1919 Journal of the American Medical Association  
search is made for them. The absence of other phys¬ ical signs and the negative findings in roentgenograms prove that other cause does not exist for the history; and correction of these defects, with prevention of further intestinal or omental pinching, removes the gastric symptoms. Chronic pelvic inflammatory dis¬ ease in women, and old adhesions involving the intes¬ tinal wall in a former peritonitis, are other conditions that at times may simulate ulcer in the way described. Pelvic
more » ... n, giving direct or positive evidence, and .roentgenograms giving indirect or negative evi¬ dence, call attention to the site of the real pathologic condition. 6. Gastric Crues.-The hardest lesson to learn about abdominal disease is that of "gastric crises," due to no disease within the abdomen itself, but to disease in the spinal cord. These crises come at irregular inter¬ vals, weeks or months apart, with good health between. They last for days or weeks, and the attacks are char¬ acterized by intense pain and by vomiting, so that the patient fears to take food and cannot keep it if he does. No wonder the first thought with such a history is of some disease of the stomach ; and commonly of ulcer as corresponding most closely in its manifesta¬ tions. The physical examination of the abdomen is negative in such case ; and the stomach contents most often show hyperchlorhydria after an attack is over. It is not surprising, therefore, if such symptoms have in the past misled us, even to the point of advising a gastro-enterostomy to prevent their repetition. Now, however, the negative roentgenographic findings come to our rescue, to save us from error ; and at all times, even without roentgenograms, we have other definite signs to point out the real disease, if only we take the trouble to look for them. First, these signs consist in alteration of reflexes, in one pupil or both ; in patellar or Achilles tendons, perhaps only on one side; or in the plantar reactions to stimuli. Second, and most important, lumbar puncture and examination of spinal fluid for cell count and Wassermann reaction afford the most constant clue to the real disease present. Gastric Neuroses.-These are still mentioned in the textbooks, in the differential diagnosis of ulcer, but their existence outside of textbooks must be considered very dubious. A history resembling that of ulcer, with hyperchlorhydria, does not occur without some path¬ ologic condition somewhere in the body, usually in the abdomen, to explain it. In times past this "acid dys¬ pepsia" has been considered as a possible result of a disturbance of the nervous system only; but such a supposition, with our increased facilities for eliciting facts, is no longer tenable. The exact cause of the clinical picture may not always be obvious, but one always exists, and careful search will sooner or later reveal it. CONCLUSIONS We have heretofore been too ready to diagnose ulcer, when it did not exist, because the history was typical ; but now we have learned how many other conditions may simulate this history, and we demand other data in addition to the patient's story. On the other hand, when the history was not typical, ulcer was not suggested by it and we were likely to overlook its existence because our other means of recognition were so meager. Now we have learned that the patient's story of his ailment is not always the same ; that some feel less discomfort from an ulcer than others do ; and that only a part of the classical symptoms may be present, even when hyperchlorhydria is found and roentgenograms show definitely a pyloric defect or a deformed cap. The only way to avoid error, there¬ fore, is to trust to no one elemenf in the diagnosis ; but to collect our data by history, by physical exam¬ ination, by laboratory reports, and by fluoroscopic examinations and roentgenograms ; and then to piece these data together as a child does the parts of a pic¬ ture-puzzle, to see what they will ultimately make. Fifty years ago Thomas Huxley wrote: Sit down humbly before facts as a little child, be prepared to give up every preconceived notion, follow humbly wherever and to whatever abyss nature leads, or you shall learn nothing. I have only begun to learn content and peace of mind since I have resolved at all costs to do this. For a number of years, there have appeared from time to time books by various authors purporting to give to the reader a complete understanding of blood pressure, the causation and the measuring of changes in the various factors, and the blood-pressure conditions to be found in all diseases. Independent observers have also put forth formulas for the determination, by means of blood-pressure estimation, of cardiac efficiency. Recently I have had the opportunity of studying blood-pressure findings in a large number of army officers and candidates for commissions in the army, chiefly in men over 30 years of age, medical officers being in a large majority. I am not here presenting statistics as to the distribution of these cases among different age periods, or as to the classifying of the blood-pressure readings obtained; for, while these figures might be of interest, it does not seem to me that such statistics help us to understand the conditions presented by the individual. What I wish to do is to point out some of the conditions met in this mass of material, to discuss the interpretation of the findings, and to suggest a new point of study in the analysis of blood pressures. Most of the medical officers examined came to camp from a considerable distance, and were examined the day after their arrival, without opportunity for rest after the long journey. Being physicians, they were almost universally very nervous over the ordeal of the examination. Most of them were naturally con¬ stipated, and this constipation was increased by the journey, by the change of routine, and by the change in diet. To many, sleep under camp conditions was at first difficult. From all of these causes, it was not surprising that a large number of the candidates showed an elevation of the systolic blood pressure. In a great majority of such cases, however, rest, catharsis, and the fact of becoming accustomed to the new rou¬ tine of life, soon brought the blood pressure down to within normal limits. It served to demonstrate in a very striking way the effect of overwork, .nervous strain, psychic stimulation, and constipation, in raising blood pressure.
doi:10.1001/jama.1919.02610200004002 fatcat:tor76oowtrfkjlnnygrqpqmcvq