts leads to a precipitation of cholesterin, and so to the formation of gall-stones.

In women gall-stone disease is more frequent than in men. This depends upon the greater frequency of diseases of the thyroid and sexual glands in women. Changes in the sexual organs produce an irritation of the splanchnic with checking of the peristaltic movements of the intestine and, at the same time, relaxation of the muscular coat of the bile-ducts. Thus there arises a deficient expression of bile, and stagnation follows, with invariable immigration of bacilli producing inflammation and precipitation of cholesterin and gall-stones. For the above-mentioned reasons constipation is far more frequent in the female, and constipation, being always accompanied by atony of the bile-ducts with stagnation of the bile, directly exposes to the risk of gall-stone disease.

In men gall-stone disease may often be considered a manifestation of old age. It appears, as a rule, after the fortieth year, and is often brought about by previous infectious diseases. In such cases obesity often develops first, and later gall-stone disease. For those who are interested in this subject we would refer to our communication^[137] on the origin of gall-stone disease following changes in certain ductless glands. Considerable, sometimes enormous, loss of weight is a very frequent symptom of gall-stone disease, and is probably due to pancreatic alterations.

Gall-stone disease may be regarded as of great importance in estimating an individual’s prospects of longevity, and at the same time as a pathological manifestation of an inactive thyroid, or deficient sexual glands in women. This applies equally well to the cause of renal colic, gravel, which was found by Professor Sajous to be prevented by thyroid preparations and a suitable diet.

Constipation, an important predisposing cause, has been shown to be an expression of such conditions. The truth of these assertions is proved by experimental evidence.

Extirpation of the thyroid provokes important changes in the liver. In myxœdema there is a condition of hepatic cirrhosis, as shown by Prun-Hudden, Vermehren,^[138] and others. Two years after we had shown that the thyroid and liver stand in close relation to one another, Professor Neusser, of Vienna, brought forward the same conclusion at the German Congress of Internal Medicine in 1906.

Another important gland that has a very close connection with the thyroid is the kidney. A direct examination of this organ is not possible, but we have means of readily judging of its efficiency by observing how it performs its function. This is to eliminate waste and poisonous products from the body by means of its secretion—the urine. Thus from the examination of the urine we may gather all the information necessary about the activity of the kidneys.

In examining the urine we must first pay attention to its appearance, the daily amount, and its specific gravity. Less than about two pints a day of a light colored urine, with a specific gravity below 1020, indicates a faulty action of the kidneys, and the possibility of a large amount of toxic products being retained, instead of being eliminated. Such a urine can often be seen in cases of thyroid insufficiency, as this condition of the thyroid causes a diminution in the activity of the kidneys. As we have shown in a communication to the Paris Biological Society,^[139] the thyroid and the kidneys are very closely related, changes in the thyroid always being followed by changes in the kidneys. Thus it was found by Albertoni and Tizzoni, by Blum and others, that extirpation of the thyroid is followed by fibrosis of the kidneys. Interstitial nephritis is the rule in myxœdema, and is very frequent in all conditions with insufficiency of the thyroid. In such patients the quantity of urine is diminished, and also its specific gravity, as well as the quantity of urea and uric acid, which in consequence are retained in the body.

The quantity of the eliminated uric acid being diminished, its retention in the body explains why gout is so frequent in people with thyroid insufficiency, and why these persons so often complain of rheumatic pains. As we have shown in our above-mentioned communication, gout is due to a degenerative change in the thyroid and kidneys, with retention of uric acid as a sequel.

The presence of albumin in quantities greater than 0.5 gramme to the liter is of grave import, and denotes important change in the kidneys. Smaller quantities, or just a trace, may not be of great importance. Traces of albumin occur from a great number of causes, and are often due to the passage of toxic products through the kidney which this organ eliminates, as one of its main functions is to eliminate toxic products from the body.

More serious than small quantities of albumin is the appearance of casts and renal epithelium. These, if present, indicate a destructive process in the kidneys. Even the occasional occurrence of hyalin casts is not without danger, for, according to Professor Senator,^[140] of Berlin, hyalin casts are formed by degeneration of the epithelium of the convoluted tubules, which play an important rôle in the separation of solid products from the blood into the urine. The loss of these structures means a hampering of the most important function of the kidneys. Even when we find only one such cast in one or two specimens, we must not forget that a pint of the urine may contain a very large number, and thus every day large quantities of valuable kidney elements are wasted and one of the most important functions in our body is hindered. Therefore we must not pass by such a condition of things without serious thought for the future of such persons. The length of their lives will largely depend upon their diet, just as in cirrhosis of the liver. If these persons are addicted to an abundant meat diet, their chances of longevity will certainly be smaller than with milk and vegetable food. As we have seen, the liver is constantly dealing with poisons arising from the decomposition of albuminous food, especially meats. The kidneys are destined to eliminate such products from the blood and pass them out with the urine. We will treat of this subject later in a separate chapter.

In patients with diseases of the kidneys, the condition of the skin is of the utmost importance, as the skin is our second kidney. Therefore patients with thyroid insufficiency have less chance of a long life if their kidneys are in any way incapacitated.

Besides the above-named vital organs, there are certain portions of our anatomy which are also of importance in the determination of our chances of life. Take, for example, the nose. In the children of parents with degenerated thyroids there is a great tendency to adenoid vegetations. These are, strictly speaking, not a disease of childhood alone, for often they may be met with in adults, even in middle age. If large they necessitate breathing through the mouth instead of through the nose, especially at night. Such children are liable to frequent catarrhs, and what is more serious, to pulmonary troubles. They are also liable to suppurative otitis media and frequent attacks of tonsillitis. These frequent attacks of tonsillitis may constitute a serious danger, as they may induce an inflammation of the kidneys. As a rule, in such cases the nephritis passes off in a few days, often without being recognized, the symptoms being ascribed only to the tonsillitis. Although the acute symptoms may have disappeared and nothing remain but a few red blood-corpuscles in the urine and occasionally a few casts and epithelial cells, yet under the ashes the fire may still creep on and chronic nephritis develop. In fact, a good number of cases of chronic nephritis whose origin is wrapped in mystery are due to such a tonsillitis.

The condition of the teeth must also be inspected, for people without sufficient teeth cannot chew their food properly, and thus gastric and intestinal catarrhs may arise.

Just as important, if not more so, than the condition of the above-mentioned vital organs, is the mental state. Thousands of years ago it was a manifest truth that the mind governs the body. In judging an individual’s chances of long life, we cannot omit the importance of his mental character. As a rule a man with a well-balanced mind, who is not disturbed by the smaller worries of life, has more chances of a green old age than a man whose easily impressionable mind exposes him to continual agitation and anxiety, and who is overwhelmed by the slightest untoward event. A man who is a born optimist and who views everything in a rosy light, has got far more chance than a pessimist who sees everything in a cloud. A man who is ambitious and never satisfied is more liable to mental and physical change than one who asks for little and easily gets it. Being disappointed in his ambition, as so often happens, he becomes despondent, especially if he is lacking in will-power, which depends on the activity of the thyroid as previously mentioned. In this condition he may not only lose his appetite and become ill-nourished, but he is also more liable to succumb to the incessant attacks of microbes, among which he lives, and which gain easy access to the body in melancholic conditions. Sorrow may act in the same harmful manner.

The chances of a bachelor or spinster for a long life are always less than those of a married person. Single people are more subject to nervous change and digestive troubles, and have a greater tendency to become despondent and melancholic. In bachelors, also, the acquisition of contagious diseases is a continual danger, and when they get older after their former merry lives, if merry it was, gloom invariably follows. Married life is the best guarantee for a long life and happy old age (see Chapter XLVIII).

Before closing this chapter we would state that it was not our intention to give a description of the physical examination of a patient from the point of view of life insurance, but to indicate certain points which must guide us in forming an opinion on a person’s chance of longevity. All vital phenomena are under the influence of the internal secretions of the ductless glands, which govern every organ of our bodies. Therefore everything depends upon finding out the condition of these glands. Any well instructed physician can make a thorough examination of the different organs of the body for the purposes of life insurance; therefore we did not think it necessary to describe here the examination of the heart or lungs, etc.

By such examination of the ductless glands we are not only able to forecast the approximate length of life, but we are able to judge a patient’s power to withstand disease when we are called to his bedside. If we find the ductless glands of such a patient (especially the thyroid and adrenals, kidneys and liver) in good working order, we can predict a successful and rapid termination to the malady. It is easy to understand that any one with a healthy skin, normally acting bowels, and plentiful urine, will more readily eliminate poisonous products than a person with a dry skin, constipation, and scanty urine. Also his tissues will be in better condition, and in the case of wounds granulations will more quickly form and fractures heal readily with firm callus.

Such an examination as the above can, however, also help us, as we readily shall understand, to foretell the chances of a person as to the prolongation of youth and the retardation of old age.