Treatment of Depression in Later Life

intensity in the other. If this claim be allowed, the next step is to explain or account for the absence of infection in one group and its dominant influence in the other. Clearly the most likely sources of infection must be sought in the mouth, the nose and accessory cavities, and the pharynx; and it can be stated at once that in the matter of cleanliness of the mouth there was an obvious difference between the two groups. All 14 members of the silent group were edentulous and had been so for several years before the presumed onset of the disease, whilst of the 3 members of the anaemic group not one was edentulous, for all possessed natural but bad teeth: in two the teeth were carious, broken, and blackened, and there was severe gingivitis; in the third patient, aged 43, the teeth were not so manifestly diseased, but actually several were found to be dead and to show x-ray evidence of root infection. Dr. J. F. Wilkinson, to whom first this patient was sent because of the strong suspicion of haemolytic anaemia, recorded: " Very pale, with suspicion of yellow in skin. Teeth almost normal in number but dark in colour and free from gross caries. Red cell count 3,500,000, Hb 37%, colour index 0.52, white cell count 16,000. " Within two weeks of an exceptionally severe operation-for this involved en bloc resection of three-quarters of the stomach, and the transverse colon with omental and mesenteric attachmentsthis patient's facial appearance had improved remarkably, though none of the teeth had been removed. The improvement continued steadily, and was no doubt later accelerated by the administration of iron. It is probable that infection of dental origin so severe as to cause the kind of illness described will only be met with in patients whose teeth and gums are badly infected; but the patient of cancer age rarely has perfectly sound teeth, and it is likely that lesser degrees of infection may be found in patients who have retained their teeth in apparently fair condition, and may well account for the varying degrees of anaemia and asthenia so noticeable in any large series of . patients with gastric cancer. Indeed, the patient whose disease runs a silent or symptomless course and whose blood picture remains almost normal in an advanced stage will, I suspect, almost invariably be found to be edentulous and to have been so for several years before the approximate time of onset of the disease. It is hardly necessary to point out that this suspicion does not imply that cancer of the stomach in a patient already edentulous will always run a silent course. Clearly there are other important factors which influence the symptoms, such as the position of the growth: cancer beginning at the inlet or outlet of the stomach will produce obstructive troubles before infection has had time to play a part; cancer aeveloping in a chronic ulcer is very unlikely to be symptomless; and the primary cancer which imitates closely in its earlier stages the clinical and even radiographic features of a gastric ulcer is almost a clinical entity which is probably quite independent of infection. Furthermore, as already suggested, there are other possible sources of infection, though I have not observed these in actual practice.