Subperiosteal Fractures

FREDERICK J. COTTON
1900 Boston Medical and Surgical Journal  
The treatment tends to use up tin; acid secreted und facilitates the motor function. Starches should be limited, and of carbohydrate foods sugars or predigested starches, dextrinized flours, as Avenacia flour or Ilorlick's food, used as much as possible, since starch digestion in the stomach is impeded in these cases. For all symptoms of disorder, as distress or eructations, some proteid, as a raw egg, is to be taken. An alkali, bicarbonate of soda in half-teaspoonful doses, or 15 grains of
more » ... or 15 grains of magnésie hydrate, maybe taken in addition to food or in place of it for the relief of symptoms. In some cases large amounts of alkali, 3 drachms bicarbonate of soda, must be used in the twenty-four hours. Three pints of water ¡ire prescribed to be taken in small amounts at a time throughout the day. In addition, general rules in regard to baths, exercise, the bowels, the work, and general manner of living are laid down in writing. Debility must bo treated by tonics. Nux vómica is a most useful agent here to improve the tone of the system and thus also perhaps the motor capacity of the stomach. Where anemia is present by blood tests iron should be given. Chlorosis is not infrequently associated with hyperacidity. After an administration of iron with the regular régime for a few weeks these cases as a rule lose all symptoms of hyperacidity even with cessation of treatment. There is little doubt that it is a similar improvement in nutrition which accompanies the increased diet, and good regime and freedom from nerve disturbance which ensure the cure in a majority of all the cases. The exact details of treatment of course vary with the eases. Many cases of hyperacidity are intermittent or paroxysmal. These cases it is necessary to treat locally only during the period of attack, while a general method of regime should lie employed constantly to prevent recurrence. In some cases the acidity is only after one meal, as, for example, dinner. This must be borne in mind in the. determining of the diagnosis as well as in the treatment. Wo must get the contents at the period of symptoms. This treatment gives excellent results in the great majority of cases. In some, relief is immediate, and with the return of normal tone it is possible after a month or two to drop special treatment. In ¡i majority of these eases the acidity is found in time to be normal, in others the acidity remains as at first, though the symptoms disappear. In a certain proportion of cases the treatment must be followed in a general way permanently. It is impossible to collect accurate statistics of cure from an out-patient clinic. But it is certainly a rare exception to see a case of hyperacidity which does not yield to this treatment when properly applied. In my records 1 find less than 10% of cases returned as not relieved after trial of this simple treatment of régime, diet and alkalies. In these obstinate cases lavage is often a useful adjunct to treatment. After a few weeks of lavage combined with a very special diet worked out by experience with the case, the patient is raised to the regular regime. In these cases it is often necessary to feed small amounts frequently and to use concentrated food substances, as the Leuke-Rosenthul meat solution, Mosquera beef meal, somatóse, which have a high capacity for combination with hydrochloric acid. Such cases are, however, exceptional. As a rule the diet of easily digested or liquid foods is the loast useful one that can be chosen. In some obstinate cases I have used nitrate of silver for internal treatment and for lavage, with success. It is well known that our cases of hyperacidity ¡ire of two types ; One in which a neurosis or functional hyperaetivity appears to be the fundamental element in the case, and one in which a marked increase in the gland tubules and oxyntic cells of the gastric membrane is present as an underlying pathological condition. This hitter condition, a form of chronic gastritis, the gastritis acida of Cohnheiin, is diagnosed by the presence of fragments of the pathological membrane in tho stomach washings. It is said by some observers (Ilemmeter) that 50% of the cases of hyperchlorliydria have some such hyperplasia of the tubular structures. Typical eases of this condition are, however, much less common, and such fragments ¡ire, in my experience, found in ¡i much less per cent, of cases by ordinary methods of examination. When our condition is obstinate, and does not tolerate the regular treatment, it is well to investigate specially as to whether our case is one of this gastritis acida. For such cases, and indeed for ¡ill cases proving obstinate to the proteid treatment, the method of continuous treatment upon low proteid diet should be tried. It has been urged that the method of treatment of hyperacidity by the utilization of the acid by food simply aims to offset the acidity of the contents, not to control the secretion, and that ¡i more fundamental method of treatment would consist in aiming to lessen this secretion. Also it is claimed by certain observers that the secretion of acid in the stomach is proportionate to the amount of food requiring acid for digestion, that is, the proteid food. And that therefore the proteid diet, while relieving symptoms, tends to increase the disorder, while a low proteid diet will tend to decrease the actual cause of disturbance, and thus give permanent cure. Ilemmeter reports some observations upon dogs which tend to support this theory. In the few cases in which I have tried this latter method I have found it difficult to keep up. It does not give the immediate relief of symptoms obtained by the proteid method and the patients do not keep to the diet as well as in the proteid method. The proteid treatment, whatever its aim, certainly ends in reducing the secretion of acid in many cases. It controls symptoms at the time in almost all cases. Since it acts so effectually I have used it regularly as a first resort in all cases where it is tolerated. Where it fails the other method should be given a trial. About a year ago a somewhat peculiar case of subperiosteal fracture called my attention to this class of cases ; the cases here presented are such as have come under my notice since that time. They are presented not with the idea that they show anything actually new, but because subperiosteal fractures are very common in children and a proportion of them seem on closer examination to have little in common with the type known as green-stick fractures, with which they are usually classed.
doi:10.1056/nejm190011291432203 fatcat:7je46xwesjhbnpilzag66gztam