Page images
PDF
EPUB

other specimen was shown in which the clinical diagnosis of hour glass stomach had been made, by auscultatory percussion and r-ray shadow. The specimen verified this diagnosis so far as contour was concerned but a more careful, histologic examination would be necessary to determine whether there was a genuine hour glass division of the stomach or whether the constriction, through which the opening barely admitted a slate pencil, was at the pylorus, the lower cavity in that case being the dilated duodenum.

DISCUSSION.

The discussion was opened by Dr. HENRY R. HOPKINS, who said that the question is of the greatest obscurity. Accurate notions of gastric ulcer are difficult to attain, and in the majority of cases are reached only after autopsy. A few of the questions at present unsolved are: (1) is gastric ulcer increasing in frequency? (2) is it directly related to hyperacidity due to hydrochloric acid? (3) can it be accurately diagnosticated? (4) is there an acute form? (5) is it rare in the upper classes of society? The doctor thought that pathologic micro-organisms play a very large part in the causation of this disease, because certain infections, tuberculosis, syphilis, endocarditis,-are likely to be associated with gastric ulcer. Dr. Hopkins referred to a case of a woman who died from gastric hemorrhage after confinement, probably caused by the strain of the labor. There is no disease. in which the expectant treatment is so nearly a crime as in gastric ulcer.

Dr. STOCKTON would not agree with Dr. Benedict as to the importance of hemorrhage. We cannot make a positive diagnosis without hemorrhage, neither can we make a diagnosis because of hematemesis.

Dr. Dowd related the case of a woman in whom a mistaken diagnosis of gastric ulcer was made. She was hysterical.

Dr. ALLEN A. JONES emphasised the trophic nature of gastric ulcer. A part of the stomach may be so injured by trophic conditions as to allow peptic action to attack it.

In closing the discussion, Dr. BENEDICT said that he realised that in suggesting a different use of terms to that in vogue, he had invited criticisms, but that clinical experience was forcing the necessity of recognising the existence of other forms of solution. of continuity of the gastric wall, than that commonly termed peptic ulcer. Certainly, it could not be true that the very class of persons in whom cerebral apoplexy and embolism, calcifica tion, arteriosclerosis and similar lesions in general were rare,

should have organic vascular disease of the stomach. On the other hand, ulcers of the stomach are common, both ante- and postmortem, in which there is nothing to suggest the ordinary peptic ulcer. As to the bacterial cause of gastric ulcer, he had not undertaken to enter into the ultimate causation of ulcers in general, except so far as was necessary to the classification. In many cases, possibly in all, the toxemia due to bacteria might be the underlying cause of the loss of vitality of the cells, but this point had not been demonstrated and he was not prepared to accept it as a general theory. So, too, bacteria might participate in the destruction of necrotic areas, and they certainly did in the case of gangrenous and phlegmonous ulcerations. But, as to the pathogenesis of gastric ulcer in general and, especially, of the ordinary peptic ulcer, there was no question but that the actual excavation of the ulcer was due to peptic digestion. As to the connection between ulcer and hyperchlorhydria, the condition contraindicated the use of the tube for exact diagnostic purposes and the theory that hyperchlorhydria produces peptic ulcer is not supported by a sufficient number of quantitative examinations. In many instances, such conclusions have been based on very crude methods. On the contrary, we do know that ulcer sometimes develops in patients. who have previously shown diminished hydrochloric acidity, and that hyperchlorhydrics usually fail to develop an ulcer.

Attendance at the meeting, 44. Adjournment at 10.35 p. m.

Section on Medicine, November 8, 1904.

REPORTED BY FRANKLIN W. BARROWS, M. D., Secretary.

THE regular meeting of the medical section was held in the Academy rooms, Public Library Building, Tuesday evening, November 8, 1904. In the absence of the chairman the meeting was called to order at 8.50 o'clock by the president of the Academy, DR. ARTHUR W. HURD. The minutes of the previous meeting. were read and approved.

The paper of the evening was presented by DR. W. GILMAN THOMPSON, professor of medicine in the Cornell University Medical College, New York City, entitled,

PROBLEMS IN DIETETICS.

(Abstract.)

The paper discussed certain problems, such as the feeding of patients in whom a combination of diseases might appear to demand diametrically opposite systems of diet; the evils which may result from too long continued restriction in diet, such as

weakness and anemia; the diet of obscure nutritional disorders such, for example, as arthritis deformans; and the prophylactic diet of such diseases as gout and rheumatism.

The author advocated the early feeding of typhoid fever patients with semisolid food, in suitable cases-namely, very mild cases in general; those in which a low grade of fever persists for many days in spite of improvement in the condition of the tongue, the stools, the abdomen, and the mental symptoms; cases in which a rapid loss of weight with low temperature appears to be the most serious symptom, and in uncomplicated cases on the first day of normal temperature. Relapses, he said, are rarely, if ever, attributable to carefully regulated increase in the diet, but, on the contrary, such increase may better enable the patient to withstand a relapse.

In arthritis deformans the diet should resemble that of the early stages of phthisis, consisting largely of fats and animal foods, and effort should be directed toward maintenance of nutrition by every means, including forced feeding.

In chronic nephritis, especially when complicated by cardiac disease, too long continuance of a milk diet is liable to increase the anemia and weaken the heart muscle. It is better, therefore, in many cases to allow a moderate quantity of meat in the diet, with eggs, fish and other lighter forms of animal food. The patient's weight, strength and degree of anemia constitute safer guides for feeding than the urinalysis alone. When chronic nephritis is complicated by a diabetes which demands an opposite dietetic system, it should be determined which disease appears to threaten life the most, and then establish the proper regimen for that disease. For example, in a man past fifty years of age, a moderate glycosuria may be disregarded in the presence of the greater danger of a serious chronic nephritis, with a pulse of high tension and diminished proteid elimination. The amount of fluid ingested in chronic nephritis with anasarca should be regulated by the pulse tension and urine elimination. With too much fluid the heart may be overtaxed and arterial tension raised; whereas, with too little, there is danger of retention of the urinary waste products, and the plugging of the renal tubules with casts. Hence, in each case the quantity should be adapted from time to time to changing conditions.

In the dietetic treatment of diabetes the writer disregards entirely the use of gluten flours and breads, as being unreliable in composition and unsatisfying to the patient, whose natura! craving for starches is not appeased by the innutritious gluten. Potatoes contain, bulk for bulk, less than one half as much starch as wheaten bread, and may often be allowed to the extent of a

be

couple of ounces a day; or one or two small slices of bread may eaten twice a day. In any well developed case periods of total abstinence from starches and sugars should be made to alternate with their moderate allowance, as improvement in the urine and general symptoms ensues. If the patient continues to lose weight and forms sugar out of his own body proteids, large quantities of fat foods should be eaten, such as butter, cream, bone marrow, lard and suet used in cooking, olive oil, fat meats and fat fish, such as mackerel or salmon, and sardines soaked in oil.

Too rigid adherence to the so-called "antidiabetic diet" is often productive of more harm than good through starvation and anemia, and a better rule is to allow the moderate use of bread and potatoes as long as the patient appears to be in "nitrogenous equilibrium," that is, not consuming his own tissues and emaciating, and in all cases fat foods should be ingested in considerable quantity.

Lithemia demands a temporary vegetable and fruit diet, with large quantities of water, until proteid waste is thoroughly eliminated. Return to a diet of animal food should be made very gradually after ten days or a fortnight. Patients should be cautioned against overtaxing their nerve force through excessive exercise, and exercise should be definitely regulated, together with periods of rest, both before and after meals.

The influence of diet upon arteriosclerosis was discussed and, although it is admitted that mental and physical strain appear to be the chief etiological factors in many nontoxic cases, it also appears desirable in such cases to restrict the overeating of proteid food, and to regulate fluid ingestion in relation to arterial tension and the work of the heart.

In the treatment of goutiness between acute attacks of gout, of greater importance than the abandonment of occasional articles of food in a long dietetic list, are the following general principles: first, to reduce the consumption of food as a whole; second, to increase the consumption of water; third, to eliminate entirely sugars and sweets of every kind, as well as alcohol; and fourth, to reduce the consumption of red meats to a minimum.

The ad interim or prophylactic dietetic treatment of acute rheumatism is distinctly disappointing, and if this disease is an infection, as there are good grounds for believing, there is little reason for seeking aid in dieting, except in the milk diet of the acute attacks. A diet designed to prevent anemia and maintain a high standard of nutrition is the best preventive, and to this end animal food must be largely included.

Although the paper purposely omitted discussion of the dietetic treatment of diseases of the alimentary canal, the writer protested

against the common fallacy of drawing conclusions for dietetic rules from a single gastric analysis; for repeated analyses in the .same case often show all variations from anacidity to hyperchlorhydria. The common test meal of a roll and glass of water is not sufficiently appetising to always excite gastric secretion; or, the latter may be inhibited by the dread of the passage of the stomach tube.

DISCUSSION.

DR. CHARLES G. STOCKTON, in opening the discussion, said he had never heard so much common sense applied to a scientific subject as in this paper. Dr. Thompson's views express the results of scientific observation as well as clinical study. He was unable to endorse the views of the paper on the early feeding of solids in typhoid. His own experiences warn him to wait until the temperature has been normal for some time. As to nephritis, he agrees with the paper. The best diet in this case is that which is best for the liver. As is the primary digestion, so is the liver; as is the liver, so, usually, is the kidney. The paper is right in pointing out the unwisdom of using gluten breads in diabetes. If the patient can assimilate fats they are useful; but to a considerable class of diabetics the fats are toxic. If oxybutyric and diacetic acids are abundant in the urine it is best to drop fats from the dietary. The speaker agreed with the ideas of the paper on lithemia.

DR. FREDERICK C. BUSCH said that there is a lack of experimental research in the metabolism of various diseased conditions. Such work, along the lines of some existing physiologic studies in metabolism, would be useful, but difficult to accomplish. The speaker had observed cases of typhoid fever in which purpuric or scorbutic symptoms appeared under a milk diet. Peptones and broths improved the condition. Recent researches, in Harvard University, with x-rays, indicate that when food passes the ileocecal valve there is an antiperistaltic wave; later on, the bowel contents are carried onward by peristalsis. Food introduced by rectum may be carried into the small intestine by the antiperistaltic wave; hence rectal feeding is unlikely to protect typhoid ulcers.

DR. DELANCEY ROCHESTER, in reply to the last speaker, said that he never resorted to rectal feeding until the stomach refused to retain food. In typhoid he had often found the yolk of egg useful. Predigested milk with orange juice added is seldom refused by the patient. The speaker had made many gastric analyses in cases of arthritis deformans, and found that in dieting

« PreviousContinue »