We are also in possession of some facts that tend to show that fats. inhibit gastric secretion. It is my custom to advise patients to eat plentifully of butter and cream, and olive oil in doses of two tablespoonful with each meal. The fats are especially valuable, when it is thought best to restrict the albuminous foods, because of their high caloric value, and they do not appear to interfere with the motor power of the stomach. Strauss has given as high as three hundred fifty grams of fat daily, only seven per cent of which was discoverable in the feces and much of this was saponified or in the form of fatty acids. Sugar may be freely used in the majority of cases for its inhibiting effect, and chocolate for its combining effect.

It is difficult to lay down any definite rules as to the number of feedings and the quantity to be given. The three-meal-a-day plan is the best upon general principles as the majority of cases of hyperacidity are among individuals who run, so to speak, on schedule time. Large, easily digestible meals are to be preferred in this class. Those who can devote their whole time to taking care of themselves may employ frequent light meals to advantage. Some patients quite often complain of the symptoms of hyperchlorhydria who, after a test breakfast, show a normal or possibly low hydrochloric acid value, but if an ordinary meal be withdrawn from the stomach at the time when the symptoms begin a high value of hydrochloric acid will be observed. The stimulus is greater than it was with the small meal. It is upon this principle that the method of feeding at frequent intervals is based.

The following chart illustrates the progress of a severe case of true hyperchlorhydria in a working man who was treated on the threemeal-a-day plan with carbohydrate or meat-free diet, and lavage. He has taken no flesh of any kind into his stomach from April 19, 1902, to the present time excepting once, when he ate plentifully of meat hash. Two or three hours after eating the hash he was taken with as severe pain as he had ever complained of, and the stomach contents removed by lavage at that time was very acid. The patient is now practically well although his secretion of acid is not as low as I hope to see it.

As in the other charts the lower curve represents free hydrochloric acid, the upper total acidity. The records of the first three days represent the acid values after the ordinary test breakfast, while the other records represent the acid values five hours after an ordinary carbohydrate or meat-free dinner. The two curves illustrate further the difference in the degree of free hydrochloric acid stimulation by a small meal and a large one.

Medicinal Treatment.-The treatment of hyperchlorhydria by medicines is limited almost entirely to the employment of alkalis. Some writers prefer one, some another, the majority a mixture of two or more alkalis. Objections have been raised as to the use of sodium bicarbonate on the ground that it causes considerable evolution of carbon dioxid gas, but as a matter of fact to many patients the effervescence in the stomach is quite pleasing and unless dilatation associated with atony is present little harm, if any, can come from its proper

use. It is claimed by some that sodium bicarbonate stimulates a flow of gastric juice by reason of the sodium chlorid that is formed. Clinical experience, however, does not seem to bear out this idea, and the amount of sodium chlorid thus formed cannot be great. The fact that sodium bicarbonate, as well as other alkalis if given on an empty stomach, will stimulate hydrochloric acid to neutralize it, cannot be employed as an argument against its use, for no one would intelligently administer sodium bicarbonate at this time in hyperchlorhydria. June July. aug. 5

1402 April

Im ay.

DATE.

17 18

192025

30

2

9

21

2

may 29

90

The light magnesia, magnesia usta, and the biborate of soda recommended so highly by Jaworski, are useful, especially when combined.

The alkali mineral waters may be employed to advantage. Foremost among these are Vichy and Carlsbad; they appear to have a beneficial effect in helping to reduce the secretion of acid. Especially is this so of Carlsbad, which has in addition to its alkali reaction slight cathartic properties quite sufficient to overcome the constipation associated with most cases. The other waters, Birliner, Saltera, Neueander, Fachinger and others, recommended by many writers, I have had no experience with. The Saratoga Vichy (Saint Louis, Michigan, spring) is

equally as good as the imported Vichy but unfortunately it costs little less. The waters are best given two hours after meals in sufficient quantity to produce the required effect. Carlsbad ought always to be given in tumberful doses to get the laxative effect. Vichy is best given in milk; equal parts.

Of medicines that have been used to reduce the activity of the glands, belladonna, atropin and preparations of opium have been advocated. Belladonna and atropin lessen the secretion of the stomach glands in the same manner that they lessen the secretion of other glands. These alkaloids appear to have an effect in reducing the pain in hyperchlorhydria. I have only resorted to this method a few times, always with failure, however, to obtain relief from pain within a reasonable time. If patients are given atropin or belladonna continuously a reduction of the acidity will occur but will not be permanent. The atropin soon loses its effect and the dose has to be increased. The method I think can hardly appeal to one when the facts are known. Its effects cannot be otherwise than pernicious and its use should be condemned.

It is claimed that opium preparations reduce the secretion of the gastric glands because of their central action, but this subject requires further elucidation. These preparations, especially codein and codein phosphate, are valuable during paroxysms when other methods fail. Their effect then can only be in the reduction of pain, for the increased acidity is already present and unless it is reduced or the sensitive stomach benumbed the pain will not cease.

Lavage.-Stomach washings may be dispensed with as a rule in those cases which show normal or hypermotility. It is always better to reduce the number of stomach washings as much as possible. If in a certain case there is a hypersecretion of mucus it might be well to wash the stomach, but in many of these cases the fasting stomach is found to contain little or no mucus. The secretion of mucus during the meal and period of hyperchlorhydria has an effect to lessen the irritation of the acid and for this reason it is probably poured out. In those cases wherein it appears to be limited or absent demulcent solutions, flaxseed, gum arabic and slippery elm are at times very grateful to the patient. Mucin has been recommended, but I have been unable to get a good solution of the powdered article. The stomach may be washed with these mixtures or they may be administered by mouth.

When there are signs of retention or atony lavage should be carried out systematically. Simple warm water or water to which a little Carlsbad salts or sodium bicarbonate is added, a teaspoonful to the quart, may be used. Too much alkali must be avoided and should only be used when the stomach is found to be acid. Silver nitrate has also been recommended both as a douche and by mouth, but my experience with this method has been too limited for an opinion.

Lavage is often the only means whereby the extreme pain, even in cases where the stomach is empty, can be relieved, and in beginning cases it will frequently terminate the condition after several treatments.

1

Washings should always be thorough and discontinued when the water returns clear after agitation.

Diastase and other Ferments.-The theory of the use of diastatic products is very reasonable but the practice does not give the results one would be led to expect. This is explained by the fact that the majority of these preparations are either entirely inactive or very slowly active. I have already called attention to this matter. A good diastase could be used to advantage in cases showing distension after carbohydrate foods, if administered along with the meal or directly after. But attention to the chewing of food and the use of dry zwieback at the beginning of each meal will frequently obviate the necessity for these substances. Papoid preparations have been warmly recommended in hyperacidity. I think there is little reason manifested in such recommendation. Peptic digestion is almost always good, though hypopepsia may occur. I only speak of this to condemn it. In papoid preparations a worse condition of affairs exists than in diastase preparations, for with the latter a proper ferment reaction may sometimes be obtained with a few preparations. Most papoid preparations are inert.

Constipation will often be overcome simply by the use of antacids, frequently by lavage and the establishment of good habits. Foremost among the cathartics I place rhubarb, the powdered extract which I give together with the antacid. Bitter cascara, if a reliable preparation can be obtained, comes next in value. As the case improves these remedies should be gradually removed. Massage of the bowels will often take the place of cathartics This may be accomplished by a masseur or by the use of a cannon ball rolled around the belly for ten minutes before rising in the morning and followed by a glass of cold water. Prunes and sugar may be tried. It will be seen that all of these methods of treatment are dependent the one upon the other. They will in time, if judiciously prescribed, bring about more or less permanent relief.

Special symptoms are to be treated according to well-known principles governing their care in other stomach states. Peptic ulcer must always be excluded before instituting too radical measures, and it must be ascertained whether the hyperacidity is reflex from pathologic conditions in other parts of the body, as the uterus and the gall-bladder.

The etiology of each case must be carefully considered and as far as possible the cause removed. Efforts should be made to make the patient's life as equable as possible. A patient who is in the habit of worrying will often get well with little medicinal aid if this symptom can be relieved. It will be found that the patient has often to be treated in preference to the disease.

Now as to the question of the apparent recovery of cases of hyperacidity so far as the distress is concerned. Not infrequently a patient recovers, but on repeated examinations it will be found that the average secretion of hydrochloric acid remains only a little below the highest point it attained during his acute illness. In such a case all the characteristic symptoms of hyperchlorhydria may have been present and the

stomach analysis may have shown persistent hyperchlorhydria. How can this be explained? We can only conclude that we have been dealing with a case of hyperesthesia and that the hypersensitive mucosa has become tolerant to what we call an increased acidity. Because our experience in the stomach laboratory has shown us high hydrochloric acid values in a number of apparently normal individuals selected with the view of ascertaining normal stomach states we cannot say that a case like the one in question is really one of hyperchlorhydria for that individual. We find the same condition of hyperesthesia in individuals whose free acid secretion is within the so-called normal limits and when they are treated as we treat a case of hyperchlorhydria they are relieved of their distress.

FIBROMATA AS COMPLICATIONS OF PREGNANCY.

BY REUBEN PETERSON, A. B., M. D., ANN ARBOR, MICHIGAN.

PROFESSOR OF GYNECOLOGY AND OBSTETRICS IN THE UNIVERSITY OF MICHIGAN.

UTERINE fibromata as complications of pregnancy have been discussed thoroughly in the medical journals during the past two years. So true is this that if one were to judge by the number of such articles alone, he would be forced to the conclusion that the complication is met with more frequently now than formerly. Such, however, is probably not the case. A better explanation seems to be that here, as elsewhere, the obstetrician is attempting to rid himself of antiquated, expectant lines of treatment for all cases and is endeavoring to formulate rules for the adoption of the more modern surgical methods in certain other cases. During the past decade the technique of pelvic and abdominal surgery has been so perfected that at the present time we can advise safely and with complete confidence for the complication under consideration, certain surgical procedures which would have been inadvisable and rash fifteen years ago. This does not mean, however, that every pregnant woman with a fibroid tumor should be operated upon. That the abdomen can be opened and one or more uterine growths be removed with safety at all stages of pregnancy, should not relieve the obstetrician. from the necessity of studying carefully his cases with a view of deciding which should be allowed to go to fuil term and which should be operated upon. Indiscriminate operating for the removal of such growths is as unscientific and objectionable as is the far too frequent practice of some surgeons to spend but scant time endeavoring to ascertain the exact nature of a pelvic lesion or abdominal growth, remaining satisfied with the thought that the diagnosis will be much easier after the abdomen is opened. Such methods are not only shiftless and unwarrantable, but they lead to unnecessary operations and often to grave mistakes.

If, then, we eliminate the two extremes of treatment of pregnancy complicated by uterine fibromata, operation for every sizable tumor, and nonoperation, no matter how severe may be the symptoms, the

* Read at the Detroit meeting of the MICHIGAN STATE MEDICAL SOCIETY, June, 1903.