1914 Journal of the American Medical Association  
the first time following the operation. This complica¬ tion following operation for pyonephrosis and perirenal abscess has been noted, but is, fortunately, very rare. The fistula forms independent of any injury to the peri¬ toneum or bowel. I am certain that in our case no injury was done to either the peritoneum or bowel. The dis¬ charge of bowel contents through the wound did not occur until after a laxative had been given. The most probable explanation of this complication in our case would
more » ... in our case would appear to be that the peritoneum overlying the abscess in the upper pole of the kidney became involved and the loop of bowel became adherent at this point. When the support was removed by drainage of the abscess, the peritoneum and bowel gave way before pres¬ sure. 2006 Columbia Road. It has been my fortune during the past few months to observe seven cases of gastric ulcer which originated under conditions which are not encountered in the experience of the ordinary practitioner and which throw light on the conditions that in some instances at least bring about this trouble. The cases occurred in practice in the town of Tanana, Alaska. This town is situated in the central portion of the territory on the Yukon River. All the cases of gastric ulcer were in men who had been living under conditions peculiar to the country and to a primitive mode of life. They were all strong, robust men who had endured lives of hardship with hard work of the camp and trail. During the same period in the practice of this community there were no other cases of gastrointestinal disease. Gastric ulcer appears to be about the only kind of digestive disturbance these men have. Of course so small a number of cases is too few to form a basis for generalization or for conclusions as to the causes of gastric ulcer. These eases are of interest in demonstrating that some conditions will cause the stom¬ ach to ulcerate. They are also of interest in that when the conditions which had caused the development of the ulcer were corrected the symptoms promptly subsided in every case treated. No operative interference was required to effect a cure. In all of these cases the clinical manifestations were typical. Three were of the hemorrhagic type. In two of them there were profuse and repeated hemorrhages from the stomach, of 500 c.c. or more. There is no reasonable doubt as to the correctness of the diagnoses. All of the men were engaged in outdoor occupations. They were hunters, trappers and miners. One was a telegraph operator at an isolated station on the Yukon Biver. He had, however, lived under the same conditions as the other patients. His diet had been the same. The conditions of life in Alaska are such that few but strong men remain in the country and none but strong men can follow the trail and live in the woods and camps for a long time. The diet is such as the country affords, with the addition of tea, coffee, some liquor and canned goods. The meat is mostly bacon, or canned meats, and game, the latter being plentiful ; meat forms a large share ,of the food. Vegetables are few. The bread is either baking-powder biscuit or the "sour-dough" hot cakes. From October until June there are no fresh vegetables. In some instances berries, put up with equal amounts of sugar, uncooked, were eaten as a preventive of scurvy. There was usually an attempt to keep potatoes unfrozen, which could be eaten as an antiscorbutic. Scurvy did not appear to be a factor in the cases which were treated for gastric ulcer, though it would seem that it might reasonably be taken into consideration as a contributing cause, especially in the hemorrhagic cases. The use of alcohol was carried to excess in but one case. The other men lived under conditions which made it very hard for them to get liquors. They were not hard drinkers, even when liquor could be easily obtained. The essential factors which all these cases had in com¬ mon were the following: 1. In all instances the food was rough. 2. There was a large proportion of nitrog¬ enous food. 3. The cooking was poor. 4. Few green vegetables were used. 5. The meats eaten were either salt or dark meats, mostly game. 6. On account of the hard life which these men lived and the conditions of extreme cold they became accustomed to eat immense quantities of food which had a high caloric value. These men needed a great amount of food to furnish energy for the strenuous physical exertion which their method of life necessitated as well as to maintain the heat of the body while they were exposed to the rigors of and extremely cold climate. The body called for an excess¬ ive amount of nourishment and the stomach had to fur¬ nish it. To furnish heat and muscular energy for the body the stomach was given coarse food, which was mostly nitrogenous and which was in some instances poorly cooked. Taking into consideration what the stomach had to do and what it had to do it with, it appears that the stomach deserves high credit for the way it attempted to do its work. One sample meal consisted of one duck, four potatoes and six baking-powder biscuits. A pound of beans and a pint of coffee is not an unusual simple meal for one of these men. For a time the patients got along well. After a year or two there were usually symptoms of gastric ulcer. The histories usually gave the record of pain after eating. Indigestion and pain in the stomach would come on toward spring. The men found that they needed a change of food. They were no longer able to eat beans. There are a great many men who only reach this stage of the disease. They come to town where they can get eggs and raised bread and green vegetables. Some of them take warning from the premonitory symptoms and pay more attention to their diet. These men are suffer¬ ing from the early symptoms of gastric ulcer. They cure themselves by changing their diet in response to the demands of Nature, which are manifested by cravings for certain foods that will be better suited to the stom¬ ach. After all, Nature is our best physician, and if we but obey her demands many of the diseases from which we suffer will be cured in their incipiency. The stomach is a willing and a faithful servant to most of us. When our bodies demand nourishment the stomach seldom complains. It seems to know when it is required to do its best because the body needs food or when food is simply being thrown into it for the satisfaction of an overindulged appetite. When the body needs food the stomach usually does its best to furnish nutrition. When unneeded food is placed in the stomach, the stomach resents the imposition and refuses to digest the food. Among city dwellers who overload their stomachs we get indigestion. Among frontiersmen who have to overtax their stomachs we find the stomachs doing their best to accommodate their activities to meet the demands of the Downloaded From: by a Penn State Milton S Hershey Med Ctr User on 05/26/2015
doi:10.1001/jama.1914.02560260023006 fatcat:vpisd3o5xjbt3hmigmgz4pkdaa