The Journal of the Philippine Medical Association

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Part of The Journal of the Philippine Medical Association

Title: The Journal of the Philippine Medical Association
Issue Date: Vol. XXII (Issue No. 6) June, 1946
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extracted text: THE JOURNAL OF THE Philippine Medical Association Devote<i. to the Progress of Medical Science and to the interests of the Medical Profession in the Philippines Manila, Philippines VOL. XXII JUNE, 1946 CoPYRJGHT, 1946, Bv PHILIPPINE MEDICAL A ssoc1ATION ®rigimd J\rtides NO. 6 BLOOD BILIRUBIN DETERMINATIONS AS AN AID IN THE DIFFERENTIATIONS BETWEEN PEPTIC ULCER AND PORTAL CIRRHOSIS IN GASTRIC HEMORRHAGE ' R. j. NAVARRO. M.D , P IGNACIO, M.D. AKD j. A. SILVA, M.D: College of Medicine. University of the Philippines. One of the most dramatic and most alarming symptoms of diseases of the gastro· intestinal tract and/ or its accessory organs is massive gastric hemorrhage resulting in profuse hematemes.is. This is not only a dreadful episode for the patient and his family which almost shatters all hopes of recovery, but also a perplexing problem for the attending physician. The latter's diagnostic ability is many times taxed to the limit and speculative considerations often come to play. This is especially true cf the types unheralded and unaccompanied by any symptom or set of symptoms indicative of any existing disease which may lead to such hemorrhagic attacks. Such disca..-.es as new growth of the stomach or duodenum, hemorrhagic diseases like idio· phathic purpura hemorrhagica, hemorrhages in deep jaundice, traumatic injuries of the stomach JJr duodenum, acute gastritis due to corrosives, simple peptic ulcers and hepatic disease like Banti's disease and portal cirrhosis are naturally considered. But because many of these diseases are almost always accompanied by definite histories, diagnostic symptoms, and important physical or laboratory findings, their recogni· ti on is often easy. Two of these diseases however-peptic ulcer and portal cirrhosis-arc often without defini•te diagnostic findings either before or during the hemorrhage, so that their recognition is very difficult if not impossible. If their recognition is not easy, their l Read before the 39th Annual Meeting of the Philippine Medical Association, May 9, 1946. 224 BLOOD BIL/RUBIN DETERMINATIONS-Navarro et al. Jour.P. M.A. June, l~:J.16 differentiation is even more difficult. These two diseases happen to be the most frequent causes of massive gastric hemorrhage i.n the Philippines. Their frequency is such that when profuse hematemesis, which is not preceded nor accompanied by any definite phy· sical or laboratory findings, occur in an adult individual of either sex, peptic ulcer and portal cirrhosis are given the first consideration; and a great majority of these tum out to be due to either of these diseases. Since the two conditions re· quire entirely different treatments, an early diagnosis is not only a scientific neces· sity but also an important prerequisite in the management arid ultimate treatment of the disease. Any procedure, therefore, or means of differentiating between these two conditions would be a welcome addition to our diagnostic armamentarium. Six cases who suffered from massive gastric hemorrhages resulting in hemate· mesis, form the basis of this report. Three of them were admitted in the Medical Wards of the Philippine General Hospital, two were private patients admitted in the Pay Sec0 tion of the same Hospital, and the sixth, is an American internee ad· mitted in a special ward for these patients, also in the same Hospital. Two of the charity patients died from subsequent hemorrhages, and the American internee died of acute generalized peritonitis. Their bodies were autopsied at the City Morgue and the cause of the hemorrhage was therefore accurately determined pa· thologically. The two private patients were both operated on after repeated massive hemorrhages, so that the cause of the hemorrhage was also accurately deter· mined hy direct vision and by direct palpation during the operation. The third charity patient did not die nor was he operated on during the hemorrhagic episode under consideration; but the history, the clinical, physical, laboratory and X-ray findings are so characteristic that there is very little doubt as to the diagnosis of ·the cas.e. REPORT OF CASES CASE I. Ricardo Nolan, male, Spaniard, 71 years old, lawyer, admitted on June 28. 1943. Personal History: well to do; widower. a gourmand and a habit· ual heavy alcoholic drinker. Past Diseases: nothing relevant; had no signs of chro· nic gastro·intestinal disorder. Present Illness: Hematemesis was profuse, painless 5 hours before admission, apparently spontaneous. Melena noticed day following. On admission he was in a collapsed condition, rather pale. Pertinent physical findings: fairly well develop· ed and fairly well nourished patient; heart and lungs apparently normal; abdomentympanitic and scaphoid, no evidence of engorgement of superficial veins, no mas.ses and no tenderness. spleen not palpable, no evidence of ascites. Observation: Patient had 5 hematemesis in the ward. Was given repeated blood transfusions. Laboratory examinations: Bilirubin determination ( 6/29) Bili. I - traces, Bili. II - none, Takata test - negative ( .:___). Impression at first given was portal cirrhosis, until the result of the bilirubin determination, Takata test and X·ray findings were known. X·ray of the stomach: the stomach showed hour glass contraction with the bismuth meal remaining in the cardiac or fundic portion. In the six·hour film. although most of the meal had gone down, yet one could still see the cardiac coated with the remaining contrast sub· ~::::~~. ~xn BLOOD BIL/RUBIN DETERMINATIONS-Nava1To et al. 225 stance to make that portion quite clear. In this film one could visualize still the hour-glass contraction seen in the previous film. Due to these findings, the first consideration was the possibility of newgrowth infiltrative type, especially if functional spasticity could be entirely eliminated. It was also perhaps worthwhile hav· ing the Wassermann's test and the resolubility test. Histological section: portion of the stomach sent for biopsy showed chronic peptic ulcer with acute exacerbation and hemorrhage, pyloric portion of the stomach. Operation and partial gastrectomy was performed. CASE 2. The case of Dr. Manahan. Around the end of 1928, he began to have frequent attacks of epigastric pain which at • times amounted only to some discomfort and tympanism. Occasionally he had sour eructations. These symptoms persisted till the end of February, 1929, when after feeling faint for some time he had profuse mclena, after which he collapsed. He stayed 24 days in the Hospital and was apparently all right until June 1930 when he had to stay in bed on account of moderately severe epigastric pain and tympanism. Melena was slight this time. For almost years, he was apparently symptom-free, and then around the middle of 1932, he again noticed the slight melena, preceded hy the usual epigas· tric discomfort and sour eructations. In 1933, he was appendectomized. Since the last attack of epigastric pain and melena, he had 5 other attacks similar in nature, mekna varying in amount from slight to profuse; in durntion from 2 to 15 days but accompanied invariably by cpigastric pain or discomfort, sour eructations and tympanism. Finally, around the end of July of 1942 to Augu~t 2, 1942, he had profuse melena and hematemesis followed by collapse, for which 3 blood transfusions and a gastro·enterostomy were done, but nevertheless, the patient declined gradually and died. Blood extracted on the day of the operation was negative for both bilirubin. CASE 3. Hipoli·to Niguidula, male, 31 years old, admitted for the first time on January 9, 1943. Chief complaints: epigastric pain, hemateme>is and melena. Present illness: About three years before admission as burning pain localized a-t the epigastrium, occurring at around 11 o'clock in the morning, subsiding after the ingestion of food or coffee, only to recur after about two hours and again relieved by taking food. The pain occurred seldom at night or in the morning, and was not colicky in character, nor was it transmitted anywhere. After three days of this pain, he vomited abou·t I / 3 urinal full of blackish material and when he moved his bowels the following day, he noticed tha·t his stools were also black. He sought medical attention. was given medicine ·taken by mouth and dieted on lugao and ba· nanas for several days. after which the pain in the epigastrium was only occasional, but usually occurring when he was hungry and relieved by intake of food. He had become slightly pale since the onset of the illness. There was no history of fever or jaundice or acholic stools. Four days before admission there was recurrence of the vomiting of blackish material, amounting to about one-half urinalful; he also passed blackish stools. The epigastric pain became more or less persistent, so he sought admission. On admission he was afehrile, slightly pale; and he complained of epigastric pain, B.M. regular. 226 BLOOD BIL/RUBIN DETERMINATIONS-Navarro et al. Jou .. P.M.A. June, 1946 Pertinent physical findings: Fairly well developed, poorly nourished, pale pa· 1ient. Conjunctivae, pale. Heart and lungs apparently · normal. Abdomen <;'mme· trical, slight tenderness of the epigastric region on deep pressure. Spleen and liver not palpable. Laboratory examinations: Blood rbc 2,550,000, wbc 11,400, neutro· philes 80/} , lymphocytes 20'/o, Hemoglobin 7 gms. (Sahli): rbc 3,450,000, wbc 8,050, neutrophiles 72 <Jo, lymphocytes 287':. Urine normal. Feces showed traces of occult blood in one examina-tion. Gastric Juice Analysis: (First examination) First hour-free 75° total 88° comhined 15 ° : Second hour - Free 50° total 65° combined 12°; (Second examination) First hour - free 54° total 67 ° combined 10° ; Second hour - free 56° total 69° combined 11°. Bilirubin determina-tion (January 19, 1943) B·I traces, B-2 none, X-ray of the stomach : There was irregularity of the mucous folds in the antral and duodenal bulb region suggestive of chronic ulcer with certain gastritis. X-ray of the lungs: prominence of both hila, especially right. Diagnosis: Peptic ulcer, chronic with hemorrhage. CASE 4. John B. Taylor, 68 years old, male, American, was admirted for the. first time on November 27, 1943. Chief complaints : epigastric pain, hematemesis, nau>ea. and general body weakness. Present illness apparently started 6 mon1hs ago as dull ;iching pains at the region of the epigastrium, unrelated to meals, coming on and off at irregular inteivals and of varying duration. This was accompanied occa· sion:illy by sour eructations. About two weeks before admission, he was apparently feeling well when he suddenly became nauseated and vomitted a large amoun·t of dark clotted blood. He became dizzy and afterwards fainted. Following this hemateme· sis, be passed blackish stools for several days. Since then he felt rather weak, wrth marked pallor and occasional nausea and dizziness. Laboratory examination done while he \\'as still in the &to. Tomas Internment Camp Hospital showed persistent occult blood in the feces up to the time of his admission here. Blood examination showed a rapidly increasing anemia-from 2,000,000 rbc on the day after the hemorrhage to 1,500,000 ten days later. On admission the patient was febrile (37.5°C). He could still walk, but he suffered occasional epigastric pains, dizziness, and nausea. He vomitted but wi·thout blood. He had been constipated for the last three days before admission. Pertinent physical findings were: well developed and well nourished patient, con· junctivae, pale, no icterus. Heart wunds rather weak, but regular. No adventi· tious sounds. L~ngs normal. Abdomen slightly scaphoid, lax, with no rigidity or tenderness. Integument pale. Laboratory examinations: Blood-rbc 1,650,000, wbc 7,850, neutrophiles 79%, lymphocytes 21%. Urine normal. Takata test: negative (-) . Gastric Juice Analysis Free HCL ........ . . .. . . ... . Total acidity .. . . .... ..... . . . Combined acidity . . . . . .. . . .. . Occult blood .. . ... ..... ... . First Hour n• 78 3 + Bilirubin determination (11129) B·I none, B-11 none. One hour after test meal 74° 83 6 + Obs.eivations: The patient developed very severe epigastric pains 8 days after ~:::~~XII BLOOD BILIRUBIN DETERi';I/NATIONS-Nava,.,.~ et al. 227 admission in the ward. The pulse became very weak, almost imperceptible. After having been given blood transfusion of 2 50 cc., he became slightly stronger; but the abdomen was noticed to· be slightly bulging and tympanitic. On the foliowing day the abdomen continued to be tympanitic without much rigidity, and another hlood transfusion was given; hut he did not react, and he died soon after. Pathologic Diagnosis; Peptic uker, perforated with secondary peritonitis. CASE 5. Jose Sanchez, male, 30 years old, jobless, from Balanga, Bataan, was admitted for the first time on September 6, 1943. Chief complaints: left hypochon· driac and epigastric pain, and hematcmes.is. Present illness: Five months in duration as recurrent a~tacks of epigastric and left hypochondriac pain, which apparently were not related to meals. While in Corrigidor, one month after the onset, he had malaria accompanied by epigastric discomfort, nausea and vomiting of blood, once amounting to a cupfull, but no melena. Two weeks later, while in Capas. he had persistent epigastric and left hypochondriac pain, occurring for two weeks. After his release, he was comfined in San Lazaro Hospital for fever and cough and discharged improved with the diagnosis of bronchopneumonia. After his discharge, he had afternoon fr· ver for four days and frequent bowel movements, the S'tools being neither bloody nor mucoid. On the night previous to admission, he had severe pains over the left hypochondrium, accompanied by cold clamy perspiration. He also vomited blood three times, consisting of fresh and clotted blood amounting to one half urinalfull. For this symptom he was admitted in this hospital. Past diseaE.e: Had malaria in 1939 and 1940. On admission he was very weak. pale; and he vomited plenty of blood amounting to 1/3 cupfull. Pertinent physical foidings: Fairly well developed and fairly well nourished. Conjunctivac rather pale. Sclcrae, subictcric. Heart and lungs apparently normal. Abdomen showed a palpable spleen about 4 fingers below the costal arch. Liver not palpable. No ascitcs. No rigidity but with mo· derated tenderness at the epigastrium and left hypochondrium. Integument pale. No prominent blood vessels. Previous records show that he was admitted in 1940 and was diagno£ed as a cw.e of malaria, chronic. Laboratory examinations: Blood - rbc 2,120,000; wbc 4,ROO, neutrophiles 71 y(, lymphocytes 22%. monocytes 7%. Urine and feces were apparently normal. Blood smears positive for rare ring forms of benign tertian malaria. Bilirubin determina· tion: (9/ 12) B·l 0.658, B-2 1.110; (9/ 8) B·l 0.419, B-2 none. Takata: (9/ 12) negative, (9/8) negative. 0b£.ervations: The patient stayed for 7 days in the ward and during this whole stay he vomited 5 times, the vomitus consisting of fresh and clotted blood. He was semiconscious most of the time and talked incoherently. Final diagnosis: Portal cirrhosis with hemorrhage (?); Malaria, chr.; Anemia, severe; sec.; hypos· tetic pneumonia. Anatomical diagnosis: Cirrhosis, portal; splcnomegaly; hemorr· hage, intestinal tract; pneumonia, hypostatic; anemia, acute, secondary. CASE 6. Candido Victorino, male, 48 years old, driver, admitted for the first time on July 7, 1942. Chief complaints: melena and hematemesis, general body weakness. Present illness : For several years before admission the patient had been suffering from vague epigastric pains which was not related to meals. Since then pain had been persistent. There is definitely no history of sour eructation, al-though he 228 BLOOD BILIRUBIN DETERMINATIONS-Navarro et al. Jou•·.P.M.A. June, 19-16 had occasional nausea with acutal vomiting. There was no previous history of jaun· dice, although one week before admission he had noticed that his sclerae were slightly yellowish. This yellowish discoloration of his· sclerae persisted up to the time of his admission. About three days before admission, he started vomiting blood profusely and passed dark colored stools. Once in a while the vomiting of blood subsided, but on the day of admission, he again vomited profusely. For two months before admission, he had been coughing occasionally, accompanied by thick mucoid expectoration. Together with this he had occasional rise of temperature. There was no appreciable loss of flesh. On admission he was afebrile and he complained of marked general body weakness and occasional vomiting of blood. Pertinent physical findings: Fairly well developed, somewhat poorly nourished patient. Sclerae subicteric. Heart apparently normal. Lungs showed impaired resonance over both apices and right base with crepitant rales on the left apex. Abdomen : liver and spleen could not be palpated, and there was no evid· ence of fluid; superficial abdominal veins prominent; no tenderness and no rigidity. Extremities showed no edema. Laboratory examinations: Takata test ++ + Bilirubin determina·tion (7 / i) B·I 0.822; B·2 traces. Patient stayed for 11 hours in the ward and died. Final diagnosis: Portal cirrhosis; P.T.B. chronic. Anatomical diagnosis: Cirrhosis, portal with wlit~ry newgrowth at junction of right and left lobe. Oesopha· geal varices; blcod 'mall and large intestines; fibroid T.B. right apex, lungs; pleurisy with effusion; right with bloody hemorrhagic fluid; miliary T.B., apex right. DISCUSSIONS By reviewing and analyzing the clinical abstracts on each of these patients, fr. will be readily seen that either peptic ulcer or portal cirrhosis could explain the re· peated hemorrhagic episodes in all of them. With the exception of Case No. 3 where the clinical, laboratory, and X·ray findings are all in favor of peptic ulcer, all cases show findings that can hold t~e with both diseases. Take Case No. 1 for example. The absence of symptoms referable to the sto· mach or upper gastro·intestinal tract before or during the hemorrhage will make one strongly suspect portal cirrhosis as the cause of the hemorrhage. The X·ray report in this case points strongly to the stomach as the seat of the pathologic change, although functional spasticity could also produce the same picture. Case No. 2 showed vague abdominal symptoms which were interpreted by the patient and his close associates as symptoms of peptic ulcer. The hemorrhagic episodes in the form of melena lend support to this contention, but these can also be found in a case of portal cirrhosis. A patient with such symptomatology-vague abdominal complaints with gastric hemorrhages in the form of melena and hema·temesis once in a while - died in one of the hemorrhagic attacks, giving the clinical impression of peptic ulcer with hemorrhage or of portal cirrhosis. Partial autopsy on the body re· vealed a duodenal ulcer. The history and the clinical, laboratory and X·ray findings in Case No. 3 are all in favor of the clinical impression of peptic ulcer. Although this was not ve· rified by operation or by au'.opsy findings, the diagnosis appears well supported. Case No. 4 was apparently symptomless up to 6 months before admission when ~~~:::,~~XII BLOOD BIL/RUBIN DETERMINATIONS_:_Navrz1To et al. 229 he began to have dull aching pains at the epigastric regions. Thes.e pains were not related 1:o meals. They were variable in duration and came on and off at irregular intervals. These symptoms could be those of either disease, but the absence of siln· ilar symptoms previous to 6 mon·ths before admission to the Hospital makes the case appear to be more of portal cirrhosis, although the gastric contents showing slightly increased acidity, are more in favor of peptic ulcer. In case No. 5 the clinical impression of peptic ulcer is well supponed by the clinical history and physical findings. Such findings as subicteric sclerae and pal· pable spleen - usual findings in ponal cirrhosis - could be explained by the malaria that this patient also had. The absence of ascites and the absence of any prominent vessel or spiderweb angiomata in the abdominal chest walls fail to suggest or to support any ilnpression of ponal cirrhosis. Case No. 6 showed several findings pointing to portal cirrhosis: the history of slight yellowish discoloration a week before admission, the subicteric sclerac, the pro· minent superlicial abdominal veins, and ·the positive Takata in the blood on admission. But the absence of ascites and palpable spleen and the history of vague epigastric pain with occasional vomiting are indicative of peptic ulcer than of portal cirrhosis. Summing up all the findings on this patient, no definite diagnosis could be made, al· though a final impression of portal cirrhosis was arrived at. Case No. 7 showed no definite symptoms indicative of either disease, except the palpable spleen which is more in favor of portal cirrhosis. The table shows clearly that a sharp contrast between the group of "peptic ulcers" (Cases !, 2, 3, & 4) and that of "portal cirrhosis" (Cases 5, 6 8 7) is found in the amount of B·I in the blood. The first group (peptic ulcers) shows practically no bilirubin while the second group (portal cirrhosis) shows definite amounts of B·I. Theoretically speaking this is as it should be, for it is well·known that portal cirrhosis is a degenerative disease leading to necrosis and disappearance of liver cells (I) . The liver must, therefore, be functionally deficient, although known functional tests give disappointingly normal results. (2) However, by "special" bilirubin deter.mi nations (3) ( 4) , functional disturb· ances of the liver and interference in the outflow of bile can be accurately measured. By special bilirubin determinations, therefore, diseases associated with functional de· feces of the liver can be differentiated from those not accompanied by dificient liver functions. Since peptic ulcer is not known to be associated with any liver affection unless there is a concomitant "gall-bladder" disease, liver functional deficiency is therefore absent in this disease. But in portal cirrhosis a functional disturbance has always been found (3), and in its absence a diagno>is of portal cirrhosis has been given with caution. Our findings in the last three years on patients with portal cirrhosis admitted ·in the Medical Wards of the Philippine General Hospital show that B·I is always present in definite amounts ( 3). When it is absent, a diagnosis of portal cirrhosis, in our experience, appears not fully supported. To illustrate this point, an interesting case is herein briefly summarized. A middle-aged man from Pampanga was admitted in the Medical Wards of the Pllilip· pine General Hospital complaining of painless enlargement of the abdomen of a few months duration; there was also slight edema of the lower extremities. There was 230 BLOOD BIL/RUBIN DETERMINATIONS-Navarro et al. Jou1·.P.M.A. June, 1946 nothing relevant in ·the past history, except a questionable malarial attack several years before. Physical examination showed a well-developed but sligll'tly emaciated walking patient, with nothing pertinent in the head and neck. The ab· domen bulged markedly showing clear evidence of fluid; surface abdominal veins were prominent and the spleen was definitely palpable; the liver was questionably palpable at the region just below the xyphoid process; both lower extremities were slightly edematous. On paracentesis the abdominal fluid was found thin, yellowish, and defini·tely transudatc. The more common laboratory data showed nothing definite: blood smears showed no malarial parasites after repeated examinations. Takata's test in the blood was strongly positive. The blood showed neither B·I nor B·II. The attending physicians gave a diagnosis of portal cirrhosis. This was confirmed by senior clinicians. The diagnosis of portal cirrhosis in this case could not be questioned especially on clinical grounds; but, contrary to our findings in this disease so far, no B·I was found in the hlood. While we could not get away from the diagnosis of portal cirrhosis, we included "malarial endothelosis" and parasitic (Schistoso· miasis) liver disease as po..<sibilities. The syndrome of ascites, palpable spleen and distended abdominal veins is not impossible nor even unusual in malaria infestation as shown by Sison (A. G.) and his co-workers (5), Schistosomiasis of the liver has frequently been seen to manifest physical fi'ndings similar to those of advanced portal cirrhosis. This patient died after an operation for the removal of • the spleen. Autopsy revealed a slightly enlarged and indurated liver which on microscopic examinations showed numerous ova of Schistosoma. There was neither gross nor microscopic find· ings suggestive of portal cirrhosis. It was revealed after the autopsy findings had been known, that the patient had stayed for sometime in a place known to be ende· mic for Schistosoma: Thug syndromes pointing to portal obstruction, unless accom· panied by definite evidences of liver dysfunction (presence of B· I in definite o~ sig· nificant amount) can be the results of pathologic processes other ·than portal cirrhosis. The two diseaseg herein considered, therefore, as causes of mas.sive gastric hemorrhages leading to profuse hematemesis can possibly be differmtiated by their ;issociation or non-association with destructive processes of the liver resulting in hepatic hypofunction. While clinically, physically, and with the aid of lahoratory and X·ray findings a differentiation between the two is often possible, such findings may not be sufficiently definite •to allow definite differentiation. The presence of B·I in the blood in significant amounts, or its complete absence, may therefore serve as distinct help in their diffcrentia·tion-its presence favoring portal cirrhosis while its absence, peptic ulcer. SUMMARY AND CONCLUSIONS I. Seven cases with massive gastric hemorrhage resulting in profuse hematemesis form the basis of this report. Four of thes.e were admi·ttcd in the Medical Wards of the Philippine Gener;tl Hospital, two were patients admitted in the Pa}' Section of the s:imc Hospit:,I, and the sixth was an American internee admitted in a special ward for internees of the same hospital. 2. Four of these patients died, and a complete pathologic report for each 'was i!\:.~ ~xn BLOOD BIL/RUBIN DETERMINATIONS-Navarro et al. 231 available. Two were operated on, and accurate operative findings were also available for these patients. One had no operative or autopsy verification of the clinical irn· pression. But this appears well supported by clinical, laboratory and X-ray findings. 3. Four of these patients were found suffering from peptic ulcer and the other three, from portal cirrhosis. The patients with peptic ulcer showed practically no bilirubin in the blood (Whether B·I or B·II) while those with portal cirrhosis showed significant amounts of B·I. 4. When clinical, laboratory, or X·ray findings are not sufficiently dis.tinct for the differentiation of these two condrtions in cases of massive gastric hemorrhage, the bilirubin (B·I) content of the blood may help in •the differentiation. Peptic ulcer is not accompanied by B·l in the blood, while portal cirrhosis is always accompanied by functional disturbances of 1he liver. This is shown by the constant presence of B·I in the blood. NAME OF CLINICAL AMOUNT AMOUNT PATIENTS DIAGNOSIS OF B·l OF B·2 I. R. M. PORTAL Traces None CIRRHOSIS Or Peptic Ulcer 2. D. G. M. Peptic Ulcer None None 3. H. N. Peptic Ulcer Traces None 4. J. B. T. Portal Cirrhosis None None or peptic ulcer 5. ). s. Peptic Ulcer or 0.658 I.HO Portal Cirrhosis 6. c. v. Peptic Uker or 0.822 Tr<!ces Portal Cirrhosis 7. A. L. Cerebral Malaria? 0.740 Trace6 Portal Cirrhosis? BIBLIOGRAPHY I. Boyd-Textbook of Pathology-Lea & Febiger, Phil., 1940. 2 . Boyd-Textbook of Pathology- Lea fi Febiger, Phil., 1934. OPERATIVE T.'\K/\TA OR .AUTOPSY FINDINGS. Neg;;:.tiv~ Peptic Ulcer. Negative Peptic Ulcer. Not operated; not dead (Pep• tic ulcer) Negative Peptic Ulcer. Negative Portal Cirr· hosis Mod. Pos• Portal Cirr· sitive. hosis. Negative Portal Cirr· hosis. ~ . Bilirubin Stu.dies II-Bile Pigments in Different Diseases associated with Jaundice-to be published-rfavarro, R.)., Tangco, A. and Silva, ). A. ..; . Bilirubin Studies I-Separation and Quantitative lJetermination of chloroform soluble and Water Soluble Pigments-Navarro, R. )., and Tangco, A.-Acta. Med. Philippina, III, 21 , 1941. 5 . Malaria in the Philippines with Studies, Clinical and Pathological of its Hepatic Manifesta· tions-Sison, A. G. and others. INCIDENCE OF CARDIAC ARRHYTHMIAS JOSE M. BARCELONA, M.D. Departmen= l of Medicine, College of lvfedicine, University of the Philippines. This paper seeks to show ·the incidence of the most common types of cardiac arrhythmias in different cardiac and non-cardiac conditions and in different age groups. Irregularities of the heart beat are often significant of organic heart disease, but at times they can be functional in origin. Electrocardiography is considered one of the best instrumental methods in the study of cardiac arrhythmias. Physical examination, consisting mainly in studying the rhythm and rate of the heart beat at the precordium and of peripheral pulses, and in establishing the pulse deficits -in many instances, physical examination is accurate enough; but it can, at times, be inadequate and inconclusive, and instrumental methods, particularly electrocardiography, has to be employed. This paper des.cribes the diagnoses of the various types of cardiac arrh}"lhrnias by means of electrocardiographic tracings done,. on patients in the Wards and Dispensaries of the Philippine General Hospital, the big majority of whom are from the Department of Medicine. The period of observation was from March, 194 l to October, 1942. A total of 838 electrocardiographic tracings are included in the <eries. The records and charts of the various cases used were carefully analyzed for the main cardiac and non-cardiac diagnoses; and, whenever the case.; had come to autopsy, more weight was given to the post-mortem findings than to the ante-mortem diagnosis. The criteria advocated in the Nomenclature and Criteria for Diagnosis of Disea.es of the Heart by the Criteria Committee of the New York Heart Association (fourth edition, 1939) were adhered to in making the main cardiac diagnoses. The principal cardiac diseases included and the main diagnostic points for each are : ( 1) Arteriosclerotic heart disease - "cases of heart disease showing definite evidence of arteriosclerotic disease in any of the palpable arteries or retina, or fluoroscopic evidence of sclerosis in the arch of the aorta, or else belongs to the age group where arteriosclerosis is apt to occur, provided there are characteristic cardiac signs or symptoms". (2) Hypertensive heart disease - "persistent hypertension associated w;th heart disease"; hypertension is "present when the systolic blood pressure is persistently above 140 mm Hg or the diastolic pressure above 90 mm Hg." (3) Cor pulmonale - "when there is cardiac insufficiency, there is present a specified pulmonary disease, and there is evidence of enlargement of the right ventricle". ( 4) Rheumatic - "when there is history of polyarthritis, muscle or joint pains, ' Read before the 39t.h Annual Meeting of the Philippine Medical Association, held May 10, 1946. 234 CARDIAC ARRHYTHMIAS-Barcelona Jour. P. M.A. June, 1946 subcutaneous nodules, chorea, and evidence of structural lesion of the heart plus ~ history of periods of recurrent fever and cardiac insufficiency. ( 5) Syphilitic - "when • there is history of syphilitic infection and evideric.: of one of the structural lesions of the aorta; a characteristic structural lesion of the aorta withoU't history of syphilis but with a positive Wasserman reaction; a charac· teristic structural lesion of the aorta together with evidence of syphilitic disease elsewhere, such as cerebrospinal syphilis even in the absence of a positive Wasserman reaction or a history of syphilitic infection." (6) Beriberi - when there is heart insufficiency associated with polyneuritic symptoms and other evidences of avitaminosis B,. (7) Congenital heart disease - when there are present characteristic radio· logic findings and physical signs. (8) Hyperthyroidism - when there "is evidence of hyperthyroidism with abnormal cardiac function such as sinus tachycardia, paroxysmal or permament auri· cular fibrillation or flutter, or occasional premature beats." The standards in ·the ]\(omenclature and Criteria for D iagnosis of Diseases of the Heart were used in making the electrocardiographic diagnoses. Whenever digi· talis or allied drugs had been used on the patient, an attempt was always made to determine whether the observed arrhythmia was produced by the digitalis. If w , was discarded from the series. T he following most common types of cardiac arrhyth · mia were included in the study: sinus. arrhythmia, auricular fibrillation, auricular flutter, second degree auriculo·ventricular block, and auricular and ventricular pre· mature bea·ts. The observations obtained are summarized in the following tables: TABLE 1- Sinus Arrhythmia Age ncidencc A sso. Disease Normal Rheumatic Arteriosclerot. Hypertensive Hypovit. B1 0·9 10· 19 20·29 30·39 40·49 I 1 0 0 0 5 5 0 0 L' 5 3 1 1 0 0 l 0 Thyrotoxicosis O O I) 1 O Syphilis 0 o I (?) 0 J ~_:_;_~c_cn_i_ta_I __ / ~ I ~ I ;~ ~ I ~ TOTAL - - - 3- --10IO, -6- --750·59 0 0 1 •) I 0 0 0 4 TABLE 2- - Auricular Flutter A sso. Disease I Age Incidence 0·9 10·191~ ;0.39 40·49 50·59 Rheumatic --- --J__l_j_L 2 0 0 Hypertensive 0 1 0 TOTAL·---- --0 0 0 ' I 0 60·69 70·7~ - 0 - - 0 - 0 0 0 0 0 0 0 3 I 0 0 0 0 0 4 4 60·69 7•)·79 --- --:) 0 0 0 ·- - - --0 0 Total l 'J 9 6 I 15 i I 3 i ~ I -+I Total --2 I I -3, Volume XXU Number 6 A$SO. Dis<.as.: Normal Rhcumati.: Arteriosdcrot. Hypertensive Thyrotoxicosis Cor Pulmonale TOTAL - CA.RD/AC ARRHYTHMIAS-Barcelona TABLE 3-Auricular Fibrillation Age Incidence 110~19 0·9 20·29 30·39 40·49 j 50·59 ! w-69 I 10.19 --- --- --- --- --0 0 0 0 0 0 0 0 3 12 10 9 I 2 z 0 0 0 0 0 0 I 3 1 2 0 0 0 0 0 I 3 ! 0 0 0 1: 1-- 1: i I 0 0 0 0 0 0 I 1 0 0 -- --0 3 11 9 5 2 TABLE 4-Suond Degree AuricuJo .. Ventricular Bloc~ 235 I Total --0 38 6 5 4 1 --54Age Incidence I -.'\!'so Disease - - - - - - 1 ~ 10·19 20·29 , 30·39 , 4o-49 ~~~ 60·69 70·79 ~ ~~:.~::~):rot. ~ ~ i_1l1l j_ j_ l1· __ L TOT AL ·- o 1 0 0 0 1 0 5 TABLE 5-Auricular Premature Beats Age Incidence Asto. Disease 0·9 10·19 20·29 30·39 40·49 50·59 60·69 70·791 Total -- - - - - - - --- --- --- --- --- ---Normal 0 0 l 0 0 0 0 0 1 Hypertensive 0 0 0 0 () 1 0 0 I 1 --- --- -- - --- - - - - -- -0-1- - 2TOTAL - I 0 0 I 0 0 l 0 - TABLE 6- Ventricular Prtmature Beats 1~ Age Incidence Total I Asso. Disease 20·29 30·39 40·49 I so-59 60·69 70·79 10·19 --- - -- --- --- - - - i Normal I 0 l 0 l 0 0 0 0 2 ! Rheumatic 0 4 3 4 2 2 1 0 l(> Arteriosclerot. .. 0 0 0 0 0 1 0 1 2 Hypertensive 0 0 0 2 1 5 3 1 12 Thyrotoxicosis 0 0 3 0 0 1 0 0 4 Cor Pulmonale 0 0 0 0 0 1 0 " 1 I Congenital 0 l 0 0 0 0 0 c 1 I .. '\nemia. (malaria) 0 0 1 0 0 f-1-IJ__ 0 1 Hypovit. B, 0 0 0 1 1 0 2 I l TOTAL -- -- --- --- -- ---4-1 1 - 0 6 7 8 4 10 4 2 The next table summarizes the incidence of the above forms of cardiac arrhyth· mia among 1he various age groups: 236 CARDIAC ARRHYTHMIAS-B<ircelona TABLE 7-Cardiac Arrhythmia Among Age Groups Cardiac Age Incidence Arrybthmia 0·9 10·19 20·29 >0·39 40·49 50·59 6C·69 -- - - - - - - - - --- --Sinus Arrhythmia 3 10 10 6 7 4 4 Aur. flutte, 0 0 0 2 1 0 0 Aur. fibrillation 0 3 1' 10 11 9 5 Sec. degree A.Y block 0 3 1 0 0 0 l Aur. premature beat.; 0 0 1 0 0 1 0 Vent. premature I+ beac. 0 7 8 I 10 4 - - - - - - - -- - -- - -TOTAL - 3 33 26 H 24 14 Jou"r. P. M. A. June, 194$ 70-79 Total --- --4 48 0 3 2 54 0 5 0 2 2 41 - -- --8 153 From the tables above we find that below the age of 10. sinus arrhythmia is the only type of cardiac arrhythmia observed. This form of irregularity is observed in all the age groups, but almost 50'./o (23 out of 48 cases) of it is seen below the age of 30. Auricular flutter, auricular fi'!irillation, and second degree auriculo·vcntri· cular block are found mainly between the ages of 10 and 50 years, the same age period in which there is a high incidence of chronic rheumatic affection of the heart. Ventricular premature beats are seen mostly between the ages of 10 and 60, and has its highest incidence in the age-group of 50·59 years. Summarizing the total incidence of each type of cardiac arrhythmia, we find that in the 153_ cases of cardiac arrhythmia studied, sinus arrhythmia represents 31.4%, auricular flutter 1.9%, auricular fi!brillation 35.3%, second degree auriculo·ventricular block 3.3 'lo, auricular premature beats 1.3%, and ventricular premature beats 26.8%. The next table summarizes the incidence of the various types of cardiac arrhyth · mia among the most common cardiac and non-cardiac conditions associated with cardiac arrhythmias: Associated Condition Normal Rheumatic Artcnosclcrot Hyperte1lsivc j Thyrotoxico"'i"" ·nypo\·it. B1 ICor PuliTion;ilc Congenital Anemia· Syphilis Toxic TOTAL - TABLE 8- Cardiac Arrhythmia Among Diseases Sinus I Aur. I ~:~j. I :;d/~ Arrhy. Fi utter _ _ _ __ _ __ _ _ __ lation _ _ Block. ~ I 3~ I ~ 19 9 6 6 ? 3 0 1 0 1 1 48 ! I ! I ~ ! ~ i : I ~ ~ II ~ I ~ 0 0 0 --3--54-1--5Aur. Prem. Beats I 0 0 1 0 0 0 0 0 0 0 Vent. Prem. Deats 2 16 2 :2 4 2 l l 1 0 0 41 Total 23 68 ts .25 ,o I I I l l l 153 Per· cent 15.0 44.4 9.8 16.3 6.5 3.3 1.3 1.3 0.7 0.7 0.7 100.0 From this table it is clear that, in normal individuals, sinus arrhythmia is the only form of cardiac irregularity that has a high incidence. There is no incidence what· Volume XXll Number 6 CARDIAC ARRHYTHMIAS-Barcelona, 237 soever of auricular fibrillation or auricular flutter in normal subjects. In rheumatic heart disease, auricular fibrillation is the most prevalent form of cardiac arrhythmia. Ventricular premature beats also have a high incidence. In arteriosclerotic and hy· pertensive subjects, almost all the various forms of arrhythmia are seen with none having any markedly high incidence, except ventricular prem<rture beats in hyper· tensive heart disease. In thyrotoxicosis auricular fibrillation and ventricular premature beats are found the most common types of cardiac irregularity. Sinus arrhyth· mia and ventricular premature beats are the forms of cardiac irregularity seen in th~ cases of hypovitaminosis B1 observed. In other condi·tions s.tudied, there are only isolated cases of cardiac arrhythmia, probably because not enough cases were observed. On the whole, it can be seen that, out of the 15 3 cases studied wi·th cardiac arrhythmia, only 23 (or an incidence of 15.0% ) are seen in normal indivi· duals; and of these, 19 are sinus arrhythmia, which is considered physiological in children below the age of 14. In our studies, 13 of these cases of sinus arrhythmia belong to the age groups of 0·9 years and 10·19 years. All the other cases of cardiac arrhythmia are seen associated with s.ome form of pathologic condition, either specifically of «he heart or involving the hzart in some way. BIBLIOGRAPHY l. Andrus, E. Cowles.: Disorders of the Heart Beat, Tice's Practice of Medicine, v. VI, pp. 149·220, Prior, 1940. 2. Levine, Samuel A.: Clinical Heart Disease, sec~nd edition, Saunders, 1940. 3. Fish berg, Arthur M.: Heart Failure, second edition, Lea and Febiger, 1940. 4 . Criteria Committee, New York Heart Association.: Nomenclature and Criteria for Diag· nosis of Diseases of the Heart, fourth edition, 1939. 5. Ashm•n, Richard •nd Hull, Edg•r. : Essenti•ls of Electrocardiography, M•cmillan, 1937. DIGENIA SIMPLEX AS A SUBSTITUTE IN THE TREATMENT OF ASCARIASIS ' H. LARA, M.D., T. M. GAN, M.D., M. Y. MATIAS, M.D. AND A. C. REYES, M.D. INTRODUCTION The practical usefulness of any anthelmintic may be considered under seven headings, namely: (1) Availability, (2) Cost, (3) Preparation of the patient prior to the administration of the drug, (4) Effectivity, (5) Contraindication, (6) Toxi· city, and (7) Ease of the preparation· from the raw material. To be an ideal an· thelmintic it must satisfy the following requisites: First, there must be a local source or murces of the raw materials from which the active principle is obtained; and the source must be abundan1, Second, the medicine must be relatively cheap. A drug both locally prepared and .locally available is generally cheaper than one imported from other countries. This, however, is by no means always the rule. Third, the drug should not require preliminary preparation of the patient before it is administered. The extra precaution or preparation of the patient before and after the main anthelmintic is administered sometimes serves as a drawback. At times this is more frightening to patients than the ascaris infestation itself. An ideal anthelmintic must, therefore, not need such preliminaries. Fourth, the drug must be highly effective in the expulsion of the worms. Fifth, the drug should have no contraindication. The practical usefulness of an otherwise efficacious an· thelmintic will be limited by the risk of its administration. In order that the drug can command popularity, it must be, in addition to other desirable qualities, one which can be administered under any circumstance. Sixth, the drug must have a relatively low toxicity - or, better still, non-toxic. Toxicity and contraindication of a drug run pari·pasu with each other. The ·toxicity of a drug has always been a good excuse for many physicians to avoid its use. especially if the margin of safety of an effective dos.e is very narrow. An ideal anthelmintic must, therefore, be devoid of any toxic effect. At best. if it has some undesirable effects. there must be a wide margin of safety. It must not be forgotten that "patients and not diseases are treated." Seventh, the preparation of the medicine must be easy. The ease, simplicity, and absence of many complicated apparatus in the preparation of the drug are ass;ts that can not be too greatly emphasized. It may truly be said that these attributes may even outweigh some undesirable qualities of the drug. Hence, preference must be given to one that can be easily prepared, especially if the other requirements have been satisfied. OBJECTS OF THE INVESTIGATION This study was first conceived in the early part of the Japanese occupation when drugs became more scarce, and prices rose higher, day by day. By and large, we I Read at tho l9th Annual Meeting of the Philippine Medical Association, held May !(', 1946. 240 DIGENTA SIMPLEX-Lara et al. Jour. P. M.A. June, U46 have always depended on other countries, especially the United States, for medicines used in the treatment of intestinal parasitism--of all other diseases, for that matter. The medicinal stock of the country dwindled gradually to exhaustion at about the end of ·the Japanese rule; so that, by the latter part of the occupation, an individual who was so unfortunate as to fall ill, ran the risk of dying without receiving any medical treatment. Although, ordinarily, ascariasis does not seem to produce any appreciable harm, yet it undermines the heahh of the individual affected to some degree. Hence, the necessity of eliminating the worms. The objects of our study are to determine ( 1) if Digenia simplex is capable of expelling ascaris from a patient, (2) the extent or degree of effectiveness, ( 3) contraindications if there are any, and (4) toxicity. MATERIALS AND.METHODS In this study, we made use of our patients in the Urban Health Demonstration Unit, popularly known to the public as Paco Health Center, and medical students who voluntered to be treated with our preparation. The Digenia simplex, a sea· weed, was secured at the instance of the senior author, from the north·eastern coast of lsabela Province. This seaweed is found in abundance, not only in this region, but also in the eastern coast of the entire length of Palawan. Having no guide to start with, we distributed ·the crude drug in packages of I 0 and 15 grams each - the former to children below 7 years of age; and the latter, to children 7 years and older. This dosage was based purely on experience. The patien·t was instructed to boil the seaweed in about one glass of water for a few minutes and then to drink the extract. It did not take long for us to realize that the idea was not practical on account of the high cost of fuel. We abandoned the plan and decided to prepare the medicine ourselves. After a few treatment,, we were convinced that a highly concentrated decoction is more desirable, as many of our patients were young children to whom the medicine was more easily administered if i·ts bulk was smaller. Usually we prepared a kilo of the seaweed in 6 liters of water, and boiled the seaweed until the liquid was reduced, so that the concentration of the drug was 50% to 100%. In the latter part of our investigation, how~~er, we fixed :he strength of our decoction at 100%. After not more than 10 cases were treated, we decided to increase our dosage to 15 grams for children below 7 years of age and 20 grams for children 7 years and older. This dosage was also arbitrary. In a 100% preparation, 1 c. c. presumably contains what 1 gram of the raw materials would have of the active principles; and we speak of it as con· :aining 1 gram of Digenia simplex. Each patient was required to bring stool specimen for examination. If found positive for as.caris ova, a dose of the decoction was administered. Then the patients were instructed to report to us whether ascaris was expelled or not in a period of one week; whether the worms were expelled dead or alive; whether they were ex· pelled in the process of defecation or came out alone; and if they came out through the mouth. We also required them to remember the time of expulsion of the worm>, in order for us to be able to determine how soon the worms were expelled after the administration of the drug; and to n0te any undesirable effect resulting from taking Volume XXU Number 6 DIGENIA SIMPLEX-Lara et al. 241 the drug. In every case, we tried 10 make a personal follow·up in the homes of the patients everyday up to the seventh day. In other cases, especially when the patients lived In another district, we required them to bring us the worms expelled for check up; but we recognized the difficulties arising from this. Then from 1 to 7 days after the first expulsion of worms, we required them to bring a sample of stool specimen, in order to determine if the stool continued to be positive for the ova of the parasites. In a few cases, we administered the drug without first examining the stool. The pat~ents, however, gave a history of passing out worms either through the mouth or through the anus. Except for the preliminary stool examination, this groups was handled in exactly the same way as the first group. To satisfy our curiosity, we ad· ministered the drug to a few whose stools were negative for ova of the parasites. RESULTS AND OBSERVATIONS During.the liberation of Manila, the raw data of our investigation were all burned. Fortunately, the rough draft of our progress report was salvaged in the ruins of the Institute of Hygiene Building. This draft contained only about half of the total number of cases under study. Based on these few cases, we are presenting our ob· serva1ions. First, we noted that the longer we boiled the Digenia simplex, the more effective it became in expelling out worms; but boiling it more than four hours would not in· crease its effectivity any further. Second, no undesirable effects were noted following administration of the dr'ri(s in the dose mentioned above. Third, the drug could be administered under an)· ·circums.tances before, during, or after meals; and there seemed to be no need to prepare the pa~ient before the drug was administered - such as dieting or - giving of purgative and enema. The drug was administered both in cases of purely intestinal parasitism and in those with concommi·tant diseases. Fourth, the efficacy of expulsion was 73.61 7c for ·the group with a preliminary stool examination; and. 84.69, for the other group for which no stool examination was possible before the adminis.tration of the drug. These findings are shown in the following table: TABLE !. Effectivity of Worm Expulsion with Digenia simplex. With Stool Examination Prior Without Stool Examination Prior To Initial Treatment To Initial Treatment Number expelling I Num.ber not expell· Number expelling I Number not expell· ascari.§ 1ng ascaris ascaris 1ng a~.cans 120 I 43 22 I 4 163 ·26 189 We had 27 additional cases with negative stool examination to whom we ad· ministered the drug. Two of these passed out adult ascaris a few hours following the administration of Digenia simplex. In both cases no verification was made as 242 DIGEN/A SIMPLEX-Lara et al. Jour. P. M.A. June, 1946 to the sex of the worms. If the worms were males that would explain the negative stool examination. If, on the other hand, the worms were female, the only possible explanation for the negative stool is that the eggs were few and that no concentra· tion method was followed in any of the stool examination. CONCLUSION Based on the cases we are presenting, Digenia simplex seems to have a bright future as a substitute in the trea1ment of ascariasis and possibly of other intestinal worms. Our observations have led us to make the following conclusions: (1) The effectiveness of the drug (73.61%) holds a big promise, especially if we consider it together with other qualities that it possesses. (2) The drug is non· toxic, a requisite which makes it superior to all other drugs commonly used in the local treatment of intestinal parasitism. (3) The drug can be administered under any circumstances without the neces• sity of preparing the patient prior to the actual taking in of the medicine. ( 4) The ease of preparation and the local availability and abundance of the raw material are added advantages over those imported from other countries. THE HYPERALIMENTATION TREATMENT OF PEPTIC ULCER WITH AMINO ACIDS (PROTEIN HYDROLYSATE) AND DEXTRI-MALTOSE* CO TUI, M.D., ARTHUR MULLEN WRIGHT, M.IJ., }. H. MULHOLLAND 11·!.D .. ' T. GALVIN, M.D., I. BARCHAM, M.D. AND G. R. GERST, M.D. With the nursing assistance of MARY COUGHLIN and the technical assistance of LILLY SCHMIDT, LOUIS SUTHERLAND and FRIEffA WOLF from the Labora:tory of Experimental Surgery, The Department cf Surgery, of the New 'Yor~ University College of Medicine and the New 'Y or~ University D ivision uf Surgery, Bdlevue Hospital. New 'Yor~ INTRODUCTION In the course of studies on the effect of a hyperalimentation regimen with high caloric and high amino acid feedings, (using a mixture of amigen and dextri·maltose) on convalescence after gastrectomy (I). it was thought advisable to try the regimen in the preoperative management of some cases. Accordingly, four patients with pep· tic ulcer, R. B., M. K., J. B., and F. P. were given this treatment. All had epigastric distress, one had persistent vomiting, and two had occult blood in the stools. All experienced relief of distress in twenty·four hours after treatment was instituted; the vomiting stopped in twenty·four hours and the occult blood disappeared in four days. All gained from 3.5 to 4.7 kg. in from eight to ten days. The return of strength and well-being was prompt and striking in all, and one patient left the hospital, refusing operation. Three decided to undergo operation, eight and ten days respectively after the initiation of the regimen, and in two of them (R. B. and J. B., table I) the ulcers were found still to be present; in the third (M. K.). an ulcer scar was found. The striking clinical improvement obtained, suggested that this feeding regimen could be a satisfactory treatment for peptic ulcers, and it was tried out in twenty·six more cases. The results of this study, together with those obtained in the four original cases, are presented here. CLINICAL MATERIAL This includes twelve cases of duodenal ulcer, five of combined duodenal and gastric ulcer, seven of gastric ulcer, one of suspected marginal ulcer, and one of *Reprinted with permission from Gastroenterology, Vol. 5, No. l , July, 1945, except thP: Addendum which appears on page 254 of this issue.-Editor. 1 Professor of Clinical Surgery, New York University College of Medicine, now Lieut· enant Colonel, Medical Corrs, United States Army. The work describl."d in this papl'r wa~ dnne undn a cc:tntr:ict recommended by the Com• 1nittee on Medical Research between the Office of Scientific Research and New York Uni· v<-r!'ity. The Amiiren anrl dextri·maltosr used were supplied bv the Mefld· Jonhson Comnanv of Evansvi11e, Indiana. The experimental. protein hydrolysate wa~ supplied by E. R. Squibb f5 Sons. 244 TREATMENT OF PEPTIC ULCER-Co Tui et a/. Jour. P. M.A. June, 1946 radiologically confirmed marginal ulcer. The criteria of therapeutic efficacy were time of disappearance of symptoms, improvement in roentgenologic findings, gain in weight and gain in strength as measured by a bedside ergograph (2). The gastric pH and acidity, free as well as total, was determined in eighteen cases before treat· ment. The effect of the feeding mixture on the gastric pH and acidity was studied in only three cases. The nitrogen balance was determined in fourteen, as was the plasma, alpha·amino·acid level (3), the blood proteins and hematocri·t reading. Except for the s.ix cases complicated by frank hemorrhage, in all except one the patient was semi-ambulatory; that is, in the hospi·tal but not confined to bed. The one exception, P. B. was treated in bed at her home. The length of ulcer history varied from one month to twenty years. Fourteen were "intractable" cases; that is, the symptoms had not improved on complete bed rest and strict Sippy treatment (with or without amphojel) af.ter from one to fi've weeks. One person had a history of perforation five years previously, and one had a perforation five years before the present attack. Six patients had had profuse hemorrhage, three with hematemesis and three with melena; six had six·hour gastric retention, respectively 20~. 50%, 60 7o, 7070, 90 % and "complete." Three had signs of deep penetration of the ulcer. THE TREATMENT J\litrogenic and caloric inta~e. All the patients except one were placed on two· hourly feedings of "amigen" and dextri·maltose. "Amigen" is an enzymatic hydro· lysate ·of casein and pork pancreas cont;iining all the essential amino acids and poly· peptids. It contains 12 per cent total nitrogen, 65 % of which is amino ni·trogen and the balance polypepti<l nitrogen, imino nitrogen, ring nitrogen, and ammonia nitrogen. One patient took an experimental protein hydrolysate wi·th a nitrogen content of 13.5'/c. The mixture fed contained from 0.5 to 0.8 gm. of nitrogen and 40 to 50 calories per kilogram of body weight per twenty-four hours. For a 60 kilo man the amount of "amigen" taken in twenty-four hours was from 300 to 400 gm., with a nitrogen content one and one half to three times that of a high protein diet. Each gram of "amigen" yields 3.7 calories, and each gram of dextri·maltose adds 4 calories. The mixture was made up by adding three parts by weight of water to one part of '"ami· gen." The mixture was divided into eight or nine feedings to be given every two hours during the waking period. In cases in which the ulcer distress was severe ·the feedings were given hourly. The amigen preparation is offensive to some patients but not to others. It seems to us that peptic ulcer pa-tients as a class have the least objection to its taste. There is no one method of administration acceptable to all patients. Some prefer it cold, others at room temperature and still others, hot. Many prefer it withou·t flavor. Some patients prefer to take the concentrated amigen mixture first and then follow it with the dextri·maltose solution as a "chaser." In case of extreme intolerance, a small Levin tube may be used which the patient can either swallow in the morning and keep until ·the last feeding is given during the twenty·four hour period, withdrawing it before retiring; or, after some training, he can swallow the tube before each feeding, withdrawing it thereafter, repeating this every two hours. Mention may also be made of the fact tha·t this mixture is a good medium for bacterial growth and for that reason Volume XXlI Number 6 TREATMENT OF PEPTIC ULCER-Co Tui et al. 245 must be kept in the icebox once it is made up. The ingestion of the bacteria·laden mixture may provoke vomiting and diarrhea. The mixture was given exclusively for from two to three weeks, depending upon the subrequent X·ray £,;dings. If after two weeks the X·ray examination indicated healing of the ulcer the pa·tient was given a bland diet supplemented by two-hourly feedings of amigcn. 'The mineral inta~e. The chloride content of "amigen" (4) was approximately equal 1o I. 7-2 '.fo sodium chloride, so that with the higher doses of amigen the daily ingestion of sodium chloride was a-t most 6·8 grams daily. In addition to sodium chloride, the approximate composition of amigen ash, which comprises 5.5 './o of the bulk. is as follows: Phosphorus . ...... . ........... . . . . . SullUI .. . ... . . ..... . ...... . .. . . .. . Potassiun1 ............... . . . . . .. . . . per cent 0.9 0.6 0., Calcium . . . . . . . . . . . . . . . . . .. • . . .. . . . . ... .. .... . ... . . . . . . .. . . . . . 0. 4 Magnesium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0. 0 5 Iron.. .. ......... .. .. ............. . . . .. . .. . .. . . . . . .. . . . . . . . 0.02 Copl'fi. . . . . . . . . . . . . . . . . . .. .. . . . . . . .. . . . . .. . . .. . . . . . . . . . . . . . 0 . 00 2 The intrtke. therefore, of minerals contained in from 300 to 400 grams of amigen approximated the daily requirements as given by Macy (5) and by Heath (6). Supp!ementary measures. During the period of amigen feeding. the following complement of vitamins was given daily; namely, thiamine chloride, 50 mgm.; ascorbic acid 100 mgm.; riboflavin and niacin. each 50 mgm. Liver extract, 15 USP units, was given intramuscularly twice a week. No antacids or antispasmodics have been found nea..'\Sary. Whenever there was a tendency to diarrhea, "amphojel" was given in 4 cc. doses, -twice a day, a dose too small and too occasional to affect the course of the treatment by its antacid property. None of the patients were required to abstain completely from smoking. ANALYSIS OF RESULTS Symptoms. The twenty·s.even cases in which pain or epigastric distress was the presenting symptom, the pain and distress stopped in twenty·four hours, in four· teen, and in forty·eigh>t hours in thirteen. Seven of those in the former group and three in the latter group were "intractable" cas.es. Of the thirteen cases in which vomiting was a symptom, it stopped immediately after the institution of the" diet in six, in twen~·four hours; and in one (treated at home), in forty·eight hours. Of the fifteen cases with occult blood, this disapp.eared in two days in two; in three days in six; and in one week in six. Gastric acidity. Since the treatment seemed so efficacious without the use of antacids, the factor of gastric acidity has not received systematic study in this series. However, of the eighteen cases in which gastric analysis was performed, eight showed mild and six severe hyperacidity, while four showed normal acidity. Table l shows the effect of feeding amigen and dextri·maltose mixtures in (a) a patient the pH and free acidity of whose gastric contents was relatively low; and who was fed a mixture containing 50 grams of amigen and 58.6 grams of dextri·maltose, the pH of the mixture being 5.39; (b) a patient in whose ga~tric contents the pH was low and the 246 TREATMENT OF PEPTIC ULCER-Co Tui et al. Jour. P. M.A. June, 1946 free acid fairly high but who was fed every hour, practically half of the average dose (25 grams amigen and 37 grams dextri-maltose, pH 5.35); (c) a patient whose gastric pH was also low, whose free acid was higher but who was fed a mixture containing 51.1 grams amigen and 58.6 grams dextri-mahose with a pH of 5.22. It will be seen from (a) that the pH rose slightly after the feeding and the free acid dioappeared for two hours and twenty minutes. In (b) the pH was raised from an initial value of 1.75 to 4.40 after the first feeding, while the free acid had disappeared. The pH declined gradually but was again raised olightly by the second feeding, after which it began to decline again un-til at the end of the second hour, it was lower than at the end of the !i~st hour. The free acid at the end of the second hour had also returned to a figure above the ini1ial values. A third feeding rai~ed the pH again but did not neutralize the free acid. At the end of the third hour the pH was lower than a·t the end of the second hour, and the free acid was the highest it had ever been, Whether this gradually weakening effect is characteristic of small feedings or due to other factors is at present not clear. In (c), with an initial pH of 1.92 and a free acid of 59. ·the feeding of 51.1 grams of amigen and 58.6 grams of dextri-maltose cauo.ed the pH to be raised to 4.21, and the free acid to disappear for about two hours, after which the pH began to fall and the free acid to rise. While these studies have not been systema•tic, they suggest that two-hourly feedings or larger quantities are more efficacious than one-hourly feedings of small quantities. It is quite possible that with further study, a feeCiing formula may be evolved which would relate the frequency and dose of feedings to the initial pH and free acidity of the gastric contents. One addi·tional small point may be made here, that of the two samples of gastric juice taken a few minutes apart after the Levin tube was introduced; the first sample had a higher pH and a lower free acid value than the second sample, suggesting the presence of the tube provoked secretion. TABLE 1 TIME pH FREE ACID TOTAL ACID A 10:00 4 . 25 1.0 56 .0 10:10 5 . 38 14. 5 64.0 Feeding: Amigen: 50 g. Dextri·Maltose: 58.6 g.-10:10 10:45 ' 4.45 192.0 11 :06 4. 72 218 .0 ll: 15 4. 76 224.0 11 :30 4 ' 68 259 . 5 11 :45 ,4' 50 267 .0 12 :00 4' 50 232.0 12: 15 4.00 175 .0 11 :30 3. 89 170 .0 Formula: 5. 39 489.0 B 10:30 1.90 26 . 5 48 . 0 10:35 I. 75 42.0 66 . 5 Volume XXII Nmnber 6 TIME 10,40 IO:SO II :30 12:00 12 :10 12:30 12:40 I :20 1:30 Formula : c 10:00 10 :10 TREATMENT OF PEPTIC ULCER-Co Tui et al. 247 TABLE 1.-Continued. !st Feeding : Amigen 2S g. Dextri·Maltose 37 g.-10 :3S pH FREE ACID TOTAL ACID 4.40 0 211.0 4.01 0 289.0 >. 39 0 243.0 2nd Feeding: Amigen 2S g. Dextri·Maltosc 37 g.-11:30 L6S 0 209.0 >. 64 0 2S9.0 2. S9 74.0 180 .0 3rd Feeding: Amigen 2S g. Dextri·Maltose J7 g.-12:30 >.83 SJ .0 190 .0 3. 71 12.0 177 .0 2 .JS 88 .0 180.0 s. 3S S02 .0 2.0S 47 .0 6S. s 1.92 S9 .0 78 . s Feeding: Amigen: SI.I g. Dextri·Maltose: S8.6 g.-10 :10 10:4S 4. 21 20S. s 11:00 4. 24 269 . S 11: IS •I. IS 24 }. 5 II :30 4.07 ;os.o 11 :4S 4. 22 293 .0 12:00 4 . 18 286.S 12 : IS 3.68 3 .0 212 . s 12 :30 3.01 H.S 191. s FormUla: s. 22 4S6 .0 pH, free and total acid values of gastric contents in three cases of peptic ulcer before and after feeding with amigen and dextri·maltose. The high total acid values are due to the presence of amino acid. The above pH and free acid figures are in good agreement with those of Levy and Siler (7), who first demonstrated the practical effect of amigen feedings on the pH and free acid values of the gastric contents of normal persons. 'The nitrogen balance. Of the twenty·nine .cases, the nitrogen balance was followed for from thirteen to eighteen days in twenty·one. Their "nitrogen hunger" was exemplified by the large amounts of nitrogen stored. In these cases the nitrogen retention averaged between 9.84 and 16.61 grams daily, most values ranging around 12 grams. This represents a daily protein gain to the body of from 61.5 to 103.8 grams. There seems thus to be a protein deficiency in a large number of peptic ulcer patients, a finding which is consonant with evidences of other nutritive deficiencies found by Riggs, Reinhold, Boles and Shore (8) . 'The body weight. The nitrogen storage in these patients is reflected in the steady gain in body weight. In only one patient was there no gain registered and this patient was already in good nutrition on admission. In all the others the gain 248 TREATMENT OF PEPTIC ULCER-Co Tui et al. Jour. P. M. A. June, U46 varied from 1.8 kilograms in eighteen days to 14.3 kilograms in forty-six days. However, it must be mentioned that patient R. B. developed temporary edema after four weeks of "amigen" feeding. Whether latent edema was present in the other patients, it is not possible to state, although the discontinuation of exclusive "amigen" resuked in a loss of from I to 3 lbs. in some of the patients on the first two to three days, af.ter which the weight remained steady. Bedside ergography. Sixteen of these patients had their endurance tested periodically with the bedside ergograph described in a previous report (2). Briefly, this apparatus records on a moving drum the excursions made by the upper extremity in lifting a constant weight every three seconds. The time of performance in seconds is called •the ergograph time (E.T.) . While this method seems crude, it has served in our convalescence studies as a better index of clinical improvement or retrogression than any other clinical criteria now in use. lt was found in the ulcer cases tha·t all these so studied improved markedly in their performance, the E. T . increasing from 75 to 4007'0 in ·the course of the treatment (fig. I) . 'The hematocrit reading, plasma proteins and fasting amino acid levels. Most of the initial hematocrit and plasma protein values were sligh·tly below normal in spite of some hemoconcentrat:on, evidenced by the drop to lower values on subsequent days when be~ter hydration had been achieved. These subnormal values are in ~ccord with the findings of Riggs, et. al., referred to above. It seems also that the hematocrit and plasma protein values dropped further as treatment continued. This may be due to overhydration. All these values are relative, and unle,.; the alteration in the plasma and ex·tracellular fluid volume are determined quantitatively, Fm. 1-Ergogram of Pail:ient D. R; Showing Different Periods after 'Treatment Volume XXll Number 6 TREATMENT OF PEPTIC ULCER-Co Tui et al. 249 these values lose much of their significance. The fasting plasma alpha-amino acid levels, as far as they have been determined, are interesting. In six cases, two were below the lower limit of normal, as established by Hamilton and Van Slyke (3), and A B FIG. A.-Patient S. V . Ulcer and Clover·li~e Deformity of Duodenum FIG. 2 8 .-Patient S. V. Picture After 2.~ Days of Treatment A c FJG. 3 A .-Pa.tient F. G. Ma.r~ed deformity duodenum with clover leaf formation and ulcer defecii mid·portion of duodena.I cap. FIG. 3 C.-Pati<nt F. G. 6 Wce~s of 'T'r<atm<nt. Showing M..,-~,d lmprov<m<nt 250 TREATMENT OF .PEPTIC ULCER-Co Tui et al. Jour. P. M. A. June, 1946 three were wi·thin normal limits. As the treatment progressed, the fasting alpha· amino acid levels first rose, f~lling again slightly during ·the later course of treatment. This drop may again be related to a tendency to retain fluids found in some of these cases as the treatment progressed. X -ray chec~s. X-ray checks were made in twenty-one cases in from ten days to three weeks after the initiation of the treatment. In the duodenal ulcer group, in the • ten ca•es in which this check-up was made, there were two in which an ulcer crater disappeared in ten days, one in which it disappeared in two weeks, and one in which it disappeared in twenty-five days. In other cases signs of lessened irrita• bility of the duodenal segment ~ppeared in ten, fifteen and nineteen days. Figure 3 shows the improvement in the roentgenologic appearance of the duodenum after twenty-three days of treatment. In those cases not showing such marked improvement, the spasm and tenderness elicited by palpation under the fluoroscope disappeared in ten, eleven and eighteen days. In other cases there were signs of improvement in eight, ten and eleven days. In two cases of retention, one of 60% and one of 90% , this retention had disappear• ed roentgenologically by the tenth and the fifteenth days respectively. In the eleven cases of combined gastric and duodenal ulcer, the disappearance of the gastric ulcer was noted by the ·tenth day in one, by the twelfth day in two, by the thirteenth day in one in two weeks in two, by the twentieth day in one, and in one month in one. Marked reduction in the size of the ulcer was found in ·ten, fourteen, and fifteen days, and one was smaller by the fifteenth day. A B Fie . 4 A .--Patient C. B. Large Crater, Lesser Curvature Fie. 4 B.-Patient C. B. Almost Complete Healing in JO Days Figures 2 to 6 show healing of gastric or duodenal ulcers of various sizes as demonstrated roentgenologically. While such rapid roentgenologic healing of gastric ulcers has been reported by various authors u•jng different types of treatment, (see Brown [9), Palmer [10) and Golden (11 ]), it was more the exception than the rule, while with the hydroly5'3.te regimen, prompt healing seems to be more the rule than the exception. Figure 6 shows the relief of marked retention after three days of treatment. Volume XXII Numh~r 6 TRE.4TMENT OF PEPTIC ULCER-Co Tui et al. A c E Fit. 5 A.-Patien:t R. B. Large Ulcer Crater, Lesser Curvature Pars Media Fie. 5 C.-Palien< R. B. Gradual Filling up of Defee!, 4 Wee~s of 'Treatment Fie. 5 E.- Patient R. B. Gradual Filling up of Defee<. 7 'h Wee~s of 'Trea<men< 251 The X·ray checks of the two cases with suspected gastrojejunal ulcer merit further comment. Both patients were admitted with pain and vomiting and with marked loss of weight. The roentgenograms showed marked tenderness over the stoma, and dilation of the stomach and proximal jejunum. Patient ]. S., who also showed a gaetrojejunal ulcer, had a 50% retention. There seemed to be a poorly functioning proximal loop in both. After treatment there was in both cases prompt disappearance of the pain and vomiting and a marked clinical improvement with 252 TREATMENT OF PEPTIC ULCER-Co Tui et al. Jour. P. M.A. June, 1946 rapid gain in weight and 'trength. X-ray checks showed disappearance of pain and tenderness over the s,toma in about three weeks. In J. S., however, in spite of ·these signs of quiescence and clinical improvement, the proximal · jejuna! loop still remained dilated. This suggested that while the nutritional status and pathological status improved, the underlying mechanical defect in the anastomosis otill remained, a situation which was to be expected. follow -up studies: Since the treatment is being reported as a measure for promptly rendering inactive a bad ulcer but not as one for producing a permanent cure, the follow-up studies do not constitute an essential par<t of this report. The treatment is still in its infancy, the oldest case having been disA B Fie. 6 A.-Patient E. B. "Complete .. Obstruction FJG. 6 8 .-PatieTU E. B. Disappearance of obslruction afttr 24 hours of treatment. Ulcer defect in duodenum. charged only eleven months ago. However. the follow-up remits now available are informative on at least one point. Twenty·two of the twenty-nine patients were discharged over three months ago. Of the eight who were discharged without dietetic instruction six returned with distress, which in all cases was promptly controlled by two-hourly hydrolysate feedings. However, one person in this group preferred gastrectomy to following a regulated regimen, which included avoidance of alcohol. From the ten persons instructed to adhere to a "bland diet", no report has been received. The remaining four were instructed not only to follow a bland diet but also to take two-hourly feedings of "amigen" or milk andl to avoid excessive smoking. All of the'e reported that they ~ere in greatly improved health three to six months after discharge. These follow-up results, scanty as they are, suggest that this treatment is no more efficient than other treatments in insuring against a recurrence of symptoms when the patient returns to old habits associated wit.h the persistence of ulcers, such as irregular feedings, the eating of rough food, or indulgence in Volume XXII Number 6 TREATME!'fT OF PEPTIC ULCER-Co Tui et al. 253 tobacco or alcohol. The prompt control of recurrent symptoms by feeding with •the mixture suggests that this treatment may prove to be a satiofactory ambulatory treatment even in cases of severe ulcer. This possibility is now being put to a test in the out patient clinic. DISCUSSION The question arises how this prompt improvement with "amigen" is brough•t about. It is possible that the antacid property of the amino acids, previously demonstrated by Levy and Siler, was a factor . In fact, these authors, on the basis of their studies, recommended amino acid mixtures as a treatment for peptic ulcers. A second and perhaps equally important factor is that in addi· tion to its being a natura·l antacid, the protein hydrolysates are a rich source 9f nutriment. It is well known •that in most s·trict methods of treatment of peptic ulcer the food intake, especially of nitrogen, is mually insufficient, and the patient is left with reduced strength and weight. Considering the pre-existing circulatory deficiencies as demonstrated by Riggs, ct al. and con· firmed in part by us in this work, and the protein deficiency demonstrated here, it is conceivable that in the presence of this nutritional dtficiency, tco few "building. blocks" are available for the process of replacing the tissue defect · in the ulcer, no matter how adequate the antacid therapy may be. With the new form of treatment, both the antacid factor and the nutritional factor are furnished by the same therapeutic agent and hence, the improve· ment and rehabilitation of the patient and the healing of the ulcer should go hand in hand at a faster pace. Two additional points may here be stressed. First, the fact that "amigen" is well tolerated by stomachs showing partial to complete obstruction suggests that it imposes less of a digestive task on the diseased gastrointestinal tract than natural food. This has been the impression gathered from its use in cases of other type& of gastrointestinal disease. This is to be expected since the tract is .!!pared the necessity of taking ingested foodstuffs apart to enable absorption to take place. The prompt relief of pyloric obstruction which we have noted should not of course be expected in all cases. of organic ob· struction. In our cases the treatment probably overcame spasm and edema of the pylorus. The results obtained in these cases are ro promising that ;t would seem worth· while for gastroenterologists to try this trea~ment and compare the results of those obtained with other types. SUMMARY AND CONCLUSIONS I. A hyperalimentation treatment with a high caloric and high amino acid (protein hydrolysate) mixture has been found to be efficacious in promptly bring• in. g acute peptic ulcers 10 a state of quiescence. 2. It is also a prompt method of simultaneously rehabilitating the strength and body weight of the . ulcer patient. 3. The prompt improvement appears to be due to the giving of a substance 254 TREATMENT OF PEPTIC ULCER-Co Tui et al. Jour. P. M.A. June, 1946 (protein hydrolysate) that is simultaneously an antacid and an easily assimilable food which·can be built into tissues. 4. The treatment does not insure against recurrences when the patient reverts to old dietary habits. 5. In the course of this work, a protein deficiency has been demonstrated in a large percentage of peptic ulcer ca~es. 6. The suggestion is made 'I.hat gastroenterologists try this treatment and com· pare the results with those obtained with other regimens now in use. REFERENCES 1. Co Tui, Wright, A. M., Mulholland, J. H., Carabba, V., Barcham, I., and Vinci, V. J. Ann. Surg., 120: 99, 1944. 2. Co Tui, Barcham, I., Mulholland,). H., Kutisker, M. ) ., and Wright, A. M. : Ann. Surg., J 20: 123, 1944. 3. Hamilton, P. B., and Van Slyke, D. D.: ). Biol. Chem., 150: 231, 1944. 4. Supplied by the manufacturer, Mead Johnson and Company. S. Macy, j . G.: Principal Mineral E1ements in Nutrition. Chapter in Handbook of Nutrition, American Medical Association, 1943, p. 91. 6. Heath, C. W. : Iron in Nutrition. Chapter in Handbook of Nutrition, American Medical Association, 1943, p. 115. 7. Levy, J. S., and Siler, K. 'A. : J. Dig. Dis., 9: 354, 1942. 8. Riggs, H. E. Reinhold,). G., Boles, R. S., and Shore, P. S.: Am. ). Dig. Dis., 8: 383, 1941. 9. Brown, R. C.: Oxford System of Medicine. Chapter Ill, Vol. lll, Ulcer of Stomach and Duodenum, p. 170, Oxford University Press. 10. Palmer, W. L.: Cecil's Textbook of Medicine. Chapter Diseases of Digestive System, W . B. Saund.ers Publishing Company, 6th Edition 1943, pp. 693, 694. 11 . Golden, R.: Roentgen Ray Examination of Digestive Tract. Chapter V, Diagnostic !foentgenology, Vol. I, p. 279. ADDENDUM* THE HYPERALIMENTATION TREATMENT OF PEPTIC ULCER WITH AMINO ACIDS (PROTEIN HYDROLYSATE) AND DEXTRI-MALTOSE Since publication of the above work, there have been an additional series of 176 cases, all treated ambulatorily. The pertinent data on these cases are sum· marizec;I in Tables I. 2 and 3. The treatment may be divided into two parts-(a) Intensive period of exclu· sive hydrolysate and dextri-maltose feeding, (b) A less intensive period during which 3 bland meals replace 3 hydrolysate feedings. The more precise method of calculating the caloric and hydrolysate intake re· quired during the intensive period is to use the following formulas : Body weight (kg) x 50 W No. of calories required per day. Body weight (kg) x . 6 = X = Grams of nitrogen required per day. * Dextri·maltose is used in preference to glucose for the theoretical reason that the former being a simpler sugar, would presumably be absorbed so rapidly that some may be spilled in the urine. Dextri·maltosc :j:; 2 contains no sodium chlori<le, which -.. ... ·ould oth~rwise be J?ive-n in an over dosage, there being already some 2-4'1" in the hydtolysate. Volume XXII N\Ul'lber 6 TREATMENT OF PEPTIC ULCER-Co Tui et al. 255 x - - - - - - - - - x 100 % of N in hydrolysate W·4Y 4 z y No. of grams of hydrolysate required per day. No. of grams of dextri·maltose required to supply the balance of calories. For the ambulatory patient the following approximation may be made: take 5 grams of protein hydrolysate and 6 grams of dextri·maltose #21, per kilograms body weight. This formula, however, must not be applied to hydrolysates with a ni· trogen content which exceeds or falls much below 12 o/o. Since most hydrolysates in the market, as well as dextri·maltose contain 8 grams of material to the level tablespoons, it is usually more convenient to instruct the patient how many table· spoons of each material may be taken, instead of how many grams. The two powders are suspended in about a quart and a half of hot water, and the mixture is divided into 8 to 9 2·hourly feedings taken during the waking hours and conti· nued until the patient is pain·free for 2 weeks. Some patients prefer to take the two separately, taking the protein hydrolysate solution first to be followed by the dex· tri•maltose as a "chaser." The hydrolysate solution is better tolerated when chilled. If the amounts given every two hours is too large to be tolerated, it may be divided into hourly feedings. If night pains occur, a feeding should be given. (This feeding should not be taken out of the daily mixture, but should be made up as a separate dose.) If pains occur before the end of the two-hourly interfeeding period, the total amount of the feeding may be divided into 9 or 10 H/2·hourly feedings. A full complement of vitamins may be given daily after the first week. Water may be given ad libitum. No antiacids or antispasmodics have so far been necessary. Kaomagma or Kaopectate ( 4cc), one or more times a day is given only to control diarrhea. Milk of magnesia may be given for constipation. (b) Following this intensive treatment, i.e., after the patient has been pain· free for 2 weeks, the second part of the regimen may start. The patient is given a bland meal 3 times a day, so timed that they take the place of 3 hydrolysate feedings and so that he now takes only 5 hydrolysate feedings and 3 meals, main· taining the 2-hourly feeding schedule. This period may be ushered in by giving the patient an experimental break· fast the first day, the subsequent 2·hourly feedings to be still of hydrolysates. If at supper time, the breakfast has caused no distress, then a bland supper may be given. According to this plan, therefore during the first day of the second period the patient takes 2 bland meals and 6 hydrolysate feedings. If food still p~ovokes distress, the patient reverts to exclusive hydrolysate feedings for another week. If no distress is caused, the patient takes 3 bland meals a day, beginning the second day of this intensive period. At this stage, the hydrolysate may be given without dextri•maltose, unless it is desirable to add to the patient's weight. The patient on this new regimen is con· I Grateful acknowledgment is. made of the companies mentioned in Table 3 for the supply of protein hydrolysates used in the treatment of this series. 256 TREATMENT OF PEPTIC ULCER-Co Tui et al. Jour. P . M. A. June, 1946 tinued for 2 months, after which 2·3 tablespoons of dried milk powder may be substituted for the hydrolysates. The 2-hourly feedings must be continued for at least 6 months. Articles of bland diet which we have used are eggs, chicken, fish lamb, beef, provided these are not fried, with milk and toast and mashed potatoes. Fruit juices and pured vegetables are added to the diet during the second month, one un· known a·t a time, to be discontinued if they cause distress. During the intensive part of the treatmen•t, good response is shown by prompt subsidence of pain and usually by gain in weight of 1 to 3 pounds in 2 to 3 days. (Table 2) Most "intractable" cases do not need to give up work but occasionally some need home rest. The patient must be warned that the feedings do not taste good. No tobacco smoking is allowed. for at least 6 months, thereafter tobacco is allow· ed only after meals. For mild cases: i.e ., cases without daily attacks of pain or distress. The intensive part of 1he above regimen is omitted and the patient is started on 3 bland meals a day and 5 hydrolysate feedings without dextri·maltose similar to the second part of the above regimen. It will be seen from Table JI, 1hat there is an incidence of 9% failure, i.e., 91 % of the£e patients who have been screened by other methods of medical therapy from Sippy, amphogel to Larostidine ( 18 cases) responded favorably to the treat· ment. The response of most of the cases was spectacular but in a few, relief was obtained less promptly. To ·these failures must be added 24 who for reasons of taste could not tolerate the feedings. Whether this number could have been re· duced by feeding the hydrolysate and the dextri·maltose separa·tely is at present not clear. However, it may be mentioned that the last 9 cases who first showed intolerance. were able to continue ·the treatment when the two substances were taken separately. Table 3 summarizes the 8 preparations of hydrolysates used in this second series. With only 5 of these was the series large enough to be of any signifi~ance . It will be seen from Table 3 that in a ·total of 207 cases ( 176 of the pre· sent <.cries, plus 31 of the original) 120 were treated with Squibb material, 41 with amigen, 8 with protolysate. and 14 with each of edamin and aminonat. It must be mentioned that for some still unexplained reason, patients who are not able to tolerate one hydrolysate may be able to tolera1e another. Therefore, a doctor must learn how to use more than one type of preparation. Sex Types TABLE 1.-Data on 174 Cases of Peptic Ulcers 'Treated Ambulatorily With Protein Hydrolysates 166 M. 8 F. 154 Duodenal 16 Gastric 4 combined Ages 11·58 Severe Mild 156 18 Volume XXII Num~r 6 TREATMENT OF PEPTIC ULCER-Co Tui et a/. HISTORY Duration 5 ·to 17 years Night pain Malnutrition 58 102 Melena Hematemesis Perforation TABLE 2.-Response to 'Treatment RELIEF OF PAIN GAIN IN WEIGHT (j-24 lbs·3 wks) With first feeding 48 No gain 24·48 hours 92 48 hrs. to I week 20 Night pains (!st 3 days) 35 Night pains (!st 5 days) 23 Failures 16 TABLE 3.-Hydrolysates Used In 'Tl1is Series COMPANY NAME OF PRODUCT NO. OF CASES Elli Liliy Liver-protein Frederick Stearns and Company Gelatin Company of America Mead Johnson & Company National Drug Company Sheffield Farms Co., Inc. E. R. Squibb & Sons Vico mineral mixture Essenamine Amigen Protolysate Aminonat Edam in Casein Hydrolysate Yeastamin 2 11 6 14 14 119 4 257 10 8 148 24 DISTURBANCES OF THE ASSOCIATED OR CONJUGATE MOVEMENTS OF THE EYE 1 GEMINIANO DE OCAMPO, M.D. St. Anthony's Hospital, Manila Disturbances of the associated movements of the eyeball have been extensively studied. What little is known about them is not fully appreciated and utilized by many ophthalmologists, internists, and neurologists. Probably many have met them in practice, but few have had the opportunity to study them for Jong stretches of time or up to the autopsy. • Associated movements of the eyeball mean the simultaneous movements of the two eyes upwards, downwards, sidewards (right and left) , inwards (convergence) and outwards (divergence). That there are separate nuclei for each of the ocular muscles is definitely accepted. So is the nucleus of convergence (Perlia's). A divergence nucleus is, however, not well established, although the existence of a divergence impulse is generally recognized. The existence of supranuclear apparatus has universal acceptance. The occipital and temporo-parietal lobes have higher motor centers for the eyes, and they have mainly a reflex function. The voluntary occulomotor center is in the frontal lobe; and, according to Duane, it contains the chief center for conjugate and other associated movements. It is also known that between these higher cerebral association centers and the individual nuclei for the ocular muscles, there exists a coordinating apparatus similar to a player piano with the ocular muscle nuclei corresponding to the keyboard. This is located just above the occulomotor, trochlear and abducens nuclei a·t the floor of the third and fourth ventricles, but not identical to •the posterior longitudinal bundle. Autopsy has never revealed a precise anatomical lesion. In case of neoplasm, involvement is always seen in the region of the quadrigeminate bodies; but the localization is always indefinite and the paralysis of convergence is sooner or later associated with other paralysis. This is demonstrated in some of the cases included in this report. Case I. A case of Parinaud's syndrome (Paralysis of convergence, upward and downward gaze). Male, 25 years old, came for inability to move the eyes up and down and for a slight difficulty in reading and walking up and down stairs. About 11 years before, he had an illness lasting a few months with characteristics of an acute infection, probably of encephalitic nature. About three months before he was seen he had a drinking bout, being a heavy drinker but not a habitual one. He became unconscious for several days. When he came to, he could not look sideways. Nor could he converge his eyes. The pupils were dilated with slight and retarded direct and consensual light reaction. Pupillary reaction to accommodation was sluggish. Accommodation was weak, slow, and retarded·-almost paretic at the I Read before the 39th Annual Meeting of the Philippine Medical Association, held May 9, 1946. . 260 CONJUGATE MOVEMENTS-De Ocampo Jour. P. M.A. June, 1~4.6 right. Vision was practically normal for distance. Fundi normal. No scotoma. Visual fields normal. There was slightly grade 3 fusion. Prism test for muscle paralysis showed movements in the lateral directions but none for up and down. Bell's phenomenon was positive. The aural findings were: Hearing was practically normal. bular tests, douching and turning elicited practically normal rel'.pon~ In the vesti· from 1the hori· zontal canals but no nystagmus was observed when the vertical canals were stimulated, ahhough there were past-pointing, falling, and vertigo. Wa5'.ermann test of the blood and other laboratory examinations were negative. Comment : The lession in this case seems to have been the supranuclear appara·tus around the superior quadrigeminate bodies involving the posterior longitudinal bundle but not all the fibers leading to it. Those coming from the horizontal canals have escaped, while those from the vertical canals have been caught. The fibers from the cortex were intact, so that they produced vertigo. Those from the cerebellum were unaffected, because there were past-pointing and falling. The median nucleus or convergence mus·t also have been involved. The nearest etiological consideration was encephalitis of virus or alcoholic nature. Multiple sclerosis could not be entirely ruled out. I observed this patient for several months. Then I lost tract of hire, Case 2.-Paralysis of upward gaze with paresis of downward gaze (incomplete Parinaud's syndrome) . Male, 28 years old, first s.een for impairment of vision with slight papilledema which was interpreted as optic neuritis. Dental extraction for focal infection was advised. Headache then appeared with definite choking of the disc but with meagre localizing symptoms except paralysis of upward gaze. After craniotomy, paresis of downward gaze was observed. The patient was taken home against advice, and he died after a few days. No autopsy could· be done. Comment.-There was in all likelihood a tumor in the region of the supra· nuclear apparatus around the third and fourth ventricles. An incomplete Parinaud's syndrome was a clear localizing finding. Case 3. Conjugate deviation to the right due to encephalitis. Female child, 8 years old, with definite history and findings of encephalitis. She had these ocular manifestations: She seemed to be always looking to the right. There •was no definite squinting. She could move the eyes to the right normally. When directed to look to the left she could move the eyes as far as the median line but not any further. There was slight convergence movement, especially of the right eye. The upward and downward movements were normal. The pupils were nor• mal. There was slight haziness of the nasal border of the right disc and slight venous congestion of the two sides. This child was not observed long enough; but it seemed that encephalitis, where the lesion is usually at the basal ganglia, had caused a unilateral longitudinal bundle rather than mere involvement of the right abducens nucleus or right cortical centers. Case 4. Paralysis of lateral conjugate movements and convergence. Male, 24 years old, came for attacks of twitching of the left lower lid, later involving the left side of the face, accompanied by dizziness and vomiting. When first seen, the right eye could move only up and down but not sideways. The left could move in all directions but not inwards. No diplopia could be elicited. Convergence slightly Volume XXU Number 6 CONJUGATE MOVEMENTS-De Ocampo 261 impaired. After three weeks, there was complete immobility of both eyes except upwards and downwards; and convergence was completely lost. Two weeks later, before he died, there was a slight impairment of up and down movements with nystagmoid movements in the vertical direction. With only slight disturbance of hearing, there was lack of response to caloric on both sides. Vision and fundus were practilally normai. Except for a paralysis of the right side of the face, there were no other important neurological fJndings. Autopsy by Dr. Galang showed a hard tumor mass 3 cm. in diameter in the region of the fourth ventricle above and attached to the velum and in between ·the medulla and the cerebellum, with moderate hydrocephalus. Histologically it was a ganglioneuroma. Comment.-The steps in the development of the lateral associated paralysis with tha~ of convergence were obseMd. Disturbance of the vertical movements were already starting when the patient died. The tumor must have compressed the vestibular fibers to the ocular nuclei, to the cerebellum, and to the cerebrum; but not the cochlear nerve bundles. Case 5. Divergence paralysis secondary to pineoblastoma. Male, 12 years old, was seen complaining of headache, dizziness, and internal squinting for two months.. The hearing was also impaired, especfally that of the right. Tests shwed mixed deafness. The internal squinting was periodic. Diplopia was present in all portions of the visual field for far and near, except in the center for near where - it was absent especially during convergence. The vision was slightly subnormal, at first compatible wi·th bilateral papilledema. Later consecutive or secondary optic atrohy developed. X-Ray of the skull showed separation of the coronal suture, indicative of increase intracranial press.ure, blurring of the sella tursica, and slight calcification of the pineal gland. Ventriculography, which was suggested by the neurologist and the neurosurgeon, was not done before he left the hospital. He returned after six months in a comatous condition and died after a few days. Autopsy by Dr. Monserrat showed tumor about the size of a "Chico" in the tela choroidca infiltrating the walls of the third ventricle, ex·tending to the lateral ventricle and with the involvement of the medullary tracts of the cerebellum and cerebral hemisphere, more on the left; softening of the corpora quadrigemina by pressure; internal hydrocephalus; protrusion of the cerebellum through foramen magnum; and atrophy of the optic nerves. Histologically it was found to be pinealoma. Comment.-The findings were similar to those in a report by Robbins on a Case of divergence paralysis. He said, "The presence of a divergence center is questioned by some writers. Nevertheless, in the light of our present knowledge, it seems the most tenable-explanation of the syndrome." The defect of hearing was probably one of "Central deafness" from local and general pressure of the tumor. Case 6.-Convergence and divergence paralysis with paresis of upward movement. -Male, 19 years old, was first seen for diplopia in the right fields and slight internal squinting of the right eye. With chronic suppurative otitis media especially of the right, Grandenigo's symdrome was first considered. Persistent headache and ataxia with choking of the disk s.oon appeared. The slight internal squinting almost disappeared; but diplopia could be elicited in all regions of the visual field, especially when looking toward the median line. There was also a slight impairment of upward gaze. Blind spots were enlarged although the visual fields were 262 CONJUGATE MOVEMENTS-De Ocampo Jour. P. M.A. June, 1946 not definitely constricted. Hyperalgesia was marked all over the body. X-ray ~howed a calcified spot above and to the left of the sella turcica in the region of the pineal body. The patient died after ventriculography. Autopsy by Dr. Sapi· noso showed tumor in the median line in the roof of 1he third ventricle with internal hydrocephalus and dilatation of the third and lateral ventricles. The tumor was attached to the thalamus. Histological examination by Dr. Sta. Cruz revealed pinealoma with calcification. Commem.-The development of the diplopia would show that the disturbance started wi·th weakness of one lateral rectus, developing into a divergence paralysis, and finally involving the convergence center. The upward conjugate movement was beginning to be impaired when the pa1ient died. The diplopia has some simi· larity to that of case 5, but here it was present even in the center for near because of simultaneous convergence paralysis. SUMMARY AND CONCLUSION Disturbances of divergence and convergence should be kept in mind in cases where diplopia is a complain1 and can be elicited throughout the visual field, especially when no definite squinting is present. In any case of disturbance of the associated or conjugate ocular movements, a brain tumor and encephalitis should be considered among other caus.es. When· ever a brain tumor is suspected, the presence of paralysis of any associated or con· jugate movement is a localizing finding. EVALUATION OF DIETS SERVED TO WOMAN STUDENTS OF THE UNIVERSITY OF THE PHILIPPINES ' P. I. DE JESUS, M.D., Dr. P. H., AND S. G. JAO, M.D., M.P.H. Nutrition Laboratory, Institute of Hygiene, University of the Philippines INTRODUCTION The University of the Philippines has two committees that look into the living conditions of the students; namely, the President's Committee on Dormi·tories and the University Council Committee on Students' Living Conditions. When one of the authors (P. I. ].) was appointed to head both committees, an intensive campaign was undertaken to investigate the sanitary conditions of the dormitories and boarding houses patronized by our students. Regular and frequent inspections of the dormitories were made and suggestions were given whenever any defect was noted. But the inspections had hardly started when complaints about food came thick and fast from the students, &J that very soon an inv~stigation of the foods served by each dormitory was undertaken. METHOD OF INVESTIGATION Foods composing one meal were collected without previous notice to the dormi· tory manager while they were being served to students. Foods of the other meals were taken in the same manner on other days, so tha·t in each dormitory investigated three meals - namely, breakfast, lunch and supper - were collected at random. It must be mentioned in this connection that this study has been greatly facilitated by the full cooperation given by the dormitory owners. It is only to be regretted that our study was terminated by the outbreak of the war before we could complete the investigation of the dormitories for male students. The quantitative study of diets was done in accordance with the precedure for "Institution Survey" recom· mended by the Technical Commission on Nutrition of the Health Section of the League of Nations (I). The "weighing method" for diet survey was employed. It consists of taking food samples (breakfast, lunch, and supper) and evaluating the protein, fat, carbohydrate, vitamin A, thiamin, ascorbic acid, calcium, iron, and phosphorus contents by the item·by·item method. Proper allowances based on ac· tual observations and weighing, were made for the food which was not actually consumed by the students. The tables compiled by the College of Agriculture (2), Daniel and Munsell (3), Fixsen and Roscoe (4), and Chatfield and Adams (5) were used in the computations. NUTRITIVE VALUE OF THE MEALS SERVED Analyzing the nutritive value of the diet served by private donnitories to female students of the University of the Philippines as shown in Table 1, we found that 1 Read at the 39th Annual Meeting of the Philippine Medical Association, held May 10, 1946 264 EVALUATION OF DIETS-De Jesus et al. Jour. P. M. A. June, 1946 the average caloric intake was 1713 per capita which is 34.l % below that recom· mended (2600 calories) by the National Research Council of the Philippines for moderately active adult females. Carbohydrates furnished 56.5% of the total calo· ries; protein 22%, and fa1 21.5%. The protein daily intake averaged 94 grams, which is 34.3% above that recom· mended by the National Research Council of the Philippines (70 grams for females). Our finding for protein is, however, within the standard set up by Sherman (6) who suggested that proteins should supply about 14 per cent of the total calories. We found by calculation that plant foods furnished 46%, and animal foods 54% of the total protein. The diets under investigation were all found to be deficien·t in vitamin A, thiamin, and vitamin C. The average vitamin A content of the daily diet ration was found to be 706 International Units, which is equivalent to only 17.6% of 1hat suggested by the Section of Nutrition of the National Research Council which is 4000 International Units of vitamin A for female adults. The vitamin B, conten1 was calculated as 223 International Units, which is only 46.5% of that recommended by the Na·tional Research Council of the Philippines for a moderately active female adult. The average vitamin C content of the daily dictary intake was observed to be 6.5 mg. or only 11.8% of that recommended by the Na·tional Research CoL1ncil of the Philippines which is set at 5 5 mg. for the female adult. The average calcium content was found to be 0.48 Gm. while the phosphorus content was 2 Gm. fer the daily dietary intake. The figure for calcium is 68.6% of that suggeeted by the National Research Council of the Philippines. No interpretation and conclusion was deduced from the Ca: P ratio of 1 :4.1, because phosphorus in cereals is only partially available and the diets analyzed have a high cereal content. The average iron content was calculated to be 27.3 milligrams. This is more than twice that recommended by the National Research Council of the Philippines which is 12 mg. daily for female adults. In general the typical cons-tituents of the average diet served by the dormitories consisted of rice (or bread in the morning) ; meat; fish; small amounts of fruits and green leafy vegetables, and occasional servings· of eggs, beef, sherbet, jams, jellies, and sweets. The commonest foods served included fish, meat, and bananas in limited amounts. COMMENTS When the dormitory owners were notified of ·the results of our dietary survey, they explained that the deficiency was due to the keen competition in the dormitory business which had forced them to charge very low rates. Although this claim was partly true, our study revealed that even with the present fees the foods could be further improved by better selection. In view of this finding, the Committee was able to make many suggestions for improving the diet without materially increasing the cost. These suggestions included liberal servings of eggs; yellow fruits such as mango, papaya, pineapple, and banana; citrous fruits like calamansi; green legumes; green kafy vegetables; mungo and other beans; occasional servings of glandular organs; and reduction of, such expensive i1ems as sherbet, jams, jellies, and sweets in the menu. Volume XXII Number 6 EVALUATION OF DIETS-De Jesus et al. 265 Furthermore, attempts were made to educate the dormitory managers and owners on the fundamentals of nutrition. SUMMARY AND CONCLUSIONS A quantitative study of the diets served by private dormitories to female students of the University of the Philippines was undertaken in accordance with the procedure recommended for "Institution Survey" by the Technical Commission on Nutrition, Health Section of the League of Nations. The average nutritive values of the daily diet were found to be as follows: calo· ries, 1713; protein, 94 Gm.; fat, 41 Gm.; vitamin A, 706 I. U.; thiamin, 223 I. U.; ascorbic acid, 6.5 mg.; calcium, 0.48 Gm.; phosphorus, 2 Gm.; and iron, 27.3 mg. From the analysis of the diets studied, it is apparent that the food served was highly deficient in caloric requirement, vi•tamin A, thiamin, ascorbic acid, and cal· cium. The diet consisted chiefly of rice, bread, meat, fish, small amounts of fruits (chiefly bananas). green leafy vegetables, and occasional servings of eggs, sherbet and sweets. Such a deficient diet may be improved by liberal servings of eggs; yellow colored fruits as mango, papaya, pineapple, bananas, etc.; citrus fruits as calamansi; green legumes; mungo; green leafy vegetables; and occasional servings of glandular organs,· especially liver. BIBLIOGRAPHY J. League of Nations: Report by lhe Technical Commission on Nutrition on the \Vork of its Third Session held in London from Nov. 15th to 20th, 193 7. Bulletin of the Health Organitation. Geneva Vol. VII, No. 3. June, 1938. 2. Handbook of Philippine Agriculture. College of Agriculture, U. P. Los Banos, La· guna. 1937. 3. Daniel, E. P. and Munsell, H. E. Vitamin cor.tents of foods. U. S. Dept. of Agricul· ture, Miscellaneous Publications No. 275. Washington, D. C. June, 1937. 4_. Boas·Fixsen, M. A. and Roscoe, M. H. Tables of the vitamin content of human and animal foods. Nutrition Abstracts and Reviews. Vol. 9, No. 4, April, 1940. 5. Chatfield, C. and Adams, C. Proximate composition of American food materials, U. S. Dept. of Agriculture, Circular No. 549. Washington, D. C., June, 1940. <>. Sherman, H. E.: Chemistry of Food and Nutrition. 5th Edition, 1937. 7. National Research Council of the Philippines. Daily allowances for specific nutrients. Section of Nutrition. Unpublished 1940. TABLE !.-Evaluation of diets served by private Dormitories to female students of the University of the Philippines. DORMITORY ProximateComposition Vitamins I Minerals (Gm.) (Gm.) :::AL0·1--~-~-- - - - - - - - 1 Pro· Carbo· RIES A B, I ,_______ teins ~ d~!.~s ___ (l.U.) _ o.U.) C(mg) ___::__ _P _ _:_ 1. Catholic Worn· en's League: Breakfast Lunch Supper TOTAL 18 28 27 11 16 7 79 80 79 487 438 558 64 487 63 121 0. 7 0.075 0.447 0.0059 138 0 0.149 0.927 0.0040 97 1.0 0.128 0.892 0.0104 I. 7 0.352 2.266 0.0203 266 EV ALU AT ION OF DIETS-De JeBUB et al. TABLE 1.-Continued. Proximate Com position Vitamins (Gm.) Calo· DORMITORY p I /Carbo· ries A B, c ro• . Fats hy· (l.U.) (l.U.) (mg) terns drates --- ------ -- -- -- -2. St. Theresita's: Breakfast 29 8 102 596 D 69 1.2 Lunch 34 9 108 649 102 211 0.8 Supper 24 7 75 449 422 40 0.8 --- -- -- - --- -- -TOTAL 87 24· 285 1694 547 320 2.8 --- -- -- -- -- -3. St. Mary's: Breakfast 14 17 31 333 190 83 0 Lunch H 8 65 456 500 8 4.0 Supper 41 16 63 464 21 105 0 = -- -- - - ---- = TOTAL 96 41 159 1353 711 196 4.0 --- -- -- -- -- ---4. Hugh Wilson : Breakfa•t 34 4 108 604 51 174 1.0 Lunch 33 12 78 552 32 50 0.8 Supper 27 7 98 563 9 63 0.2 94123 -- - - -- -- -TOTAL 284 1719 92 287 2.0 S. Avenue: Breakfast 28 9 69 469 452 37 0.8 Lunch 28 8 78 920 392 92 0 . 8 Supp•r 33 16 81 600 32 38 0 . 8 -- -- ------= TOTAL 89 33 228 1989 876 167 2 . 4 -- -- ---- -- -6. Varsity: Breakfast 23 9 128 68S 150 34 0 Lunch 27 9 74 485 88 120 1.0 Supper 16 5 68 381 347 25 0.8 - -- -- -- - - -- -- -TOTAL 66 23 270 1551 S85 179 1.8 -- -- -- -- - --- -7. Y. M. C. A. : Bruk fast 22 17 lOS 561 1'7 ;i 1.4 Lunch 29 12 74 S20 126 n 0 Supper 33 10 63 482 65 ~2 0 --- - - ---- -- -- -TOTAL 84 39 144 1563 348 21.5 1.4 --- -- -- ---- -- -8. Cosmopolitan: Breakfast 26 16 97 636 290 3S 59. 5 Lunch 33 14 75 5S8 296 ~2 0.8 Supper 34 16 77 588 436 111 0 - - - -- - - - - = = -TOTAL 93 46 149 1782 1422 228 60. 3 --- - - -- -- - --- -9. Doanes : Breakfast 13 14 ~o 498 477 19 0 Luncb 40 31 106 763 310 18 0 Supper 46 10 69 5SO 62 66 0 --- -- - - --- --- -TOTAL 9Y SS 2SS I 1811 849 133 0 Jour. P. M.A. June, 1946 Mineral (Gm.) Ca p Fe --- --0.036 0.526 0.0451 0.218 0.871 0.0150 O.OM 0.650 0.0097 -- -- --0.322 2.047 0.0698 ---- - 0.022 0.153 0.0013 0.090 0.573 : 0.0050 0.079 0.785 0.0060 --- - 0.19! 1.511 (l.Ql 23 --- -, _ 0.091 0.643 0.0093 0.308 1.030 0.0076 0.145 0.751 0.0060 -- - - 0.544 2.424 0.0229 0.421 0.460 0.0057 0.113. 0.680 0.0110 0.204 0.847 0.0087 ---- = 0.736 1.987 0.02S4 ---- - 0.059 0.326 0.0016 0.096 0.75S 0.0098 0.054 0.657 0.0077 ---0.209 1.738 0.0191 -- --0.218 0.677 0.0104 0.144 0.7SI 0.0057 0.062 0.768 0.0039 -- -0.424 2.196 0.0218 -- -- --0.111 1.000 0.0190 0147 0.61S 0.0140 0.139 0.748 0.0143 -- -- --0.397 2.363 0.0473 -- -- --0.074 O.Sl3 0.0122 0.499 0.422 0.0070 0.938 1.510 0.0108 -- -- --1.511 2.445 0.0300 Volume XXIJ Number 6 DORMITORY 10. Phi Ii pp in e Women's Col· lege Hall: Breakfast Lunch Supper TOTAL 11. University Women's Hall: Bceakfast Lunch I Supper TOTAL 12. Oregon Hall: Breakfast Lunch Supper TOTAL 13. St. Joseph: Breakfast Lunch Supper TOTAL TOTAL (Anrage) EVALUATION OF DIETS-De Jesus et al. 267 TABLE 1.-Continued. \Proximate Composition Vitamins Mineral (Gm.) (Gm.) Calo· Pro· Carbo· ries A B, c Fats hy· (LU.) (1.U.) (mg) Ca p Fe teins drates - - - - - -- -- --- -- -- ---- --22 17 10 521 588 19 J.0 0.050 0.55) 0.0036 .;o 23 148 999 8 101 1.0 0.109 0.348 0.0084 33 9 120 693 112 173 .) 0.080 0.647 0.0108 -- -- -- --- -- -- -- -- --105 49 BS 2213 708 293 ; .o 0.239 1.550 0.0228 ----- -- -- --- -- -- -- -- --22 13 50 386 325 90 0.6 0.034 0.214 0.0040 37 41 126 921 212 69 0 0.315 0.815 0.0038 37 8 75 520 254 74 0 0.117 0.705 0.0084 ----- -- -- --- -- - - -- -- --96 62 151 1827 791 233 ~.6 0.466 1.734 0.0162 --- -- -- -- - -- -- -- -- -- --8 3 31 218 911 39 l .0 0.046 0.122 0.0070 43 33 34 805 21 26 0 0.465 0.834 0.0040 18 '.\ B 391 75 22 0 . 7 0.065 0.600 0.0090 -------- -- - -- -- --- -- -- - - -- --69 44 188 1414 1007 87 I. 7 0.576 1.556 0,0200 ------- -- -- -- -- -- -- --21 18 88 598 568 62 ~ . 5 0.041 0.517 0.0050 125 33 13 849 l05 n 2.0 0.156 1.060 0.0180 n J2 53 408 • 78 0 0.045 0.628 0.0038 =====1=== -- - - - i6B 63 154 1s55 · 677 197 2.5 o.242 0.0268 \~~1~l 1m--;;-- m ~ o.477 2.205 2.002 0.0273 TABLE 2.--Compa"Ti.wn of the nu:ritive values of the diet se"Tved by private doYmitories to female student.5 with the daily allowances for specific nutrients as recommended by the .St,1 tion of Nutrition, National Research Council of the Philippines. foY moderately active adult female. NUTRIENTS DIET SERVED RECOMMENDED DAILY .ALLOWANCE Calories 1713 2600 Protein 94 Gm. so Gm. Vitamin A 706 I. u. 4000 I. u. Thia.min (B,) 223 I. u. 480 I. .u . Ascorbic acid (C) 6 . 5 mg . 60 mg . Calcium 0.48 Gm. 0 . 7 Gm. Iron I 27. 3 mg. 12 mg. TREATMENT OF PNEUMONIA IN CHILDREN 1 (A Report of 414 Cases in 1945) FE DEL MUNDO, M.D. North General Hospital, Bureau of Health COMPARISON OF CASES IN 1944 AND 1945 In 1944 we admitted 113 pneumonia patients at the City Chiklrcn 's Hospital (now the Children's Department of the North General Hospital). At that time, we were fairly well-satisfied with the results of our treatment which gave a recovery rate of 38%. During that year, sulfapyridine was the drug most easily available to our patients. By 1945 our pneumonia patients had increased more than three-fold as may h..: noted in Table I. Indeed, during the latter months of 1945, pneumonia cases constituted about one half of our pa·ticnts in the wards. Fortunately for the patients, more adequate and more effective drugs had been available since the liberation. Henc.:: our fatality rate decreased from 17.7'.(c in 1944 to 1.9% in 1945. TABLE !.-Comparison of Results in tlie 'Treatment of Pneumonia Number of cases - - - - Treatments given were : (any of them) Recovery Rate Fatality Rate 1944 113 Sulfapyndinc Sulfathiazole Symptomatic 38. 05~ 17.7% 1945 414 Sulfadiazine Penicillin Combined Penicillin and Sulfadiazine Symptomatic 62 . 5% 1.9% The increase in the number of pneumonia patients in 1945 may be attributed to various factors. Since the liberation, the population of Manila increased, not only because of the return of evacuees, but also because of migration of people from the provinces to _this city for jobs or for business purposes. This increase in population plus the destruction of thous.ands of homes in various districts of Manila made overcrowding unavoidable in districts that had escaped the ravages of war. Such overcrowding did not only result in lowering resistance but also favored the rapid spread of such contagious diseas.es as acute upper respiratory infections, measles, and pertussis. As will be noted in Table 2 in our group, these conditions are important in predisposing children to pneumonia. Reopening of schools brought children together again, while improvement in transportation facilities facilitated visiting; both factor& plus excessive dust are favorable for the spread of respiratory diseases. 1 Read at the 39th Annual Meeting of the Philippine Medical Association, May 10, 1946. 270 TREATMENT OF PNEUilt/ONIA-De/ Mundo TABLE 2.-Important Predisposing Diseases Jour. P. )I.~\. June, 194.6 Acute Upper Respiratory Infections . . . . . . . . . . . . 187 Cases Measles . . . . . . . . . . . . . . . . .. .... .. .. . . . ..... , . . 89 Pertussis .. .. . . .... .. ........ " .. .. .. .. .. .. .. 15 Some Foci of Infection . . . . . . . . . . . . . . . . . . . . . . . . 13 Primary . . . . . . . . . . . . . . .. . . .. .. . . . .. .. . . .. .. . . 110 Tot a 1 .. . .. .. 414 Cases It is well·known that our epidemics of measles and pertussis were alarming and prolonged in 1945, and hardly a non·immune child from any social stra1a escaped the disease. The marked increase in pneumonia cases in 1945 has given us materials for study, and this report includes 414 cases. DIAGNOSIS Our diagnosis of pneumonia in infants and children was hased on the clinical history and physical findings. We confirmed the diagnosis by blood count and fluoroscopic examination. A threat smear of every patient was also taken on ad· mission. As far as possihlc we tried to have the laboratory work and the fluoroscopic examination done before we instituted trea1ment; hut, with serious patients, we could not follow this procedure. We promptly treated the patients. A urinalysis was Jone on admission and during the course of treatment, so as to watch any. toxic effects <>n the kidneys. Due to lack of films, we could not possibly do X·ray examinations for every case; hut. for doubtful cas.es, we had an X·ray picture taken. In this paper we have not a'ttempted to make a detailed classification of pneumo· ma. For our clinical and therapeutic purposes, we were concerned with the severity and extent of the lesions rather than with ·the type. PLAN OF TREATMENT The majority of uur patients (226) received sulfadiazinc since we had a steady and adequate supply of this prepara·tion. Whenever we had a regular supply of penicillin 'or when parents could afford it, we made use of this antibiotic ( 120 cases). For a handful of mild cases or for those who were already improving on admission, we simply gave supportive treatment and aspirin as antipyretic. TABLE 3.-'Treatm·ents given to 414 Pneumonia Patients (1945) Supportive Treatment . . . . . . . . . . . . . . . . . . . . . . 13 Sulfadiazinc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226 Penicillin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Combined Sulfadiazine Ci Penicillin . . . . . . . . . . . 55 Total 414 Hydrotherapy was given to all febrile cases in the form of either tepid sponge baths or hat packs. The usual jacket compress was not used; neither did we make use of counter·irritants to the chest and back. As we had no oxygen supply, we were Volume: XXII Number 6 TREATMENT OF PNEUMONIA-Del Mundo 271 deprived of this useful therapeutic remedy. Simple cough mixtures were given for distressing cough. We did no starve our patients; rather, we went by their appetites. Fluids were encouraged by mouth, particularly when the patient was taking sulfonamides. Fluids were given parenterally when indicated. Eight patients were given blood transfusions when they apparently failed to respond to reasonable doses of either $Ulfadiazine or penicillin. Intravenous sodium sulfadiazinc had to be resorted to only in two very serious cases. Our course of sulfadiazine consisted in giving the drug orally-starting with an initial dose of one grain per pound body weight (0.10 Gm. per kilo) followed by 1/6 of the first dose every 4 hours day and night. Administration of the drug was continued up to the time the patient was afebrile two days. We did not give sodium bicarbonate with it, but we encouraged fluids orally or gave them parenterally when indicated. We watched for toxic reactions. Penicillin was given intramuscularly in doses of I 0,000 to 20,000 units every 2 or 3 hours, depending on the age of the patient and severity of the disease. The intravenous route was resorted to only for serious patients. As with sulfadiazine, we continued administering penicillin until the patient was afebrile two days. Cases which after a fair trial did not seem to respond to sulfadiazine, were switched to penicillin and vice versa. For very ill patients we tried to observe the effects of the two drugs together. We did not compare the results of combined therapy with those of either penicillin or sulfadiazinc alone, because patients to whom we gave both drugs were in serious ~ondition. Therefore, any comparison would not have been fair. OBSERVATIONS We made these observations on four hundred fourteen cases of pneumonia in children during the year 1945: TABLE 4.-Distribution by Month February 8 Cases March 6 April ~ May June July 16 August 22" .. September 38 October 53 November 47 December 71 January 79 February - 62 Total - - - 414 Cases TABLE 5.-Age Incidence Age Cases I 12 months 150 13 24 102 4 years 67 7 44 8 10 30 11 14 21 Total-- - - - - 414 TABLE 6.-Sex Incidence Males - - - - 199 Females- - - - 215 Total - - - 414 272 TRE.-\TMENT OF PNEUMO!Y/.4-Del Mundo Jour. P. flol.'A. June, 1916 TABLE 7.-Side of Lesions Right lobe - 49 Cases Left lobe - 31 Bilateral -314 T o t a I - - 414 Cases EFFECTS OF TREATMENT TABLE 8.-Comparison In 'The 'Treatment 0f Pneumo·r1ia Penicillin Sulfadiazine Number of Cases . . . . . . . . . . 120 226 I. RESULTS Recovered Improved Unimproved .. . .. . .... . Died ... . .. . ... .. . .. . 56. 27c 23 .0%' 10 .87c 10.0% In less than 48 hrs. stay - 9 cases Over 48 hrs. stay -3 II. IN THE RECOVERED CASES Average length of Therapy - Average amount given 5.3 days 432,000 Units DISCUSSION 70.3% 20.3% 5.3% 4 .0% - 7 cases -2 5. 4 days 16.6 Grams A comparison of typical charts of penicillin· and sulfadiazine·treated patients showed that, with sulfadiazine, the temperature dropped almost by crisis after the second or third dose. Then a sudden rise up to about 38°C. was observed in 24 hours. This stayed for just about 4 hours, and then it went back to normal from the third day of treatment. The child showed marked clinical improvement also by the third day, and the lung findings cleared up within a week. With penicillin the fall in temperature was not so steep; and, although there was also a spurt after 24 hours, the return to normal was more gradual, and it took ap· proximately 4 days before the child became completely afebrile. As with sulfadiazine, clinical improvement was observed about the third day and lung findings cleared up within a week. Except for very faint, transient morbilliform rash in 2 cases, untoward reactions were not observed in penicillin-treated patients. In the 226 sulfadiazine·treated pa· tients, toxic manifestations were observed in 7 patients as follows: 3 developed general· ized rash; 1 case had hyperpyrexia; 2 cases had vomiting; and 1 case had puffiness of the lids and hematuria. All ~f them improved upon withdrawal of the drug. None of these toxic manifestations were severe enough to be alarming. CONCLUSIONS I. From February 1943 to February 1946, 414 cases of pneumonia were ob· served in the Children's Department of the North General Hospital. This number was 300 more than the number of cases treated in the same hospital in 1944. Volume XXll Numhn 4) TREATil/JENT OF PNEUMONIA-De/ Mundo 273 ~. In 1he series of 414 cases in 1945, the recovery rate was 62.5% and the fatali1y rate was 1.9% as compared to the recovery rate of 38.0% and fatality rate of 17.7% in 1944. 3. Cornmdn childhood diseases like acute upper respiratory infections and measles are frequent predisposing condi1ions to pneumonia; and, definitely, infants below one year were found higbly susceptible. 4. Penicillin and sulfadiazine were effective in the treatment of pneumonia; the average amounts given were 432,000 units and 16.6 grams respectively for a period of approximately 5 days. The response in the 1wo groups was almost identical. 5. Although there were .slightly more toxic manifestations with sulfadiazine (3.050) than with penicillin (1.6%). they were neither permanen1 nor severe enough to cause alarm or even fear for the former drug. 6. Under present circumstances, since adequate doses of either drug will pro· duce identical and an equally sa1isfactory response in moderate and uncomplicated cases, the cost, availability, and ease of administration make sulfadiazine a sati;· factory drug, provided proper precautions are taken. THE JOURNAL OF THE Philippine Medical Association Published monthly by the Philippine Medical Association under the supervision of the Council. VOL XXll Office of Publication, 547 Herran, Manila, Philippines Devoted to the progress of Medical Science and to the interests of the Medical Profession in the Philippines. JUNE, 1946 The Council NO. 6 Officers of the Philippine Medical Association, 1946· l 94 7 f'Ttsidtnt: Dr. Januario Estrada Vice· Presidents: The Council consists of the President, the Vice·Presidents, the Secretary·Treasurer, and the following Councillors: Dr. Juan Z. Sta. Cruz Dr. Gonzalo Santos Secret4ry·Trea.surer: Dr. Antonio S. Fernando Dr. W . de Leon Dr. A. Villarama Dr. Jose C. Locsin Dr. M. Canizares Dr. Victorino de Dio..ANTONIO S. FER"ANDO, M.D., Editor I. V . MALLARI, Copy Editor PEDRO M. CHANCO. Business Managu Associate Editors (alphabetically listed) V1cToR1No DE D1os. M. D. josE GumoTE, M. D. RENATO MA. GtlERRERO. M D. w ALFRIDO DE LEON. M. D. CARMELO REYES, M . D. AGER1co B. M. S1so:<, M . D. ANT0..,10 G. SISON, M. D. Signed editorials express the personal views of the writer thereof, and neither the Asso· ciation nor the Journal assumes any responsibility for them. ifbitorial ENTRANCE REQUIREMENTS FOR MEDICAL STUDENTS This year the total enrollment of ,the colleges giving the premedical course is unusually large; and it is difficult to imagine how all these students could be taken care of-with most of our facilities destroyed by the war; and with ·new materials and equipment difficult, if not altogether impossible, to obtain either from the United States or ,·from Europe. It is clear that we have somehow to limit the enrollment, and one way to do 276 EDITORIAL Jour. P. M. A. June, 19·16 it is to require of students seeking admission to first yiear medical classes at least an extra year of preparation. There is, however, a far: more significant and vital reason for this requirement. For, within the last decade or so, there has been a marked deterioration in the quality of the educational preparation given to students with ambitions to take up medicine as a profession. The cause of this deterioration is not far to seek. The so-called vocational trend in education has shifted the emphasis from the classical study of the humanities. Instruction - the mere filling of the student's mind with facts - has taken the place of education-the drawing out of the latent physical and intellectual power of the student. But it is far fro1n sufficient for a medical student to have acquired nothing more than a disorganized body of facts. Like the medical practitioner, he should possess a broad cultural background. Having to deal with all kinds of people just when they are not at their best, he has to be familiar with all the. vagaries of human nature. He must have a profound compassion for, born of a thorough understanding of, the travail of the body and of the spirit that the flesh. is heir to. This understanding, this sympathy, can be developed only through the sys~ematic education, not only of the intellect, but also and particularly of the emotions. This is what is meant by a. truly liberal education. It means a broad and comprehensive knowledge of the humanities - art, literatm·e, and philosophy; languages, not only modern but also classic; as well as both the social and the natural sciences. Medicine being an art as well as a science, the medical practitioner should have the mind of a scientist and the heart of an artist. He should not only know facts and how to classify and organize them ; he should also and especially know how to make use of those facts, of the elements of knowledge, in such a way as to promote the well-being and the happiness of his fellowmen. That, after all, is the mission of the physician. The physician is only as good as his training. That training, to be complete, must have a broad and solid cultural foundation. And the extra year of preparation cannot but help build that necessary foundation. - R. Ma. G. tlllli.srellaneou.s ABSTRACTS FROM CURRENT LITERATURE ABSTRACTORS lsabelo Concepcion, M . D. Walfrido de Leon, M: D. Felisa Nicolas· Fernando, M . D. Carmelo Reyes, M. ·D. Effat of Certain Amino Acids on Hec.1ling of Experimental Wounds of t11e Cornea. by A. ]. Schaeffer. Proc. Soc. Exp. Biol. & Med., 61 :165, (February) 1946. Fischer found that. in tissue cultures in vitro, the embryonic extracts could be replaced by an artificial medium in which amino acids furni5hed the building stones for the synthe~is of protoplasm. Cystine, which seemed to function both as an cncrgy·f urnishing ingredient and ~s a growth catalyst, apparently played a major role in this medium. Encouraged by Fischer's results, the author has made an attempt to influence the regcnera· t!on of experimental wounds of the cornea by administration of amino acids to this tissue in vivo. For the final experiment, 36 guinea pigs were used. In 18 of thcs.: a!limals, the amino acid solution was dropped into the right eye every hour, while the left control eye received ; .. corresponding amount of salt solution. In the remaining 18 animals, an ointment containing the amino acids was applied twice a day to the right eye, tog.:!ther with a 51 % boric acid oph· thalmic ointment, which was applied to both eyes. · The amino acid solution was made in 6£'/o sodium .chloride and contained 2 mg. cystine, 5 mg. proline, 6 mg. asparagine, and 14 mg. ~lutamine per cc.; and was adjusted to pH 7.2. The result of the experiment was a complete regeneration of the corneal defect in the eyes treated with amino acids. This was achieved within 12 to 42 hours, while the healing. process in the control eyes required 5 5 to 120 hours.-1.C. Polit Acid 'rh<rapy in Macrocytic Anemia of Infancy. by W. W. Zuelzer, and F. N. Ogden, Proc. Soc. Exp. Biol. Ii Med. 61 :176, 1946. This report presents the results obtained with the four patients, the data on whom have: been calculated. The patients were white !nfants ranging from 2 to 12 months in age, one male and three females. All came from average homes and had been well cared for. The clinical picture was not characteristic. The pertinent findings of the physical examination on admission to the hospital were marked palor, usually a slight cardiac enlargement, and • i soft systolic murmur. The spleen was moderately enlarged and firm. All patients had severe ma• crocytic anemi~ '"'accompanied by moderate to marked diminution of the blood platelets. A few nucleated red cells were invariably present in blood smears and often suggested a megaloblastic origin. Treatment with folic acid was not begun until preliminary observation had established the absence of a spontaneous reticulocythosis. The response to folic acid treatment was character· ized by a rise jn the reticulocyte count on the third or fourth day, which reached the maximum on the 6th or 7th day and was followed by steady rises in the hemoglobin values and red blood cell count. Characteristic changes in the bone marrow took place as early as the 4th day. The authors consider the folic acid therapy as specific in this type of anemia for the fo1low· ing reasons: ( 1) It produces an adequate reticulocyte response, followed by a marked lasting improvement in the red blood count and hemoglobin value: (2) Equally important the me· galoblastic pattern of the bone marrow is transformed into a normoblastic onc.-1.C. 278 ABSTRACTS FROM CURRENT LITERATURE Jour. P. M.A. .June. 19~6 Treatment of Sprue with Synthetic L. Casei Factor (folk Acid. Vitamin M), by \V. J. Darby, and E. Jones. Proc. Soc. Exp. Biol. ii Med. 60:259 (November) 19"5. This is a report on two cases of sprue treated with synthetic L. casei factor (folic a.dd, \.'itamin M.) The authors found that four day~ after intramuscular injection of 15 mg. of the synthetic L. casei factor, the symptoms of J!)os~itis disappeared. On the ninth day. the reticulocytes reached ai peak of 15.3% ; and a marked increase of thrombocytes was noted. The hematological improvement continued, ;iccompanied by marked general betterment, in· duding regeneration of the lingual papillae, ~u bsidence of the diarrhea, and J. considerable gain in . weight.-1.C. Effect of Pyridoxine of Granulopenia Caused by 'Thiouracil. by E. H. Fishbcrg and J. Yor:imer, Proc. Soc. Exp. Biol. ii Med. 60:181 (November) 1945. This is a report on eight hyperthyroid subjects receiving the usual dose of thiouracil plus 200 mg. of pyridoxine given daily by mouth. The authors found that previous to the adminis· tration of pyridoxine owing to the destrUctive effect of thiouracil on the bo~e marrow, the r. ranulocyte count dropped from 3700 to 400 cells per cu. mm. within 2 days. Administration of 200 mg. of pyridoxine hydrochloride by injection resulted in an increase to 1800 granulocytc~ per cu. mm. within 2 hours. This was repeated on 4 successivi:: days (thiouracil being with· drawn), with <an increase of the granulocytes count to 4900 cells per cu. mm. According co the authors, the results of their treatment seems to indicate that pyridoxine can bring about a rapid and significant rise in the number of circulating granulocytes in the blood in humaru rnbjects after a depression caused by thiouracil. Although there is a large element of self re· covery after removal of the toxic agent, there seems to he no doubt that the rcco"ery procc-:s is much accelerated by pyridoxine.-1.C. CfJ1e Availability of Ascorbic Acid in Papayas and Guavas, by Eva R. Hartzler, J. Nutrition, Vol. lO, No. 5. l55 (November) 19/15. The a\'ailability of the ascorbic acid of papaya and guc\\'a juice was determined by com· paring the urinary excretion of ascorbic acid by human subjects maintained on a diet )(lw in ~~corbic acid: {a) when receiving 75 ' mg. of synthetic ascorbic acid per day; and (b) when receiving an equivalent amount of ascorbic acid in the form of papaya or guava juice. Two C'xperimcnts in\'olving a total of fourteen subjects (eight men and six women) were carried out. The author found no · significant difference in the availabilitr of the ascorbjc acid of p<i:• pay.:i or guava juice as compared with synthetic ascorbic acid in either experiment. In studying blood plasma ascorbic acid level, the author found that subjects rec.:ivin~ 75 to 80 mg. of ascorbic acid per day o\'er a period of 5 weeks maintained plasma levah 11>f from 0.7 to 1.0 mg.o/c.-1.C. 'The 'Taft-Smith-Ball N<'tional Health Bill. (Editorial) JI. A.M.A. !JI :289 (May ZS) 1946. Senator Taft of Ohio introduced into the Senate early in May a program for health which was promptly hailed by the •press as an opposition measure to the Wagner·Murray·Dingell bill. The measure introduced by Senator Taft emphasized thf: creation of <{ national health agency under which all health functions of the federal government would he administered. It was referred to the Senate Committee on Education and Labor, which is now conducting hearinJ?5< on the current Wagner·Murray·Dingell bill. This agency would he directed by an admini<;~ trator for whom the Surgeon General of the United States Public Health Service would sub· .stitute when necessary. The main portion of the bill would appropriate two hundred million dollars annually for the next five years to be allocated to the individual states in order that they might be encouraged to provide Mspital, surgical and medical service for those ir need or those able to pay only in part. The plans developed in the individual states would require approval by the Surgeon General of the United States Public Health Service. but, on failure to approve, the state agency could appeal to a National Health Council. This c.ouncil would consist of the Surgeon Gen.era) ex oficio as chairman and eight members appointed by the ad .. ministrator. Five of these would be persons well known in the health field, and at least three '(olum~ XXll Number 6 ABSTRACTS FROM CURRENT LITERATURE 270 \J.•ould be doctors of medicine. The other three would be persons familiar with the needs for medical care. Another section of the bill would provide dental health service through allocation tc.• the individual states and would also provide for research, including particularly neuropsychiatric research. Fina11y the measure would permit government employees to Jllow deductions from their :-.alarles for participation in health insurance plans. The measure proposed by Senator Taft obviously does not aim at the nationwide inclu· ~iveness of the Wagner .. Murray .. Dingell bill. Neither does it require nationalization of th•: medical profession. From the point of view of a scientific attempt to move forward along the lines of extending medical services, it would not revolutionize medical care. The bill is therefore preferable to the measure it oppos~s.-F. N. F. Single Injection of Penicil!in Oil Baswa.x Mixture in Gonorrhea, by B. D. Chinn, S. Olan· sky and I. G. Murphy, Medical Annals of, District of Columbia, Washington, 15 :55·98 (Peb· ruary) 1946. Chinn and his associates used a peanut oil mixture which contained 300,000 units of peni .. cillin per cubic centimeter. The penicillin oil beeswax mixture consists of 4.8 per cent bees· wax in peanut oil in which is suspended calcium penicillin. The material is solid at roorri temperature and must be well warmed and liquefied before use. Injections were made into the gluteal muscle with a 2·1/2 inch needle, gage 18 or 19. One cc. or a single dose of 300,000 units was administered. A total of 115 cases of gonorrhea were treated. A cure rate of ap .. proximately 95 per cent was obtained. CultUres were made after forty·eight hours and seven to ten days following treatment. This method appears to be a highly satisfactory procedure and suitable for both clinic and private practice. The possible coexistence of syphilis should be kept in mind, and periodic serologic tests for syphilis ~hould be made over a 90-day, period.F. N. F. SOCIETY PROCEEDINGS SECTION ON OPHTHALMOLOGY AND OTOLARYNGOLOGY May 9, 1946 3'9th /\.nnual Meeting Philippine Medical Association Dr. A. S. FERNANDO, Chairman of the Se01ion, Presiding Dr. JOSE N . CRUZ, Secretary ABSTRACTS OF THE PAPERS Chairman's AddressDr. Antonio S. Fernando President, Philippine Ophthalmologicc.11 and dtolaryngolog1'ca.I Society. My dear Friends and Colleagues: I am scheduled in our program to give an address. It is the usual practice in the A. M. A. for the chairman of a section to give an address on an ilnportant scientific subject about '.\'hich he has made a long and careful study. And because the Philippine Medical Associa· cion is patterned after the great American Medical Association, I am also probably expected to do the same. But this time I hope I will be excused from that great responsibility, in view of the shortness of time to prepare an address. The 5ubject of intra-cranial complications of otitic origin is close to my heart; and, if I had been given more time, I would have glad!)'.' talked on it. I believe that it should be the practice in the Philippine Oplithalmological and Otola· ryngological Society for the President to outline his general polici~s at his installation. Then: at the Sectional Meeting of the Annual Meeting of the P.M.A., he should discourse on a scientific subject in which he is much interested; and, at the Annual Meeting 1\l November, he should report on the accomplishments of his administration, and should express his per• rnnal opinion regarding the future of the Society in particular, and on our specialties in gen• cral . Our Section is the first approved by the Philippine Medical Association. This is a source of gratification for all of us. Our speciaJties are thereby given the splendid opportunity to thrive and dC\·elop and become: robust as we want them to be. The Philippine Medical As~ociation is generous to our Section, perhaps btcause it is the first regular Se·ction to be af•, filiated to it. The proceedings of our Inaugural Meeting was published in the February issue of the· Journal, and we can have reprints for distribution to our members and to EENT Societies throughout the world. I have already made contacts with several famous societies in Ame'rka, and these have promised to send us records of their transactions. We will have them in our library. Let us exert all our efforts to ha\'e a library, of which we can be proud. Incidentally, since our country, is affiliated with the United Nations Organization, it is bound to become better known abroad. It follows that our National Medical organization will <t.lso acquire greater prestige. Volume XXII NwnbeT 6 SOCIETY PROCEEDINGS 281 As Editor of the Journal of the Philippine Medical Association, I have already recei\'ed requests for exchanges from many parts of the scientific world. This cannot but enhance our responsibility to raise the standard of our practice and to advance our knowJedge. The pres· tige of the Journal will depend, not upon the Editor. but upon the quality of papers pub· lished in it. These papers should be the resuits of intensive and careful investigation ; ex· tensive reading; judicious consideration of the subject under study; logical deduction of the principles involved; and clear, accurate, and forceful presentation. To give an incentive to the writing of good articles, the Council oi the Phi1ippine Medical Association', [ am happy lo tell you, has approved a recommendation to give prizes for the first and second best arti· des to appear in the Journal in a given year. An important activity of our Society, specified in our Constitution, is the giving of prac· tical post•graduate courses and demonstrationi. In drafting our Constitution and By-Law;;, I had in mind the injunction in the Oath of Hippocrates to pass on 01.1r experience to bur young brothers in the profession ·• . .. . teach them this art (medicine) if they shall wish to learn it, without fee or stipulation • . . . " Dr. Reyes wiJl announce to you presently the schc· dule of the course his, committee has prepared. Next year, we hope to announce this schedule earlier, to give time to our own members and those other members of the Philippine Medical Association who may be interested to attend. Founding a; Society and keeping it ali\'e and robust is a difficult matter. But even though jts membership is small, if all the members are greatly interested in its welfare, it is bound to succeed. In the Calcutta Medical Journal for November 19'45, \·olume 42, is an article entitled "Ophthalmology in India" by B. N. Bhaduri, Professor of Ophthalmology, Carmichael Medical College, Calcutta. He had delivered this as an address when he was the ~ucst speaker at the Inaugural Meeting of Bihar Opbthalmological Society, August 18, 1945. I would like you to read this article. AmOng other things, he said:. "It is not quite easy to start an As1ociation like yours, far less maintain it. I can tell you from my personal experience that it is an extremely difficult job. Would you be surprised to learn that the United States of America, where at the present moment nearly one hund.red ophthalmological societies are successfully functioning, the largest number that any country in the world can boast of. had for ten Jong years the strange exrcricncc of only two members attending the meetings of one of these societies." My dear friends, there is an excellent example of perseverance. May we also ha\'.:: that virtue! I thank you. OCULAR WAR INJURIES A. R. UBALDO, M.D. AND C. V. YAMBAO, M.D. The cases of ophthalmic war injuries studied in this report con:;isted of the ca~U<lltlcs among the civilian population in the City of Manila and its environs from September 21. I 944, to January, 1945. A total of 14 cases of uniocular war injuries due primarily to bomb ex· plosion was studied. The injuries were classified as follows : ( 1) Ocular war injuric~ from concussion with one case of retinal detachment: (2) Ocular injuries from penetration with or \vithout a foreign body-I I cases constituting the majority of the ophthalmic injuries h;l\'ing a percentage of 78,57%; (l) Wounds of the lids and orbit with 2 cases. First aid 'measures as regards asepsis and antisepsis were instituted the moment the patients were admitted in the hospital. Although antitetanic serum was not administered in the majority of our patients due to its limited supply, tetanus was not observed in our patients. The im· portancc of localization of foreign body in the eye or orbit was emphasized. Enucleation was done in 9 patients with perforating injury of the globe. One important observation noted in the enucleated eye after the operation was that the amount of damage or the extent of the injury 282 SOCIETY PROCEEDINGS Jour. P. M.A. June, 1·946 was much greater than the external appearance of the wound would warrant. So far. sympa, chetic ophthalmia was not observed in our patients probably due to early preventive enudeation. LOCAL INSTILLATION OF PENICILLIN IN ACUTE CATARRHAL CONJUNCTIVITIS GREGORIO FARRALES, M.D. St. Lu~<s Hospital artd Afable College of Medicine The successful resulcs of penicillin in ocular infection has been shown by the works of Keyes, Struble, Bellows, Floreys, Von Sallmann, and Meyer. According to the investigations of Struble, the topical application is the most suitable form of administration for external infections of the eyeball and adncxa. Encouraged by the remarkable results of these wcrkers, I tried clinically the local instillation of this Jrug during a small epidemic of conjunctivitis which was observed in the dispensary of St. Luke's Hospital. Medication and Dosage Local.--The dose was 1000 to 2500 units per cc. The instillation \"!a S 1 to 2 drops every hour for 3 to 4 hours in every acute cases, then every 2 hours. In other cases 1 - 2 gtts. every 2 hours, then every 3 hours. Results of treatment in 60 cases: Cured .... . ... . Jmproved Unimproved .... . . . ..... . .. .. ....... . .. . •. , . , .... . Worse . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . l ~~ Unknown due to failure co report ... . . . . , . • . • . . . . . . 30% Duration of Treatment. 12 hours 14 48 days Unknown due to failure to report 1% 40% 23% 5% 1% l0% Ob\'iously. the maximum effect of penicillin occurs during the first and second d::.y of treatment. COMMENT Penicillin is a very effective drug in the treatment of acute conjunctivitis. The more acute, the better the <"ffcct. The relief is prompt and rapid, the effect is felt in a few hours. Symptoms of pain, photophohia and discharge quickly disappear. Thd last to disappear i:; redness. Th~ ~ction is sometimes startling and marvelous. It shortens the number of days of treatment and is very much better than that afforded by other medications such as argyrol and other silver preparations. DISTURBANCES OF THE ASSOCIATED OR CONJUGATE MOVEMENTS OF THE EYE GEMINIANO DE OCAMPO, M.D. This paper is based on the records of six patients before and during the last world war. The first case one of complete Parinaud's syndrome (paralysis of conveq:~:ence, upward and downward gai.e): the second was an incomplete Parinaud's syndrome (paralysis of upward gaze with paresis of downward gaze) : the third was a conjugate deviation to the right; the fourth Volume XXII Numbea· 6 SOCIETY PROCEEDINGS 283 had a para1ysis of lateral conjug~tc movements and convergence; the fifth was a divergenc.;, paralysis; and the last had convergence and divergence paralysis with paresis of upward movement. It is fortunate that the last three cases were followed up to the autopsy. This has added tc the literature further clinica1 evidences of the presence of a supranuclear mechanism around the third and fourth ventricles, the disturbances of which by a tumor, for ex.ample, as in these cases, caused associated ocular paralysis. It is, however, unfortunate that anatomical localization was not so definite as in other cases previously reported. The foilowing observations in these cases are worth remembering : Disturbances of diver· gence and convergence should be kept in mind in cases where diplopia is a complaint and car. he elicited throughout the visual field, especially when no definite squinting is present. .!a any case of disturbance of the associated or conjugate ocular movements, a brain tumor and encepha· litis should be considered among other causes." Whenever a brain tumor is suspected, th~ pre· sence of paralysis of any associated or conjugate movement is a localizing finding. Functional tests of the vestibule and hearing are necessary for the full interpretation of disturbances of' the associated movements of the eyes. CHRONIC IRIDOCL YLITIS WITH OCCLUSJO ET SECLUSJO PUPILLAE HERMINIO VELARDE, M.D. E. de 0., 28 years, was admitted to the Philippine General Hospital on August !L 1942, for biindness of both eyes. About three years before she had had attacks of dull headache with ~light dimness of vision. She had had pains and redness of both eyes and her "ision had become worse. The worst attack had come about six weeks before she was admitted to the hospital. Sh<: had rather severC and persistent headaches with continuous lacrimation, and her vision wa!' greatly reduced. These symptoms gradually abated, but the vision continued to become poor. On admission she was fairly strong, but rather poorly nourished. Physical examination ~howed that all her systems were normal. Eye examination showed that her vision was limited to light projection. There was some circumcornea1 injection of both eyes. Intraocular tension was noticeably reduced on palpation; and, with Schiotz's tonometer, was 8 mm. of mercury. The anterior chambers were shallow and both pupils were non•mobile and covered with whitish organized exudates. Pupils dilated neither with atropin nor with atropin and adrenalin sub· conjunctival injections. After the active stage of the eye inTlammation had subsided, both eyi::s were submittt:d to operation in several sittings. On September 1. 1942, optical iridectomy was performed on the right eye. Tissue of the iris about 3 mm. in diameter was removed from the upper outer quadrant. The Jen~ was!ound cataractous. On September 12, iridectomy and cataract extraction were pe;formcd. The techni;: was as follows: Under cocain local anesthesia, with :i Graefe knife, corneal section with con· junctival flap ~as made. The iris was adherent to ihe underlying $tructures. With iris. scissors, a circular incision of iris, a.bout four mm. in diameter was made. The detached iri~ with the lens underneath was removed with the capsule forceps by "torsion and sommersault «xtraction." Vision immediately improved an~ moving fingers were seen by the patient. Healing was J!OOd ; but the iris dosed again, and another iridectomy was performed on September 26. The left eye was submitted to same operation. The iris of both eyes required two post· operative iridectomies-the last one for the right eye on January 16, 19.43. This last operation was in the nature of iridotomy. The eyes, after this last operation, remained in fair con· dition; and, ·three. months later, or March 1943, her vision enabled her to count fingers at about five feet distance with the right eye, and at abcut two feet distance with the left eye. With + 4.00 sph. her vision was improved. 284 SOCIETY PROCEEDINGS RETROPHARYNGEAL ABSCESS IN CHILDREN A. R. UBALDO, M.D. "'" ). N. CRUZ, M.D. Jour. P. M.A. June, )!146 Upper rcspiracory obstructive dyspnea as a symptom·compl.:x in respiratory diseases i., commonly observed. Of the many varied causes of this symptom-complex, a retropharyngeal abscess should always be considered as a strong possibility, especially in children. In this series of cases admitted to the Philippine General Ho_ spital from September 1940 to April 1946 inclusi\'e, we have IO, five of which or 50 per cent were below one year of age. As to etiology, almost all of our cases were either associated with, or accompanied by, some degree of enlargement of the cervical lymph glands. The disease seemed to start as an in· fcction of the lymph glands and co extend gradually to the :-etropharyngeal tissue. Scrofulous diathesis was very common. The predominant sympton manifested on admission was upper respiratory obstructive dyspnea, so that an emergency treatment was always deemed necessary. Representative case reports with comments were gi\'en in this paper. PRACTICAL CONSIDERATIONS IN REFRACTION FELISA NICOLAS-FERNANDO. M.D. The writer records her experience in refraction work during the last 25 years of private practice and 12 years (1929·1941) in the University of the Philippines Infirmary, where i~ was not uncommon to have from 10·15 cases oi refraction a day. five hundred fifty·four eye9 with errors or refraction observed within the past ele\'en months were analyzed. This paper appeared in the April, 1946, i~sue of the Journal of the Philippine Medical A ~~ociation . THE FOGGING METHOD OF REFRACTION GEMINIANO DE OCAMPO, M.D. This is an attempt at clarification and appraisal of the objectives, indications, method, usefulness, and limitations of fogging. The subjects for ~tudy are private patients within the last eight years. The records of 58 cases where both fogging and cycloplegia were used are grouped and analyzed. In 42 per cent, fogging and the usual method of cycloplegia were equal; while, in 12 per cent, they were almost equal in uncovering and measuring the true condition of th.: ametropia. In 10 per cent, fogging was superior tO' the cycloplegia as far as the degree of relaxation of the ciliary muscle attained was concerned; while, in 24l per cent, the use of atro· pine uncovered a greater amount of ametropia than fogging. However, in this last group, only one case gave 0.75 5 and two gave 0.50 5, while all the rest (78.2 per cent) gave 0.25 5 in favor of atropine. Jn 6.9 per cent, the findings fwrn fogging were more in one ey~ but leSs in the other eye than those under atropine, by 0.2S' 9 to 0.50 5. These reversed results arc neutral as far as the choice between the methods of refraction is concerned. In 5 per cent, with irritable or unstable ciliary musde, atropine was tlecidedly superior to fogging in determining the strength and axis of the astigmatism. An almost equal number of cases (55) where prescriptions for lenses were mainly based· on the results of fogging, were also analyzed. From 311 these, it seems that, for clinical purposes, fogging is an effective way of con., lrolling accommodation almost equal ro. if not better than. the ordinary cycloplegia, except pro· bab1y in 10 per cent of cases where the ciliary muscle is either spastic or irritable with ever• changing tone. In prescribing, it is preferable:, in some cases, to err towards a little undercorrection by deducting . f2 D to 0. 25 t> from the value obtained in foggin~. than to be carried by th~ Volume XXJI N~mber 6 SOCIETY PROCEEVINGS 285 misconception that fogging is gcncr<lliy inferior to the usual cycloplcgia in uncovering latent hyperopia. Th11: results of this study Justify its wider clinical use hy ophthalmolog:i!'ts and opticians, when properly indicated and correctly done. LOCAL INSTILLATION OF PENICILLIN IN CHRONIC SUPPURATIVE MAXILLARY SINUSITIS JESLJS TAMESIS, M.D. Fifteen cases of chronic s1.1ppurative maxillary sinusitis were treated with local instillation of penicillin after displacement irrigation with normal saline. No bacteriologic determrnati10n of the causative organism was made. fifty thousand units were instilled daily after irrigation ior varying periods of time. Attempts were made to keep the drug inside the sinus by means of positional rests favorable to penicillin retention. A patient was declared completely recovered if, after 3 or 4 ·days of irrigation without penicillin, no nrncoid discharge was passed out. Incomplete recovery was declared for i:hose cases who continued to have mucoid discharge but who were re:iicved of other subjective com .. plaints. Average follow up was 5.8 months and ranged from. 4 to 8 months. Eleven case .~ (73'"/<) completely recovered. Four cases (36'i() had recurrences. Average recurrence period was more than 5 months. The rate of recovery was found to be ind~ pendent of the chronicity of the disease. Penicillin exerted strong deodorant effect on the foul suppurative cases. Local and consti' ttttional improvement was observed in all cases. The therapeutic value of thifl mode of ad, ;-i1inistration ii; thus proven and s.hould henefit patient unable to undergo radical intervention. FOREIGN BODIES IN THE FOOD AND AIR PASSAGES JOSE N. CRUZ, M.D. Foreign bodies as a cause of dis~ases of the food and air passages have been o~ lat.:: commonly observed. This paper presents an analysis of 95 consecutive cases of foreign 1:-iodies in the food and air passages removed by the J.uthor at the Bronehoscopic Clinic of the Philippine General Hospital. In 76 of these 95 cases, the foreign bodies were in thl· 0f:sophagus: and in 19, in the respiratory tracts. The different foreign bodies and their incidence, the location of che foreign bodies in the oesophagus and respiratory trace, and die age incidence were discussed. The most common symptoms, the diagnosis, and the complications were also given. Bronchoscopy and removal of the foreign body was the only treatment worthy of con· s.ideration. Complications were trc;:1ted accordingly. ACUTE EPIGLOTTITIS DR. C. \I. YAMBAO This article was written on account of the ~carcity of the literature on the subject. Fifteen cases of acute primary cpiglottitis admitted in the Eye, Ear, Nose and Thrbat De.rartment of the Philippine General Hospital were studied as regards etiology, symptomatolog:y, diagnosis, and treatment. The disease has a tendenq· to attack the young and middle,aged males. The symptoms ni" a<;utc cpiglottitis are like those of anyi other acute tonsillar infection. Of these, dyspnca is the most prominent. The author emphasiz.ed the importanc~ of a \'igilant watch of the patients' breathinj!. Scarification and incision arc considered to be the best forms of tre;itment under direct laryngoscopic guidance. The avi!ra~e number of d.1ys of hosoitaliz.ation is seven. Su1fadia• :ine given together with penicillin shortens the course of the disease to 4 .. 5 days. 286 IMPORTANT NOTICE Jour. P. M . . \ . .i ane, }9.fG Original articles are accepted for publication only with the understanding that they have not been and are not to be published elsewhere. The Editorial Board reserves the right to accept, reduce, or reject all manuscripts submitted for publication. Any number of reprints will he furnished at cost price provided that written rcqueot be made by the author at the time the article is submitted for publication. 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