25, OF GASTRO-ENTEROPTOSIS TfE BRITISH JUNE 1932] TREATMENT [IMEDICAL JOURNAL 1163

In the more severe type of non-responsive case, an even IRRATIONAL EXPECTATIONS FROM RESULTS more elaborate form of vaccine treatment may be required This is the last cause of failure to be mentioned. Too as a preliminary measure-namely, the enmployment of a much in certain cases is expected of a mode of treatment, donor to provide an autogenous immune serum. A whole- the action of which must necessarily have definite limita- blood immune transfusion may be used as an alternative in tions. Vaccine therapy is not in any sense a " cure-all," specially debilitated cases with good immediate, though and even if there are conlditions in which it may be more temporary, results, and may be followed up by the sensi- or less successfully employed as a non-specific agent in tized vaccine similarly obtained. protein shock therapy its essential sphere is that of a The other and commoner group of non-reactive and specific immunizing agent against specific infections. non-responsive cases does not show these grave signs of If a presumed infective debility, but is condition proves, on investiga- apparently impervious to any effect what- tion, to be one of metabolic derangement, and the in- ever of ordinary full doses of vaccine. Such a condition fector is only one of is often found secondary although perhaps con- in cases with marked furunculosis and other tributory importance, vaccine treatment of this must not conditions of local infection, less frequently in chronic be if catarrhal and blamed failure to correct the primary non-infective rheumatic conditions. The usual vaccine condition results. In most chronic infections it is at doses are inadequate, and will be written down as a failure unless doses of much times more important to treat the associated and resultant greater amount than usual are derangements of tissue metabolism than to concentrate employed. For instance, in certain cases of furunculosis which solely upon the infection itself, and, unless vaccine treat- have been abandoned as failures, completely satis- ment is combined with factory results have been other remedial measures, it can- obtained when the dosage has not be expected to produce the result or improvement been increased to three or four times the usual maximum amount. which is anticipated clinically. Vaccine treatment is an invaluable therapeutic measure, and all too frequently INSUFFICIENT DURATION OF TREATMENT advantage is not taken of its help in the scope of clinical This is a further cause of failure, and applies especially practice. It is either not employed early enough to be to the chronic type of infections. It is irrational to of real service, or too much is expected of its exhibition expect a few small doses of vaccine, however carefully under conditions which preclude its success. they are prepared and arranged for, to arrest an infective There are, therefore, several causes of failure in vaccine process that has been present in the system for months treatment, some of which may be avoided by a proper or years, and much less to reduce or replace pathological appreciation of the underlying difficulties which are apt processes which have been established. Good results are to exist, others which depend upon the presence of patho- usually obtained by persistent, careful treatment. But logical conditions beyond the scope of clinical control. vaccine therapy is not a simple and easy matter. It Nevertheless, when all details are considered, failures frequently demands much patience and thought, and gives occur in not more than 20 per cent. of cases, and, as scope for considerable nicety in the successful manage- pointed out above, may with proper care be definitely ment of a difficult case. Without such care, failures are less. more often due to the lack of proper administration than REFERENCES 'Jenkins: British Medical Journal, March, 1928. to any fault in the vaccine or therapy itself. 2 Crowe, Warren: Treatment of Chronic Arthritis. Although many may do well after a single course of ten SolisPCohen, M.: Joburn. Exper. Path., 1927, viii, No. 3, 149. to twelve inoculations, most cases of chronic 'Lowe, Cronin: British Dental Journ., May 1st, 1928; British infection, such Medical Journal, July 21st, 1928; ibid., July 13th, 1929. as the rheumatic group, will require many more, and it is quite usual to have to continue a systematic treatment with vaccine for at least a year. Nor should it be con- sidered extravagant to suggest that in the severe cases THE MODERN TREATMENT OF treatment may have to be carried on, perhaps with GASTRO-ENTEROPTOSIS intervals, for two or even three years before ultimate ST success is obtained, when it is considered how extensive A. P. CAWADIAS, O.B.E., M.D.DuRH. AND PARIS, the tissue damage may be, how long the infection has M.R.C.P.LOND. been present, and how debilitated the patient's general LATE CHIEF OF MEDICAL CLINIC, PARIS UNIVERSITY, BEAU'JON condition has become. If vaccine treatment in cases of HOSPITAL rheumatic infection, for instance, was commenced earlier and persisted with efficiently, a large percentage of the Inefficacy in the treatment of gastro-enteroptosis is due *permanent disabilities from this cause would be prevented. to our erroneous conception of the unity of this morbid The first aim of vaccine therapy is to arrest the infec- condition. Gastro-enteroptosis is not one disease. There tive process by raising an efficient bacterial resistance. are four distinct forms of it, and we could, in fact, from When this has been accomplished, further treatment must the nosographical point of view, speak of four different still be directed to the maintenance of an active immunity diseases. These are (a) the constitutional gastro-entero- and to the recovery, so far as is possible, of pathological ptosis, or Stiller's syndrome; (b) the neurotic gastro- tissues. These later courses of vaccine will usually allow enteroptosis, or Adler's syndrome; (c) the organic of a considerable increase of interval between doses, gastro-enteroptosis, or Glenard's syndrome; and (d) the which are themselves only increased in amount when gastro-enteroptosis complicated by perivisceritis. For further improvement is absent. In some cases the naturai a perfect individualization of our therapeutic handling- power of maintaining an adequate resistance to a par- the only safe way to success-we must consider this ticular infection appears to be deficient, and in such the division, which is based, not on a static, but on a dynamic best method of maintaining their freedom from reinfection clinical observation of gastro-enteroptosis and also on is by the persistent continuation of vaccine treatment at, the observation of the action of various therapeutical perhaps, monthly intervals. Numerous sufferers from agents. chronic respiratory, intestinal, and rheumatic infection STILLER'S SYNDROME have been changed from a life of invalidism to compara- The term " Stiller's syndrome " is applied to this form of tive normal activity by the employment of this method gastro-enteroptosis because it was Stiller (of Budapest) who of-continuous* vaccine-treatment, which, if omitted for -first pointed out the relation of gastro-enteroptosis to a too :long an interval, results inl the gradual reappearance type of constitution-that is, to a particular psycho- of some well-recognized symptoms of relapse. physical construction of the individual. OF THE BEITISTIS 1161164 JUNEJUN 25,25 1932] TREATMENT GASTRO-ENTEROPTOSTS 1932]A TRATETUFRATR-ETROTOL MEDICAL JOURNAL This form of gastro-enteroptosis is not a morbid con- in other words, to express their difficulties by what Adler dition but a special type of constitution-one of those has called jargon-a dyspeptic syndrome develops. special " types " into which men have been grouped Thanks to their physician, they have been furnished according to their morphological features. It coincides with a convenient form of organic expression of and is synonymous with what is known as asthenic con- their difficulties. The first rule, therefore, in handling stitution (Stiller and Kretchmer), linear type (Stockard), constitutional gastro-enteroptosis consists in the avoidance microsplanchnic hypovegetative constitution (Pende). of drawing attention to the visceral condition, but this Individuals who possess the features of this biotype have rule does not summarize the whole attitude of the internist. usually a stature below the average. Their thorax is Something more positive must be done. The life of the bigger than the , and is narrow and long. The patient must be adapted so as to make him avoid great abdomen is restricted both in the transverse and in the physical and mental strain. His diet particularly must antero-posterior diameter, and has flaccid and thin muscular be adjusted so as to be of easy digestion, substantial walls. The limbs are long, the muscles thin, showing quantitatively, and complete from a qualitative point of scarcely any outline. There is a very great scarcity of view. fat. Clinical and radiological examination of the internal ADLER'S SYNDROME organs shows a small and dropped heart, - The term " Adler's syndrome " must be applied to this meaning elongation of the , which brings the form of gastro-enteroptosis because it is owing to Adler inferior pole of this organ into the pelvis-coloptosis, and that we understand the mechanism of the expression of the nephroptosis. These persons have a low blood pressure. mental difficulties of an individual through symptoms Psychologically-as has been emphasized by the work related to an organ in a condition of inferiority, in other of Kretchmer-they have a tendency towards intro- words, through organ jargon. version. They do not show any symptoms, and it is, From a clinical, descriptive point of view sufferers from in fact, remarkable how an intensely ptosed stomach Adler's syndrome have the morphological features may function perfectly. It must not be forgotten, described with the preceding form-the gastro-enteroptotic however, that on account of their endocrine, vegetative habitus. They are not, however, free from symptoms, and psychical inadequacies, they are predisposed to and even as children they give evidence of psychical in- certain diseases; in other words, they resist certain external balance, being nervous, sensitive and difficult. The real aetiological factors less well than do others. Thus defects and complete morbid condition occurs later, and beginis of diet will produce in them various dyspeptic disturb- at certain periods of life corresponding to situations of ances, infections will easily localize in the digestive tube, mental difficulty as, for example, in puberty, marri-ge, while psychical trauma will readily develop neurotic menopausis, or following great emotional stress. WIheIn conditions of the introvert (schizoid type). Certain the morbid condition is completed, symptoms may be infections, like tuberculosis or scarlet fever, will develop grouped into two symptom-complexes-digestive and more intensely than is the case with other people. nervous-which are added to the morphological symptom- It is important to bear in mind the physiopathology of complex or gastro-enteroptotic habitus. Morphological, this condition. Such individuals are born with certain digestive and nervous symptom-complexes can thus be inadequacies of their endocrines and of their vegetative described as constituting the gastro-enteroptotic tripod. nervous system-vegetative imbalance and thyroid and The digestive symptom-complex is of the irregular type. gonad dysfunction. On account of this there occurs a Patients complain of lack of appetite. They feel a great maldevelopment of the stature, of the viscera, and also weight on the abdomen immediately after meals-even of the central nervous system, particularly of the psycho- while they are taking their meals. Gas is expelled from associational cortex, the seat of the mental processes. the mouth fQllowing aerophagy, or from the anus. In- The maldevelopment of the viscera consists in viscero- testinal symptoms such as often occur. All ptosis, which can be explained as follows. The stomach these symptoms are not relieved in the reclining position, and the other abdominal viscera are maintained in position nor are they relieved through Glenard's test, to be (a) by the tonus of the vegetative nervous system; (b) described later. Their essential feature is that they are by the intra-abdominal fat, which constitutes a sort of erratic. The nervous symptom-complex comprises head- cushion ; (c) by the tonus of the muscular retention aches, insomnia, depression, a tendency towards brooding apparatus-diaphragm, abdominal muscles, and dia- upon themselves (Kretchmer's schizoid syndrome) and, phragma pelvis. As in the individuals we are describing principally, anxiety as to their condition. These patients there occurs a constitutional disturbance of the vegetative often think that they have a severe abdominal disease. nervous system and of the storage of fat, the production They restrict their social activities. They restrict, in of this gastro-enteroptosis is easily understood. particular, their diet, and thus a vicious circle occurs, From a therapeutic standpoint one may say regarding because the inanition to which they condemn themselves constitutional gastro-enteroptosis what Osler said of hyper- accentuates their gastro-enteroptosis. This inanition tension. The greatest complication of this form of gastro- causes, in fact, the disappearance of the scanty intra- enteroptosis is that a physician may discover it and abdominal fat that remains, the atrophy of the muscular communicate his discovery to the patient. Constitutional wall of the abdomen and of the viscera, and the dysfunc- gastro-enteroptotics show no symptoms, and although the tion of the badly nourished endocrines and vegetative patients cannot lead a very strenuous life they can nervous system. maintain perfect health up to a very old age. When, They thus differ clinically from those patients showing however, they are told by their physician that they have the pure Stiller's syndrome-a difference which can be a dropped stomach the clinical picture changes completely. explained by the study of their physiopathology. In this From that day onwards their life becomes terrible. Their case also patients are born with the same psychical, attention being drawn to the dropped stomach, their endocrine, and nervous vegetative inadequacies which, mental balance-which as we have seen is not perfect- in conjunction with certain external factors, help in the is upset. On the strength of their tendency to intro- development of the constitutional gastro-enteroptosis of spection they develop a syndrome of anxiety neurosis Stiller's syndrome. There is, however, a certain peculiarity centred on their digestive functions. As, on account in the aetiological constellation of Adler's syndrome in -of their special mental make-up, they have the tendency that the psychical constitutional inadequacy is more to shirk the difficulties of life by the flight into disease- marked. Further, another mechanism interferes. Such TREATMENT OF r THE BRITISIH 1165 JUNE 25, 19321 GASTRO-ENTEROPTOSIS L MEDICAL JOURNAL individuals remain for a certain time without any sym- to take his meals lying down, or at all events to rest ptoms, as in the pure Stiller's syndrome, until they find oIn a couch during the digestive period. themselves in a difficulty-in a position of psychical Next to psychotherapy and dietotherapy it is a com- coniflict. By the well-known psychical mechanism bination of physiotherapeutical procedures that is of emphasized by Adler, this psychical conflict will express the greatest imp6rtance in this type of patient. The itself in organic language. To get out of his difficulty best physiotherapeutical method in my experience is the the patient grasps his inferior organ, the ptosed stomach, continuous galvanic current-one electrode on the back, and concentrates his mind on it. He becomes aware and another, slightly smaller, on the abdomen. Small of the slight disturbance of digestion due to gastro-entero- doses, 10 to 20 milliamperes, are sufficient, but often ptosis, and he cultivates this disagreeable symptom as an patients cannot stand more than .5. A series of four- escape from the conflict. A vicious circle is established, teen treatments, one every two or three days, brings great because the concentration of the mind on the stomach amelioration of the condition. Gymnastics, in the form accentuates the disturbances of the organ. As I have of the various Swedish movements, respiratory exercises, already pointed out, this introduction of the psychical and general massage, are of great help. The focusing element into the gastroptosis is ofteni initiated by the of the attention on the gymnastics of the abdominal physician who speaks to the patient about a " dropped muscles is not here so important as it will be for the stomach." next form of gastro-enteroptosis. Climatotherapy is also Value of Psychotherapy valuable. A short sojourn in a mountain climatic station, The physiopathology of this syndrome being different or in the Highlands of Scotland, or at a height of over from that of Stiller's syndrome, treatment will also follow 3,000 feet on the Continent, is of great benefit. If, different lines. Psychotherapy is the basic, but not the durinig this sojourn, a careful dietotherapy is applied, exclusive, therapeutical procedure. The first thing that and the psychological environment is cultivated, a very must be done is to find out the difficulty of the patient- beneficient physiotherapeutical synergy is obtained. his conflict-and endeavour to remove it. This does not clemand those long psycho-analytical explorations which Further Methods - have been the fashion for a certain time. The careful study The therapeutical constellation will be completed by of the personality of the patient will be made while the the following adjuvant methods: (a) actinotherapy under physician is treating him with other methods. It is much the form of carbon arc irradiation, with carbons rich in safer not to concentrate on a pure psychotherapeutic short ultra-violet; (b) pharmacotherapy in the form of handling, but to permeate with psychotherapy our whole alkalis; (c) biological therapy in the form of pancreatic procedure. or gonad preparations. Crenotherapeutical, orthopaedic, The next element of the psychotherapeutical handling and surgical procedures are not indicated. It is useless of the neurotic gastro-enteroptotic patient consists in to waste time with a sojourn at a spa when a stay in diverting attention from his digestive disturbances. This a climatic mountain health resort is far more beneficial. is a very delicate part of treatment, because such patients The wearing of an abdominal belt makes these patients often hold fast to their morbid condition, as it is for feel uncomfortable, and rather helps them to cultivate them the means through which they satisfy their will their 'disease by concentrating their attention on their to power. Thus we must endeavour to change the dropped viscera." attitude of the patient to his disease. This will not be As for surgery, it is when this procedure is applied secured with rough optimism, the famous " pull yourself to such a form of gastroptosis that the term "vandalism," together" principle, but with a careful psychology, the used by Stiller, becomes adequate. In most cases patients success of which does not depend on this or that method, suffer after the operation as much or even more than but on the tact and personality of the physician. While before. In exceptional cases some relief may be obtained, we are changing the attitude of the patient to his disease but I think that on these occasions we have to do with we have to encourage him, and of course this encourage- an intense form of psychotherapy. A few years ago I ment will be more easily accomplished through a distinct myself advised an operation in a case of amelioration of the physical condition. Such patients wvhich did not yield to any treatment, because I considered are not purely mental. They have an organ inferiority erroneously that the patient had organic gastro-entero- of the stomach and intestines which must be dealt with. ptosis. On opening the abdomen the surgeon found that They have an abnormal condition of their vegetative the visceral condition was not such as to justify radical nervous system and endocrines which also must be fixation, and he closed the abdomen without any special considered. Pure psychotherapy has never been a good interference with the viscera. Notwithstanding that, the method of treatment. patient got rid of her symptoms. Unfortunately many errors are committed in this Other Foryns of Treatment direction because, by a singular coincidence, patients Dietotherapy is also a star of first magnitude of the attacked with this affliction clamour loudly for active therapeutical constellation to be applied to these patients. surgical intervention. When struck with what Texor calls Abundant, substantial, and easily digested food must be the " mania operativa passiva " they may find themselves given, after taking into consideration the individual in the presence of surgeons afflicted with a " mania reactions. Many of these patients eat too little, not only operativa activa," and the most fantastic operations may because their digestive capacity is diminished, but also result from such an unlucky meeting. ont account of a certain mental element of anxiety. This voluntary inan;ition accentuates, as we have seen, their GLENARD' S SYNDROME morbid condition, by the mechanism of a vicious circle The organic gastro-enteroptosis, or Glenard's syndrome- which must be broken through dietotherapy. As with named thus from the Vichy clinician who first described all therapeutic methods, dietotherapy must not be applied gastro-enteroptosis in general and this form in particular exclusively, but in combination with other means of -is not a pure constitutional type like Stiller's syndrome, treatment. The high caloric and substantial diet which nor a nervous disease like Adler's syndrome, but an is advised in gastro-enteroptosis may not be s'upported organic disease of the digestive organs. In other words, without the help of certain pharmaceutical procedures. although there is in such patients a constitutional and a The patient will be advised at the beginning of the cure psychical element, it is the local organic condition of the TREATMENT OF [ THE BRITIWS 1166 JUNE 25P 1932] GASTRO-ENTEROPTOSIS IMEDICAL JOURNAL I digestive organs that dominates the clinical picture and easily develop. It is here also that we meet with intense directs the therapeutic handling. , the so-called " duodenal migraines." Here also is found the same basic morphological sym- (d) In gastro-coloptosis the colon as well is ptosed, and ptom-complex, the gastro-enteroptotic habitus which in many cases the colon involvement predominates, being characterizes the three forms of gastro-enteroptosis, but often limited to the right colon (mobile caecum). Intes- this morphological symptom-complex is more accentuated. tinal symptoms, particularly constipation and attacks of Here also we meet with nervous and digestive symptoms, diarrhoea, constitute the essential symptom-complex in as in the neurotic gastro-enteroptoses, but they differ from the latter type. those of the neurotic gastro-enteroptoses and depend on The physiopathology of this condition explains these the anatomical condition of the organs involved. The clinical peculiarities. Such patients are born with the common feature of these symptoms is the orthostatic same inadequacies of endocrines and nervous system accentuation. Symptoms are more intense when the as those belonging to the preceding forms. There is, patients pass from the horizontal to the vertical position, however, a more localized maldevelopment of the viscera, and, in general, rest in a horizontal position brings great and particularly anomalies of the development of the relief. Symptoms are also relieved when Glenard's test . Later in life external aetiological factors is applied-that is, when the physician, placing himself act with greater intensity than in the case of the neurotic behind the patient, makes a sort of belt with his arms, gastro-enteroptosis, and act particularly on the static and tries either to raise with his two hands the hypo- condition of the viscera. These factors consist in faults gastrium or to press the whole abdominal surface from in diet, in malnutrition, in various cachetic diseases, the front backwards. This relief through horizontal repeated pregnancies, and sudden diminution of intra- position and through Glenard's belt test is not met with in abdominal pressure, such as, for example, occurs in evacua- any other form of gastro-enteroptosis. tion of ascites, or in removal of large abdominal tumours. Thus this localized constitutional maldevelopment of the Features According to Localization viscera and this intense action of external aetiological The anatomical condition of the digestive organs causes factors on intra-abdominal conditions explain the pre- some variation in symptoms. ponderance of the organic visceral element. (a) In the total gastro-pyloro-duodenoptosis-that is, in cases in which the inferior pole of the stomach, pylorus, Visceral Orthopaedy and Other Treatment and are all lower than normal-the gastric The preponderance of this visceral element indicates a evacuation is disturbed in general, and symptoms take the line of treatment different from that of the preceding form of hyposthenic dyspepsia with aerophagy. Patients forms. The basic therapeutical procedure here is visceral complain of weight in the stomach immediately orthopaedy. This consists in the application of various after meals (and even while they are taking them), of belts or bandages. Such belts are of two kinds: the flatulence, , and constipation. The general con- Glenard type, which is a simple bandage, and the dition is much impaired. There is a general feeling of Enriquez type, which has a pneumatic cushion that can depression and slight headaches. The pulse rate is usually be filled with air. As far as possible, the first application accelerated, this acceleration also diminishing when the of these belts must be made with the help of a radio- patient lies down (Leven's orthostatic tachycardia). logical examination ; at all events, the action of these belts (b) In the vertical dislocation of the stomach its lower must be followed closely for a time. Often patients feel pole is ptosed, but the pylorus and the duodenal bulb a great relief, but in certain cases this does not occur, remain fixed. There thus occurs a sort of obstruction in and there may even be an accentuation of the symptoms. the pyloro-duodenal passage, and the clinical picture is This means either that the suspension of the viscera has that of the pyloric syndrome. At a certain interval after not been well made, and on this point an x-ray examina- meals patients suffer from pains, acidity, and sometimes tion will give certain information, or that there is a vomiting. These symptoms are grouped into periods of superadded nervous vegetative disturbance, in which case suffering-weeks or even months-and there are intervals the belt must be discarded. of calm, as in the case of duodenal ulcer. Relief is marked Visceral orthopaedy will be completed by a com- in the horizontal position or during Glenard's test. The bination of special electrotherapeutical and kinesi- depression and the headaches are more accentuated. therapeutical procedures, consisting of massage of (c) In gastro-pyloro-proto-duodenoptosis the lower pole the abdominal muscles, special gymnastics of the of the stomach, the pylorus, and the duodenal bulb are abdominal muscles, aided by the application to the latter ptosed, but the second portion of the duodenum remains of galvanic interrupted current. This form of physical fixed. The pylorus and the protoduodenum drag down- treatment cannot, however, yield any results unless it is wards the second portion of the duodenum, and so make applied by the gastro-enterologist himself. As we have it describe a sort of horseshoe. The evacuation of this seen, conditions in gastro-enteroptosis are so complicated portion is thus disturbed, an occurrence which is accentu- that an unqualified masseur, or a simple technician electro- ated by the closing of the duodenio-jejunal angle on account therapeutist, can do more harm than good. The evolution of that dragging down of the second portion of the of gastro-enterology towards the application of physical duodenum. It is the disturbance of evacuation of the methods by the specialist himself finds, in such cases, duodenum that explains the severity of the clinical picture, an ample justification. which takes the form of the duodenal stasic syndrome. Dietetic treatment cannot follow, in this form, the lines Pains are late, as in the preceding group, and are accom- indicated for the two preceding forms, because there is panied by vomiting. An attack of diarrhoea often marks a great incapacity of the digestive function. We must, the end of the painful attack. There often occurs a however, try to give patients substantial feeding, follow- slight jaundice, this hepatic involvement being due to ing the individual reactions of each individual case, and the disturbance of the evacuation of the bile, from the help the digestion with various pharmaceutical prepara- abnormal position of the duodenum. The general con- tions. Among these the best are alkalis, in small doses dition is much disturbed, and the nervous symptoms are taken immediately after meals, mixed with sodium much more accentuated. It is in this form that we meet sulphate (half a drachm of each in a tumblerful of Vichy with the greatest cachexia, a condition wlhich diminishes so water taken in the morning on awakening). This last much the resistance of the body that tuberculosis can preparation has the property of stimulatting the function THE BRITISH JUNE 25, 19321 FOOD ALLERGY NMEDICAL JOURNAL 11671 of the liver, and Glenard himself showed the importance us to distinguish four essentially different conditions, of the hepatic element in such conditions. Insulin treat- each one susceptible to different therapeutic procedures. ment, combined with glucose feeding, also constitutes The constitutional gastro-enteroptosis, or Stiller's syn- ani important element in the treatment of such patients, drome, is a constitutional type and not a disease. The lout is not successful with all of them. It is better applied neurotic gastro-enteroptosis, or Adler's syndrome, is a in a nursing home. Crenotherapy must be applied to nervous disease. Glenard's syndrome, and the gastro- such patients when their condition is not far advanced. enteroptosis with perivisceritis, are both organic diseases. The Vichy type of spa is essentially indicated, because This division is, of course, important only from a it acts as Glenard has shown, through the modification nosographical point of view; we treat individuals and not of the functions of the liver. Carlsbad and Chatel-Guyon diseases. In order to treat individuals, however, and to are indicated in forms with distinct constipation; Harro- be able to detect the individual peculiarities of each gate, Bridge-of-Allan Spa, Cheltenham Spa, Leamington patient, precise clinical descriptions of groups are neces- Spa, Vittel, Kissingen, and Wiesbaden for a milder sary, and the justification of the description I have given treatment. is that it serves as a better introduction to individual Surgery must be considered only as an adjuvant method, treatment than does the usual textbook conceptioln. anid is indicated exclusively, in may opinion, when the luodenum is involved. Even in this case everything must be done to treat the patient medically before there is any surgical intervention, and also to continue inter- A NOTE ON FOOD ALLERGY IlistiC treatment after surgical operation. I have seen so many patients, after a more or less short temporary BY relief following operation, relapse into their previous A. M. KENNEDY, M.D., M.R.C.P. I more and more sceptical PROFESSOR OF MEDICINE, UNIVERSITY OF WALES, AND DIRECTOR condition, that am becoming OF THE MEDICAL UNIT, WELSIH NATIONAL SCHOOL OF about the success of these procedures. I am asking myself MEDICINE, CARDIFF if that temporary relief has not been determined by the enforced rest and severe treatment in a nursing home Hypersensitiveness to the proteins of certain kinds of necessitated by the operation. Such nursing home treat- food is more common than is generally realized, and may ient, incidentally, is much indicated in these cases. show itself by various forms of reaction. The appearance of an urticarial rash, and occasionally vomiting and GASTRO-ENTEROPTOSIS WITH PERIVISCERITIS diarrhoea, in some people, following the ingestion of This is the fourth form of gastro-enteroptosis, and shell-fish (for example, oysters) has been recognized for differs from a clinical, physiopathological, and thera- a long time. But proteins from many other foods may peutical point of view from the others. Clinically it is produce allergic reactions in susceptible individuals, and, characterized principally by the fact that pains are more moreover, it would appear that the exciting agent need intense, more permanent, and are not relieved in the not necessarily be a protein, but that non-nitrogenous horizontal position, nor by Glenard's test. Digestive substances may possibly be responsible in some cases. disturbances, gastric or intestinal, are also more marked, more permanent, and also persist in the horizontal position SYMPTOMATOLOGY OF FOOD ALLERGY or in the eliciting of the Glenard's test. The general Acutte Cases.-Symptoms may be gastric or intestinal, impairment of nutrition is great. Pain is elicited on or both, and come on promptly after eating the particular pressure in various parts of the abdomen, and radiological food to which the patient is sensitive. In many cases exploration shows the immobilization of the viscera. sickness and vomiting, abdominal pain, colic, distension, These patients are organic gastro-enteroptotics in whom constipation, and sometimes diarrhoea, are the most perivisceritis has determined adhesions. This peri- frequent symptoms. They are probably due to spasmn visceritis is most frequently the effect of abdominal of the smooth muscle with congestion and oedema of the operations. The soil is very important, and it has been mucous membrane and resulting hypersecretion. Some noted that there are individuals in whom post-operative of the severe cases may simulate an acute surgical adhesions are produced more easily than others. Peri- abdomen, and symptoms of obstruction-due to muscular visceritis may, however, be the sequel of a simple . spasm and localized angioneurotic oedema-may lead to Treatment differs from that of the other forms. The an unnecessary laparotomy being performed. basic therapeutical method is abdominal diathermy, which In other cases the colon reacts and a mucous colitis -as all the physical methods relating to digestive diseases occurs. An attack of urticaria or angioneurotic oedema -must be applied under the direct supervision of the may accompany the gastro-intestinal disturbances, but gastro-enterologist. The diathermy is helped in its action this is by no means a constant feature. An acute by certain protein shock preparations. Visceral ortho- oedematous swelling of the lips, mouth, and pharynx, paedy in this form does more harm than good, and associated with a burning sensation in the mucous mem- patients feel very uncomfortable with abdominal belts. branes, occasionally arises, and may be accompanied by MIassage is contraindicated. Surgical intervention may mucous colitis. Urticaria and angioneurotic oedema may bring a temporary relief, but it is well known that occur independently of other manifestations, and may adhesions separated surgically are easily reformed. Care affect any part of the body. Sometimes an attack of must be taken to prescribe for these patients a diet as migraine or other cerebral disturbance is set up; at others complete from a qualitative and quantitative point of. there may be an attack of dyspnoea or bronchial asthma. view as possible. Psychotherapy is important, but is not In a few instances, fortunately very rare, alarmingly grave the predominant method, as in the case of neurotic gastro- symptoms resembling acute anaphylactic shock appear eniteroptosis. Treatment in a nursing home is strongly at once. Here there is severe abdominal pain accom- advisable. Crenotherapeutical procedures are useless. panied by sickness, vomiting, and diarrhoea-sometimes bloody-urticarial rash, collapse, and even death within GENERAL CONCLUSIONS a few hours. Enough has been said to show that within the frame Sutbacute and Chronic Cases.-Among symptoms met of the textbook gastro-enteroptosis, modern clinical with are abdominal discomfort or pain of varying degree, observation-the basis of the science of treatment-allows a feeling of sickness, and sometimes vomiting. They may