CHAPTER XL (Part 2)

drawn up, hands clasped over the stomach; belching of gas and sudden emesis, without apparent effort, which gives relief. The vomitus is pale-green or yellow color, fluid, and contains an excess of HCl. It will digest egg albumen. Usually a rise of temperature at onset, but later becomes subnormal. Tongue is clear, moist, and red. Treatment. Diet. Milk and egg diet for a few days often relieves milder forms. Proteid diet is indicated, as it uses up the acid. Carbohydrates should be greatly restricted. Don't allow wines, liquors, tobacco, con- diments, smoked meat, sour foods, or radishes. Lavage. Washing out the stomach, preferably in the evening, with an alkaline solution or a solu- tion of silver nitrate (1:1000) gives excellent results. Medication. Alkalies, especially the earthy, are indicated. The following is a good antacid: IJ Sodii carbonatis, Magnesii carbonatis, Bismuthi subcarbonatis aa gr. xv Misce et fiat pulvere No. I. Dentur tales No. XX. Sig. : Powder two or three hours after meals. 24 DISEASES OF THE STOMACH. To check secretion use belladonna or atropin: IJ. Extract! belladonnse g^-Vs Magnesii oxidi gr. x Misce et fiat pulvere Xo. I. Dentur tales No. XX. Sig. : Powder after meals. If fermentation occurs, witli eructation of gas: I^ Phenolis • • gr. xxv Glycerin! 3 i j Bismuthi subcarbonatis 3 iv Lactis magnesise q. s. ad § iij Misce et fiat solutio. Sig. : Shake well and take a teaspoonful after meals. Or: IJ. Argenti nitratis gr. iij Aquse destillatae § iij Misce et fiat solutio. Sig.: Dessertspoonful two hours after meals. Distress after meals may be relieved by: ' IJ. Creosoti TT], sv Sodii bicarbonatis gr. xxx Spiritus chloroformi, Spiritus ammonii aromatici . . . . aa 3 ss AquEB menthse piperitse .... q. s. ad § iij Misce et fiat solutio. Sig.: Dessertspoonful after meals. For the nervousness give: IJ Sodii bromidi 3 j Resoreinolis ( Merck ) gr. xxv Aquse anisi q. s. ad § iij Misce et fiat solutio. Sig.: Dessertspoonful after meals. Hematemesis. Remember that fatal syncope may occur without any vomiting. The blood vomited may be fluid or clotted, and is usually dark in color. Anemia and HEMATEMESIS. 25 edema develop early, and convulsions, hemiplegia, or blindness may occur. Remember that gastric hemorrhage may be the first symptom observed in leukemia. Remember that fatal hemorrhage may be due to rupture of varix in esophagus, and blood run into the stomach; hence no gastric lesion is found. Remember that the blood is vomited if it comes from the stomach, while it comes up from the lungs after a fit of coughing; as a rule, blood from the lungs is free of clots, or, if any, they are small. The blood is frothy, because of the contained air and alkaline in reaction. Tkeatment^ Absolute quiet in bed. Nothing by mouth, except cracked ice. Morphin and atropin hypodermatically to effect. Ergot or ergotin hj^Dodermatically. Give 10 drams of Merck's gelatin, 10-percent, sterilized, and repeat as long as blood appears in vomit or stools. Ice bag over epigastric region. Feed only per rectum. Tincturse ferri chloridi in 5 to 15 drops may be given. Plumbi acetatis gr. ss-gr. j may be given every two hours. If severe or oft repeated, opera- tion is indicated if the patient's condition is good. Most cases recover quickly with rest, and st^iotics per OS may cause vomiting. Hypodermoclysis of normal saline solution or transfusion by Crile's method may be life-saving. CHAPTEE n. DISEASES OF THE INTESTINES. Acute Enteritis. Remember that exposure to cold or sudden and decisive drop in the temperature may cause an enteritis, probably due to influence on cutaneous nerves. Improper food, especially in children, is a very frequent cause. There is no question that some cases are due to malaria, and quinin readily controls the diarrhea when other remedies fail. The dominant symptom is diarrhea. The stools are thin, mushy, or watery, and pale-yellow or greenish color, and contain mucus, but rarely any blood. In severe form stools lose color, assume the rice-water character, are foamy, and have sour odor. With the microscope portions of undigested food, mucus, bacteria, epithelial cells, and calcium oxalate and phosphate crystals may be seen. Colic is often present. The severity of the pain varies, and may cause collapse. Pressure over the abdomen affords relief. Abdominal distention and borborygmi occur, due to gas formation. Great thirst and diminution of quantity of urine occur from loss of water by the bowel. In severe cases urinary suppression occurs, followed by general edema. Albumins and casts may be found in the 26 ACUTE ENTERITIS. 27 urine. Skin may be cyanotic, cold, and clammy. Emaciation is rapid in children, and eyes become sunken. Fever may occur, but is usually absent. Remember that, in case fever is present, it lacks the peculiar curve and persistency found in typhoid, and the absence of slow pulse; the enlarged spleen and the absence of eruption would also exclude typhoid. Etiologic Treatment. If pain be severe, give hypodermic of morphin and atropin. If due to cold, give sudorifics and ex- ternal applications to produce sweating. Where ma- laria is cause, give quinin. If due to chemical poi- sons that can be neutralized, give the proper anti- dote. If caused by toxins that can not be neutralized, too coarse food, or impacted feces, rid the bowel as soon as possible of irritating substances. Cathartics. We have two means of cleansing the bowel — drugs and colon irrigation. Owing to the inflammatory condition, only mild drugs should be given. Castor oil or calomel is best. Castor oil should be administered in one large dose, ^ ounce in orange juice, to which may be added a few drops of tincture of opium to prevent griping. Calomel is especially indicated in persistent vomiting. Best to give one large dose — gr. iv-gr. vij — as small repeated doses may irritate the bowel. 28 DISEASES OF THE INTESTINES. Colon irrigation is the least harmful. Use 1 quart of warm water, and, to assist in retaining it, add 20 drops of the tincture of opium. Soap, glycerin, or oil may be used in the water. Diet is important. Reduce the work of the bowel to the minimum by using concentrated diet, with little residue. Complete abstinence for twenty-four hours, with teaspoonful of tea for the thirst, is ex- cellent. Allow only gruels from barley, rice, sago, or arrow-root. Give one or two tablespoonfuls hourly. Albumen water is allowable. Of liquids, tea is best, given tepid or hot. As the diarrhea decreases give broths, with yolk of egg, crackers, and. breadcrusts. During the attack give food in small quantities, neither very hot nor cold. Milk may be tried by giving a tepid tablespoonful hourly, and, if it increases the diarrhea, stop it. Medication should be such as meets the indica- tions. Soft capsule of olei ricini ttl x-ttl xx and salol gr. V are very efficacious. Or creosote may be used as follows : IJ Creosoti TTl, xv Tincturse gentianae compositse TTt xxx Spiritus vini gallici 3 iij Misce. Sig. : Teaspoonful three times daily. Or: I^ Bismuthi benzoatis 3 ij Salolis gr. xxiv Pulveris opii gr. vj Misce et fiant pulveres No. VIII. Sig.: Powder every three or four hours after the bowels have first been cleansed of irritating material. ACUTE ENTERITIS. 29 Or: IJ Tannalbini 3 ij Resorcinolis (Merck) gr- xv Glyeerini § j Aquse cinnamomi q. s. ad § iv Misce fiat misturse. Sig. : Shake well and take a dessertspoonful every three hours. For adult a tablespoonful should be given. For relief of thirst and to replace the fluid lost by the body, the continual seepage of normal saline solution into the bowel is excellent. The technic of continuous flow is very important and is as follows: a fountain syringe, or a can with a large rubber tube attached, and a hard-rubber vaginal tip, with several openings at the end, is all that is required. Flex the vaginal tip about two inches from the end by placing it in hot water and bending it, thus forming an obtuse angle. Insert until the angle fits closely to the sphincter, then bind the tube to the thigh with strips of adhesive to prevent its being expelled. The douche bag or can is suspended from the foot of the bed so that its base is six inches above the level of the patient's buttocks. Put one and a half pints of solution in the bag at a tem- perature of 100° and keep it at this tempera- ture. It should require no less than forty nor more than sixty minutes for this amount to percolate into the bowel. If administered more rapidly, it will be expelled. A hypodermoclysis of normal sa- line solution into the subcutaneous tissue may be resorted to in desperate cases. 30 DISEASES OF THE INTESTINES. Chronic Enteritis. Remember that constipation is the rule in the chronic, but may alternate with diarrhea. Always examine the stools, as they contain the diagnostic evidence. Remember that mucus in the stools is always in- dicative of enteritis, and never occurs from ulcer or cancer alone ; but the presence of blood always signi- fies a complication, such as piles, ulcer, or cancer. Undigested portions of meats, fats, and starch may be abundant. "Sago-pearls" are swollen, glassy particles of mucus, and may be seen in the stool. Yellow mucus granules are soft particles of mucus stained by bile pigment, and originate in the small bowel. Colicky pains over lower portion of abdomen, tenesmus, and gaseous distention are often present. Where colitis exists, tenderness over the course of the colon may be elicited by jDalpation. There is pallor and loss of flesh. Treatment. The diet is of great importance. It must be nourishing, so that the patient's strength is built up and yet avoid irritating the bowel. Meats suit- able are white meat and fish, scraped beef, calves* brains, chopped meats. Broths, eggs — raw, soft boiled, or scrambled — may be added. Farinaceous foods. Broths are liable to irritate, and, when given, the vegetables and meat should be strained CHRONIC ENTERITIS. 31 out. Rice, sago, and arrow-root are good. Milk is excellent; one to two quarts daily; add lime water if it causes any trouble. Fats — only form is butter. Fresh fruit should be entirely forbidden. Time. Meals should be given five times a day. The stools should be watched for particles of undigested food or milk curds. Colonic irrigation is best if the large bowel is in- volved. May use warm water, saline solution, or olive oil. Castor oil or calomel is best laxative, and should be given in one dose to prevent irritation of mucosa. Astringents may be needed to control the diarrhea ; these may be added to irrigation solution, using tannin 1 dram to the quart, or boracic acid 5:1000, or silver nitrate 1:2000. Medication. Tannigen and tannalbin are excel- lent astringents. They are tasteless, and are not affected by gastric juice. B Tannalbini gr. xv Fiat capsula No. I. Dentur tales capsulse No. XXX. Sig. : 4 to 6 capsules daily. Or: IJ Tannigeni gr. vi j Fiat capsula No. I. Dentur tales capsulae No. XX. Sig.: Capsule every two hours. Alum gr. iss-gr. iv may be given every two hours. Lead acetate gr. ss-gr. iss may be administered. Silver nitrate internally is not efficacious, as hydro- chloric acid in the stomach converts it into the chlo- rid; when used, it should be given in capsules hard- ened with formalin, so that the gastric juice will 32 DISEASES OF THE INTESTINES. have no effect. Bismuth is excellent; use either subnitrate or salicylate in large doses. IJ Bismuthi subnitratis gr. xx-gr. xxv Extract! opii gr. %-gr. % Misce et fiat pulvere No. I. Dentur tales doses No. XXX. Sig. : Powder every two or three hours. Or: B Bismuthi subnitratis gr. xxx Bismuthi subgallatis gr. x Misce et fiat charta No. I. Dentur tales chartae No. X. Sig.: Powder every two or three hours. Or: B Plumbi acetatis 9 j Extracti opii 3 ss Resorcinolis (Merck) 3 iss Misce et fiant capsulae No. X. Sig.: Capsule every three hours. Or: U Salolis 3 j Sodii bicarbonatis, Sodii benzoatis, Bismuthi salicylatis aa 3 iss Misce et fiant pulveres No. XX. Sig.: Powder every four hours. Obstruction of the Bowel. Remember that the symptom complex will vary according to the degree of obstruction. There may be slight difficulty in the discharge of feces, or fecal retention may occur, and onset may be sudden or gradual. Accumulation of feces and gases occurs above constricted area. Distention of abdomen. Peristal- OBSTRUCTION OF BOWEL. 33 tic waves can be seen above obstruction. In complete obstruction there are great distention, collapse, feeble pulse, coldness, and cyanosis of tbe extremi- ties. Vomiting, at first greenish, later resembles feces and has a fecal odor. Intussusception. Remember that it most often occurs at iliocecal junction, and usually found in infancy. 1. Sudden onset of pain — severe, continuous, or paroxysmal; referred to umbilicus. 2. Vomiting occurs early. More constant in chil- dren. Rarely have fecal vomiting in children. 3. Stools are characteristic, containing blood and mucus. Tenesmus is severe. 4. Tumor is egg or sausage-shaped, movable, and firm. It changes its position as the intussusception progresses. Treves says, "It nearly always can be felt during pain. ' ' Clubbe says, ' ' Very sudden onset in previously healthy baby is a peculiarity of intus- susception. The child screams, turns pale, vomits, which ceases but to recur again. ' ' 5. Pulse and temperature remain normal. Issue. May terminate in one of three ways: 1. Union at the point of invagination, with sloughing of the invaginated portion of the gut, and recovery. (Rare.) 2. Peritonitis. 3. Ulceration and perforation. 34 diseases of the intestines. Treatment. Never administer cathartics and purgatives, even in fecal impaction. Enemata of water or saline solu- tion with rectal tube, with hips of the patient ele- vated, is best. If an intussusception is seen early, the distention of the bowel with either air or water may reduce it; but if the invaginated portion be- comes edematous, it will be of no avail. Remember that it is a safe rule to operate in in- testinal obstruction of any cause other than fecal impaction, and do it early before peritonitis sets in. Remember that obstruction of the bowel due to fecal accumulation is positively the only form that does not belong to the surgeon. Chronic Constipation. Remember that persistent constipation, continu- ing for weeks, is incompatible with good health. Remember that constipation is a relative term. Autointoxication is supposed to be the cause of a great many ills due to the resorption of noxious mat- ter from retained feces. Remember that the fecal mass may become chan- neled and diarrhea occur. An habitually consti- pated woman, seized with diarrhea, nausea, and vomiting, should cause a thorough examination of the large bowel. Remember that dysmenorrhea and sacral neural- gia may be caused by impacted feces. Piles, colonic ulceration, occlusion of the bowel, and perforation CHRONIC CONSTIPATION. 35 may be caused by persistent retention. As a rule, raental depression, lassitude, headache, coated tongue, and anorexia are the more common symp- toms. Attack of colic may occur. Treatment . ' Diet is very important. Coarse foods, as whole wheat, rye, or cornmeal bread. Fruits, except ba- nanas. Vegetables, as cabbage, turnips, tomatoes, spinach, onions, celery. Sweets, if they do not cause indigestion, are laxative. Fats, as butter and olive oil. Water freely during the day; a glass of water at night or morning acts beneficially. Punctuality at the stools must be urged ; best time is after break- fast. Massage will relieve if continued for a long period of time. The hand should be placed over the cecum and follow the course of the colon. This is contra- indicated in spastic constipation. Exercise of the body in tennis, rowing, lifting the legs while lying on the back, walking. Enemata will stimulate peristalsis and lessen con- gestion. Overdistention produces colonic dilata- tion; hence, in time, they lose their beneficial effects. Drugs. Aloes and strychnin are indicated. I^ Extract! aloes gr. ss Extract! rhe! gr. i j-gr. v Extract! nuc!s vomicae gr. 1,4 E,es!n8e podophyll! gr. i,{o Extract! belladonnse gr. ^ Extract! taraxac! gr. j M!sce et fiat pilula No. I. Sig. : P!ll night and morning. Not to be given in preg- nancy. 36 DISEASES OF THE INTESTINES. Or: IJ Extract! belladonnse g^^•^2 Extract! nucis vomicae gr. % Extract! colocyntliidis gr. ij Misce et fiat pilula No. I. Sig. : Pill three times daily. In atony of the bowel use: IJ Extract! rhamn! purshianse 3 j Extract! nucis vomicae gr. viij Extract! physostigmatis gr. ij Extract! hyoscyaminse gr- v Misce et fiant pilulae No. XXX. Sig.: Pill night and morning. If anemic, add iron or use: IJ Ferr! sulphatis gr- x Extract! aloes aquosi gr. v Extract! rhamni purshianae gr. xx Extract! belladonnse, Extract! nucis vomicae aa gr. iij Misce et fiant pilulae No. X. Sig.: Pill after meals. In old people use the following: IJ Aloini gr. vj Podophyll! gr. ij Misce et fiant pilulae No. XII. Sig.: Pill night and morning. Phenolphthalein is good and causes no griping. It is the principal ingredient in recent proprietaries. It is not harmless, as collapse, with vomiting and diarrhea, have occurred with purgen. IJ Fluidextract! rhamni purshianae aro- matic! S iv Sig.: Teaspoonful night and morning. The morning dose taken with a glass of hot water half an hour before break- fast. APPENDICITIS. 37 Gradually withdraw drug as habit of daily evacu- ation is established. Appendicitis. Remember that the various forms described are only various stages in the progressive changes of one pathological condition, and that an unchecked inflammation of the appendix will terminate in gan- grene and death. Of all the inflammatory condi- tions in the abdomen occurring in persons under thirty, appendicitis is by far the most common.