Journal of the American Medical Association

not uncommon for each coat of the artery to take on a special type of inflammation, yet all frequently become involved.

Endarteritis obliterans is an inflammation of the inner coat of the artery, usually of a chronic type. The inflammation may arise from an irritant in the blood cur

arteries and veins for the passage of blood, renders it a unique end organ, and its arteries susceptible to arteriosclerosis. This, together with endarteritis obliterans, predispose the arteries to degeneration and necrosis. This is a thickening of the arterial walls, especially of the intima. It is secondary, according to Hektoen, to certain inflammatory or degenerative changes in the media. This is seldom observed early in life. commonly found after puberty, but more frequently at the senile stage, from forty years on. The causes producing arteriosclerosis in other parts of the body produce it in the pulp arteries.

It is

Fig. 4. An enlarged artery in an early stage of thickening, the small vessels plugged up, well marked myxomatous pulp tissue. (x225.)

Bands of fibrous tissue develop. The blood vessels become obstructed and finally obliterated, impeding the circulation (Fig. 3).

The structure pulp, made up of loops of blood vessels and situated within bony walls, with only one or two

Fig. 5.-Pulp stones scattered throughout, here and there a form of round-celled infiltration, longitudinal nerve trunks, few degenerated vessels surrounded by hyaline degeneration in the middle of nerve trunk. Early sclerosis and cloudy swelling or granular degeneration. Adontoblasts in situ. (x21.)

walls become irritated, resulting in thickening of the arterial coats.

"The inebriate, whose brain and body after death exhibit a confused mass of wreckage, which the pathologist is often unable to trace back to the exact causes and conditions, has, according to Crothers, always sclerotic conditions of the large and small arteries, together with atrophic and hyperatrophic states of the heart, kidneys and liver, with fatty degeneration and calcification of the coats of the arteries. These organic changes are so frequently present in inebriates that they constitute a marked pathology which is traceable to the use of alcohol."

These irritants, acting through the vasomotor system and increasing the arterial pressure, finally cause paralysis and diminution of the caliber of the arteries and capillaries, producing stasis of blood (Fig. 4). This

morbid state of the arteries tends to produce any or all of the other degenerations previously referred to.

The inflammatory process of the intima was first charged to direct irritation of material floating in the blood. Rokitansky and Thoma are of opinion that it is secondary and dependent on the degenerative changes of the middle coat. This view I can not accept, since

and fatty degeneration. These conditions are observed in connection with such diseases as typhoid fever, septicemia and other acute infections and toxic diseases. The tissues present a whitish or shiny appearance, without fibrous structures. Under the microscope the tissues present an opaque mass and do not take stain. The cells are quite large and swollen (Fig. 5).

"When a tissue, as for instance the heart muscle, receives a diminished quantity of blood on account of the narrowing of the lumen of the arteries due to thrombosis, embolism or disease accompanied by thickening of the intima, albuminous and fatty changing, remarks Hektoen, usually result. In the case of the different forms of anemias, degenerations with fat production are found in the liver, heart, kidneys and muscles. In such conditions there is not enough oxygen and other nutritive material to maintain the function of the cells. In actual starvation there is first absorption of all the fat in the body, accompanied by a marked diminution of the struc

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Fig. 8.-Calcareous deposit, medullary nerve. Early connective cell formation. (x225.)

ture. In the later stages, albumin and fatty degeneration take place. Albuminal and fatty changes are very common in febrile diseases. They occur in practically infectious diseases and in a large number of the intoxications, such as the drug poisons. They are also found in abnormal metabolism, due to direct action of poisons and the abnormal process of oxidation." Owing to the pulp's peculiar structure and environment, fatty degeneration is commonly found in its tissue (Fig. 6).

Amyloid degeneration is a peculiar degeneration of the connective tissue, causing an albuminous substance to be deposited in the surrounding tissue. The walls of the blood vessels also become involved. It presents a shiny appearance and differs from other tissues in that it turns a dark red color with iodin. The morbid state is found in syphilis, tuberculosis, chronic dysentery, etc. (Fig. 7). Almost every structure in the body may be in

volved.

Hyaline degeneration (Fig. 8) is, according to Stengle, closely allied with amyloid, mucoid and colloid degenera tion, and all can pass into each other. It can occur in tis

sues during infectious and septic processes, following traumatism, in autointoxications such as drug poison, hemorrhages in cicatrices, in senile blood vessels, arteriosclerosis, endarteritis obliterans and in the nervous system. It can also occur in connective tissue which has undergone a change by inflammation. This morb.d state depends for its action on local or general nutritive disturbances. The pulp, therefore, is susceptible to it. The intima, as well as the entire walls of the small blood vessels in the pulp, easily becomes involved. Some investigators believe that fat connective tissue cells so arrange themselves as to undergo a change into myaline substances (Fig. 9). These ultimately lead to calcification. This raises the question of calcic deposits or socalled pulp stones. Pathologists know that tissues elsewhere in the body (which have necrosed or degenerated) are the localities where lime salts are deposited. Dying tissue which has undergone more or less change possesses, according to Ziegler, a kind of attraction for the lime salts in solution in the body. The tissues, to which

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Fig. 9. This shows medullary nerve fibers and internodes, axis cylinders, myolin degeneration. (x280.)

attention has been called, are especially susceptible to calcic changes; hyaline and fatty degeneration, tissues involved in disease or drug poisoning, already mentioned here and elsewhere. Regions affected by slight degeneration and in structures 1.ke the pulp, a constricted end organ, are predisposed to deposits of lime salts. Calcic deposits have different shapes and location in the pulp tissue. Circumscribed structures appear solid under the miscroscope, to the naked eye or to the touch, are not pulp stones or calcic deposits, but in a large percentage of cases belong to other retrogressive changes. These deposits (Fig. 10) are, no doubt, due to degeneration of pulp tissue, especially in structures undergoing hyaline or fatty degeneration. Large masses of deposits in the form of spherules often occur. Bone formations are sometimes observed. These deposits, both in pulp stones and spherules, take on a dirty, bluish-violet color, with hematoxylin. These Dr. Latham

Fig. 11.-Shows interstitial fibrosis with acute inflammatory cells. Odontoblasts have been destroyed. (x22.)

will only refer to fibroid degeneration in closing. Fibroid. growth of the pulp may be both rapid or slow. Inflammatory reaction in fibrous pulps is rare, although when followed by infection or exposure, it may take place.

Various degeneracies like those already mentioned are liable to occur, especially those in which connective tissue in general is predisposed. The fibers are observed in bundles, closely packed together, with many connective tissue corpuscles shown at intervals. Fibroid degeneration is easily distinguished from the other degeneracies of the pulp (Fig 11).

In these cases, the blood vessels and nerve tissue are relatively few. The blood vessels remaining usually have thickened walls, especially in the external and middle coats. This, of course, narrows the lumen. Not infrequently the blood vessels are entirely obliterated. These fibromas, very common in exposed pulps, are not now under consideration. In nearly if not all of these degenerations the blood vessels are first involved, later nerve tissue.

All these degenerations, including the pathologic processes of evolution, are the direct constitutional causes of tooth decay, erosion and abrasion brought about by diminution of tooth vitality.

NOTE. The discussion on the papers of Drs. Andrews, Talbot and Latham will follow the paper of Dr. Latham, which will appear August 20.

TUBERCULOSIS IN THE JEWISH DISTRICT OF CHICAGO..

THEODORE B. SACHS, M.D.

Instructor Internal Medicine College of Physicians and Surgeons; Examining Physician Maternal Jewish Hospital for Consumptives; Attending Physician Cook County Hospital.

CHICAGO.

The Jewish population of Chicago can be estimated at 75,000. This element of population is not as homogeneous as any other of the numerous nationalities found in this city; the ideas, customs and mode of life of Jews differ according to their place of nativity or length of residence in this country. The so-called immunity of the Jewish race from certain diseases varies in degree according to the economic and hygienic conditions in which they live; tuberculosis, for instance, may be comparatively rare among the wellto-do, but is very common among the poor. The same can be said about all kinds of infectious diseases, the spread of which is favored by poverty, overcrowding and its attendant unfavorable conditions of life. ditions in which the different elements of the Jewish population live influence the degree of prevalence of certain diseases to a much greater extent than any racial characteristics.

Con

THE JEWISH DISTRICT OF CHICAGO; ITS AREA AND POPULATION.

The largest percentage of the Jewish poor of Chicago are found in a district bounded by Canal Street on the east, Blue Island Avenue west, Taylor Street north and Fourteenth Place south (Chart 1). This area measures 244.6 acres and corresponds to one-half of the Ninth and a fraction of the Nineteenth wards of this city.

Its population can be estimated at 31,000, of which 22,500 are Jews. The Russian Jew represents the predominant element; Jews from Austro-Hungary, German Poland, Roumania and other European countries are in the minority.

All trades are represented here to a certain extent. Tailor-trade and work in factories and stores furnish means of subsistence to the greatest number. Of men

engaged in outdoor work the largest percentage are peddlers.

Constant emigration from this district of the Americanized and more prosperous Jewish element is compensated by a continuous influx of new immigrants; thus the general aspect of this part of the city remains about the same. The non-Jewish population is found chiefly at the outer belt of this district and consists of Bohemians, Italians, Irish and a small number of Lithuanians and Poles.

HYGIENIC CONDITIONS. MODE OF LIFE.

The air in this part of the city is constantly filled with dust and clouds of smoke from the vast number of factories, foundries and railroads of the adjacent river district. It is further polluted by emanations from piles of refuse accumulating in streets and alleys. A large portion of this area is but seldom swept or sprinkled. There is only one small playground and no parks in sight for a distance of three miles. Hunger for pure air is the cry of the neighborhood. A more comprehensive idea of the existing conditions. was gained by a detailed study of a square block in the center of this district (Chart 2), in which a house-tohouse investigation was made by myself and Miss Bertha Hazard, a resident of the Hull House. This block is bounded by Jefferson street on the east, Union Street west, Maxwell Street south, and O'Brien Street north. West Thirteenth Street, one of the narrowest streets in Chicago, runs through its center. The area measures eight acres and has a population of 2,007 Jews and 214 non-Jews, or about 278 people per acre. Sixty-six per cent. of buildings are two stories high.' Forty-five per cent. of population in this square block live in rear flats, rear buildings or basements. position of buildings is such that very little or no light can enter through the windows on either side. The average family consists of parents and four children. Three or four-room flats are the general rule. Extreme poverty compels a large number of families to utilize. only half of their rooms during the cold season. dows are generally kept closed through the entire winter. The extremely unsanitary conditions in which these people work and live, their abject poverty and overcrowding would naturally lead to a high rate of mortality from all diseases, but the effect of these unfavorable conditions is greatly mitigated by certain features of Jewish life, among which I could mention their early marriages, chastity, rarity of syphilis and alcoholism, easy access to medical aid, tendency to consult a physician for the most trivial ailment, careful selection of meat, its thorough cooking, etc.

MORTALITY FROM TUBERCULOSIS.

The

Win

From May 1, 1902, till Nov. 1, 1903, 51 Jews died from tuberculosis in the Jewish district of Chicago. This represents an annual death rate of 1.51 per 1,000 living, or 138.5 deaths from this disease in 1,000 mortality from all causes (see Table 1). The corresponding death rate from tuberculosis in the central block (Chart 2) was 2.81 per 1,000 living, or 228.5 deaths from this disease in a total mortality of 1,000. During the same period of time the annual mortality from tuberculosis among the non-Jewish population of the Jewish district was 5.02 per 1,000 living, or 179.7

1. The per cent. of two-story dwellings in the entire Jewish dis trict is 90. The greater density of population in the Jewish district of New York (488 per acre) is made possible by the existence of numerous large tenement buildings.