CHAPTER XL (Part 1)

CHAPTER XL Infectious Diseases 216 Typhoid (Enteric Fever), 216; Bacillary Dysentery, 227; Amebi(? Dysentery, 231; Measles^ 233; Scarlet Fever (Scarlatina), 236; Malaria, 243; Diphtheria, 251; Rheu- matic Fever (Inflammatory Rheumatism), 255. CHAPTER XIL Constitutional Diseases 280 Arthritis Deformans, 260; Gout, 263; Diabetes Mellitus, 267 CHAPTER XIII. GENEBAL CoNSIDEEATIONS r. >: i.i . > . . 272 Physician and Patient, 272, GOLDEN EULES OF DIAGNOSIS AND TREATMENT OF DISEASES. CHAPTER I. DISEASES OF THE STOMACH. Gastric Ulcer. Eemember that, while the tripod pain, vomiting, and hematemesis are somewhat characteristic of peptic ulcer, they possess certain peculiarities. The pain of ulcer is localized in a circumscribed area in the epigastrium, and radiates to the back at about the tenth dorsal vertebra. Tenderness is found over the area of pain. Remember that the pain occurs paroxysmally when food is taken and digestion is at its height, produced by irritation of acid gastric juice and the peristalsis. Emptying the stomach, either by vomiting or with stomach tube, relieves pain. Many patients will produce emesis to get relief. Eemember that vomiting is rarely absent and oc- curs at the height of pain; and when the stomach is emptied, vomiting ceases and the pain is relieved. 9 10 DISEASES OF THE STOMACH. Hydrochloric acid is always present in vomitus of nicer, and frequently is excessive. Remember that copious, free hemorrhage is far more common in ulcer than in any other disease of the stomach. Remember that profuse, painless, sudden hema- temesis in an elderly patient suggests hepatic cirrhosis rather than gastric ulcer. Dilatation occurs after the ulcer heals. It occurs only when the ulcer is near the pyloric opening and the contracting scar tissue partially closes it. Don't mistake the anemia of ulcer for malignant cachexia. Remember that the vomiting of bright-red blood is almost positive evidence of ulcer. Remember that the first symptom of ulcer may be perforation or a fatal hemorrhage. The area of tenderness in ulcer is about two inches below the ensiform cartilage and a little to the right of the median line. Remember that the pain of ulcer may be referred to the lower intercostal nerves, or axillary plexus, or down the arm. Pain may persist after the ulcer heals, caused by nerve filaments being caught and compressed in contracting and hardening of the scar tissue. Remember that ulcer is twice as frequent in women, and occurs between the fifteenth and twenty -fifth years. Remember that the pain of gastralgia is diffuse. GASTRIC ULCEE. 11 and pressure or food relieves it, and neither hema- temesis nor anemia occur. Remember that in the pain of gallstones the liver is enlarged and tender, and that jaundice and pal- pable gallbladder is frequently present. Always examine the stools, as frequently they contain blood, either macroscopic or occult, when the vomitus does not. Remember that the appetite is good in ulcer, but vomiting prevents digestion and nutrition is re- duced; hence these patients lose in weight. Remember that perforation is announced by sud- den, sharp, lancinating pain; weak, rapid pulse; shallow, hurried breathing, and cold, clammy sweat, with muscular rigidity and tenderness over the ab- domen. Remember that surgery is imperatively indicated in the early hours of perforation, before peritonitis develops. It is the importance of early surgical in- tervention that demands careful watchfulness on the part of the physician. It is gross ignorance or criminal carelessness to wait until peritonitis begins. Remember that passing a stomach tube may cause rupture at site of ulcer. Treatment. Remember that there must be mechanical as well as functional rest of the stomach, and the only way to obtain it is to keep the patient in bed. Remember that thirty-six hours of fasting, ex- 12 DISEASES OF THE STOMACH. eluding even water, is the very best way to begin the treatment, unless the patient is greatly ema- ciated or old. Eelieve thirst with salt solution enemata. Begin rectal feeding at the end of thirty-six hours. Nutrient enamata during the fasting period will stimulate reflexly the gastric secretion, and this will irritate the ulcer and cause pain. Remember that the rectum has no digesting power; hence all foods must be ready for absorption. Predigested milk, to which is added one raw egg, makes an excellent enema. Don't give too large a quantity at a time, or it will be expelled. Four ounces, repeated every four hours, is best. Remember that panopepton is excellent in rectal feeding. Add it to normal salt solution. It is also excellent to begin feeding by mouth. Don't feed per rectum too long, as the bowel be- comes irritated and will not retain the enema. Feed per rectum exclusively for five days and then give some food by mouth. Two ounces of milk every three hours, with careful watching for return of pain, and, when absent, gradually increase the amount, is a good plan. At the end of the second week add meat broth, mashed potatoes, and white meat of fowl. The medicinal treatment is important, but not so effective when the dietetic regimen is omitted. The following prescription and method of admin- istering it give good results: GASTRIC ULCER 13 IJ Bismuthi subnitratis 3 ij-3 v Aquae B i j Misce. Sig. : Give at one dose, with patient in the recumbent posture. Have the patient move from dorsal to side posi- tion slowly, then to the other side, thus allowing the bis- muth to coat the mucosa. Or: R Cerrii oxalatis gr. i j Magnesii carbonatis levis gr. x Bismuthi subcarbonatis gr. xx Misce et fiat pulvere No. I. Sig.: Powder from three to six times daily. Iron may be added to the above if anemia be se- vere. This will relieve vomiting and is antacid. Or: Tfi Relbrcinolis (Merck) 3 j Argenti nitratis gr. vj Extracti hyoscyaminge gr. xxx Misce et fiant pilulse No. XXIV. Sig.: Pill three times daily one hour before meals. Astringent, antiseptic, and relieves pain. Or: IJ Argenti nitratis gr. vj Extracti belladonnas gr. v Extracti hyoscyaminse gr. xx Extracti gentianae q. s. Misce et fiant pilulae No. XXIV. Sig. : Pill one hour before meals. This is an excellent combination — astringent and tonic. Silver nitrate may be given in solution, either gr. ^ or solution 1 :1000 can be made and gradually increase dosage. Ortner's prescription is good. 14 DISEASES OF THE STOMACH. IJ Extract! belladonnae gr. viiss Bismuthi subnitratis, ■ Magnesii oxidi, Sodii bicarbonatis aa 3 iiss Misce et fiant pulveres. Sig. : A good pincb three times daily after eating. (Ortner.) For liematemesis, complete rest, and be^t obtained by hypodermic of morphin and atropin. Ice bag to epigastrium. If severe, bandage extremities and raise foot of bed. Replace lost fluid with normal salt solution, either in rectum or into cellular tissue, by hypodermoclysis. Ortner now gives 10 drams hypodermatically of Merck's 10-percent gelatin solution as long as blood may be seen in vomitus or stools. , Tincture of the chloride of iron 5 to 15 drops every two hours is recommended. IJ Stypticini (Merck) gr. x Antipyrini gr. xl Elixiris simplicis 5 j Misce et fiat solutio. Sig.: Teaspoonful in water every two or three hours as needed. Or: I^ Aeidi tannici 3 ij Pulveres aluminis 3 j Garantose gr. ss Misce et fiant pulveres No. XVI. Sig. : 2 powders every fifteen minutes, followed by water. Where the cicatricial tissue causes obstruction at the pylorus, thiosinamin may be used to cause ab- sorption. GASTRIC ULCER GASTRIC CANCER. 15 IJ Thiosinamini 3 j Glycerini 3 ii j Alcoholis diluti 3 vj Misce et fiat solutio. Sig. : Inject 8 to 15 minims subcutaneously every two or three days. Gastric Cancer. Remember that cancer of the stomach is on the increase. A large majority of the cases occur be- tween the fortieth and seventieth years, but it is fre- quently found in young adults and even children. Remember that enlarged and painless cervical or inguinal lymph glands found in a dyspeptic past midlife strongly indicate cancer. Nodular swellings found under the skin about the navel or between it and the costal arch are meta- static cancer growths. Remember that many cancer patients have edema about the ankles or anasarca. This condition de- velops toward the close and is due to debility. In cancer the vomiting frequently occurs late in the day or during the night, with insomnia. Fre- quently insomnia is the most troublesome symptom. Remember that a tumor can be palpated in three- fourths of the cases. Remember that a gastric tumor can be moved to any part of the abdomen, or even into the pelvis. Remember that a tumor that moves with respira- tion, but has neither respiratory fixation nor lateral movements, is not gastric, but hepatic. Remember that hydrochloric acid is absent or 16 DISEASES OF THE STOMACH. greatly diminished, and lactic acid is present and Boas-Oppler bacillus may be found. Always examine gastric contents, and better give test meal. Remember tliat in palpating a gastric tumor three tilings are found: 1. Changes on deep inspiration, but is free from respiratory movements. 2. Wide area of aortic pulsation. 3. Intrinsic movements occurring in the contrac- tion of the hypertrophied muscularis of the tumor, causing it to appear and disappear, lifting the ab- dominal wall overlying the tumor. Remember the value of inspection and observe — 1. The state of general nutrition. 2. Fullness in the epigastrium. 3. Peristaltic waves. 4. Nodules under the skin. Remember that the pain of carcinoma is constant and gnawing, not often referred, and vomiting af- fords no relief. Remember that fatty stools, uncontrollable diarrhea, glycosuria, and perhaps the palpation of an immovable tumor are signs of pancreatic cancer. Remember that emaciation, loss of weight and strength, vomiting of coffee-ground colored ma- terial, and cachexia, with presence of gastric tumor, leaves little doubt of cancer. As a rule there is no vomiting of bright-red blood or clots, that are fre- quently associated with peptic ulcer. GASTRIC CANCER. 17 Remember that the duration is short, seldom ex- ceeding one year. Treatment. Surgery offers the only hope, and the diagnosis must be made early if an operation be of any benefit. Remember that, medicinally, the object sought is relief of pain and vomiting. Tonics should be given. Washing out the stomach often relieves pain and vomiting. Use saline solution or boracic acid solu- tion. Condurango bark, given in powder of 30 grains each three times daily, gives excellent re- sults as to the amelioration of symptoms and im- provement of appetite. Elixiris ferri quininae et strychninae (U. S. P.) o ij, three times daily after meals. Liquoris potassii arsenitis ill iij vel nrt v is not only a good tonic, but is very beneficial in fighting the anemia. Where pain is due to superacidity, the following relieves by neutralizing the acid: IJ Sodii bicarbonatis gr. xv vel gr. xx Magnesii carbonatis gr. v vel gr. x Acidi hydrocyanici diluti TTl iv Aquae mentlias piperitse . . . . q. s. ad g j Misce. Sig. : To be taken at one dose and repeat three times daily. Creosote in minim doses in gelatin capsule after food is very highly praised by Yeo. He says espe- cially good results are obtained in the scirrhus form of cancer. 18 DISEASES OF THE STOMACH. IJ Dionini gr. vii j Acidi hydrocyanici diluti TTL xxx Bismuthi subnitratis 3 ij Aquae chloroformi q. s. ad 5 iv Misce et fiat solutio. Sig. : Shake well and take teaspoonful every two or three hours. Or: IJ Resorcinolis ( Merck ) gr. xxx Vini rhei 3 j Syrupi aurantii 3 iv Decoctionis condurango ( 1 : 12 ) q. s. ad 5 vj Misce et fiat solutio. Dispense in dark amber bottles. Sig. : Tablespoonful every two hours. Gastritis. Remember that the history of the case, especially that relating to the diet, will be of great help in diagnosis. Usually find excess at the table, the eat- ing of tainted food or overripe fruit. Remember that a majority of the cases are afebrile, and recovery in forty-eight hours is the rule, except where the attack is due to toxic sub- stances contained in the food. Always test the knee jerk and reaction of the pupil, because gastric crisis occurring in locomotor ataxia frequently simulates acute gastritis. Remember that a severe case may require time to clear up the diagnosis. For instance, an attack ac- companied by severe headache and delirium occur- ring in a child might be mistaken for meningitis, or the pain may be so severe as to suggest gallstones, and frequently it marks the onset of many of the GASTRITIS. 19 infectious diseases, as measles, scarlatina, and ty- phoid. Always examine the heart, liver, and lungs in all cases of chronic gastric catarrh, as it is often due to portal stasis. Remember that the vomiting of mucus, or where the gastric contents are thickly coated with mucus, is found only in catarrhal processes. Remember that alcohol is an important factor in causing chronic gastritis, and it must be discon- tinued if treatment be of any avail. Many cases of cardiac palpitation or dyspnea are due to gastritis, causing the food to ferment and the gas distends the stomach. Treatment. In an acute attack allow no food for twenty-four hours. Stimulate vomiting by giving a tumbler of warm salt water and repeat until the stomach is thoroughly cleansed. If water checks the vomiting by diluting the irritant, produce it by tickling the fauces. Use the stomach tube if possible and wash out thoroughly. Follow with a cathartic. Olei recini qJ, given in orange juice, with 2 or 3 drops of tincturse opii if needed, is excellent. If icterus develops, or vomiting persists, give the following : 3 Hydrargyri chloridi mitis gr. iv Cerrii oxalitis gr. x Sacchari lactis gr. xxx Misce et fiant pulveres No. XII. Sig. : Powder dry on tongue every fifteen minutes. 20 DISEASES OF THE STOMACH. Two hours after last powder give saline. A mus- tard plaster over the epigastrium gives relief. For continued nausea allow cracked ice. Follow with a liquid diet, preferably milk, to which add lime water or soda water. Allow a wineglassful every three or four hours. After cleansing the stomach a sedative is indicated and bismuth is the best. IJ Bismuthi carbonatis, Sodii bicarbonatis aa 3 i j Spiritus chloroformi 3 j Aquae menthae piperitse .... q. s. ad 5 iij Misce et fiat solutio. Sig. : Tablespoonful every four hours. If the pain is severe, the deodorized tincture of opium may be added to the above. Later a bitter tonic may be needed. The following is good: IJ Tincturae nucis vomicae 3 ij Tincturae gentianae compositae 5 iss Tincturae cinchonae compositae q. s. ad ^ iv Misce et fiat solutio. Sig.: Teaspoonful before meals. Dilute muriatic or nitromuriatic acid may be added if needed. In chronic cases remove the cause, if possible. If due to alcohol or iced drinks, prohibit them. If secondary to cardiac, hepatic, or pul- monary conditions, relief will follow improvement in those conditions. It is in the chronic form that stomach washing gives the most brilliant results. After a thorough washing with clear water, the following solution may be run into the stomach as a final douche: GASTRITIS. 21 IJ Thymol gr. viij Acidi borici 3 iv Aquae O j Misce et fiat solutio. Sig. : Use in stomach tube. If the tube can not be used, have the patient drink a pint of hot water in which is dissolved a half dram of sodium bicarbonate on arising in the morning. This will dissolve the mucus, and thus cleanse the gastric mucosa as well as stimulate the circulation. Direct patient to take meal without liquids. This insures thorough mastication and in- salivation. Diet should be light and nutritious. A glass of milk containing a raw egg, given twice a day between meals, is excellent. If dilatation exists, give dry diet and small quantity every four hours, and wash out stomach once a day. For sour eructations and distention of stomach by gas the following is excellent: B Phenolis gr. xxv Glyeerini 3 iv Bismuthi subcarbonatis 3 v Lactis magnesise q. s. ad 3 iij Misce. Sig.: Shake well and take teaspoonful after food. The following before meals gives good results : 3 Resorcinolis ( Merck ) 3 j Bismuthi salicylatis 3 iiss Tincturse catechu 3 vj Syrupi aurantii § i j Aquae q. s. ad 5 iv Misce. Sig.: Shake and take dessertspoonful half hour before meals. 22 DISEASES OF THE STOMACH. Where neurasthenia coexists : R Arseni trioxidi gr. j Extracti nucis vomicse gr. x Euquinini (Merck) gr. xxx Ferri carbonatis 3 ij Mucilaginis acaciee q. s. Misce et fiant pilulae No. LX. Sig. : 2 pills after meals. Hyperchlorhydria. Remember that under this term is included a con- dition of excessive formation of hydrochloric acid, due entirely to nervous influence, and no anatomical lesion is found; hence it is quite common in chloro- sis, hysteria, and neurasthenia. It is frequently found in brainworkers. Pain is variable, from mild discomfort after meals to an intense gastralgia, developing at the height of digestion and caused by the presence of free hydrochloric acid. Vomiting or eating of proteid food will relieve the pain, because it removes the acid. Eructation, heartburn, increased salivation, and vomiting of sour liquid occurs. Remember that there is no "tender spot" or hematemesis as seen in ulcer. Remember that the absence of excess of mucus and excess of HCl with the history excludes gas- tritis. Examination of stomach contents shows HCl, no lactic acid or Oppler-Boas bacilli, and the duration of disease will exclude cancer. HYPERCHLORHYDRIA. 23 Remember that this condition occurs in children, and usually presents the following picture : a highly neurotic child is attacked at midday by severe head- ache, causing it to cry out with pain, increased by moving the head, or by coughing or sneezing; next a violent pain in the stomach, with legs