ROENTGEN SICKNESS

The phenomena of X-ray sickness or intoxication are exciting great interest at the present time because of the greatly increased use of deep-seated intensive therapy. Many theories have been advanced in explanation of "Roentgen-sickness," such as high induced voltage in patients during irradiation, gas-poisoning in X-ray rooms, and psychical causes, but the chief clinical and experimental studies of the condition have centered about the essential biochemical changes resulting from X-ray and radium irradiation. Temporary depression of the functions of the kidneys, gastrointestinal tract and liver, "acute uremia," acidosis, proteolytic toxemia or autolysis, anaphylactic conditions, etc., have been regarded by various writers as the cause of the clinical disturbances following irradiation. The literature upon this subject is already very large, and growing rapidly. Miescher noted radiation sickness in 40 per cent of 160 cases treated, the disturbance being most marked when the radiation was over the epigastric area. Groedel and Lossen thought that the sickness depended upon the amount of glandular tissue irradiated. Pfahler, Guthman and others have suggested the possibility of gas-poisoning as the important factor in the production of the condition. Rieder has suggested the possibility of induced high voltage of the patient's body during intensive X-ray treatment. Damage to the kidneys was early suggested by Warthin, Edsall and Pemberton and others. Toxic products of protein decomposition from the tissues or autolytic enzymes from the white blood cells destroyed by the irradiation have been regarded as the possible agents acting upon the kidneys, either causing a toxic nephritis or depressing the renal function temporarily. Andersen and Kohlmann regard Roentgen sickness as analogous to an acute uremia, and to be essentially

a vagus stimulation causing altered mineral content of the blood. They recommend the administration of calcium salts, both by mouth and intravenously, for prophylaxis and treatment of the condition. Evidence as to the theory of acidosis is very contradictory; some workers have found evidence of acidosis in experimental animals after irradiation, others have not. Likewise, the theory of anaphylaxis advanced by Bergonié and others has no supporting evidence. Prendergrass thinks that the toxemia is due to the action of cholin and neurin produced by the breaking up of lecithin lipoids; and Werner has shown that the effects of irradiation may be imitated by the injection of cholin and enzytol. Hall and Whipple noted autolytic changes in the intestinal epithelium in experimental irradiation of dogs. They regard X-ray intoxication as similar to the intoxication following burns, and due to the toxic action of decomposition products of protein. Other observers, Theiss, Werner, Mills and Warthin have noted the occurrence of hepatic lesions after irradiation with X-rays or radium. Czepa and Höglar found that hepatic functional tests applied after irradiation showed a marked depression of liver function. It is probable, therefore, that the factors entering into the production of Röntgen sickness are complex in nature, and may vary greatly in any given case. E. C. Dodds and J. H. D. Webster have studied the metabolic changes associated with X-ray and radium treatment (Lancet, March 15, 1924, p. 533). Their observations were made almost entirely on the urine, although some blood examinations were made. The patients were in bed and kept on a uniform diet. The urine of each patient was studied for a week before the irradiation in order to fix the levels of their urinary constituents. Observations were made on the volume, urea, uric acid, ammonia, acidity, total nitrogen, ammonia coefficient, phosphates, chlorides, creati

nine and diastase. Some of the investigations were carried out over a period of five months. The observations were classified, according to the site of irradiation, in four groups; abdominal irradiation, cervical, thoracic, and irradiation of any other part of the body. The results of this study showed that similar effects were produced by either X- or gamma rays. The changes in the metabolism were found to vary with the part irradiated. Irradiation of head, thorax and limbs produced no changes in the metabolism of the cases examined. Radiation of abdomen and spleen produced definite urinary and blood changes. There was a sudden fall in the twenty-four-hour amounts of urea, uric acid, nitrogen, ammonia, titratable acidity, creatinine, total nitrogen and phosphates. The volume of urine was also greatly decreased. After three days the excretion of these substances rose to about the normal figure. In the case of uric acid and phosphates, the twenty-four-hour amounts continued to increase after the normal level had been reached but returned to normal again in about five days. The chloride content and diastase showed an immediate increase

returning to normal in about three to six days. The ammonia coefficient showed an increase for about three days, falling to normal in six days. The blood analysis showed a marked decrease in the urea content with very little change in any other of the blood contents. Examination of the feces showed an immediate increase in the fecal fat content, almost solely in the neutral fat fraction. From these results the authors conclude that the effects of irradiating the abdomen can be explained by a temporary inhibition of the functions of the principal abdominal glands, such as the liver, pancreas and kidneys. No support is given to the acute uremic theory of Andersen and Kohlmann. The rise in the ammonia coefficient is in agreement with the acidosis theory of Lange, and the increase in fecal fat content also supports the work of Whipple and Hall. The fall in blood-urea is difficult to explain but may be due to inhibition of liver function. A considerable number of cases were given prophylactic treatment with calcium chloride and a few with sodium bicarbonate, and all showed less reaction.

Written primarily for practitioners of medicine, this practical book on the methods of determining the facts upon which accurate diagnosis rests will be also of great value to Junior and Senior students in our medical schools. According to the author, the book is intended to furnish an intermediary between the classical descriptions of the textbooks of medicine and the treatises on the latest methods of treatment. It is a handbook of practical diagnosis from a broader standpoint than that of laboratory methods alone. It emphasizes the need of training the senses of touch, sight and hearing if refinement of diagnosis is to be achieved. Its contents consist of chapters on the theory of diagnosis, the assembling of data, the physical examination of the body as a whole and of its most important areas and systems, and the especial diagnostic methods, other than the physical examination, applied in the study of abnormal conditions of any organ or system. All of these methods of diagnosis are given a practical application to the most common and important diseases involving the various parts of the body, and the most salient points in differential diagnosis are accorded due consideration. There is a final chapter on immunological tests. The book is illustrated with 67 figures, plain and colored. A book which gives the individual standpoint of any skilled clinician with reference to his diagnostic methods must convey a great deal of the individual atmosphere of his clinic,

and this fact adds increased value to a book of this type. In addition to the practical value of the assembling of methods of recognized value there is added the rarer value of the personal point of view.

Differential Diagnosis. Presented through an Analysis of 317 cases. By RICHARD C. CABOT, M.D., Professor of Medicine and Professor of Social Ethics, at Harvard University. Volume 2, third edition, Revised. Octavo of 709 pages, 254 illustrations. Philadelphia and London: W. B. Saunders Company, 1924. Cloth, $9.00 net.

The third edition of Volume 2 of Cabot's well-known differential diagnosis presents considerable modification and enlargement of the introductory discussions to the cases which remain unchanged. This is true particularly of those concerned with abdominal and other tumors. These changes are all of importance in bringing the material of the book more nearly up to date, and thereby increasing greatly its value. In this volume there are nineteen chapters dealing with the following subjects: Abdominal and other tumors, vertigo, diarrhea, dyspepsia, hematemesis, glands, blood in the stools, swelling of the face, hemoptysis, edema of the legs, frequent micturition and polyuria, fainting, hoarseness, pallor, swelling of the arm, delirium, palpitation and arhythmia, tremor, and ascites and abdominal enlargement. The plan of treatment followed in this work is well-known. It represents a highly-individualized point of view, both as to experience and as to diagnostic conclusions; and this is its chief value. It is highly stimulating, provoking both agreement and dissenting opinions. For these reasons, if for no other, Cabot's two volumes are of immense value to the practitioner.

Medical Diagnosis for the Student and Practitioner. BY CHARLES LYMAN GREENE, St. Paul, Minnesota. Fifth Edition Revised and Enlarged. With 1453 pages and 14 colored plates and 623 other illustrations. Philadelphia: P. Blakiston's Son & Co., 1923. Cloth, $12.00.

Greene's well-known book on medical diagnosis has been revised and enlarged by many additions, notably the sections on cardiovascular diseases, influenza, and pneumonia. Polygraphic and electrocardiographic technique and interpretation have been accorded especial attention, and the work has been brought up to date in many other particulars. In others, however, it lags behind. The pathology throughout is the weakest part of the book, and much of it is antiquated or too superficial. The paragraphs devoted to syphilis and to diabetes may serve as examples. There are many important omissions, both of English and foreign medical literature. The difficulty of keeping a book of this type up to date without completely rewriting it every two or three years is, of course, obvious; and, since this has not been accomplished, the work, while containing an immense amount of accurate and useful material, is very uneven in spots.

The Pathological Physiology of Surgical Diseases. By Prof. FRANZ ROST of Heidelberg. Authorized Translation by STANLEY P. REIMANN. With Foreword by JOHN B. DEAVER. 535 pages. Philadelphia: P. Blakiston's Son & Co. Cloth, $6.00. While designated by the author as "A Basis for Diagnosis and Treatment of Surgical Affections," all of the material

included in this volume is of essential value to the internist in the differential diagnosis of non-surgical and surgical affections. It is to the internist first, that the great majority of patients that ultimately become surgical go; and it is in his hands that the first differentiation between purely internal conditions and those demanding surgical interference must be carried out. This volume considers the literature of surgical pathologic physiology in twelve chapters devoted to the oral cavity and esophagus, stomach, pancreas, liver and gall-bladder, spleen, peritoneum, intestines, male genito-urinary apparatus and hypophysis, thyroid gland, chest cavity, brain and spinal cord, and the extremities. This literature is almost wholly the older literature. Very little of it dates after 1912. The translator has introduced some recent references. On the whole the literature has been very well abstracted, and put into a practical and readable form. It has been improved in the translation which reads easily and smoothly, and renders the essential thought clearly. It is a book of great library value to every practitioner of medicine. The practical technique of surgery is not touched upon. The physiologic effects of surgery on the living human subject and as illustrated by animal experimentation, and the deductions from such observations constitute the chief subject matter; and, as this is derived from numerous articles scattered through the literature, its collection and condensation into the present volume make it of very great value to those practitioners who have neither the time nor the opportunity to do this for themselves.