INFANT FEEDING. (By CLIFFORD G. GRULEE, A. M., M. D., Assistant Professor of Pediatrics at Rush Medical College; Attending Pediatrician to Prebyterian Hospital, Chicago. Third Edition Thoroughly Revised. Octavo of 326 pages, illustrated. Published by W. B. Saunders Company, Philadelphia and London, 1917. Price $3.25.)

This book can be recommended to both practitioners and students, as it has the rare characteristic of being at the same time scientific, practical and concise.

The chapters in physiology and metabolism are well worth reading.

Probably more space could be allotted to milk mixtures, albumin milk being just passed over when a chapter could easily be given to it. The classification of gastro-intestinal diseases is that of Finkelstein, except that the field of weight disturbances is narrowed; probably without improvement to the classification.

T. L. BIRNBERG.

INTERNATIONAL CLINICS. (Edited by H. R. M. LANDIS, M. D., Philadelphia, U. S. A., with the colloboration of CHAS. H. MAYO, M. D., of Rochester, SIR WM. OSLER, M. D., of Oxford, etc. A Quarterly of illustrated clinical Lectures and especially prepared original articles on Treatment, Medicine, Surgery, Neurology, Pediatrics, etc., and other topics of interest to students and practitioners, by leading members of the medical profession throughout the world. Vol. I, Twenty-eighth Series, 1918. Published by J. B. Lippencott Company, Philadelphia and London. Price, $2.50.)

In this volume, L. F. Bishop, M. D., gives a very interesting clinical lecture on the value of historytaking in cardiac disease and discusses a few cases most painstakingly.

John B. Haws, 2nd., M. D., has an article on "A Clinic for the Treatment of Non-pulmonary Tuberculosis in Out-Patient and Dispensary practice." Here he describes the methods used in the clinic at the Massachusetts General Hospital and some of the cases there treated. The lesson to be learned is one of more treatment of the patient suffering from tuberculosis in the forms suggested, and less surgery of the lesion. The results the author gets by ordinary hygienic-dietetic-tuberculin methods are very satisfactory to him and far less disfiguring than the formerly more common scars.

F. P. Weber, M. D., has a lengthy article on some pathological conditions of the finger nails. One in par

Surgical articles are also included. ticular is worthy of note, namely: "The Secondary Suture of Infected Wounds after their Chemical Sterilization with Dichloramine-T" by W. E. Lee, M. D. In this article some conditions are described which responded to such treatment, particularly one of a carbuncle of the back extending from one scapula to the other which was opened by a crucial incision eight and one-half inches long by three inches deep. The history of the case is unusual.

The usual articles on war-surgery are given.

The whole volume is up to its usual standard and is worthy of general interest. After twenty-seven years of successful production these Clinics now have a host of friends deservedly.

C. E. SMITH, JR.

MEDICAL BACTERIOLOGY. (By JOHN A. RODDY, M. D., Assoc. in Hygiene and Bacteriology, Jefferson Medical College; Chief Assistant, Department of Clinical Medicine, Jefferson Hospital; Professor of Hygiene and Bacteriology, Philadelphia colllege of Pharmacy. Sometime Serologist to the Philadelphia General Hospital. First Lieutenant Medical Section O. R. C., U. S. A. Published by P. Blakiston's Son & Co., 1012 Walnut Street, Philadelphia, Pa. Price $2.50.)

This small volume contains a very large amount of information in a condensed form. Perhaps too condensed to make the reading always easy and clear. The facts are there but it is not the kind of a book one would turn to readily-consequently, the author's stated purpose of writing for beginners, as well as medical practitioners and pharmacists, seems imperfectly realized.

A very good chapter is that on Diagnosis, in which the various methods are described for collecting material for diagnosis, for instance the method of obtaining the spirochetae pallida from the venereal sore. Also the chapter on the Wassermann and other complement fixation tests is very complete and well written.

One could wish that the final chapter on Immunity had been left out, as here the author merely "hits the high spots" and discusses opsonins, the side chain theory, and anaphylaxis, without any comment on the present value of these different theories.

C. N. HENSEL.

Vol. I

ORIGINAL ARTICLES

GASTRIC CRISES AND RELATED ABDOMINAL PAIN.*

E. L. TUOHY, B. A., M. D., Duluth, Minn.

At a previous meeting of this society, the writer in collaboration with Dr. N. L. Linneman, presented a report and classification of some 280 cases of lues. This report will take up a more limited group (45 in all). Some cases presented in the original report are here included. All of these cases have been encountered in the course of an intensive routine examination of patients whose chief complaint was severe intermittent abdominal pain. In many of these, the symptom-complex strongly suggested intra-abdominal surgical disease. All but two had repeated positive Wassermanns or changes in the spinal fluid characteristic of specific disease.1

The degree of pain, intensity, duration, and position, has naturally varied greatly. This may bring into question my right to call them all "Gastrie Crises." This will depend upon how narrow an interpretation is put upon that term. The title of this paper is misleading if we restrict the use of the term to that type seen most characteristically in 30 to 40 per cent of

No. 7

the development of tabes. It is well known that many years intervene between the original infection and the full development of the disease syndrome. Osler mentions an instance of occasional lightning pain which preceded the full development of Rombergism, pupillary changes and absence of the knee jerk, by fully ten years. Newer forms of treatment have shown us the way to at least greatly alleviate many of the awful and disastrous sequelae of lues. Not a few people doomed to hopeless invalidism have been returned to usefulness by persistent and judicious treatment. Some cases proceed to a fatal issue with luetic disease with alarming swiftness. I recall a young man, aged 26, who in the short space of eighteen months after the development of a chancre had gone so far with his nerve lesion as to have a doublesided subluxation of the hip joint. The rule, however, is for the disease to proceed very slowly. A perusal of the data of this paper is respectfully suggested, with the idea in mind that abdominal pain may be one of the signs indicative of luetic virus in the body. Whether any of them will go on and ultimately develop the full signs of tabes is beside the question. I wish it to be definitely understood also that no attempt at this time is to be made to explain the pathology represented. Whether the condition in all cases is a true luetic lesion of the central nervous system or a toxic influence cen

*Read before the annual meeting of the Minnesota State Medical Association, October 11 and 12, 1917, St. Paul, Minn.

This group might be made much larger were it not that only those cases are included that remained under observation long enough so that anti-specific treatment has added additional weight to the diagnosis of lues. In view of the growing skepticism accorded Wassermann studies in general, it should be strongly insisted upon that the therapeutic test for lues is just as good now as it was in pre-Wassermann days.

thing difficult to dogmatically enunciate or clinically prove. It will not be attempted. It will be seen that the earlier cases have lesser degrees of pain and longer intervals of freedom, gradually only developing the associated diagnostic criteria, such as Rombergism, girdle sensations. One of the striking lessons to be learned is the amount of surgery that has been

done or advised on these patients. The diagnostic and therapeutic responsibility is unmistakable, and if old tabetics can often be greatly helped, we should stand a chance of doing much more for these, at the same time accomplishing something prophylactically.

A discussion of the mechanism by which true crises are produced is similarly interesting, but inconclusive. It is surprising how indefinite the literature is on this point, or how guardedly men well qualified to give an opinion are in expressing their opinions. The pathway of sensation in any intra-abdominal pain must be essentially complicated. It is assumed by many that the so-called "girdle" sensation is an expression of true "root pain," following upon a diffuse lesion of the posterior fibres of the cord. Using this as an illustration of the general in definiteness of the pathological physiology involved, it can be stated that the pain in herpes zoster, which is definitely known to be the result of pathology in the posterior nerve roots, is clinically quite different from crises. The mechanism of pain registration in hollow viscus organs can well merit attention. Meltzer's crossed enervation theory is ingenious; the role played by spasm in the colic of gallbladder disease or ureteral stone, receives confirmation by the researches of Carlson and his school (studies growing out of their original work on "hunger pain"). I have on occasion witnessed a man with gastric crises under the fluoroscope with a stomach filling. The organ was in a state approaching tetany at the height of his pain. Lyon reported instances of gastric crises due to spinal lues, in whom the passage of a small duodenal tube into the stomach allowed the contained air to escape and thus relieved tension, promptly terminating the attacks. This is in keeping with Bevan's reported instance of severe ureteral colic, terminated by a kidney drainage without removal of the stone, to again recur when the drainage became temporarily blocked.

Since it is the writer's desire to emphasize particularly those cases in which violent abdominal pain was their most striking symptom, only six true tabetics are included. These are presented chiefly to show, (1) the length of

2Gastric Crises of Spinal Syphilis-Meeting A. M. A., New York, June 7, 1917.

time they had symptoms, (2) associated lesions they presented, (3) variability and intensity of their pain and distribution, (4) their surgical interest.

A large number of irregular cases have not been included in this report at all. (1) Because, while they had more or less abdominal discomfort, it was not their dominant symptom, or the patient did not remain under observation long enough to furnish reliable data; (2) those having a good deal of abdominal pain, but having enough additional pathology, often surgical in character, to confuse the issue, and to make less reliable conclusions known to benefit from a combined surgical and antispecific therapy.

In order to avoid a detailed individual discussion of these cases, each of which often presents a problem of its own, an attempt will be made to classify them in groups. Whether by chance or not, these sub-groups seem to bear out the reputation lues has for copying true organic diseases. Not that these gallbladder symptoms, for example, copy in all details that of true gallbladder disease, but, carelessly taken histories or hurried examinations may, and often do, confuse them. We can usually safely say that with conscientious examinations, proper serum studies, a judgment of the patient's reflexes, pupils, areas of sensation, etc., confusion will rarely be necessary for very long. A differentiation in the way of sex and age, and length of time they have had symptoms, offers some additional information, and this will be tabulated. In all there were 30 females and 15 males.

I. Stomach Group-Some simulating ulcer; others giving the findings of a so-called "neurosis:"

he was explored by a surgeon of national reputation, and in the absence of any signs of ulcer, the appendix removed. He was some better for a short time. Six months later, planning marriage, he had several Wassermanns taken, two of which were made at the State University under the best of control, and all were found negative. On this basis he married. Four months later, very severe headaches brought him to me for further advice, and two blood Wassermanns were negative, one after the provocative use of mercury, and it was my conclusion that his basilar headache was probably of neurasthenic origin. Within two weeks, however, he began to vomit profusely, and a spinal puncture was done, yielding a four plus Wassermann of the spinal fluid, a positive globulin, and 184 cells over 3 in the spinal fluid count. On this basis vigorous anti-specific treatment was instituted, with a return to health, which has been maintained since, although intensive treatment has been necessary to keep him well.

II. Gall Bladder Type:

a-Giving symptoms suggesting stone...12

b-Giving symptoms suggesting cholecystitis (without stone)..

(Note great predominance in females).

6

Average duration of symptoms 1.8 Illustrative Cases: (a) Female, aged 38, divorced. A very long history of abdominal pain following upon four pelvic operations that had been performed four years previously, and a gastroenterostomy done for relief of stomach symptoms one year previously. It is probable that the surgeon in operating had in mind the gall bladder, but finding this apparently healthy, for some reason did a gastroenterostomy. When she came under my care she had in addition to recurring attacks, severe abdominal pain centered over the right upper quadrant, severe nocturnal headaches, a moderate anaemia, and a general sense of extreme weariness and total loss of interest in life. Four

Wassermanns of the blood were all four plus. Vigorous anti-specific treatment has returned her to health. Whereas she had severe abdominal pain at intervals of every four or five weeks, she has had none now for over a year.

It should be stated here that close observation of one of these patients in an attack reveals several striking differences between these attacks of pain and true gall bladder disease, either that of stone or caused by inflammation. The patient localizes his pain in the G. B. region, but there is usually no definite tender

ness; the pain radiation is not so distinct nor onset so sudden. As a rule, the patient will complain of a general discomfort, which is not affected by position-in fact he is apt to be up and walking around-and the pain is likely to persist longer, gradually fading away much as it came on. In addition to these points of difference, there is never associated the signs of inflammatory disturbance so characteristic of true gall bladder disease.

(b) Female, aged 40. Had had recurring attacks of vomiting with "bilious" headaches. Three physicians had advised her definitely to have the gall bladder removed, stating that the attacks were not severe enough for stone but that the stomach symptoms were typical of gall bladder disease and that a chronically inflamed gall bladder would probably be found. On examination I found peculiar scars in the region of the left knee, and she stated that she had been treated for a rheumatism of the left knee 17 years previously. Three blood Wassermanns in succession were four plus, and the patient in a period of three months has made a very striking improvement. Not only has she lost her so-called "indigestion," but she now recalls that she is better in many other ways, including pain in the left leg at night, and tendency to headache (usually more severe at night), and a freedom from a general tendency to aches in the shoulders and back which she had grown so accustomed to that she didn't even mention it at the first consultation.

III. Duodenal Group-Simulating ulcer or pyloric obstruction:

Average duration of symptoms..5.65 In explanation of this group, organic pathology was demonstrated in only 1, and this roentgenologically. Two women had marked delay in emptying time of the stomach, with absolutely negative stomach contour, and with a normal duodenal cap easily visualized and showing no defects. Both of these made striking improvement under treatment, and this improvement has remained after two and one-half years. At the same time, it is important to note that even after that time both of these patients retained nearly as much barium residue after six hours as they did when first examined, despite great improvement in their general ap