■ '■ ■ ■■ i» fjNIOl Class Book Gu_ Copyrightlf_ °\ )0 COPYRIGHT DEPOSET. Clinical Therapeutics A Handbook on the Special Treatment of Internal Disease BY ALFRED C. CROFTAN Author of "Clinical Urinology." Third Edition, Revised " Nihil temere affirmandum nihil contemnendum." (Hippocrates.) " Medicine is an Art that sometimes cures, often relieves and always comforts." (F. Berard.) CHICAGO (ftietrcfattii Press 1910 V Copyright 1910 BY THE CLEVELAND PRESS CHICAGO des palpitation (see also page 68). Valerian in the form of quinine Valerian valerianate, dose one to three grains (0.5 to 0.15 gm.), is also often useful. In extreme cases of gastralgia cocaine may be used. A convenient way to administer the drug in this condi- Cocaine in tion is to prepare a five per cent, solution, to pour twenty drops S astral S ia 20 COMPENSATED VALVULAR LESIONS OF THE HEART Diet No large meals Avoidance of fermenting foods Extractives Albumen-fat diet of this into about one-third of a glass of water and to adminis- ter a teaspoonful of this mixture every fifteen minutes for four or five doses or until the pain is relieved. In the treatment of all compensated valvular lesions of the heart the diet is of extreme importance. It should be nutritious so that the heart muscle can sustain the excessive labor that it is forced to perform in order to maintain compensation, it should neither irritate the heart nor, by distending or inflating the stomach and bowels, mechanically interfere with the heart's action. The diet should, therefore, incorporate the full complement of calories requisite to maintain nutritive equilibrium (see the Chapter on Metabolic Disorders.) Large meals should, how- ever, never be allowed, for a full stomach pushes the diaphragm upwards, interferes with its respiratory excursions, and hence embarrasses the right heart. Aside from mechanically interfering with the heart's action large meals favor a determination of venous blood to the diges- tive viscera and hence impose much labor on the right heart, while at the same time setting certain nervous reflexes in mo- tion that cause palpitation and irregular cardiac action. There- fore a patient with a compensated heart lesion should be in- structed to eat small meals, at frequent intervals, rather than two or three large meals at long intervals. For similar reasons the diet should contain a minimum of those articles that cause gaseous distension of the stomach, as for instance, cabbage, potatoes, peas, beans, lentils, sauerkraut and aerated beverages. Nor should the diet contain any articles that can irritate the heart, for stimulation of the heart muscle when it is already working excessively is to be strenuously avoided; thus all meat extractives (see below), condiments and spices, tea and coffee should be forbidden. Alcoholic beverages should be taken very moderately and tobacco should, preferably, be absolutely forbidden. The diet should therefore consist largely of albuminous and fat foods and should contain relatively little of starchy foods. An albuminous diet increases the hemoglobin content of the blood so that the nutrition of the heart muscle is thereby aided. Some discretion should be exercised in advising the kind of albuminous food and its mode of preparation. Raw, rare, smoked and cured meats, as well as all internal organs like liver, sweet- breads, kidneys, etc., should be forbidden, or at least greatly re- stricted, because they are rich in extractives, and the latter (consisting largely of purin bases and their congeners), noto- riously irritate the heart and increase the blood pressure. For COMPENSATED VALVULAR LESIONS OF THE HEART 21 the same reason bouillons and meat extracts should be tabooed, for they are practically a solution of these extractives. All other meat preparations, all vegetable albumens and milk, are very useful sources of readily digestible albumen. Fats, in the form of butter, cream, olive oil, a little bacon, Fats mayonnaise, etc., are valuable adjuvants to the diet, for they possess a high nutritive value (1 gm. of fat develops nine cal- ories) and at the same time soon produce a sense of satiety and hence prevent the patient from overloading the stomach. Fresh or stewed fruits and green vegetables fulfill a similar purpose and also act beneficially by counteracting constipation. The use of bread, potatoes, pastry, cereals, rice, sweets and Carbohydrates other carbohydrates should be reduced to the minimum com- patible with maintenance of the appetite and the enjoyment of food, for starchy and sweet foods are apt to produce flatu- lency and if taken abundantly cause engorgement of the liver and consequently impose added labor upon the rig} t heart, which, above all, should be spared in valvular lesions for the right ventricle is by structure less fitted to undergo compensa- tory muscular hypertrophy than the left ventricle. One of the most beneficial dietetic means of treating com- Reduction of pensated valvular lesions of the heart is to reduce the liquid iqm s intake. For in this way the heart and arteries aie relieved of much labor, the stomach is not so apt to become distended, the blood becomes more concentrated and hence acquires more hemo- globin to the unit, and the weight of the body is reduced. Various theories have been advanced to explain these phe- OertePs ex- nomena, but none of them as yet offers a convincing explana- P lanatlon tion. Practical experience demonstrates clearly, however, that drink restriction generally produces good results both in com- pensated and in decompensated valvular lesions of the heart. Oertel, who originated, or, better, revived the method of drink restriction in heart disease, presupposed the existence of an hydremic plethora, i. e., an increase of the volume of the blood, especially in cases of failing compensation, which could only be corrected by reducing the amount of liquid ingesta and at the same time favoring the elimination of water by the various emunctories of the body. Exact determinations of the specific gravity and the freezing point of the blood have not borne out Mechanical this postulate. So much is clear, however, that all of the water explanation that is introduced into the stomach must needs pass several times through the heart and arteries before it leaves the body by the lungs, the kidneys and the skin, or becomes deposited in the tissues; and it is self-evident that this labor can be reduced by giving less liquid and that consequently the heart is thereby 22 COMPENSATED VALVULAR LESIONS OF THE HEART Determination of water equilibrium Technique of drink restric- tion Fasting Reduction of common salt Rest and ex- ercise spared. For this reason drink restriction constitutes a very- valuable prophylactic measure, and also has a place, subordinate, it is true, to other more energetic means in the treatment of de- compensated heart lesions. It is frequently important to determine whether a disturb- ance of the water equilibrium has already occurred, and this can best be done by measuring, for several consecutive periods of twenty-four hours, the water intake and output. If it is found that the excretion of water is far below the intake and if, above all, the patient during the period of observation gains several pounds in weight, then one is justified in assuming that retention of water is taking place, that, in other words, the heart and arteries are beginning to fail in their task of pumping the water to the emunctories of the body. When this occurs the patients should be instructed to reduce their liquid intake to about one to one and one-half litres of water or other fluids in the twenty- four hours. This restriction is frequently borne with difficulty, but most patients soon become accustomed to it, especially if the importance of the measure is explained to them. That more water should be allowed in summer than in winter is clear, for the loss of water via the sweat glands must be compensated ; or if there is diarrhea or emesis the loss of water from the bowels or the stomach should also be replaced. In extreme cases in which compensation threatens to fail v>^. water intake should be still further reduced. Occasionally it is a good plan to impose a complete fast for twenty-four or forty-eight hours. It will be found that when solid foods are withdrawn the craving for liquids is simultaneously reduced; for a fasting individual, even when allowed to drink water without restraint, will rarely take more than one litre in twenty- four hours. This is, of course, a heroic plan to be employed only in emergencies, but it will often be found of inestimable value. That the diet should contain as little sodium chloride (common salt) as possible need hardly be emphasized in this connection; for the ingestion of sodium chloride requires the ingestion of water to hold it in proper molecular concentration in the blood and hence, as is well known, produces thirst. That the amount of water drinking must also be governed somewhat by the presence or absence of complicating diseases, e. g., cer- tain renal and metabolic disorders, fever, etc., need hardly be emphasized. In all valvular lesions of the heart the regulation of rest and exercise is of extreme importance. It is a well known fact that many cases of heart disease, with threatening decompensa- tion, recover completely when placed at rest without further COMPENSATED VALVULAR LESIONS OP THE HEART 23 treatment. In cases of valvular trouble without compensatory disturbances, complete rest in bed is, of course, unnecessary, but certain simple rules should nevertheless be adhered to in order to avoid over-taxation of the heart. Thus such patients should m ga ls a avoid moving about for an hour or more after meals, especially if they cannot adopt the plan of eating small quantities at frequent intervals; for after a heavy meal nearly two-thirds of the total blood collects in the abdominal veins, and it is mani- festly a precarious procedure in valvular disease to force all this blood through the right heart towards the periphery, an event that will invariably occur if muscular exercise is indulged in during the period of digestion. Exercise after a full meal generally produces a rise in arterial pressure and venous con- gestion in the lesser circulation, and this is to be avoided. The occurrence of dypsnea and of precordial distress after Terrain cure exercise is always a danger signal and the patients should be carefully instructed never to exert themselves to this point. In cases of compensated valvular lesions, and this applies also to cases in which the balance of compensation is not quite estab- Schott treat- iished, the so-called Terrain cure, i. e., graduated exercises on measured inclined paths, and the Schott exercise treatment* are frequently useful. They can best be carried out in certain resorts, chiefly Nanheim, where all arrangements for these treat- ments as well as skilled attendants can be found. Swedish massage, a plan of treatment that can be pursued Swedish mas- at home, is of great value in the treatment of compensated heart sa§>e lesions. It consists in a series of resistance exercises that must be regulated according to each individual case and should be carried out by an expert masseur. Some cases, owing to indi- vidual peculiarities that we do not understand, cannot bear these resistance exercises ; it is well, therefore, to avoid all routine and f a en e eral mas ~ to carefully study the reaction of the individual patient before advising the continued use of exercise treatment. All passive exercise treatment acts beneficially by facilitating the Aoav of venous blood from the periphery to the right heart, by reducing tJeThSpt** the peripheral blood pressure, increasing respiration, and by all these effects aiding the right heart *The Schott treatment is a combination of passive and active and resisting exercises of the trunk and extremities. The cardinal rules laid down by Schott for carrying out his treatment are the following: "1. The exercise should be performed slowly, steadily and without exer- tion. 2. The same movements should never be performed twice in suc- cession. 3. Each movement should exercise a different group of mus- cles. 4. The patient should rest after each exercise. 5. The pulse and breathing should be constantly controlled by the physician." The exer- cises should be performed for about half an hour in the morning and for twenty minutes in the afternoon, including pauses. If symptoms of stasis or stenocardiac attacks appear, the exercises must be stopped. 24 COMPENSATED VALVULAR LESIONS OF THE HEART Out door life Climate Altitude Hot and cold climates General massage is always useful for it, too, facilitates the back flow of the peripheral blood towards the right heart and, unless carried out too vigorously, reduces the arterial blood pressure and thus spares the heart. Massage of the heart itself has also been recommended but, unless carried out by an expert, this practice is altogether useless and may become dangerous. All exercise treatment should be carried out for a long time if any real benefits are to accrue. The patients with compen- sated heart lesions should endeavor to live as much as possible out of doors; for the breathing of abundant oxygen, by pro- moting full aeration of the blood, will exercise a beneficent effect upon the nutrition of the heart muscle. Here the selection of a suitable climate must be arranged. Four elements must be consider ed in selecting a resort for a case of valvular disease, viz., altitude, the mean temperature, the temperature variations, and the humidity. The decrease of the barometric pressure at an altitude fav- ors elimination of water and gases from the surfaces of the body and from the lungs, and stimulates an increase of the number of red blood corpuscles and of the total hemoglobin, hence in- creases respirations, exaggerates metabolism and improves the nutrition of the heart while, at the same time, increasing its labor. By sending patients to moderate altitudes this effect can be utilized to advantage as a mild stimulant and hence an exercise for the heart; but too great altitudes must be avoided for fear of overworking the heart and breaking the balance of compensation. Patients with heart disease, therefore, should be warned against altitudes over three thousand feet, and if no decompensation whatever is present, should be advised to live at an altitude between fifteen hundred and two thousand feet above sea level. If compensation threatens to fail, the patient should at once be removed from the altitude back to sea level. Extreme degrees of heat and cold should always be avoided in heart disease. Heat is always bad, for it exercises a depress- ing effect upon the whole organism, including the heart. Ex- treme cold, on the other hand, both by producing contraction of the peripheral arteries and by direct nervous influence upon the heart, raises the blood pressure and stimulates the heart to greatly increased activity that may fatigue the organ if its valves are diseased. Inasmuch, however, as it is easier by proper clothing to protect the body from the effect of cold than from the effect of heat, a cold climate, other things being equal, is less dangerous for a case of valvular disease of the heart than a hot one. Best of all, of course, is a temperate climate with COMPENSATED VALVULAR LESIONS OF THE HEART 25 slight temperature variations and no extreme degrees of heat or cold. The humidity must, finally, also be considered in selecting a Humidity resort for a heart case. A dry, warm climate is always to be preferred to a moist, warm climate; for, when the air is dry, insensible perspiration enables the organism better to counteract the depressing effects of great heat than if the atmosphere is moist; and a dry, cold climate is more beneficial than a moist, cold climate, because in the former there is less radiation of heat than in a moist atmosphere so that the body can maintain its temperature with less tax upon the general metabolism and hence upon the cardio-vascular apparatus. There is a popular prejudice against bathing in heart dis- Bathing ease. Since the principles of hydriatic treatment have been made the subject of accurate scientific research, the exact in- dications and contra-indications for warm and cold bathing in heart disease are better understood. Very hot baths (100° F. Hot baths and above), owing to their depressing effect, are always to be avoided, for immersion of the body in hot water, by producing first a sudden short contraction followed promptly by a relaxa- tion of the cutaneous vessels, and later a lasting contraction, always taxes the vaso-motor center and the heart. In individ- uals with well compensated heart lesions, who are of the neuras- thenic type, this practice is particularly dangerous because in such subjects the vaso-motor centers are already in a state of unstable equilibrium; and in sufferers from arterio-sclerosis the fragility of the arterial walls renders hot bathing most pre- carious. Cold bathing should also be forbidden in any case of heart disease, for the application of cold to the surface of the Cold bathm S body always produces a severe initial shock with a reflex increase of the heart 's action and contraction of the peripheral arterioles, in other words, high arterial tension, and this means a strain and possibly an over-taxation of the heart. Sea bathing should g , ,,. ^ therefore, always be forbidden. Lukewarm bathing, viz., immersion of the body for ten Lukewarm or fifteen minutes at a time in water of 90° to 95° F., i. e., "baths slightly below the temperature of the body, is a very useful means of treatment. The water may be medicated by the addi- tion of four to five pounds of salt to a bath tub full of water. Salt baths In Nauheim, Kissingen, Marienbad, Franzensbad and other wat- ering places baths with carbonated water are given. They can be prepared at home as follows : Half a pound of sodium bicar- baths bonate is dissolved in a bath tub full of water (of about 90° F.) and about three-quarters of a pound of commercial hydro- chloric acid are slowly added, care being taken that there is 26 FAILING OK BROKEN COMPENSATION Rationale of bath tempera- tures slightly below the body tempera- ture Medicines in compensated valvular le- always an excess of soda. The patient should at first not re- main in the tub for longer than five minutes, nor should he be given such a bath in the beginning oftener than once every other day. Later the bath may be administered daily and for fifteen to twenty minutes at a time. The temperature of the water should not be allowed to drop below 80° F. After the bath the patient should be dried with warm cloths and put to bed for half an hour or an hour, with a hot water bottle to his feet. The patient should never become dyspneic while in the watery as soon as breathing becomes oppressed the bath should be stopped. The good effects derived from bathing in lukewarm water can be explained in this way: The temperature of the water, being slightly below the body temperature, exercises a very mild stimulation, through the peripheral and vaso-motor nervous system, upon the action of the heart, slowing and at the same time strengthening its beat: the salt or the carbonic acid gas cause some relaxation of the peripheral capillaries and hence a decrease in the blood pressure. This means that the heart is being gently driven while its work is being reduced. Judiciously carried out, this treatment, therefore, constitutes an ideal ex- ercise for the heart when its energies are beginning to flag. The use of medicines in compensated heart lesions is to be eschewed. Only rarely should it become necessary to give any heart tonic or vaso-dilator, or any of the other remedies that are to be presently discussed under the heading of decompen- sated heart lesions ; nor is any special benefit to be derived from the use of so-called general tonics. That drugs may occasionally be necessary to regulate the function of the stomach or the bowel, or to correct an underlying anemia with relative incompetence of the heart valves is self-evident. This medicinal treatment will be discussed in other chapters. Drugs useful in the treatment of certain subjective symp- toms of compensated aortic insufficiency have been discussed above. THE TREATMENT OF VALVULAR DISEASES OF THE HEART WITH FAIL- ING OR BROKEN COMPENSATION. Rest Position in bed The most important element in the treatment of failing com- pensation is absolute rest in bed. In cases of cerebral anemia, i. e., chiefly in aortic insufficiency, the horizontal position may be the most agreeable to the patients, but, as a rule, they will be more comfortable when semi-recumbent or sitting up daring FAILING OR BROKEN COMPENSATION 27 a part of the day, even if there is some dyspnea ; for the blood pressure is always lower when the patient is erect or semi-erect than when in a horizontal position. It is generally difficult to persuade patients in early stages of decompensation to go to bed. If the matter is fully explained to them, however, they will usually comply with this order. As Brunton puts it, the patient should be told, "If you have sprained your ankle, you know perfectly well that every movement that you make is likely to keep up the mischief. What you must do is to go to bed and keep the ankle perfectly quiet. You must give the heart rest just as you give rest to the ankle. If you go on walking with the sprained ankle, it will become worse and worse, and finally you will be unable to do anything with it. If you go on exer- cising with a strained heart, then you will continue to get worse, and in the end you must either give it rest or die." Rest in bed to be efficacious should be continued for several weeks; the results obtained are frequently brilliant, and very often one will be able to get along very well without the use of any heart tonics or other medication. The diet should be essentially the same as in compensated Diet lesions of the heart, especially if the patient is put to bed be- fore the appearance of dropsies or passive congestion in differ- ent organs. If such complications of broken compensation have already made their appearance then the patient should be put, for a time at least, upon a diet consisting largely of milk; for Milk diet milk possesses a distinct diuretic action and constitutes an ideal food. It should be given at frequent intervals, in small quan- tities, preferably in the form of a milk-cream mixture, con- sisting of a tumbler full (i. e., about nine ounces) of a mixture of two-thirds milk and one-third cream to which are added two teaspoonfuls of lime water. It is rarely advantageous to put these cases upon an exclusive milk diet for the flooding of the circulatory apparatus with water is decidedly harmful. (See also page 210) . A little fresh fruit, an egg, or a little meat and some crackers may usually be added with impunity. The application of cold continuously or intermittently to cold to the the precordial region is a very valuable adjuvant to treatment Precordial re- and should be employed as described under compensated heart lesions (see page 19). If rest and a simple diet and local cold do not restore compensation in mild cases within a week or ten days, or if the case comes under observation at a time when Indications decompensation is far advanced, so that edema and congestion heart tonics of the lungs, the liver, the kidneys and other organs are pres- ent, then it becomes necessary to use heart tonics. The heart normally possesses a certain amount of reserve 28 FAILING OR BROKEN COMPENSATION Digitalis Dose of digi- talis Cumulative action Tolerance and susceptibility- Intoxication with digitalis force which it utilizes as soon as an excessive strain is thrown upon it. It responds, as is well known, to any sudden over- taxation by dilatation, a prolongation of the diastole and an increased force of the systole. In valvular diseases this reserve force is called upon continuously to establish compensation, and in order to meet this added requirement hypertrophy, especially of the left ventricle, occurs. An ideal heart tonic, therefore, should aid the heart in prolonging its diastole and in enforcing its systole to the maximum. The chief representative of this group of heart tonics is digitalis, for in appropriate doses it possesses precisely this power. Its chief effect is exerted upon the ventricles, stimu- lating them to increased contraction so long as the heart muscle is not in an advanced stage of degeneration. Digitalis also raises the peripheral blood pressure, partly from its action upon the heart muscle and the nerves of the heart, partly from its effect upon the vaso-motor centers, which it stimulates to cause contraction of the vessel walls; at the same time, it slows the action of the heart. Under the influence of digitalis the nutrition of the heart generally improves; this is due to the increased amount of blood supplied to the heart muscle when the ventricle contracts more energetically. The dose of digitalis is very important, for large amounts of the drug frequently produce an effect that is exactly opposite to that exercised by small doses, viz., they reduce the force of the systolic contractions and in lethal doses cause arrest of the heart in diastole. Its action is tardy, as it is slowly absorbed, so that a day or two may elapse before the effect of the drug upon the heart and the pulse becomes apparent. If the dose is increased too rapidly in the beginning (because its effect may not have appeared at once) intoxication from cumulative action may occur; and as the excretion of digitalis is as slow as its absorption, there is also always danger of cumulative action from disturbed excretion. Some individuals, moreover, seem to possess an idiosyncrasy against digitalis while others show a remarkable tolerance to its action. It is therefore always best to begin with small doses, and during the first days of its ad- ministration to carefully watch the heart, the pulse and the blood pressure for signs of digitalis poisoning. In susceptible subjects digitalis may, when first administered, produce disagreeable symptoms of a nervous character, as pal- pitation and insomnia, and sometimes symptoms of gastric or intestinal irritation, as nausea or diarrhea. These signs, however, can generally be ignored because they shortly disappear as soon as the organism accustoms itself to the drug. It is claimed thai FAILING OR BROKEN COMPENSATION 29 some of the pure principles of digitalis possess only the cardiac action without the disagreeable local or general effects. All these "Pure Prin- principles, however, according to the best authorities are so Jj2ttJj lB °* uncertain in their action and vary so much in strength that their use can hardly be recommended excepting tentatively in those cases that display an absolute intolerance against digitalis, and these cases are very rare. (See also page 41.) If no signs of cumulative action or of particular susceptibility to the drug appear within the first two or three weeks of its employment, then there is no valid objection to a continued digitalis therapy, Continued use preferably using small doses for indefinite periods of time, even ° lgl a 1S years. This practice, if it can be carried out, is warmly recom- mended by many authorities and seems to be particularly useful in heart lesions combined with chronic arteritis and arterio- sclerosis (see also page 56). Occasionally a case of valvular disease comes under observa- chronic tion for the first time with a very slow and intermittent pulse, Digitalis great muscular weakness, gastric and cerebral symptoms; if on inquiry it is found that such a patient has been taking digi- talis for a long time it is always well to tentatively stop or greatly reduce the use of the drug in order to rule out the pos- Atropin as an siblity of chronic digitalis intoxication. If the heart is alarm- ingly slow one two-hundredth of a grain of atropine, hypoder- mically, should be given until the toxic digitalis effect wears off. Digitalis is contra-indicated in any case of failing compen- contra-indi- sation in which the heart muscle has begun to degenerate, espe- cations dally in advanced myocarditis and fatty heart, as here the heart cannot react to the drug; in fact, by increasing the blood pressure digitalis may seriously embarrass a heart with a weak musculature and cause disagreeable or dangerous complica- tions. For this reason the drug is less useful in aortic insuffi- ciency than in other, especially mitral, valvular diseases, be- cause aortic insufficiency rarely becomes decompensated until extensive degeneration of the left ventricle has occurred. This is due to the fact that the walls of the left ventricle are capable of undergoing enormous hypertrophy before they begin to fail, whereas, the right ventricle succumbs much sooner to over- strain ; as a result mitral lesions and lesions of the valves of the right heart produce failure of compensation much sooner than aortic lesions, and often at a time when the walls of the left ventricle are still intact, capable of hypertrophy and susceptible care in using to the action of digitalis. For this reason digitalis should be digitalis in given with the greatest care in diseases of the aortic valves and only after the absence of myocarditis has, so far as that is pos- 30 FAILING OR BROKEN COMPENSATION Digitalis in the diagnosis of myocarditis Digitalis and strophanthus in atheroma Digitalis with nitroglycerin and nitrites Preparations of digitalis sible, been established. In fact, digitalis may be used occa- sionally as a valuable diagnostic aid for detecting the presence of myocarditis. For degeneration of the heart muscle may be assumed if a digitalis effect, i. e., slowing of the heart beat, an increase of the pulse-tension and impulse, with a forcible apex beat and increased diuresis, do not appear within two or three days after the administration of the drug. In such cases, of course, it is very bad practice to continue with the use of digi- talis. Another contra-indication to the use of digitalis is extensive atheroma or fragility of the arterial walls, for here the in- creased pressure may lead to rupture of the vessel walls. Strophanthus should be the remedy of choice in these cases, be- cause it acts as a heart tonic without causing so great a rise of the blood pressure as digitalis. If it becomes necessary to give a heart tonic in such cases it is best, however, to use digitalis or strophanthus in combination with drugs like nitro- glycerin or nitrites that can lower the blood pressure ; remem- bering always that the effect of the nitrites becomes manifest much more rapidly than the effect of digitalis, so that the nitrites should be given several hours after the digitalis; and that the effect of nitroglycerin is very short so that it should be given in frequently repeated small doses, several hours after the digitalis has been taken. Of the many preparations of digitalis, the infusion and the tincture are, from a practical point of view, at least, the best. The infusion made from the leaves (that should preferably be cut into small pieces and not powdered) should always be fresh. It should be given in doses of from one to two fluid drachms (4 to 8 cc.) according to the requirements of the case. The alcoholic tincture of digitalis is of more uncertain composition and strength than the infusion; nevertheless, in the great ma- jority of cases, it will be found to be efficacious. The proper dose is from five to fifteen drops (0.3 to 1 cc.) three times a day. Occasionally it becomes necessary in patients who do not react properly to the infusion or tincture to give digitalis in the form of the powdered leaves in doses from one to four grains (0.05 to 0.2 gm.), either in a capsule with sugar of milk or in a pill. This preparation, however, often produces irritation of the stomach, which is especially the case among patients with venous stasis in the gastric veins due to heart disease, i. e., with congestive catarrh of the stomach. Here small quantities of the infusion, diluted with milk and administered ice cold, are frequently well borne. FAILING OR BROKEN COMPENSATION 31 When the stomach will not tolerate digitalis the drug may ^.^^Ind 7 be administered in the form of an enema and the infusion can hypodermically be used for this purpose. Such a clysma, preceded by a cleans- ing enema, may be given two or three times a day. Occasionally the administration of digitalis leaves in suppositories fulfills a useful purpose. The hypodermic administration of digitalis is usually very disagreeable, because digitalis exercises a local irritant action and the injection of the drug under the skin is usually painful. The chief glucosides of digitalis, viz., digitoxin, digi- «p ure prin- tophyllin, digitalin and digitalien are all extensively used and ciples" of digi- abundant literature has appeared on the subject. So far, how- ever, I have found it unnecessary, in the great majority of cases, to have recourse to these preparations, especially as their strength and efficacy are usually uncertain; and, old fashioned as it may appear, I give the infusion of digitalis, described above, and the powdered leaves, the preference over all other digitalis preparations. The effect of digitalis may occasionally be enforced by re- stricting the liquid intake or by sweating, or both. Alcohol, given half an hour before the digitalis, also makes the latter more effective. Brief mention may be made of certain other heart tonics that should occasionally be used, either if digitalis is not well borne by the patient or if a cumulative effect appears; the most useful among these in my experience are strophanthus, conval- laria, adonis vernalis and caffein. Strophanthus, like digitalis, strengthens the action of the Strophanthus heart muscle and slows the pulse, it also raises the arterial blood pressure, but not to the same degree as digitalis, nor does it possess the same diuretic strength. It may, therefore, be used to advantage in place of digitalis in cases of Valvular heart dis- ease with arteritis. The chief advantage it possesses over digi- talis is that it does not have a cumulative action, so that this drug can always be continued with safety for long periods of time. It seems that strophanthus is more irritating to the kid- neys, however, than digitalis, so that, in cases of cardiac dis- ease complicated with nephritis, especially in Bright 's disease, the drug should be administered with care. The best mode of administering strophanthus is in the form of the tincture, in doses of five to fifteen drops, three or four times a day. It may also be given in the form of strophanthin, hypodermically, ir doses of one one-hundred-and-fiftieth to one-fiftieth of a gra'n (0.0004 to 0.0012 gm.). 32 FAILING OR BROKEN COMPENSATION Adonis ver- nalis Convallaria Convallaria retards the heart's action, increases the arterial tension and possesses some diuretic power. It is not cumulative in its action and never irritates the stomach ; occasionally it even seems to stimulate the appetite. Convallaria is usually given in the form of the alcoholic tincture (five to ten drops) or the fresh watery extract (four to eight drops). Adonis vernalis increases the arterial pressure, strengthens and slows the heart beat. On account of its great blood pres- sure raising power it acts very well as a diuretic when the kid- neys are inactive and it is especially useful, therefore, in car- diac dropsy. In cases of interstitial nephritis, however, in which the blood pressure is already high, or in arterio-sclerosis com- plicated with heart lesions, the drug should be used with great care. It is best given in the form of the fresh infusion, one to four drachms (4 to 16 cc). Caffein Caffein strengthens the heart muscle, raises the peripheral blood pressure and increases diuresis, not, however, by its blood pressure raising power but by a specific action upon the renal epithelium. This drug, too, should never be given when the peri- pheral blood pressure is high, nor should it be given to very excitable individuals, nor to alcoholics on account of its well known action upon the higher cerebral centers. It not infre- quently produces insomnia, and occasionally hallucinations and delirium. It is particularly valuable as a substitute for digi- talis and the other heart tonics that exercise their effect directly upon the heart muscle, in cases in which the latter is beginning to degenerate, because caffein presumably manifests its effect not upon the heart muscle directly but upon the nervous apparatus governing the heart beat. The best preparation is caffein citrate, which may be given in doses of two to eight grains (0.1 to 0.5 gm.), or caffein may be administered hypodermically in combination with sodium sali- cylate or benzoate, the latter salts forming double compounds with caffein and preventing its decomposition with water. The drug should be given two or three times a day in the following solution: Salicylate of soda, Caffein, Water, M. 30 gm. 40 gm. 60 cc. Dose for hypodermic use, ten drops ; or FAILING OR BROKEN COMPENSATION. 33 Caffein, 2.5 gm. Sodium benzoate, 3.0 gm. Distilled water, 10 cc. M. Sig. 1 cc. hypodermically. — (Tanret.) Of this solution each cubic centimeter contains four grains (0.25 gm.) of caffein. Theobromin, in capsule, in doses of eight grains (0.5 gm.l Theobromin Uiree times a day, or in solution with a little salicylate of soda; or dhifetin, in the same dose; may also be given in place of caffein or its citrate. Strychnia may also occasionally be used in small doses, one- strychnia hundredth to one-thirtieth grain (0.0006 to 0.002 gm.) to slow the heart and raise the blood pressure in failing compensation; it acts chiefly upon the vaso-motor center in the medulla and . the general nervous system. It slows the heart beat by its stimu- lating effect upon the inhibitory centre. It should never be used as a heart tonic when the arterial tension is high. In extreme cases of cardiac failure in which no time is given Analeptics to gradually strengthen the heart by the use of heart tonics, it becomes necessary to have recourse to analeptics, as an emer- gency measure. Chief among these are camphor, ether and am- Camphor monia. The clinical indications for the use of these remedies Ether are a weak apex beat, a feeble heart action, a great reduction in Ammonia the force of the radial pulse or its complete disappearance, cold- ness and lividity of the extremities and collapse. In such a condition, brandy or champagne and hot coffee may B , be administered, but camphor is the remedy par excellence, champagne either alone or as spirits of camphor twenty to thirty drops, or Coffee in combination with digitalis, thus: Camphor, 1 gr. (0.05 gm.). Powdered digitalis leaves, 2 gr. (0.1 gm.). For it possesses the power to excite the nervous system and to rapidly produce acceleration and increased strength of the heart's action. In an emergency camphor may be given hypo- dermically in 10 per cent, solution in ether or in sterile olive oil, twenty to thirty drops at a time. Ether, or "Hoffman's Anodyne" (Spir. iEtheris Comp.), a teaspoonful on sugar, or ether alone, hypodermically, are also the use of useful. Ether acts still more rapidly than camphor, and when- etner an <* cam- phor and am- ever it is desired to produce a very quick effect, ether should monia 34 STASIS DUE TO DECOMPENSATED VALVULAR LESIONS first be given and an injection of camphorated oil (see above) afterwards; or camphorated oil in ether, one part of ether to two of the oil, may be administered in the dose of two or three hypodermic syringes. Ammonia, in the form of the aro- matic spirits of ammonia, in the dose of fifteen to sixty minims (1 to 4 cc), frequently repeated, may also be employed. Supra- renalin, finally, hypodermically, in the dose of one-twentieth to one-tenth of a grain (0.006 to 0.003 gm.) is also a useful emer- gency medicine. Insomnia Irritability Psychoses Cheyne-Stokes breathing Stupor and Somnolence Treatment of insomnia Dangers of chloral and SYMPTOMATIC TREATMENT OF STASIS IN DIFFERENT ORGANS DUE TO DECOMPENSATED VALVULAR LESIONS. In advanced degrees of failing compensation venous stasis occurs in different organs of the body; and while the treat- ment of the symptoms produced by this passive congestion, notably in the brain, the lungs, the liver, the kidneys and the gastro-intestinal tract, is essentially synonymous with treatment directed towards improving the general heart action, as described in previous paragraphs, it occasionally becomes necessary in addition to relieve some of the most urgent symptoms that follow the congestion of these parts of the body. Passive Hyperemia of the Brain. Passive hyperemia of the brain is one of the most frequent and one of the most dis- tressing consequences of broken compensation. In mild degrees the chief symptoms are insomnia and general irritability, occa- sionally assuming the characteristics of monomanias or of other psychoses. As the medulla is, at the same time, usually in a state of congestion, respiration may become irregular and the Cheyne-Stokes type of breathing be produced. In late stages of failing compensation chronic venous congestion of the brain produces stupor and somnolence. If these symptoms do not readily yield to cardio-tonic medi- cation, then recourse must be had to remedies that control the nervous phenomena, especially the insomnia. In selecting rem- edies for this purpose among the numerous hypnotics and nar- cotics that we possess, the impaired condition of the heart must always be taken into consideration. For this reason chloral, which is deservedly one of the most popular hypnotics, cannot be used, for chloral exercises a depressing effect upon the car- diac muscle and the muscles of the blood vessels and also pro- duces paresis of the vaso-motor centres. It acts, in this respect, similarly to chloroform. Moreover, chloral is particularly contra-indicated in this form of insomnia because it produces congestion of the peripheral organs, including the brain, and STASIS DUE TO DECOMPENSATED VALVULAR LESIONS 6& this is precisely what we are attempting to counteract. The same objection applies to the use of opium and its alkaloids, for they too reduce the tone of the vaso-motor centres and the peri- pheral blood pressure, thus causing dilatation of the blood vessels and cerebral congestion. The most useful drugs in the treatment of this form of in- Bromides somnia are the bromides, for they quiet the sensibility of the whole nervous system, and in particular of the special senses, and hence enable the patient to go to sleep, simply because ex- ternal influences cannot stimulate the over-irritable brain. It has been claimed, moreover, that the bromides produce a dis- tinct anemia of the brain, and that this property can be used to counteract congestion. As a matter of fact, it has been shown by recent investigations that the anemia of the brain found in animals that were killed after having taken large doses of bro- mides, is no more intense than that found in animals killed when they were asleep ; so that the cerebral anemia observed after the administration of bromides must be considered due to the sleep, and the sleep not due to the cerebral anemia. The bromide of potassium should never be given in cerebral Bromide of congestion due to valvular heart lesions, because large doses of P otash potassium undoubtedly weaken the heart and reduce the blood pressure. The bromide of sodium produces less gastric irrita- Bromide of tion than the bromide of potassium; this drug should therefore soda be given, preferably in milk and in two divided doses of fifteen grains eachj the one about three hours before retiring and the other just before going to bed. It will be found that after a few days' treatment the patients will react more rapidly to smaller doses than in the beginning. Next in importance to the bromides are sulphonal and its congener, paraldehyde, and a group of drugs that are related to chloral but do not possess the depressing action of this remedy upon the heart, viz., chloralamid, chloralose, chloretone, and veronal. The continued use of sulphonal, however, is fraught with Sulphonal some danger and it should be employed with care in heart cases ; moreover, it does not seem to act as energetically in cases of failing compensation as otherwise. In giving sulphonal the urine should be carefully inspected. If it assumes a peculiar burgundy-red color the administration of the drug should im- mediately be stopped, for sulphonal, in persons who possess a peculiar idiosyncrasy to the drug, occasionally produces hemato- porhyrinuria.* It should be given in doses of from fifteen to thirty grains (1 to 2 gm.), in some hot beverage, about three or *See Tyson and Crof tan : Trans. Ass'n. Am. PJiys. 1901. 36 STASIS DUE TO DECOMPENSATED VALVULAR LESIONS Trional Paraldehyde Chloralamid Chloralose Chloretone Veronal Cannabis indica Bloodletting Leeches four hours before going to bed. As sulphonal is excreted very slowly it will be found that the dose can gradually be reduced. Trional acts more rapidly than sulphonal, and usually pro- duces sleep within an hour. It is given in the same dose as sulphonal, and is particularly efficacious if given in combination with codeine, one-fourth grain (0.015 gm.). Paraldehyde does not influence the heart in any way and produces a very rapid hypnotic effect, the patient usually going to sleep within ten or fifteen minutes. The drug should be given in doses of fifteen to sixty minims (1 to 4 cc), preferably in brandy and water. As the drug is largely excreted through the lungs, the patients for a day after the use of paraldehyde are apt to complain of a disagreeable odor of the breath, simi- lar to alcohol. Chloralamid is a compound of chloral and formamide and decomposes in the stomach with the liberation of formamide, a drug that counteracts the circulatory depression produced by chloral. Its hypnotic effect is very marked. Dose, fifteen to thirty grains (1 to 2 gm.). Chloralose, a glucoside compound of chloral, does not affect the heart at all and is an excellent hypnotic. It should be given in powder form in capsules containing two to five grains (0.12 to 0.3 gm.) of the drug. This dose may be increased to two or three powders on succeeding days, if the desired effect is not produced by one powder. Chloretone does not irritate the stomach, especially in wat- ery solution, nor does it depress the circulation. It usually pro- duces a marked effect in small doses of five to ten grains (0.3 to 0.65 gm.) and may be used as an alternative for some of the other remedies. Veronal, finally, is one of the most useful newer hypnotics in cerebral congestion. It acts exclusively upon the central nervous system, does not depress the heart or circulation, and leaves very slight after-effects. It may be given in doses of five to fifteen grains (0.3 to 1 gm.) in warm water or milk, or in capsule, about an hour and a half to two hours before sleep is to be produced. Of all the other commoner hypnotics that might be used can- nabis indica is mentioned merely to be condemned, for it ex- ercises a very deleterious effect upon the heart and circulation and should never be used in sufferers from valvular disease. In addition to all these hypnotic and narcotic remedies, blood-letting, either locally or by venesection, is an exceedingly useful measure for combating cerebral hyperemia. Blood may be withdrawn locally, either by the use of leeches or by scari- STASIS DUE TO DECOMPENSATED VALVULAR LESIONS 37 fication and cupping. As the latter procedure cannot be applied in blood-letting about the skull, the technique will not be de- scribed in this place. Leeches should be applied in cerebral con- gestion to the mastoid process. Good leeches should move about freely m water and should contract when touched. To induce the leech to take hold a drop of sugar solution or of milk is placed upon the skin, or, better still, a small incision is made so that a drop of blood oozes out. The skin, of course, should be thoroughly cleansed before the leech is applied. As a rule, the leech is allowed to suck blood until it lets go spontaneously. If it is desired to remove the leech before he has sucked all the blood he can, a little salt may be put upon his tail. If, on the other hand, it is desired to pro- long the bleeding after the leech has let go, the wound may be treated with a warm sterile solution of salicylic acid. Venesection usually produces a much more rapid effect and Venesection is particularly useful in venous hyperemia of the brain due to valvular disease. By withdrawing enough blood from a vein the heart is at once relieved of a great deal of labor, and re- sumes, for the time at least, its normal action, especially if venesection is enforced by cardio-tonic medication. Venesec- tion is performed as follows : The arm is compressed above the elbow with a handkerchief or a bandage, so that one of the three large veins on the anterior surface of the fore-arm becomes prominent; the skin is carefully disinfected over the place of incision and the scalpel introduced with the cutting edge for- ward into the vein. The cut should be made diagonally across the vein for by doing so both the circular and longitudinal muscle fibres, of the blood vessel wall are severed, and closure of the incision is thereby facilitated and accelerated. About 3 cc. of blood to each kilo of body weight should be with- drawn, not more. After the desired amount of blood has been allowed to escape the constricting binder is removed and the wound tied up with a small pressure bandage. If the patient should faint during venesection, bleeding should immediately be stopped and the patient placed in a recumbent position, with the head lowered. If the subject is very fat it may be necessary to dissect down to the vein, a little operation that can readily be performed under local anesthesia. Occasionally the median cutaneous nerve is severed during this operation, producing a little pain or tingling along the distribution of this nerve ; these symptoms usually disappear within a day or two. Particular care should, of course, be taken neither to wound the posterior wall of the vein nor to sever the artery, and it is always well first to determine the position of the artery and to select that vein 38 STASIS DUE TO DECOMPENSATED VALVULAR LESIONS Passive hy- peremia of the lunars Cardio-tonic medication Danger of opium Tartar emetic Ipecac Ammonium chloride Tolu Benzoin Syrup of squills Venesection for incision which is farthest removed from it. Puncture of a vein with a trocar may also be performed but this procedure is not quite so safe. Passive Hyperemia of the Lungs. Passive hyperemia of the lungs due to valvular disease is very common. As a rule the dyspnea, the bronchitis and the hemoptysis readily disappear if the heart is treated. Occasionally, however, the congestion of the bronchial muscosa becomes chronic and a bronchial catarrh is produced that may call for special attention. Here the same remedies are useful as in other forms of bronchitis, so that I refer for the special treatment of this complication to the Chap- ter on Diseases of the Respiratory Organs. In heart disease, however, certain of our most popular expectorants become dan- gerous on account of their effect upon the heart; thus tartar emetic and apomorphine should never be used in these cases. Opium, morphine and ipecac should also be given with very great care. The former, because they -produce congestion and thereby merely aggravate the pulmonary hyperemia; the lat- ter, because it may produce vomiting and in this way severely strain the cerebral vessels which are congested, and hence may possibly produce cerebral hemorrhage. If the catarrh of the bronchial mucosa is dry and the secretions are expelled with difficulty, ammonium chloride or some of the preparations of benzoin, as syrup of tolu or compound tincture of benzoin, thirty minims to two fluid drachms (2 to 8 cc.) may be given. Codeine or heroin in one-sixteenth to one-eighth grain doses (0.004 to 0.008 gm.), repeated, are very useful in this condition especially for allaying excessive irritation and reducing the cough. The syrup of squills is particularly valuable, for scilla being a member of the digitalis series, possesses a marked car- dio-tonic effect; and hence it not only increases the bronchial excretion, promotes better expectoration and relieves the cough, but also supports and stimulates the heart. It may be given conveniently in the form of the syrup of squills in the dose of thirty to forty minims (2 to 3 cc). In pulmonary and bronchial congestion venesection is again a sovereign remedy; in fact, occasionally, spontaneous bleeding from the lungs is Nature 's way of relieving the hyperemia. The treatment of this hemoptysis if it should become severe is chiefly cardio-tonic. Ergot, of all remedies, should never be given (see Hemoptysis). Passive Hyperemia of the Liver. In valvular diseases of the heart, with failing compensation, passive congestion of the liver is particularly liable to occur. First, because the hepatic veins are so near the heart, so that any interference with the entrance STASIS DUE TO DECOMPENSATED VALVULAR LESIONS 39 of the blood into the right auricle readily becomes manifest in the liver veins; second, because the pressure within the liver veins is naturally very low. For this reason we often encounter cases of valvular disease with only slight disturbances of com- pensation in which the liver is the first and only organ afflicted with passive hyperemia. Some of these patients actually com- plain of no symptoms about the heart, and suffer merely from pain in the epigastrium, a feeling of heaviness or pressure in Epigastric pain. the hepatic region, and gastro-intestinal disorders, all resulting Gastro-intesti- from the impaired circulation in the liver and the enlargement of the organ. The treatment here, as in other conditions of passive hyper- emia due to valvular diseases is primarily cardio-tonic. In addi- tion, however, it may become necessary to institute certain spe- cial treatment in order to relieve the symptoms just described. Chief among these is counter-irritation over the liver, either Counter irrita- by means of vesication, leeching or cupping. The method of iiVer° Ver G applying leeches has already been described. Cupping is per- formed as follows : The skin is shaved and thoroughly cleansed. An ordinary cup or the special apparatus that is constructed for Cupping the purpose, is warmed and placed upon the skin. Owing to the vacuum created within the cup the cupped area becomes hyper- emic and this constitutes an efficient counter irritation. If it is desired to withdraw blood by cupping the surface of the skin should be scarified and the cup applied as above; in this way several ounces of blood can be withdrawn. The ice bag also occasionally affords relief, especially if it Ice bag; is applied intermittently, i. e., left on for one hour and removed for one hour. The ice bag, of course, should never be applied directly to the skin, but a few layers of gauze or a handkerchief must be placed between the skin and the ice bag. In other cases heat is more grateful. Mustard plasters and Heat poultices made of bread, linseed, cranberries or oatmeal can also be used to apply heat and at the same time to counter-irritate. Occasionally it is useful to add some narcotic to the poultice, poultices and this can best be done by dipping a small piece of linen into tincture of opium or belladonna and placing it into the material that forms the poultice. A very useful method of applying continuous heat, locally, is to use a thermophor, i. e., an ordi- Thermophore nary rubber bag filled with sodium acetate. By leaving this bag in boiling water for ten minutes the acetate is dissolved. The thermophor is then wrapped in a hot cloth and applied to the surface of the body. As the salt crystallizes out again, heat is liberated and, in this way, a temperature of from 40° to 50° C. (105° to 122° F.) can be maintained for several hours. 40 STASIS DUE TO DECOMPENSATED VALVULAR LESIONS Anal leeching Mineral ■waters Diet in passive congestion of the liver Vegetable laxatives Another method is occasionally used in the treatment of hepatic congestion due to cardiac weakness, viz., the withdrawal of blood, preferably by leeches, from the anal region. This empirical method was first described by Sacharjin, and is use- ful as well in hyperemia of the brain and the spinal cord and in stasis in the portal circulation, as in hemorrhoidal condi- tions. The leeches may either be applied to the perineum or to the sacral region. If a leech should crawl into the rectum, a solution of common salt (2 to 5 per cent.) should be injected in order to kill the animal. In passive hyperemia of the liver the alkaline and saline mineral waters are very useful. Chief among them are the waters of Marienbad, Kissingen and Franzensbad. Bitter waters, especially Hunyadi-Janos, are also useful. Jf the kid- neys are affected, or if there is much anasarca, the taking of these waters is, however, contra-indicated. Cases of hepatic hyperemia are usually benefited by a "cure" in Kissingen or Marienbad and similar watering places, not only because they drink the waters, but also because they are forced to live a more sensible life and are placed upon a strict and rational regime. The diet should contain very little carbohydrate food, be- cause starches and sugars always produce a digestive conges- tion of the liver, an effect that is above all things to be avoided. For the details of the diet in hepatic insufficiency due to stasis, I refer to the Chapter on Diseases of the Liver. In cases of pas- sive hyperemia of the liver with renal symptoms, in which the saline and alkaline waters may have to be eschewed, certain vege- table laxatives are useful. Chief among them are rhubarb, aloes, podophyllum, cascara sagrada. Calomel also has its place in this affection. All these remedies are intended to act as laxatives, and their exact administration and dose will be found described in the Section on Diseases of the Intestine. Passive congestion of the stomach and intestine is a very common and a very disagreeable symptom of cardiac weakness. It may be due either directly to the interference with the venous back-flow from the gastro-intestinal mucosa, or to pas- sive hyperemia in the liver, with resulting stasis in the portal system. In many cases the picture presented is that of a gastro- intestinal catarrh (occasionally with hematemesis, see page 376), and the treatment of this condition differs in no respect from the ordinary treatment of snch a catarrh, with this exception, that combined with the usual dietetic and medicinal measures employed for its relief (see page 376), energetic cardio-tonic treatment should be simultaneously instituted. Here one dii- STASIS DUE TO DECOMPENSATED VALVULAR LESIONS 41 flculty is encountered, viz., the danger of giving digitalis by mouth, on account of the irritating action that this remedy oc- casionally exercises upon the stomach. This objection, however, is more theoretically constructed than practically important; for only in rare cases do we find the irritability of the stomach so great that digitalis cannot be given by mouth. If the in- Method of _ fusion of digitalis is given in small quantities at a time, and if f^lis it is given ice cold, difficulties will rarely be encountered. If necessary, dgitalis can be given in the form of an enema or in a suppository, or, as a last resort, in the form of digitalin, one- sixtieth grain (1 mg.), hypodermically. Passive Hyperemia of the Kidneys. Passive hyperemia of the kidneys, finally, aside from cardio-tonic treatment, calls for a careful regulation of the diet. It is important to recognize the character of the renal difficulty, i. e., to decide whether or not there is present a real nephritis or merely stasis in the kid- ney. The presence of valvular lesions and evidence of embar- rassment of the venous circulation in other organs usually de- cides the question. The urine as a rule is concentrated, owing to a relative increase of urea, uric acid and urinary pigments; hence its specific gravity is high and it has a tendency to precip- itate an abundant urate sediment. Its color is usually very dark. There is rarely much albumin. Hyaline casts, in small numbers, are commonly present, also a few leucocytes and an occasional red blood corpuscle. Renal epithelia, granular or blood casts are generally absent.* In these cases a milk diet is useful. Too much milk should Milk diet not, however, be ordered, nor should large quantities of milk be given at a time. The milk diet, by leading to the formation of small quantities of irritating urinary end-bodies, spares the kidneys; it also acts to a certain extent as an intestinal anti- septic and hence prevents the formation in the bowel of putre- factive poisons that can irritate the heart and the kidneys; in addition, it possesses diuretic properties which act advantage- ously by stimulating the kidneys to an increased secretion of water. The only objection to an exclusive milk diet is the dan- ger of flooding the cardio-vascular apparatus with large quan- tities of water, and hence forcing the heart to perform much labor in pumping the water from the stomach to the emunctories of the body. Consequently the total amount of milk should rarely exceed one quart in the extreme; and a little meat, fats, cereals, fresh fruits and vegetables should be added to the diet in order to make up the nutritive deficit. *See Croftan: "Clinical Urinology;* 42 TREATMENT OF CARDIAC DROPSY Rest and massage Diaphoresis Pilocarpine contra-indi- cated Hot air and steam sweats TREATMENT OF CARDIAC DROPSY AND EDEMA. Mild dropsical swellings about the ankles can usually be promptly relieved by rest in bed, massage and a milk diet. As soon, however, as an accumulation of serum occurs in the serous cavities and the subcutaneous tissues, more active treatment must be instituted. The means at our disposal are stimulation of the action of the sweat glands and the kidneys, and catharsis. If these measures fail, surgical treatment of hydrops must be in- stituted, either by incision or puncture of the edematous ex- tremities and drainage, or by paracentesis of the dropsical ser- ous cavities. The stimulation of the sweat glands should be brought about preferably by physical means; for we know of only one remedy that really possesses the power of stimulating the sweat glands, viz., jaborandi and its alkaloid, pilocarpine; and unfortunately, this drug is distinctly contra-indicated in valvular diseases of the heart, for it depresses the heart decidedly, slows its action and appreciably reduces arterial tension. Inasmuch as hot bathing is always dangerous in heart dis- eases, for reasons that have been described (see page 25), re- course must be had to sweating by the use of hot air or steam. In order to do this at home the patient should be seated upon a chair, a woolen blanket fastened around his neck and draped in such a way about the person of the patient that it covers his whole body and the chair, i. e., forms a tent with the head protruding above. By placing a lamp underneath the chair a profuse sweat can soon be induced. Sweating in bed can be produced in the same way by arranging a frame work over the patient and covering this with blankets. At the side of the bed is placed a lamp and over the lamp a metal funnel to which is attached a rubber tube which conducts hot air underneath the blanket, care being exercised, of course, that the patient is not burned by the hot air. If it is desired to give the patient a steam bath, the steam from a kettle of hot water may be con- ducted under the blanket tent by means of the same funnel and tube arrangement. In all of these procedures the patient's head should be kept cool with cold baths or an ice bag. The hot air or steam sweating may be kept up for ten or fifteen minutes with safety. At the end of the sweating the patient should be wrapped in blankets and allowed to remain quiet for half an hour; at the end of this time the surface of the body may to advantage be bathed in lukewarm water, dried with a rough towel and rubbed with alcohol. TREATMENT OF CARDIAC DROPSY 43 Among the diuretics that can be used for the relief of car- Heart Tonics diac dropsy the heart tonics (digitalis and its congeners), and Diuresis caffein, given either alone or combined, are the most useful rem- edies. To the caffein group belongs also the very popular med- icine, theobromin, and its compound with sodium salicylate, T^eobromin diuretin. All these caffein derivatives are renal diuretics and diuretin act by exciting the renal epithelia. Diuretin is best administered in powder form, in the dose of about ten to twenty grains (0.65 to 1.3 gm.) three or four times a day. A useful prescription in cardiac dropsy consequently is : 1* Powdered digitalis leaves, 0.1 gm. Diuretin, 1.0 gm. Sugar of milk, 0.3 gm. M. Sig. One such powder three or four times a day. As the hydrochloric acid of the, stomach seems to interfere with the absorption of diuretin this drug can advantageously be given in combination with sodium bicarbonate in a little milk. If diuretin fails to increase the flow of urine after two or three days, its use had better be discontinued and recourse had to some other remedy, notably calomel, in doses of two Calomel grains (0.1 gm.) repeated five to ten times a day, for several days in succession. This treatment may be repeated at inter- vals of a week or ten days. The diuretic effect of this drug is very striking. It is contra-indicated, however, if nephritis ex- ists, or if there is a severe anemia or much gastro-intestinal trouble. Salivation should be forestalled by the frequent use of a dilute solution of chlorate of potash or tannic acid as a mouth wash. (See Stomatitis.) If salivation appears, neverthe- less, calomel should be stopped at once. To counteract the irritative diarrhea five grains (0.3 gm.) of powdered opium may be given daily. Diuretic teas were formerly very popular but Diuretic teas they act presumably more through the hot water they contain than from any specific effect; as they must be taken in large quantities to be effective and as abundant water drinking, is contra-indicated, their use cannot be recommended. Sugar of milk may also be utilized as a diuretic in these cases. Sugar of milk Inasmuch as these patients are, as a rule, living on a diet con- sisting largely of milk this effect is produced anyhow; the addition of milk sugar in varying doses to the milk, however, frequently enforces the diuretic effect of the latter. Other sugars seem to possess a similar diuretic influence and the admin- 44 TREATMENT OF CARDIAC DROPSY Catharsis Saline cathar- tics Vegetable purgatives Croton oil Jalap Colocynth Podophyllum Elaterium istration of a solution of dextrose is occasionally very useful in increasing the flow of urine. Three classes of purgatives or hydragogue cathartics may be used to advantage in the treatment of renal dropsy, viz., saline cathartics, vegetable purgatives and mercurial purgatives. The chief saline cathartics are the sulphate of sodium (Glauber salt), the sulphate of magnesium (Epsom salt), the double tar- trate of sodium and potassium (Kochelle salt) and the citrate of potassium and magnesium. These salines, in contradistinc- tion to the vegetable and mercurial purgatives, do not irritate the intestinal wall, but act chiefly by in- creasing the molecular concentration (i. e., the osmostic pressure) within the intestine, and hence draw water from the serum into the bowel. In this way the blood be- comes more concentrated and in its turn draws water from the tissues; the saline cathartics also stimulate the peristaltic move- ment of the bowel through their bulk and in this way hasten the propulsion onward of the bowel contents. Sodium sulphate may be given in doses of thirty grains to an ounce (2 to 30 gm.). The sulphate of magnesium in the same quantities. Rochelle salts in doses of about one-fourth to one-half an ounce (8 to 16 gm.), and the citrate of potassium and magnesium in doses of fifteen to fifty grains (1 to 3 gm.). In addition there are a number of pleasant effervescent mixtures that may be given. The concentration of the solutions of these different saline cathartics is very important. They should not be more concentrated than ten per cent. The disagreeable taste, especially of the magnesium salts, can often be disguised by the addition of a little sugar or by giving the salts in milk. Among the vegetable purgatives the oils, castor oil and croton oil, have a very subordinate importance in the treat- ment of cardiac dropsies, because they do not produce a suffi- ciently active purgation unless given in doses so large as to produce serious irritation of the bowel wall. This applies particularly to croton oil. Inasmuch as the mucosa is gen- erally in a state of passive hyperemia in cases of valvular heart lesions that have progressed to the stage of dropsy, it is par- ticularly important not to give drugs that can irritate the bowel wall. The rhubarb, senna, aloes group are also little used in the treatment of cardiac dropsy; first, because they are all irritating and, second, because their action is relatively mild. The chief vegetable purgatives, therefore, that we must use are jalap and colocynth, podophyllum and elaterium. Of all these jalap is the most deservedly popular. Inasmuch as this drug occasionally produces nausea, vomiting and colic, it is TREATMENT OP CARDIAC DROPSY 45 best to combine it with hyoscine or belladonna which counter- act this effect. The following official preparations of the U. S. P. are all useful: The Compound Cathartic Pill contain- ing colocynth, jalap, gamboge and calomel, given three at a time. The Vegetable Cathartic Pill containing colocynth, jalap, podophyllum, hyoscyamus and peppermint oil, given in similar doses as the above. The Compound Elaterin Powder contain- ing one part of elaterin in thirty-nine parts of milk sugar, and given in doses of one to four grains (0.06 to 0.25), and finally, the Pill of Podophyllin, Belladonna and Capsicum. The ap- pearance of blood or mucus in the stools, or other signs of gas- tric or intestinal irritation, contra-indicate the continuation of these remedies. If all these medicinal measures, with sweating by hot air or surgical steam, fail to relieve the dropsy, then recourse must be had treatment to what may be called the surgical treatment of cardiac hydrops. The surgical relief of hydrops or anasarca of the lower ex- tremities is more than a palliative measure, for, in many cases it will be found that the withdrawal of the fluid from the serous cavities or limbs, when combined with active cardio-tonic medi- cation, enables the heart to regain its tone and occasionally aids in the re-establishment of compensation. Unfortunately this happy result is only rarely seen. The simplest and the safest way of removing the dropsical swelling of the extremities is to make an incision. The patient should be ordered to sit up- incision right, or, at least, to keep the legs in a dependent position for several hours before the incision is made. The feet and legs are carefully cleansed with soap and water and the skin ren- dered aseptic with bichloride solution, alcohol and ether. The best place for the incision is the external margin of the foot, below the external malleolus, or the dorsum of the foot. The incision should be at least an inch or two long and should be carried completely through the skin. By placing a cloth, wrung out of very hot water, over the wound immediately after the incision is made, bleeding can be stopped. The wound is then covered with a piece of bichloride gauze, the feet wrapped in cotton and placed in a pan containing a litle dilute carbolic acid or bichloride solution. As soon as the bulk of the fluid is drained off the wound usually closes if a simple compression bandage is applied. A second method is the so-called Southey method, which con- southey sists in the insertion of a number of trocars deep into the sub- trocars cutaneous tissues of the leg. That this little operation should be performed with all aseptic precautions need hardly be em- phasized. To the protruding ends of the little trocars are at- 46 TREATMENT OF CARDIAC DROPSY Scarification and cupping Paracentesis of the Ab- domen tached rubber tubes upon which suction may be advantageously exercised in the beginning in order to start the flow of the serum through the tube; the region around the trocar may be painted with iodoform collodion or may be covered with anti- septic gauze. After the fluid is drained off and the canulae are withdrawn, the little holes can be closed with iodoform collodion or gauze. This method is not so safe as the incision method, nor does it produce the desired effect so rapidly. The method by incision, moreover, is not so painful as the insertion of trocars nor is the danger of infection of course so great from an open incised wound as from a semi-occluded punctured wound. The method finally of scarifying the tissues and cupping through a funnel that carries off the dropsical fluids and the blood is less practical and not as efficacious as incision or trocar drainage. In draining off large quantities of anasarca fluid cerebral anemia occasionally develops, so that the patient be- comes nauseated and dizzy and finally faints. When this oc- curs drainage should at once be interrupted, the patient's head lowered and ether or camphor administered hypodermically. . Paracentesis for the removal of ascitic fluids is always in- dicated when the accumulated fluid mechanically presses the diaphragm upward and in this way interferes with respiration ' and the action of the heart, or if it compresses the stomach and bowels in such a way as to interfere with digestion. Occasionally paracentesis of the abdomen becomes necessary even without the appearance of compression symptoms in the thorax, without very considerable interference with the heart's action, and without the presence of much edema in other parts of the body. One is often surprised to find such an abdomen full of fluid in cases of valvular lesions that are not in an advanced degree of decompensation. Here the development of the ascites is due to portal stasis superinduced by the exist- ence of a "nutmeg" liver ("heart disease liver," cardiac cir- rhosis) and compression of branches of the portal vein within the atrophied organ. When performing paracentesis of the abdomen cardiac stim- ulants should always be held in readiness in order to counteract the possible occurrence of cerebral anemia that may follow the sudden engorgement of the abdominal veins with blood when the fluid is withdrawn and the intra-abdominal pressure is re- lieved. The tapping can be made with an ordinary trocar and can be performed with the patient either in a recumbent or in a sitting position. The skin should be thoroughly cleansed with soap and water, bichloride solution, ether and alcohol, and when MYOCARDITIS AND FATTY DEGENERATION OF THE HEART 47 making the puncture care should be taken to avoid superficial blood vessels. If the abdominal wall is very edematous, the local anarsaca should first be removed by massage. It is usually a good plan to make a small incision before inserting the trocar, as the little operation is less painful if this is done. The en- trance of the trocar into the abdominal cavity is readily recog- nized by a certain "give," and there is no danger of wound- ing the bowel in simple ascites. As soon as the bulk of the fluid has been tapped off, the bowel is usually felt to lightly touch the trocar point and the flow stops. This is the signal for withdrawing the needle. The wound is covered with a small piece of iodoform gauze and the latter attached to the skin with iodoform collodion. No other dressing is as a rule needed. The patient should be instructed to lie for half an hour or so on the side opposite the puncture. This treatment is, as a rule, merely palliative and has to be repeated; the ex- ceptions to this rule are the cases of hepatic ascites mentioned above, in which the withdrawal of ascitic fluid frequently ex- ercises an effect that is very long lasting. Paracentesis of the pleural cavity is very rarely necessary Paracentesis in heart lesions. It is always an emergency measure and a last of the pleural means to be resorted to only when the accumulation of fluid in pericardium 1 the pleura is very great and respiration and the action of the heart are interfered with to such extent that death would occur unless the fluid were withdrawn. The technique of this proced- ure will be found discussed under Pleuritis. Paracentesis o£ the pericardium is probably never indicated in cardiac dropsy; the technique is discussed in the part on Pericarditis with ef- fusion. MYOCARDITIS AND PATTY DEGENERATION OP THE HEART. Myocarditis is generally secondary to a variety of primary disorders of an infectious or toxic character. It is a common n , ,. . . i- P , . a ■ Causal and terminal condition m diseases of the coronary arteries and fail- prophylactic ing compensation. Cachectic conditions, chronic anemias, acute treatment articular rheumatism and malnutrition very often lead to myo- cardial changes; finally, it is a senile change. Causal and pro- phylactic treatment is throughout synonymous with the treat- ment of the underlying disorder. The recognition of myocarditis is never easy. The cardinal Recognition symptoms are a weak first sound at the apex, a weak second aortic sound, occasionally a fetal heart beat rhythm (embryo- <18 MYOCARDITIS AND FATTY DEGENERATION OF THE HEART Types Fatty infiltra- tion and fatty degeneration Diet in fat nee it Acute myocar- ditis Myocarditis in acute articular rheumatism cardia), low blood pressure, a slow, small, feeble, soft, com- pressible pulse. Moreover, a heart with myocarditis generally fails to react to digitalis, so that the diagnosis can occasionally be made if the heart does not become slower, the blood pressure higher and diuresis increased after the administration of an appropriate dose of digitalis. The degeneration of the myocardium generally assumes a fatty type. In treating established myocarditis it is important to dis- tinguish between fatty infiltration of the heart muscle, due to degeneration of the muscle fibres, and fatty infiltration due to the interposition of fat between intact muscle bundles. The latter condition is generally combined with fatty overgrowth about the heart and is in most cases a symptom of a general obesity. The symptoms of true degeneration of the heart muscle and of fatty heart (cor adiposum) are very similar, but the treatment is, as a rule, different. In the former instance the diet should be arranged in such a way as to reduce general obesity. The details are given in the Chapter on Disorders of Metabolism. Oertei's Terrain cure (see page 23) is the most valuable means, however, for treating pa- tients with cor adiposum. This exercise treatment stimulates oxi- dation, gradually exercises the heart muscle and hence helps re- store its tone by favoring the back-flow from the periphery to- wards the heart, while at the same time stimulating the heart to in- creased contractions. This treatment, of course, can only be carried out in resorts that are arranged for such purpose. In myocarditis consecutive to coronary or valvular disease with failing com- pensation it should, however, never be employed. In early stages of myocarditis the same principles should obtain as in the treatment of valvular disease of the heart with failing compensation, and of endocarditis. (For the details of this treatment I refer to the respective sections.) Acute myocarditis, when fully developed, should be treated by rest, physical and mental, a bland, non-irritating diet and counter-irritation over the precordium by means of cold, leeches, cupping or plasters. Digitalis and other cardiac tonics should always be used with great care in acute myocarditis, especially if the digitalis effect does not become apparent within two or three days after the commencement of its administration. In emergencies analeptics may have to be given to save life (cam- phor, ether, ammonia, (see page 32). In myocarditis developing in the course of acute articular rheumatism, salicylate of soda should be discontinued at once and quinine and alkalies administered instead, the former as quinine sulphate in doses of three to five grains (0.2 to 0.3 ACUTE ENDOCARDITIS 49 gm.) ; the latter preferably as sodium bicarbonate, in doses of fifteen to thirty grains (1 to 2 gm.). In chronic myocarditis due to fibroid degeneration and Chrome myo- atrophy of the heart muscle, restitution to normal conditions is impossible and treatment is altogether palliative. All violent exercise, mental over-strain or worry, and emotional shocks should be carefully avoided. Sexual intercourse should be abso- lutely forbidden. The general health should be built up by a nutritious diet appropriate to the state of the digestive organs. Tea, coffee, alcohol and tobacco should be interdicted. A course of arsenic often acts as an effective general tonic. Fowler's solution should be given, beginning with two or three drops a day and gradually increasing the dose until twenty or thirty drops a day are taken, and then slowly reducing the dose until two or three drops are again reached ; such a course may be re- peated two or three times. Constipation and flatulency should be counteracted and anemia treated by appropriate remedies (see index). Cardiac tonics should be given, if at all, under careful supervision, and the same general rules should be fol- lowed as in the treatment of valvular diseases during the stage of compensation. ACUTE ENDOCARDITIS. Acute endocarditis may appear as a primary affection, but it usually complicates a great variety of general diseases, chief among them acute articular rheumatism, scarlet fever, pneu- monia, chorea, septicemia, erysipelas and gonorrhea. Syphilis and all cachectic states also occasionally determine inflammation of the endocardium. Prophylactic treatment is identical with the treatment of Prophylaxis the underlying disorders. Absolute rest in bed, and cold to the precordium, are the only measures that can be adopted to reduce the liability of the endocardium to involvement in the disease process. Rest, above all, should be enforced in acute articular rheumatism, gonorrheal arthritis and chorea, even if the general manifestations are slight, for, in the mildest case the liability of the endocardium to involvement should be re- membered and absolute rest insisted upon. In many cases of tonsillitis, too, the heart should be repeatedly examined and upon the appearance of the slightest signs of endocarditis the patient at once put to bed. In septic, scil. ulcerative endocarditis occurring in the course Septic fori** of septicemia and puerperal pyemia, orthocresol, quinine and mercury bichlorid have been recommended. Very little at best 50 ACUTE ENDOCARDITIS Syphilitic form Rheumatic form Best Counter-irrita- tion Medicamen- tous treat- ment Aconite Digitalis can, however, be expected from any medicine in this disease. In view of the serions and usually hopeless character of this malignant form of endocarditis these remedies should, however, be tried, for it is always better at least to try a medicine that can do no harm than to stand by without doing anything and' lazily contemplate the death of the patient. The use of carbolic acid subcutaneously and intravenously will be found discussed at length in the Chapter on Malaria. Quinine and mercury bichloride may be given combined, the former as the sulphate or the hydrochlorate, in doses of from five to fifteen grains (0.3 to 1 gm.) ; the latter in the close of one-thirty-second to one-sixth grain (0.002 to 0.01 gm.) in pill or capsule, preferably with milk. In the syphilitic form of endocarditis the ordinary antiluetic medication (see Section Syphilis) must be used. In the rheu- matic form salicylates combined with alkalies, or the alkaline- quinine treatment should be administered, preferably the latter in view of the possibility of myocardial complications in which salicylates do harm (see page 48). Salicylic medication, more- over, seems to exercise a less profound effect in rheumatic disor- ders upon the endocardium (and pericardium) than upon the serous membranes lining the joints. For the mode of ad- ministering salicylates, alkalies and quinine in rheumatic endo- carditis, I refer to the Section on Acute Articular Rheumatism. With endocarditic inflammation once fully established the treatment varies according to the stage of the disease. Through- out the course of the endocarditis absolute rest in bed should be enforced ; cold should be applied to the precordium, either by means of a Leiter coil or an ice bag, either continuously or with interruptions, the latter plan being generally preferable and less disagreeable to the patient. Early in the affection cup- ping, leeching or counter-irritation with iodine, blisters or plas- ters over the heart can do no harm. The medicamentous treatment in the beginning must be chiefly directed towards maintaining the tone of the heart and preventing cardiac insufficiency. Here the tincture of aconite, one to five drops given every few hours, is the best remedy, especially in sthenic cases when the heart beats fast and strong; for this drug quiets the heart, slows its action and reduces the blood pressure, in other words, relieves the heart of much strain and reduces its labor. Later, when the heart is beginning to fail and its action is accelerated but weak and irregular, and stasis or hydrops in different organs begin to appear, then digitalis should be used (see page 28). In early stages of the disease, therefore, aconite is the proper remedy; in later stages PERICARDITIS 51 digitalis. It is clear that occasionally these drugs may have to be given together. No drug that we know of can produce absorption of the Absorption of vegetations on the valves of the heart after they have once the exudate formed. Chloride of ammonia, sodium carbonate and the iodides of soda and potash have all been recommended for this purpose; but the claims for these remedies have never been substantiated clinically, so that these drugs had better not be given in endo- carditis, especially as their administration may do more harm than good by irritating the stomach and interfering wih diges- tion. Iodides have a place in chronic endocarditis, not on ac- count of their effect upon the vegetations but for their effect on the blood pressure (see page 55). The diet in acute endocarditis should consist largely of milk, Diet gruels and broths, with the additions of a little toast, a few crackers, a little fresh fruit and vegetables. During convalescence, in view of the valvular heart lesions that usually remain, the treatment becomes the same as in com- pensated or decompensated valvular lesions of the heart and I refer to those chapters for the details. PERICARDITIS. The treatment of pericarditis varies according to the stage of the disease and the character of the effusion or exudate in the pericardium. Upon the appearance of the first symptoms c id of pericarditis absolute rest in bed, with an ice bag or a Leiter Quinine coil over the heart, should be enforced; five to fifteen grains (0.3 Morphine to 1 gm.) of quinine should be administered in divided doses; and if the pain is very severe a fourth of a grain of morphine hypodermically, two or three times a day for two or three days. If the case cannot bear cold to the precordium, a warm Priess- Warm Priess- nitz compress should be applied, consisting of a linen cloth mtz com " wrung out of hot water and covered with several layers of flannel. This should be left on undisturbed for several hours and then renewed. Oatmeal or bread poultices, belladonna or veratrine plasters or ointments also often relieve the pain. Cold piasters and or heat or counter-irritants applied in this way to the precor- poultices dium produce dilatation of the cutaneous blood vessels of this area and hence relieve the congestion in the underlying peri- cardial sac; they also reflexly deplete the pericardium. These measures usually promptly relieve at least the disagreeable sub- jective sensations of the patient. The diet in the early stage should be non-irritating and Diet should consist of liquids, milk, gruels, possibly with the addi- PERICARDITIS Digitalis Diuresis and catharsis Paracentesis of the peri- cardium and pericardiotomy tion of a little toast, bread and butter or some stewed fruit or vegetables. No medicines can act directly curatively. In the tuberculous variety ideal hygienic conditions and a proper diet, as described in the Chapter on Tuberculosis should be insisted upon. In the rheumatic forms of pericarditis an alkaline salicylate treatment (see page 550) may occasionally aid in preventing pericarditis, but upon the establishment of pericardial inflam- mation the use of salicylates should be discontinued and quinine and alkalies (see page 552) given instead. In early stages if the patient is not weakened by disease, and if the heart's action is rapid and tumultuous, aconite is the best remedy, preferably given in doses of from one to five drops of a good tincture, every two or three hours. Digitalis should be given with care, especially in pericarditis with large amounts of effusion, because digitalis prolongs the diastolic dilatation of the auricles and this particular action of the heart is always rendered difficult when pressure is exercised upon it from with- out, as, for instance, by a large pericardial exudate. If digi- talis is administered at all the pulse should be carefully watched. In very advanced degrees of pericarditis, in which the heart's action becomes seriously impaired from excessive labor imposed upon the organ, digitalis and occasionally analeptics must be employed as an emergency measure in order to save life. If it becomes very slow, 65 beats to the minute or below, or markedly dicrotic, digitalis should be discontinued at once. Digitalis^ however, has a place in the treatment of early stages of peri- carditis without much effusion, for here it is very important that the heart's action should remain as energetic as possible,, because in this way the formation of fibrinous adhesions may be rendered difficult and possibly prevented. The treatment of large pericardial exudates that form after the acute stage of the disease is over, or of pericarditis that sets in with a large serous exudate, must be considered separately. Here an energetic diuretic treatment, as discussed under the heading of cardiac dropsies (see page 42), combined with cathar- sis, may be employed with the object of ridding the organism of much water through the kidneys and bowel, thus concen- trating the blood and consequently promoting the reabsorption of the pericardial exudate. Only occasionally, however, can pericardial fluid be made to disappear in this way. In case medical measures fail, then surgical treatment must be instituted, consisting either in paracentesis of the pericar- dium or pericardiotomy. The latter measure should always be adopted if the fluid contained within the pericardial sac is puru- ARTERIOSCLEROSIS AND CHRONIC AORTITIS 53 lent. Here the pericardium should be broadly incised and free drainage established. This procedure must be carried out by a surgeon and the details need not be discussed in this book. Puncture of the pericardium, however, is a task that every internist should be able to perform. The skin is carefully shaved and rendered aseptic by scrubbing with soap and water, one to two thousand bichloride solution, alcohol and ether. The tro- car should be inserted either in the fifth or the fourth intercostal space on the left side about an inch from the left sternal margin. This point is selected in order to avoid wounding the mam- miliary vessels. It is usually best to use a local anesthetic, for instance an ether or chloride of ethyl spray, and to make a small incision at the point where the trocar is to be inserted. The nature of the operation should always be explained to the pa- tient in order that he may remain quiet, exercise self-control and co-operate with the physician. The patient will usually have to be operated upon in a semi-recumbent position; if it is at all possible, however, he should be laid flat on his back. In order to avoid injuring the heart the needle should be introduced at first directly backwards and then backwards and downwards very slowly and carefully and not, as in paracentesis abdominis, quickly. The fluid should be withdrawn gradually and a hypo- dermic injection of ether or camphorated oil be given while the fluid is being removed. The operation is not without danger and should only be resorted to as an emergency measure when all other means have failed; for cases are on record in which the heart was injured and death occurred during the operation. Puncture of the pericardium from the xiphoid angle on the left side by inserting the trocar upwards and backwards is still more dangerous and can only be carried out with relative safety in enormous pericardial exudates. II. THE ARTEKIES. ARTERIO-SCLEROSIS AND CHRONIC AORTITIS. Arterio-sclerosis in the majority of cases is the result of Causal treat- premature or normal senility. Causal treatment, therefore, in ment this category is self-evidently impossible. A small minority of the cases of arterio-sclerosis and chronic aortitis are due tc metabolic disorders, viz., gout, diabetes and obesity, or to cer- tian chronic intoxications and chronic intestinal derangement, to the abuse of alcohol, tobacco and lead, and, above all, to syphilis. The causal treatment of all these forms of arterial .degeneration is synonymous with the treatment of the un- derlying conditions, and will be discussed in their appropriate parts. 54 ARTERIOSCLEROSIS AND CHRONIC AORTITIS Symptomatic treatment Diet Reduction of calcium salts Lactic acid therapy Restriction of liquids Bathing Climate and altitude Symptomatic treatment must be directed chiefly towards preventing the over-tension of the peripheral vessels, in other words, towards keeping down the blood pressure. For the dis- eased arterial walls, owing to their lack of elasticity, determine high pressure and the high pressure in its turn presumably pro- duces further degeneration of the arterial museularis. It is hard N to say in many of the cases which was the primary event, the high tension of the blood or the arterial degeneration, i. e., the sclerosis. The dietetic rules to be observed are the follow- ing : Alcoholic beverages and tobacco, as well as tea and coffee, should either be forbidden altogether or should be allowed only very moderately. Meat should be reduced to a minimum, and particularly those varieties of meat and meat preparations ex- cluded from the diet that are known to contain extractives, for the latter raise the blood pressure (see page 20). A diet consisting largely of milk and plenty of fresh fruits and vege- tables, cereals and a moderate amount of fats is the best. In so chronic a disorder as arterio-sclerosis care must, above all things, however, be taken to maintain general nutrition. As one of the characteristics of arterio-sclerosis is calcifica- tion of the arteries, it has been suggested that the ingestion of calcium should be reduced by excluding from the diet articles of food containing this element; chief among them eggs, cheese, rice, asparagus, carrots and milk. It will be seen that, on the basis of this theoretical postulate, a milk diet would be dan- gerous and a meat diet permissible. Practical experience teaches, however, that patients with arterio-sclerosis thrive very much better on a diet consisting largely of milk and the other articles enumerated above than on a meat diet, hence the decal- cification plan, however seductive it may appear on theoretical grounds, is not practical. The suggestion has been made to counteract the deposit of calcium salts by the administration of lactic acid by mouth, and it can do no harm to adopt this plan, especially as lactic acid acts as an intestinal antiseptic and may be useful from this point of view. Lactic acid may be adminis- tered in the form of sodium or strontium lactate, in the dose 01 fifteen to twenty grains (0.1 to 1.2 gin.) three times a day, or as lactic acid in solution in syrup (1:20) a teaspoonful three or four times a day. The ingestion of liquids should be somewhat restricted, for similar principles obtain here as in the treatment of compen- sated heart lesions (see page 21). The same applies to bathing and other hydrotherapeutic means, and the choice of a resort, climate and altitude. For the considerations that should gov- ern us in advising our patients in regard to these elements of ARTERIOSCLEROSIS AND CHRONIC AORTITIS 00 the treatment I therefore refer to Compensated Heart Lesion (page 24f). The medicamentous treatment of arterio-sclerosis consists, first, in the use of the iodides, either of potash or sodium. Iodides of potash, and Iodides have long enjoyed a great popularity in the treatment so da of this disorder, and there is no doubt that empirically they act beneficially in arterio-sclerosis. It seems very doubtful whether iodides can, in any way, cause regeneration of the sclerotic ar- terial walls, as some writers claim. They certainly, however, keep the blood pressure low and this, as I have explained above, may aid Nature in partially restoring normal conditions. Iodides, according to the investigations of Romberg, presumably produce this effect by reducing the viscosity of the blood, in other words, rendering it more fluid without diluting it. This is a very useful influence, for in arterio-sclerosis, owing to the rigid- ity of the arteries and the narrowing of their lumen, the pro- pulsion of the blood is always impeded; if now the blood vis- cosity can be reduced it will flow more readily through the arteries and this factor, by relieving the heart of much labor, reduces the blood pressure. The iodides, moreover, exercise a Dose and ad- very striking effect upon the subjective symptoms of the pa- tient, especially the neurasthenic manifestations, the angina, the dyspnea, and the cardiac asthma. In order to be effective they should be given for long periods of time, preferably for years. In the beginning small doses, i. e., two to ten grains (0.12 to 0.6 gm.) should be given three times a day and the dose Alkalies later increased a little. In order to enforce the effect of the iodides, they should be administered in combination with some alkali, preferably the bicarbonate of soda, or dissolved in some alkaline water. A very useful method of administering them is to give two to ten drops of the saturated solution of iodide of sodium in a glass of milk, to which is added one-third of a tcaspoonful of bicarbonate of sodium. Iodides are best given after a meal; they should never be administered together with acid foods, nor to patients suffering from g'astric catarrh, and should never be administered in a metal spoon. In order to prevent the development of iodism the administration of the iodides should be interrupted from time to time, and a very good plan is to give them for three weeks consecutive, then to stop their use for one week and later possibly to omit them for two or three weeks at a time. For the purpose of reducing the blood pressure, the nitrites Nitrites may also be used; they are best administered in the rojt/n of nitrates combined with sodium bicarbonate, as the nitrates un- dergo reduction to nitrites in the body. Lauder Brunton, who 56 ANEURISM OF THE AORTA first advocated this treatment, recommended the following formula : i* Potassium bicarbonate, 1.8 Potassium nitrate, 1.2 Sodium nitrite, 0.03 To be given in half a litre of water, early in the morning, on an empty stomach. Nitroglycerin and amyl nitrite Heart tonics Truneczek's serum Anti-sclerosin Or nitrite of soda may be given in tablets or solution in the dose of one to two grains (0.05 to 0.1 gm.). Nitroglycerin and amyl nitrite are of very subordinate im- portance in the treatment of arterio-sclerosis. They are chiefly useful to relieve paroxysms of angina pectoris, or to stop the retro-sternal pain that is so distressing a symptom in chronic aortitis. This pain is also materially relieved by the applica- tion of the ice bag, poultices and counter irritants to the precor- dial region. Heart tonics should be given with care in arterio-sclerosis, on account of the inability of the arteries to adapt themselves rapidly to blood pressure changes. In later stages of the dis- ease, however, when the heart has become insufficient and the blood pressure is low, digitalis, administered continuously in small doses, has its place. Groedel, than whom there is probably no greater authority on this subject, speaks very warmly of this practice and claims never to have seen any deleterious effect from it. Of late years Truneczek has described a serum to be used in arterio-sclerosis, and Goldschmidt a preparation called anti- sclerosin. Some good results are reported from the use of these remedies, but it is too early to pass judgment on their efficacy. Causal treat- ment ANEURISM OF THE AORTA. Aneurism of the aorta occasionally undergoes spontaneous cure by the deposit of coagulates of fibrin within the aneurismal sac. All causal treatment that we can employ for the cure of aneurism must, therefore, be directed towards aiding Nature in producing such coagulates. In order to fulfill this purpose an endeavor must be made to cause retardation of the blood stream and a reduction of the blood pressure, and if possible, a decrease of the blood volume, for all these factors favor coagulation. ANEURISM OF THE AORTA 0/ Absolute rest in bed for many months at a time is the ortho- Rest dox treatment of this disease. When this plan is adopted, the contractions of the heart are reduced by many thousands in the twenty-four hours. Thus Baumler, for instance, showed in a case of aneurism that the pulse fell from 95 to 56 after forty minutes of absolute rest. This means the elimination of 43,200 contractions of the heart in twenty-four hours. The amount of food and drink should always be reduced in Diet -order to decrease both the blood volume and the blood pressure. It is never, however, a good plan to chronically underfeed these -cases, for a starving organism cannot develop full regenerative powers. As the patients are resting and quiescent the daily food requirement is eo ipso less; but in order to be perfectly ■safe it is always best to submit these cases, after they have been in bed for a number of days and their metabolism has adjusted itself to the new conditions, to a careful metabolic study, in •order to determine what the minimum amount of food is that the patients require to maintain nutritive equilibrium. The technique of such an examination will be found described in the Chapter on Diseases of Metabolism. The selection of the diet should be governed by the same principles that obtain in myocarditis and arterio-sclerosis. Large meals that can overload the stomach, or articles of diet that un- dergo fermentation and hence can distend the stomach, thus pressing the diaphragm upwards and interfering with respira- tion and the work of the right heart, should always be avoided. If full feeding is permitted, therefore, the patient should receive small meals at frequent intervals. One of the most popular dietetic schemes employed in the Tufnell diet treatment of aortic aneurism is the regime arranged by Tufnell. His diet is altogether inadequate to properly nourish the pa- tients; and while he obtained remarkable success in some cases, it is, nevertheless, a precarious matter to adopt so low a diet scheme as a routine. Tufnell advised restricting the total amount of solid food to 300 grammes in the twenty-four hours and the liquids to 240 cubic centimeters. This ration he allowed to be slightly increased if the patient became excited and very much dissatisfied with the restricted regime. The meals were arranged as follows: For breakfast : 50 cc. of milk or cocoa with 60 grammes of bread and butter. For dinner: 90 grammes of meat and 90 grammes of bread or potatoes and 120 cc. of water or very thin claret. 58 ANEURISM OF THE AORTA More liberal feeding Restriction of liquids Free evacua- tion of the bowels Massage of the lower ex- tremities Medicamen- tous treat- ment Iodides Gelatine Fcr supper: 60 cc. of weak tea and 60 grammes of bread and butter. It is unnecessary to carry the restrictions so far, as equally good results are obtained with more liberal feeding, especially if a metabolic study precedes the arrangement of the dietary. Tufnell's scheme is, therefore, mentioned chiefly on account of its historical interest and because he deserves the credit of hav- ing first established the principle of restricted feeding in the treatment of aortic aneurism. It should rarely be necessary to reduce the liquids to less than 1,000 cc. in twenty-four hours. When the liquids are greatly reduced the patients naturally suffer from thirst; this distressing symptom can frequently be relieved without undue increase of the liquid intake by swallowing small pieces of cracked ice ad libitum, or by chewing gum. Care should always be taken to promote free evacuation of the bowels, because " straining at stool is always a precarious- matter in aneurism of the aorta, and the abdominal plethora is to- be avoided besides. The lower extremities of the patient should be kept warm and the legs and abdomen frequently massaged; these measures act beneficially, because both the heat and the massage reduce the peripheral blood pressure and draw muck blood away temporarily from the region of the aneurism. The medicinal treatment of aneurism of the aorta is of very subordinate importance. The iodides of potassium and sodium are used extensively. It is very doubtful, however, whether they exercise" any influence whatsoever upon the progress or regress of the aneurism itself. Symptomatically, they often stop the pain in the precordium and the left upper extremity. They should be given in increasing doses, preferably beginning with five drops of the saturated solution three times a day and grad- ually increasing the dose until thirty or forty grains are being taken daily or the desired effect is produced. The same prin- ciple and technique should govern the administration of iodides, in aneurism of the aorta as in arterio-sclerosis. (See page 55.) The subcutaneous injection of gelatine has recently been recommended in the treatment of aneurism, and the claim has been made that gelatine administered in this way increases the coagulability of the blood, and hence favors the deposit of fibrin within the aneurismal sac. As gelatine is made from the hoofs of animals, there is always some danger of its containing spores of tetanus, and hence the gelatine solution should be very care- fully sterilized before it is administered, as very disagreeable accidents have happened when this precaution was omitted. One ANEURISM OF THE AORTA 59 of the best solutions to use for sub-cutaneous injection is the following : r> Gelatine, 1.5 gm. Sodium chloride, 0.1 gm. Distilled water, 100.0 cc. M. Sig. : To be sterilized by discontinued sterilization and injected warm in doses of 20 to 30 cc. on four or five successive days. The injections are best made in the gluteal region. They are frequently followed within a day or two by severe pain in the region of the puncture and occasionally by a rise of temperature. The pain may be relieved by local heat; the fever rarely lasts more than forty-eight hours and can be safely neglected. The results obtained from this practice have been sufficiently favorable in some cases, especially when combined with certain other local measures to be discussed below, to warrant its em- ployment, tentatively, at least, in sacculated aneurism. In the fusiform variety, or in dissecting aneurism, no good results have ever been published. One of the chief indices of the efficacy of gelatine injections is considered to be the disappearance of the radiating pains in the left upper extremity, signifying that the nerves of the brachial plexus have been relieved of some pressure on the part of the aneurism. A series of X-ray photographs may indicate ad oculos whether or not the size of the aneurism has been reduced. In addition to these hygienic, dietetic and medicinal measures, Surgical certain surgical means may be employed to advantage in the rea men treatment of aneurism, viz., in the order of their importance, galvano-puncture, acupuncture, filipuncture, proximal compres- sion (applicable only to aneurism of the abdominal aorta) and ligation of the carotid and subclavian. Galvano-Piincture is performed as follows : A fine insulated Galvano- needle is introduced into the aneurismal sac and connected with the anode of a galvanic battery. The cathode is attached to a sponge electrode that may be applied to the chest or the abdomen. Some authorities recommend inserting two needles into the aneurismal sac, the one connected with the anode, the other with the cathode. The former plan, however, is simpler and safer and produces the same results as the latter. The current should not be stronger than from ten to twenty milliamperes, and it should not be applied for longer than from fifteen to twenty minutes. It is well to test the coagulating power of the current before th-r needles are introduced into the aneurism, and this can be done 60 ANEURISM OF THE AORTA as follows: The white of an egg is poured into a dish and the needles inserted into it. When the current is turned on a firm clot should form at the positive needle while a frothy clot forms at the negative pole. Before the needles are introduced into the aneurism the patient should be told what it is intended to do, so that he may intelligently co-operate with the physician and exercise all his will power in remaining absolutely still. When the treatment is over, the needles are rapidly withdrawn and the little wound closed with collodion or court plaster. As a rule it is necessary to repeat this treatment two or three times at intervals of a week or so. There is always some danger of hemorrhage, and the possibility of embolism can never be excluded. A cure from this treatment is exceedingly rare, but quite a number of cases of aneurismal swellings have been reduced in size and the pain ameliorated. Pilipuncture Filipuncture consists in introducing fine needles into the aneurismal sac, as above, and scarifying the intima of the opposite wall. The roughening of the intima is intended to favor the deposit of fibrin and coagulates. A few cases of symptomatic improvement but no cures are reported from this treatment. Acupuncture Acupuncture consists in the introduction of iron or silver wire, horse-hair, silk thread or cat-gut into the aneurism, the object being to cause the precipitation of fibrin around these threads. As a rule, the pieces are only a few millimeters long; threads and wires several centimeters long have been introduced, however, without untoward results, but, unfortunately, also with- out particularly favorable effects. As this operation is very sim- ple and seems to be practically devoid of danger, and as it occa- sionally does some good, it may be employed, but only in des- perate cases, in which all other means have failed. Compression In aneurism of the abdominal aorta situated low down, com- pression of the aorta between the heart and the aneurism has been attempted; the object being to cause retardation and stasis of the blood stream in the aneurismal sac and thereby creating conditions that favor coagulation and hence obliteration of the aneurismal cavity. This procedure must, of course, be carried out under an anesthetic. The duration of the operation must vary according to the reaction of the patient, but in order to exercise any effect compression should be continued for several hours. The amount of pressure should be so great as to cause disappearance of pulsation in the sac. The operation may be repeated. The results reported are not particularly favorable and untoward consequences have occasionally been observed, for ANEURISM OF THE AORTA 61 instance, peritonitis and mechanical lesions of the duodenum, the pancreas and the celiac plexus from the pressure. Ligation of the common carotid and the sub-cl avian artery Ligation of has been used as a desperate resort, but no good results are re- subclavian ported from this operation. It is mentioned merely for com- arteries pleteness' sake and on account of its historical interest. That these various surgical measures must be combined with rest and a restricted diet, possibly the use of iodides and gelatine, (see above), need hardly be emphasized. The symptomatic treatment of aortic aneurism concerns itself Symptomatie treatment chiefly with the relief of pressure symptoms. Chief among these are pain radiating in various directions according to the location of the aneurism and the nerve branches compressed ; venous con- gestion in various organs of the body, chiefly the head and arms in aneurisms of the upper aorta; dyspnea from compression of the trachea or from congestive bronchitis or from bilateral ab- ductor paralysis (pressure on the recurrent laryngeal nerve at the aortic arch). For the relief of the pain the ordinary anti-neuralgic remedies Relief of pain may be employed. For the pain produced hy the aneurism itself the ice bag or a Leiter coil to the precordium may be used, as de- scribed in the part on Pericarditis (page 51). Occasionally a narcotic or anodyne ointment applied to the chest relieves the pain. A very useful prescription for such an ointment, rec- ommended by Ortner, is the following: Menthol, 2.0 gm. Cocaine muriate, 0.2 gm. Morphine, muriate, 0.4 gm. Olive oil, 1.0 cc. Lanolin, 2.0 gm. M. Sig: Apply locally. For the dyspnea due to pressure hyperemia of the trachea or Dyspnea bronchial mucosa, the ordinary remedies for bronchitis should be employed (see Section Bronchitis). The same precaution in the selection of expectorants should be observed, however, as in the treatment of the bronchitis due to venous stasis in decompen- sated heart lesions (see page 38), and particular care should be exercised to avoid the administration of emetic expectorants, chiefly ipecac, because the strain of vomiting is always danger- ous in aneurism. Bleeding is a very useful measure in aneurism because it Bleeding rapidly relieves the congestion and generally stops the pain. 62 ANGINA PECTORIS Pressure symptoms This applies particularly to the disagreeable congestion occurring about the face, head, neck and upper extremity ; here bleeding is without doubt the sovereign remedy for producing symptomatic relief. disagreeable symptoms resulting from the pressure of the aneurism on the vagus or the phrenic nerve must often be re- lieved symptomatically by the use of opium or bromides and occasionally, in emergencies, by whiffs of chloroform. Sometimes it may become necessary to perform tracheotomy in order to relieve laryngeal dyspnea due to bilateral abductor paralysis, resulting from pressure of the aneurism upon the laryngeal nerves. Causal treat- ment Prophylaxis Diet III. NEUROSES OF THE HEART. ANGINA PECTOEIS. Angina pectoris is, in most cases, due to ischemia of the heart muscle. The factors that determine an inadequate sup- ply of blood to the heart are manifold, and may be either organic or functional in character. In most instances angina pectoris is a symptom of a general arterio-sclerosis involving the coronary arteries and, possibly, also the endocardium; in other cases it appears that the coronary arteries alone are sclerotic, and, in still other cases, there is an aortitis, due to different causes, pro- ducing mechanical narrowing of the orifices of the coronary ar- teries in the aortic wall; or there may be thrombosis or em- bolism of these vessels. Besides, spasmodic contraction, of the walls of the coronary arteries, due to a variety of possible neu- rotic causes, may occur. Finally, there is also a symptomatic form, so-called pseudo-angina, that occasionally develops on the basis of a neurasthenic or hysterical condition. The causal treatment of angina pectoris must, therefore, take all these different possibilities into consideration. Thus all the factors that can become operative to produce arterio-sclerosis or arteritis (see page 53) should be treated provided any early evidence of arterial degeneration is determinable. Every case of angina pectoris should be given the benefit of an antiluetic treatment. If the patient is manifestly neurotic then appro- priate hydro-therapeutic, medicinal and rest treatment, as de- scribed in the Section on Gastric Neuroses, should be instituted. As a means of prophylaxis the diet should be arranged in such a way that all principles capable of exciting the heart and raising the blood pressure are eliminated. Meat extracts and bouillons, raw, rare, cured and smoked meats, internal organs, tea and coffee should all be forbidden because they contain ex- tractives (purin bodies) that notoriously irritate the heart. Alco- ANGINA PECTORIS 63 hoi should be used with the greatest care, and smoking, even prolonged sojourn in a smoke-laden atmosphere, should be inter- dicted. Very hot and very cold beverages, spices, carbonated waters, should all be forbidden and all distension and over- loading of the stomach carefully avoided, as otherwise reflex and mechanical irritation of the heart from the stomach may result. Other exciting causes to be avoided are sudden physical exercise, and especially quick movements of the left arm and left upper extremity. Unfortunately, the majority of cases of true angina pectoris are not recognized until the degeneration of the aorta and the coronary arteries has become irremediable. In such cases one is limited to regulating the patient's mode of life in such a way that all causes that can notoriously precipitate an attack are eliminated. If one could begin early, even with the prophy- lactic treatment, much would be gained, but unfortunately early manifestations of angina pectoris are usually misinterpreted, owing to the mild and transitory character of the attacks, and, above all, to the peculiar tendency of anginal pains to radiate into remote parts of. the body, thus simulating neuralgias of various parts, lumbago, renal and hepatic colic or gastralgia. For all these reasons the treatment of angina pectoris is in most cases symptomatic and limited to aborting or relieving the paroxysms. The pain is excruciating and the sense of im- pending death horrible. The ordinary analgesic remedies are Vaso-dilators altogether too slow in their action to have a place in the treat- in ^g" 31 P res ~ ° ^ sure angina ment of acute attacks of angina pectoris. As hypertension is present in most cases of angina pectoris the use of vaso-dilators is generally indicated. Here the character of the pulse and, above all, of the second aortic sound, should be carefully but quickly studied. If the pulse possesses the characteristics of a high tension pulse^and if the second aortic sound is markedly accentuated, then the use of vaso-dilators and anti-spasmodics is always indicated. This study of the heart and blood pressure need, generally, only be performed during the first attack, chiefly to determine whether one may not possibly be dealing with a case of angina pectoris due to advanced myocarditis, or to aortitis without general arterio-sclerosis ; for, in such cases the anginal attack may be due to, or may be complicated by, acute dilatation of the heart, with low arterial tension, as indicated by a weak cardiac tonics second aortic sound, possibly murmurs (due to relative, i. e., in low pres- muscular insufficiency), a correspondingly low radial pulse and angina^ 6 a weak apex beat. In this latter class of cases treatment directed against high tension is wrong; digitalis and other G4 ANGINA PECTORIS Nitrites Amyl nitrite Morphine Chloroform Applications to the pre- cordium interim treatment Nitroglycerin cardiac tonics and pressure-raising remedies are indicated, and not vaso-dilators; the latter, in fact, do much harm, fail to re- lieve the symptoms, and may even determine death. Excepting in this comparatively rare class of cases, how- ever, the nitrites are the remedy of choice. Amyl nitrite is. deservedly the most popular remedy in angina pectoris. The drug is best dispensed in glass pearls containing three to five drops of amyl nitrite; patients suffering from angina pectoris should carry these pearls with them. Upon the appearance of the attack or of premonitory symptoms, such as pain radiating into the left arm, one of these pearls should be broken in a handkerchief and the vapors inhaled. The vaso-dilator effect becomes apparent almost instantaneously, the face becomes flushed and the head feels full. If the attack is not stopped by the first inhalation, two, three or four pearls full of amyl nitrite should be inhaled at short intervals. If this treatment fails to stop the agonizing pain, then re- course must be had to morphine, a drug that acts favorably in this condition, both by its vaso-dilator effect and its tendency to reduce the blood pressure. It should be given hypodermically,. in doses of at least one-fourth to one-half grain (0.016 to 0.03 gm.) repeatedly. Theoretically, repeated doses of morphine are contra-indicated in cases of general arterio-sclerosis suffer- ing from angina pectoris, in which there is arteriosclerotic de- generation of the kidneys, because, under these circumstances^ the drug is eliminated so slowly that a dangerous cumulative effect may be produced; but this will be a rare event. Inas- much as morphine exercises its influence very much more slowly than amyl nitrite, it is best to administer a hypodermic of morphine as soon as the attack begins and while the amyl nitrite is being inhaled, for in this way valuable time may be saved. * In case neither amyl nitrite nor morphine relieve the pain r then chloroform should be given, preferably by inhalation. This is, of course, a somewhat precarious procedure in any form of heart disease and hence this plan should only be adopted as an extreme emergency measure. Locally, hot applications, poultices or a mustard plaster to the precordial region may be of some benefit ; counter-irritation of this kind should always be attempted, but only in addition to the other measures enumerated. In the interim between attacks, and in a sense as a prophy- lactic measure, nitroglycerin and nitrites may be given; to be efficacious, however, they should be given continuously. Nitro- glycerin may be administered either in the form of one one- PALPITATION 65 hundredth to one one-hundred-and-fiftieth grain tablets, two or three times a day, or preferably in the form of a one per cent, alcoholic solution, beginning with one drop of this three times a day and increasing the dose a drop every four or five days until flushing and headache appear. The dose should then be reduced a drop or two and the patient kept continuously on this amount. From time to time the dose should again be increased until flushing and headache appear; and it will be found that after a time more can be tolerated than at the beginning. A preparation of nitroglycerin that has recently attained Erythrol well deserved popularity is erythrol-tetranitrate. This remedy grants a more prolonged vaso-dilator effect than nitroglycerin. The fall in the blood pressure begins about half an hour after its administration and usually persists for three or four hours. It may either be given in tablet form in doses of one-twelfth grain (5 mg.) every four hours, or in the form of drop doses of a concentrated solution by mouth. Here, again, the appear- ance of flushing and headache indicate whether or not too much is being given. The nitrites, finally, should be administered in doses of three Nitrites grains (0.15 gm.) of sodium nitrite or potassium nitrite, three times a day, in milk or water ; or the formula of Lauder Brunton, given in the Section on Arteriosclerosis (see page 56) may be used to advantage. The use of iodide of potash has already been Iodide of n , potash mentioned above. Seizures of pseudo-angina pectoris, due to functional nervous disorders, and without evidence of arterio-sclerosis or myo- carditis, can often be successfully treated by cold and pressure over the precordium, and a strong mental suggestion. During Pseudo-angi- the paroxysm the administration of a teaspoonful of ether often nal paroxysms relieves at once. In the interim the underlying neurosal element must be attacked^ and all those general prophylactic measures instituted that are employed in true angina pectoris. PALPITATION. The disagreeable subjective character of palpitation makes it one of the most important symptoms to treat ; for patients are apt to worry more about it than about severe organic heart lesions that do not give rise to symptoms that are so noticeable. Palpitation may occur in organic heart disease, but more com- monly it is present when the heart is organically intact. In few conditions does successful treatment depend so much on a careful diagnosis. Organic disease of the heart, especially Introductory 66 PiVLPITATION Functional palpitation Organic ner- vous disease Exophthalmic goitre Anemia and malnutrition Chlorosis Early tuber- culosis Nephritis Intoxications Neurasthenia and hysteria fatty degeneration, dilatation and disease about the aortic valves, should always be carefully looked for. Congenital smail- ness of the heart and narrowing of the arteries are also import- ant findings. Palpitation in organic heart disease is always a sign of cardiac weakness and occurs chiefly when more work is suddenly thrown upon the heart than its reserve force can meet. In the majority of cases there is merely over-irritability of the heart and its ganglia without heart lesions, possibly over- action of the accelerator nerves of the heart (the sympathetic), or defective action of the inhibitory nerves (the vagus). These perversions of the action of the heart muscle and of the nervous apparatus of the heart may be purely functional, or they may be due to organic nervous disease. Hence particular care should be exercised to search for disease of the sympathetic or its gang- lia, and for disease of the central nervous system. To the same category also belong early cases of exophthalmic goitre; so that in every case of palpitation, the eyes and the thyroid should be carefully examined for evidence of Graves' disease. Inasmuch as exophthalmic goitre occasionally appears without exophthal- mos, and without goitre, the minor symptoms of this affection (the tremor, sweating, lid-signs, etc.) should be carefully looked for. , Palpitation may also be a part phenomenon of anemia or chronic malnutrition in which there is irritable weakness of the nervous apparatus governing the heart's action. Very import- ant in this respect is chlorosis, for here, as shown in another chapter, we have aside from the anemia, an unstable nervous system and very commonly congenital smallness of the heart and of the arterial capacity. In every case of palpitation the apices of the lungs should always be carefully examined for evidences of early tubercu- losis, for it is well known that in apical tuberculosis palpitation of the heart is very common. Whether this is due to a special toxemia or to irritation of the sympathetic fibres in the neck is undetermined. In nephritis, too, especially in the cardio- vascular type of renal disease ( Bright 's disease), palpitation is a common sign, hence the urine should always be carefully in- vestigated for the presence of renal elements, or albumen, and for renal inadequacy. Certain intoxications, notably by tea, tobacco, coffee, alco- hol and even heart tonics (digitalis, strophanthus, strychnia, when employed injudiciously), can all cause palpitation. Finally, there is a purely neurotic form that develops on the basis of neurasthenia or hysteria. Here exciting causes PALPITATION 67 must be very carefully looked for. These may be external and consist of some sudden emotional shock, a fright, a loud noise, or a flash of light, etc., or they may be internal and reflex in character; thus indigestion, especially when associated with gaseous fermentation or flatulency, intestinal parasites, abdom- Reflex causes inal adhesions, gastro- and enteroptosis, disorders about the genital apparatus, especially the ovaries and uterus, hemorrhoids and abdominal plethora in general, may all reflexly, in predis- posed subjects, irritate the heart in such a way that palpitation is produced. Prophylaxis To prevent the attacks of palpitation the underlying cause must be treated. In palpitation resulting from over-exertion or fatigue, especially in individuals whose heart is congenitally small or whose arteries are narrow, or in subjects with a thorax paralyticus or a phthisical habit, the amount of exercise must be carefully regulated. Such individuals must learn how much Exercise physical exercise they can stand without developing palpitation and should carefully train the heart to increased labor by means of Schott and Oertel exercises or hydriatic means (see page 23). Very hot baths, and, above all, Turkish baths, should be forbidden such subjects and the use of coffee, tea, alcohol and Bathing tobacco should be restricted or stopped. In phthisical patients particularly the administration of heart tonics and analeptics should be carried out very conservatively and preferably re- served only for emergencies. In palpitation occurring in organic disease of the heart in ^rDit^t" 11 * °'n subjects who are not neurotic, the treatment is synonymous with organic heart the treatment of the underlying cardiac disorder. One should isease constantly remember that palpitation is often an early sign of valvular disease so that the diagnosis of nervous palpitation should always be made very guardedly. Heart tonics judi- ciously administered according to the principles described under compensated valvular disease, especially when combined with drop doses of the tincture of aconite, will relieve the palpitation in these cases. If the palpitation is purely neurotic in type without organic Neurotic type disease of the heart a rest cure and appropriate hydro-thera- peutic measures, as lukewarm baths, are particularly valuable in reducing the frequency of the attacks. Suggestive therapy also helps. The patients should be carefully instructed in re- gard to the purely functional character of their heart symptoms and should be encouraged not to worry. All emotional or men- tal strain should be strenuously avoided. The patients should be instructed to reduce the use of tea, coffee, alcohol and to stop smoking;. Particular care should be taken to find possible re- 68 PALPITATION Diet in neu- rotic cases Drugs in neu- rotic cases Valerian Bromides Mux vomica flex causes for the palpitation, and, for this reason, the genital apparatus, the rectum and the nose should be carefully exam- ined and any abnormalities corrected; intestinal parasites should be looked for and removed; the function of the stomach and intestine should be regulated. The exact arrangement of the diet must depend on the functional state of the digestion and, for this reason, careful analyses of the stomach contents should be made from time to tjme and treatment instituted accord- ingly. No general rules can be formulated except that the meals should be small in order to prevent over-loading and distension of the stomach and should contain little carbohydrate in order to forestall fermentative dyspepsia, flatulency and meteorism. The food should never be too hot nor too cold, nor should it con- tain strong spices. In purely neurotic cases valerian and bromides are the most useful remedies for continuous use. Sodium bromide in ten to fifteen grain doses, two or three times a day, combined with the ammoniated tincture of valerian, one to three drachms (4 to 12 ec), and the tincture of nux vomica five to ten drops, is a useful combination; or the pill of the three valerianates (Good- dell) may be used to advantage, viz: i? Quinine valerianate, Iron valerianate, Ammonium valerianate, aa 1 gr. (0.06 gm.) M. Sig. One such pill two or three times a day. Symptomatic treatment of the paroxysm Deep breath- ing Counter-irri- tation of the nasal mucosa Faradization of the vagus Counter-irri- tants to pre- cordium The treatment of the paroxysm does not differ materially from the preventive treatment, excepting that somewhat more energetic measures are employed. Any reflex stimulation of the vagus usually stops the paroxysm. This reflex stimulation may be produced by instructing the patient to breathe deeply; or by the use of smelling salts or iodo-glycerin applied to the nose on a probe; or by an indifferent alkaline nasal spray. In very severe cases faradization of the vagus and neck, as de- scribed in the Section on Exophthalmic Goitre (page 106) is often useful. Clothing that is tight about the chest and waist should be removed. A belladonna or mustard plaster may be applied to the precordial region. Better still is the application of cold in the form of an ice bag, for both the cold and the pressure upon the heart and, in hysterical cases, the suggestive effect, aid in quieting the heart; at the same time hot water bags may be applied to the feet and the legs vigorously rubbed. Some pa* PALPITATION 69 tients of the neurotic type derive almost instantaneous relief from compression of the heart by means of a pelotte arranged like a truss, to be adjusted around the thorax as soon as palpitation occurs. Here, too, a suggestive element presumably plays an im- portant part. The medicamentous treatment in cases due to organic disease Cardiac of the heart consists in the use of strong cardiac stimulants (hot stimulants coffee, brandy, digitalis, camphor, ether, ammonia, see page 32. The special treatment of palpitation in compensated aortic in- sufficiency has already been discussed on page 19. If the blood pressure is very high, amyl nitrite may be inhaled. If there is no organic disease of the heart and no dilata- Aconite tion from over-exertion, then the tincture of aconite in drop doses every hour is the most efficacious remedy. Often in such cases a few whiffs of chloroform, or one-fourth grain of mor- chloroform phine, hypodermically, also stop the paroxysm promptly. So- Morphine dium bromide and chloral, ten grains of each, repeated every m ide hour and a half or two hours for two or three doses, will prevent clll oral the recurrence of the attack. This combination, too, is valuable as a prophylactic measure in nocturnal palpitation. Here, if given just before retiring, the restlessness and sleeplessness are allayed and the nocturnal attack of palpitation prevented. In purely hysterical cases the ammoniated tincture of vale- Valerian rian, one to three drachms (4 to 12 cc.) or asafetida, preferably Asaf etida given as the Aloes and Asafetida Pill in four to eight grain doses, occasionally stop the paroxysm. That a strong mental suggestion should be attempted in all cases of hysterical or neurasthenic palpitation need hardly be repeated. Very often a command on the part of the physician to exercise self-control will stop the palpitation. In other cases the repeated assur- ance that there is no danger, or soothing suggestions and, in extreme cases, hypnosis, may be more effective than a command. If the bowels are constipated when the attacks come on, or Catharsis if there is evidence of much abnominal plethora (hemorrhoids), meteorism or flatulency, a brisk saline cathartic, i. e., a table- spoonful of sodium or magnesium sulphate and a colonic flush- ing should be given. If there is evidence of acute distension Lavage of the or dilatation of the stomach, then evacuation of the stomach con- s omac tenets through a stomach tube followed by lavage (see index) often suffices without further medication to stop the paroxysm of palpitation. 70 ARRHYTHMIA ARRHYTHMIA. Irregular heart action, abnormal slowness or rapidity of the heart, may either accompany a variety of organic disorders of the heart and arteries, chiefly myocarditis and dilatation oc- curring in the course of infectious diseases or of arteriosclero- sis ; or they may be a part symptom of some organic lesion of the nervous system or of a functional neurosis; or, finally, they may be the result of intoxication by alcohol, tobacco, coffee, lead, etc. The different varieties of irregular heart action, viz., in- termittent, paradox, bigeminal and trigeminal pulse, embryo- cardia, bradycardia, tachycardia, gallop-rhythm and delirium cordis must all be carefully analyzed and the underlying causes determined. If due to valvular lesions or myocardial or arterio- sclerotic changes, these conditions should be treated as described under those disorders. If due to cerebro-spinal disease (syphilis, sclerosis, gumma, hemorrhage), then large doses of iodides should always be given a trial. If due to a functional neurosis, then this should be treated, at the same time reflex causes in dif- ferent organs should be sought for and removed. Th3 toxic varieties self-evidently call for the withdrawal of the toxic agent. It will be seen, therefore, that the different forms of irreg- ular heart action call for similar causal treatment as palpita- tion. The symptomatic treatment is altogether identical with that of palpitation; in fact, the combination of arrhythmia and palpitation, especially tachycardia and palpitation, is the rule. For the details of this treatment I, therefore, refer to the Section on Palpitation. Slow pulse (bradycardia), it may be remem- bered, finally, is often a physiological phenomenon, in no way endangers the life of the patient and calls for no special treat- ment CHAPTER II. DISEASES OF THE BLOOD. I. THE ANEMIAS. The nomenclature and classification of the anemias is involved Nomenclature and confusing. Every anemia is characterized by a reduction of the hemoglobin (oligochromemia). Pernicious anemia is char- acterized by the appearance of morphological elements in the blood (megalocytes and megaloblasts) that are not normally present ; in other words, there is always a qualitative perversion of the blood-forming function, involving chiefly hemopoesis in the bone marrow (megaloblastic degeneration and reversion to an embryonic type). In simple anemia there is merely under- or over-activity of this function without qualitative perversion. Until recently the pernicious variety was called primary (progressive) anemia, and the simple variety, secondary anemia. This nomenclature is incorrect, for pernicious anemia is by no means always a disease sni generis, nor "idiopathic," but often like simple anemia directly traceable to definite and determinable causes; and simple, so-called secondary anemia not infrequently develops into pernicious, so-called primary anemia. For the sake of clearness, therefore, the anemias in this chapter will de discussed under the headings of progressive pernicious anemia, simple anemia and chlorosis; the latter dis- order presenting the blood picture of a simple anemia, but dif- fering from all other simple anemias, both in regard to its gene- sis, its blood pathology and its treatment, and hence calling for special and separate discussion. PROGRESSIVE PERNICIOUS ANEMIA. The causal treatment of pernicious anemia must consider Causal treat- many factors. Many cases of progressive pernicious anemia have ment been found to be due to the presence of intestinal parasites, nota- bly bothriocephalus latus, so that in all cases this intestinal parasite should be looked for, and removed, if it is found. Here Intestinal the results are brilliant, for this variety of pernicious anemia i mrasites is distinctly curable by removing the cause. Other parasites of the bowel can also be incriminated with producing pernicious anemia, and, for this reason, anthelmintics, administered as de- 72 PROGRESSIVE PERNICIOUS ANEMIA Autotoxemia from the bowel Gastric atrophy Blood para- sites Syphilis Pregnancy General hygiene Rest Diet Hydrotherapy Arsenic scribed under Diseases of the Intestines, should as a prelim- inary step always be given a full trial in every case of progress- ive pernicious anemia that comes under observation. There is also some evidence to show that other forms of bowel intoxication may occasionally produce pernicious anemia, and for this reason free evacuation of the bowel contents should be promoted in all cases by the administration of laxatives; the latter being to advantage combined with some of the intestinal antiseptics (see index). Still other forms of pernicious anemia develop as the result of atrophy of the gastric or intestinal glands, so that it is very important to make a careful analysis of the stomach con- tents to determine the state of the stomach function and to treat any perversion according to proper rules. Again, blood parasites, notably the Plasmodium of malaria, filaria sanguinis and distoma hematobium should be looked for and their removal attempted. Here quinine and other drugs as described elsewhere are the best remedies. Syphilis, toe, occasionally produces pernicious anemia and antiluetic treatment will lead to the goal more rapidly than any measures directed towards improving the con- dition of the blood symptomatically, although the prognosis, in syphilitic anemia of the pernicious type, is not favorable even under antisyphilitic medication. The same applies to the per- nicious anemia occasionally seen in pregnant women. Statistics show that even the induction of premature labor and the removal of the fetus exercise no beneficial effect on the pernicious anemia of pregnancy after it has once become established. Aside from all this causal treatment the general hygiene is very important. The patient should be put to bed and kept there for weeks until the blood picture improves, i. e., until a remission occurs. During the period of rest the diet should be arranged according to the condition of the stomach and bowel functions. A bland, non-irritating diet consisting chiefly of milk, cereals, eggs, fresh fruits and vegetables is usually well borne. The patients, as a rule, have a very strong aversion to meat, and meat- eating should not be forced, especially as the hydrochloric acid secretion in the stomach is usually greatly reduced in pernicious anemia. Hydro-therapeutic measures, on account of the weak- ened condition of the patient, the impoverished state of the blood and the deficient vaso-motor reaction, had better be omitted, at least during the active stage of the disease. The best remedy to administer in pernicious anemia is arsenic. This drug does not cure the disease, but it certainly aids in im- proving the condition of the blood, and hence in removing many ol the most distressing symptoms that are attributable to the PROGRESSIVE PERNICIOUS ANEMIA 73 deficient nutrition of various organs, that results from the de- crease of hemoglobin in the blood. Arsenic may be administered Dose and ad- either in the form of Fowler's solution or as arsenious acid. It ministratl011 is best to begin with small doses, gradually increasing them, and to keep the patient for a time just below the maximum dose that has been reached; then gradually to reduce the dose again. Some authorities advise beginning at once with large doses, but I have never been able to convince myself that this treatment is more efficacious or more rapid in its results; in fact, I consider it occasionally dangerous, in view of the possible idiosyncrasy of the patient against arsenic and on account of definite contra- indications to its use that may not be discovered until the drug is being administered. Such contra-indications are the existence of dyspeptic symp- Contra-indi- , . .,. , -, „ ., ., . . f 7 ., , cations to the toms and of diarrhea before the drug is given, or their develop- use of arsenic ment soon after its exhibition. In all these cases arsenic should be discontinued until the diarrhea is checked or the dyspeptic symptoms are relieved. Sometimes, in very urgent cases, these contra-indications to the use of arsenic may be neglected; care being taken that some measures are instituted that can counter- act the bad effects that we must expect from the use of the drug ; thus arsenic given by mouth with abundant quantities of fat is occasionally well borne; or the addition of opium to an arsenic preparation may sometimes effectually counteract the tendency to diarrhea. In treating patients in this way we are on the horns of a dilemma, and are simply choosing the least of two evils ; for it is often most important to use arsenic, even though distress- ing symptoms are produced by its administration. If Fowler's solution is used one should begin with ten drops Fowler's in water or milk, three times a day after eating, gradually in- so u 10n creasing the quantity by a drop a dose a day, i. e., by three drops a day. As a rule, this increase can be borne for about ten days, i. e., until the patient is taking sixty drops during the twenty-four hours. Occasionally symptoms of arsenic poisoning appear before the maximum dose is reached. The patients then complain of burning in the mouth, thirst, dyspeptic symptoms with eructations and pain in the epigastrium, some puffiness about the eyelids and the appearance of red blotches in different parts of the body. When such symptoms appear, the dose of arsenic should at once be reduced and occasionally it may even become necessary to stop the drug altogether until these symp- toms disappear. Arsenious acid is best given in the form of the so-called Asiatic pill Asiatic Pills, which contain some pepper. The latter stimulates the secretion of hydrochloric acid and aids in the rapid abs^rp- 74 PROGRESSIVE PERNICIOUS ANEMIA Arseniated mineral waters Hypodermic administra- tion of ar- senic Cacodylate of soda Iron not indi- cated Bone marrow Hemoglobin Transfusion of healthy blood Technique of transfusion tion of the arsenic, thereby, in a measure, preventing injury to the gastric mucosa by the drug. One should begin with one such pill a day, gradually increasing the dose until six, or eight, or ten pills are taken a day. This latter dose corresponds to about sixty to seventy drops of Fowler's solution. Still another method of giving arsenic, in case neither Fow- ler's solution nor arsenious acid can be borne, is to use arseniated 1 mineral waters. A number of these waters are on the market (Lithico water, Roncegno, la Bourboule, Guberquelle and oth- ers). Most of these contain very small quantities of arsenic combined, as a rule, with iron. They should be administered at first in small quantities, preferably in tablespoon doses, gradually increasing the amount until a wine glass full, two or three times a day, is being taken. Their composition, however, is not con- stant and one is never sure of an arsenic effect when giving these waters. The hypodermic administration of arsenic is not to be advised in pernicious anemia, for disagreeable local symptoms are very apt to appear. The only arsenic preparation that can be given with safety is the cacodylate of sodium, in the strength of 1 to> 500, in 10 cc. doses, once or twice a day. I have had the impres- sion, however, that this method of administering arsenic, useful though it may be in certain other conditions, notably chorea and leukemia, is of very subordinate value in pernicious anemia, and certainly inferior to the administration of arsenic by mouth. Iron is not indicated in pernicious anemia. My opinion is that it does more harm than good, for it seems to exercise no effect upon the constitution of the blood, while it usually irritates the stomach and disturbs the digestion. Bone-marrow was, at one time, employed in the treatment of pernicious anemia, but its use is being abandoned. I have never seen any good results from its exhibition. The same applies to the administration of dried blood or hemoglobin in solution by mouth or per rectum. In every advanced case of pernicious anemia, in which the patient is in imminent danger of his life, transfusion of blood from a healthy subject, or of physiological salt solution, or the injection of the latter by hypodermoclysis, are exceedingly useful measures. The transfusion of blood from a healthy individual to the patient should be performed as follows : A compression bandage is applied about the arm, both of the healthy individual and of the anemic subject and the anterior surface of the arm of each thoroughly cleansed with soap and water, 1 to 1000 bichloride solution, alcohol and ether; a hollow needle connected with a PROGRESSIVE PERNICIOUS ANEMIA 75 thin rubber tube is now inserted into a vein of the healthy sub- ject and about 50 cc. of blood aspirated with a syringe. At the same time an assistant inserts a similar needle connected with a rubber tube into the vein of the patient, allowing a few drops of blood to ooze out of the tube, and then rapidly connects it with the syringe containing the blood from the healthy subject. This blood is now slowly injected into the veins of the patient, and the operation repeated four or five or six times in the course of five to twenty minutes. That everything should be rigidly sterile need hardly be mentioned. It is always safer to have a number of syringes ready, so that a new syringe can be used for each transfusion, otherwise there is always danger of coagulation occurring in the syringe or its nozzle, with the possibility of forcing a fibrin coagulate into the veins of the patient; such an accident would, of course, be fraught with very serious conse- quences. This method of transfusion is called the direct method. There is also an indirect method. It is more complicated, Indirect meth- less safe and not so easy of execution. It consists in withdraw- f us io n rans " ing about 400 cc. of blood from the normal subject by venesec- tion, rapidly defibrinating this blood by beating it with a glass rod, filtering off the clot and injecting the plasma through an ordinary transfusion apparatus into the veins of the patient. In performing this operation the canula leading from the trans- fusion apparatus must be tied into a vein in the patient's arm. This requires dissecting out the vein, a manipulation that calls for considerable skill and most rigid asepsis, and that, besides, is more painful than the insertion of a canula or trocar needle directly into the vein. Many patients react to this transfusion by a chill, a rise of Disagreeable temperature and sweating, all symptoms that are presumably due se( iuelae fo1 " to a ferment intoxication. Sometimes during the injection of fusion, blood the patient becomes cyanotic and dyspneic ; these are indi- cations to stop the infusion of blood. The results obtained from this practice are exceeding vari- Results able; some patients improve immensely at once, in others no effect whatsoever is observed, and in still others the disagree- able consequences enumerated above make their appearance. A few deaths have been known to follow transfusion. The method nevertheless should, at all events, always be given a trial, espe- cially when the cases are in so desperate a position that any measure, however dangerous it may be, becomes justifiable. Next in importance to the transfusion of blood is the trins- Transfusion fusion of normal salt solution, containing about 0.8 per cent of of normal salt sodium chloride to a litre of water; or this salt solution car? be 76 SIMPLE ANEMIA Hypodermo- clysis Treatment during* remis- sions Symptomatic treatment injected under the skin as follows:. The sterile solution is poured into a fountain syringe that is elevated about two or three feet above the bed; the fountain syringe is connected with a rubber tube that branches out into two ends each connected with a hollow needle ; the two needles are inserted either into the skin of the thigh or of the abdomen or into the pectoral fascia under- neath the breasts. From one to two litres of the solution may be injected in the course of from ten to fifteen minutes, care being taken that the region into which the fluid is injected is mas- saged during all the time the solution is flowing; this greatly facilitates the absorption of the salt solution. This method is quite painful and occasionally requires chloroform narcosis. The results obtained from saline solution are not so favorable by far as those obtained from the transfusion of normal human blood. During the periods of remission the patients should continue the use of small doses of arsenic. They should live on a nourish- ing diet similar to the one described above, and should preferably seek a resort with a moderately temperate climate, with the max- imum of sunshine and clear days, where they can lead an out- of-door existence, preferably at a moderate altitude, not exceed- ing three thousand feet. Sooner or later in the disease the condition will become aggra- vated again, provided the anemia is not due to intestinal para- sites. As soon as the condition of the blood becomes bad and the patients grow weak again, they should at once be put to bed and energetic treatment immediately instituted. Symptomatic treatment is synonymous with the treatment of the organs whose function becomes deranged ; thus the gastro- intestinal, the cerebral symptoms, the symptoms about the heart, the hemorrhages, should be treated as described in other sections. Indications for treating simple anemia SIMPLE ANEMIA. Simple anemia is always a symptom of some underlying dis- order, hence the treatment, broadly speaking, is synonymous with the treatment of the cause that produces the impoverish- ment of the blood. Every effort, therefore, should be bestowed upon finding this cause and removing it. Occasionally, however, simple anemia persists even when the underlying cause is re- moved, as, for instance, the anemia developing after internal or external hemorrhages, profuse vomiting, pregnancy, intoxication by intestinal parasites and various infectious diseases. In all of these cases the resulting anemia would, in all probability, heal spontaneously in time, but nevertheless it often becomes SIMPLE ANEMIA 77 necessary to aid Nature in. its reparative endeavors as other- wise serious nutritional disorders would develop in different organs. Again, the disease which produces the anemia may be very chronic in character, so that while the cause of the anemia is known it may be difficult or impossible to remove it. This applies particularly to the simple anemia seen in tuberculosis, in chronic suppurative processes, after prolonged lactation, in malnutrition due to stenosis of the esophagus or organic diseases of the stom- ach, in nephritis, syphilis, chronic malaria and in various forms of chronic, poisoning. Here the anemia attains almost the dignity of an independent affection and urgently calls for special treat- ment. It is well to realize that in anemia due to chronic dis- orders of an irremediable character it is usually impossible to completely restore altogether normal conditions in the blood. Very much, however, can be done in this direction and no effort should, therefore, be spared to attain the best possible conditions. In the treatment of anemia the regulation of the diet is a very Diet important element. It is clear that every effort should be ad- vanced to maintain nutritive equilibrium, that is, to supply an amount of food sufficient to enable the organism to put forward its best efforts towards producing the regeneration of the blood. This can never be accomplished if the patient is chronically underfed. Unfortunately, in simple anemia the gastro-intestinal function is frequently perverted. This must be attributed to the malnutrition (resulting from an inadequate blood supply) of the gastric and intestinal glands and of the nerves supplying them. For this reason it is a matter of great importance in ar- ranging a dietary for an anemic case to carefully study the con- dition of the gastric function by means of test-meals and accord- ing to methods described in the Chapter of Diseases of the Stom- ach. The diet should then be accommodated exactly to the func- tional powers of the stomach and intestine. Broadly speaking, the diet should contain an abundance of Much albumen albuminous food. In cases of hyperchlorhydria this regulation is, of course, very easy to carry out. If there is a lack £>f hydro- chloric acid, then the latter must be supplied if an albuminous diet is administered. Meats of all kinds, preferably raw or rare, fish, game, eggs, milk are all very useful articles of diet. In addition there should be plenty of fresh fruits and vegetables. Whether or not it is of advantage to give foods that contain rela- tively large quantities of iron is doubtful, because the amounts of iron contained in these foods can be more readily supplied medicinally; nevertheless, yolk of egg, spinach, apples and all articles that contain relatively large amounts of iron may with- 78 SIMPLE ANEMIA Lack of appe tite out harm be liberally supplied. Carbohydrate foods, that is, cereals, bread, rice, potato, sweets should be given sparingly and fats should be given in moderation. If the anemia is primarily due to some gastro-intestinal dis- order, then exceptional care must, of course, be exercised in selecting a diet. This applies particularly to cases of anemia developing upon the basis of gastric or intestinal hemorrhage from ulcer. Here it may become necessary to put the stomach completely at rest for a time and to feed the patient exclusively Bectal feeding by rectum. The technique of rectal feeding is fully described under Stomach Diseases. Proper feeding in anemia is often rendered difficult because, many patients with simple anemia suffer from lack of appetite. This element can usually be corrected by the use of bitter tonics, as tincture of cinchona, in doses of one to two drachms; tincture of nux vomica, five to twenty drops; compound tincture of cardamom, one to two drachms; or orexin, in five grain doses. Very often anemic patients are benefited by drinking on rising, and fifteen to twenty minutes before each meal, a glass of hot water containing one-third of a teaspoonful of bicarbonate of soda. In severe cases of anemia rest, bodily, mental and psychic, is of the greatest importance. In the anemia following severe hem- orrhage, either internal ar . d to *^ e of albumens in the bowel, forming insoluble iron sulphid, and in chlorosis in this way protecting the organic iron compounds of the food and rendering them available; but there is little tangible evi- dence to show that this theory is correct; for, otherwise, any of the heavy metals that can combine with sulphureted hydrogen to form heavy sulphids should fulfill the same purpose, and this is not the case. Still others imagine that the iron, owing to its astringent properties, stimulates the gastro-intestinal mucosa to increased activity and hence improves nutrition. Im- material what the theoretical indications for the use of iron preparations in chlorosis may be, the empiric fact remains that it is, in most cases, the sovereign remedy that can improve not 84 CHLOROSIS Choice of iron preparations Organic and inorganic compounds of iron Blaud's pill Perchloride of iron Reduced iron Pill of aloes and iron Citrate of iron and quinine only the condition of the blood, but also all the other disagreeable phenomena that complicate the disease picture of chlorosis. It is difficult to decide whether so-called organic or inorganic preparations of iron are more useful. Personally, I have never seen any reason to use other than the ordinary inorganic preparations, for there is no evidence to show that the numerous organic preparations of iron are either more rapidly absorbed or less irritating to the gastro-intestinal tract, or clinically more effective than the inorganic preparations. As a matter of fact, any iron preparation is converted in the stomach into the chlo- ride; this usually combines with albuminous material to form an albuminate of iron, which, passing into the duodenum, is in part, as shown above, absorbed and deposited in the spleen and liver for future use, while the bulk is eliminated in the stools. The best iron preparation of all is Blaud's Pill, containing sulphate of iron and the carbonate of potash. This pill acts beneficially, first, on account of the iron carbonate it incorpor- ates, second, presumably, on account of the potassium it con- tains, for the latter is an important constituent of the red blood cells, and, finally, on account of its content of sulphuric acid which readily combines with toxic aromatic products derived from putrefactive processes in the bowel, converting them into non-toxic aromatic sulphates (indican and its congeners). The tragacanth, finally, that these pills incorporate possesses some laxative property which is useful. One to four pills may be given two or three times a day, preferably after eating. It is usually best to begin with small doses, say one pill three times a day, and then to gradually increase the dost until four or five pills are taken three times a day. Another excellent iron preparation is the tincture of the perchloride of iron, which may be given in doses of from five to fifteen drops three times a day. This medicine should always be taken through a tube in order to protect the teeth. Reduced iron, in doses of one to five grains (0.05 to 0.3 gm.) in capsule, is also a very useful inorganic preparation. It is impossible to enumerate all the other preparations of iron that might be used. The three named above usually ful- fill all the requirements. The Pill of Aloes and Iron may be mentioned, because it is particularly useful in chlorosis com- plicated with constipation. This pill contains sulphate of iron, the proper dose being four to eight grains three times a day. Another valuable official preparation is the Citrate of Iron and Quinine, containing ll^ per cent, of quinine and 14J<£ per cent, of iron, and given in doses of five to ten grains two or three times CHLOROSIS 85 a day. The quinine in this pill is useful especially in cases that are characterized by great nervous asthenia, for the quinine un- doubtedly acts as a cerebral tonic. Among the organic preparations the following may be enu- Organic prep- merated, although, as stated above, none of them, in my opinion, ara 10ns possesses any advantage over the inorganic preparations, none is so reliable, so stable or so inexpensive. Ferratin, in doses of from eight to twenty grains (0.5 to 1.3 gm.) per diem. Carni- Ferratin ferrin, containing 35 per cent, of iron and combined with sarcinic , T arni e J™ ' r Hemoglobin acid, and given in doses of from five to ten grains (0.3 to 0.6 p e ptonates of gm.) three times a day. Hemoglobin itself may also be used. iron The various albuminates and peptonates of iron possess no par- ticular advantages. The administration of iron in combination with manganese is no more effective than the administration of Iron and man- iron alone, although extravagant claims have been made for this ^ anese therapy. There are certain contra-indications to the use of iron and Contra-indi- there is occasionally difficulty in administering it; thus in very U s e 10 of S iron * severe dyspeptic disorders, such as we not uncommonly see in chlorosis, iron occasionally aggravates the gastric symptoms. In such cases the dyspepsia should first be treated, as described in the Chapter on Diseases of the Stomach, and iron not given by mouth until the gastric symptoms are relieved; if need be iron may here be given by rectum, in the form of the tincture of iron in starch enema. Occasionally cases of chlorosis suffer from severe gastralgia, which is markedly aggravated by the ad- ministration of iron; in such cases the hyperesthesia of the stomach should be first treated by the use of hot applications to the epigastrium, a milk diet, small doses of cocaine, as de- scribed on page 19, or of silver nitrite (see index) ; or mem- thol, preferably combined with some alkali may be given in small doses (0.05 to 0.1 gm.) a day. The use of iron waters is occasionally beneficial, especially iron waters if the waters can be taken at the resort where the iron source is. The use of bottled iron waters, however, is, as a rule, use- less, because most natural iron waters contain the iron in solu- tion as a carbonate; when they are bottled the carbonic acid evaporates in great part and the iron precipitates out, so that the water itself contains practically no iron. This objection does not, however, apply to waters containing the sulphate or chloride of iron. Arsenic is less important in chlorosis than in other forms of Arsenic anemia. As it possesses a general tonic effect in small doses, its administration, however, can do no harm. It is best given in the form of Fowler's solution, beginning with small doses, e. g., 86 LEUKEMIA Dyspnea Palpitation Bleeding Sweating three to five drops in plenty of water three times a day and in- creasing the dose a drop a day until fifteen to twenty drops are being taken in the twenty-four hours ; and then the dose should gradually be reduced, and, if necessary, a second course of this kind instituted. The existence of dyspeptic symptoms, however, is a distinct contra-indication to the use of arsenic in chlorosis. Symptomatic treatment of the cardio-vascular signs is rarely necessary, because they improve under rest and iron. The dyspnea, therefore, and the palpitation (see page 65) that these patients complain of rarely calls for special treatment. A word of warning may be uttered in regard to the dangers of bleeding cases of chlorosis, a practice that has recently be- come popular again. The plethora is removed only for a short time by venesection; and in chlorosis especially, owing to the disturbed vaso-motor tone, a reactive outpouring of fluid' into the blood soon occurs, so that the purpose of the bleeding is immediately counteracted or even over-balanced and nothing is gained. The one possible benefit that could accrue from bleeding must be attributed to the profuse perspiration that usually fol- lows venesection in chlorosis; but this beneficial stimulation of the lymph flow, and the loss of fluid through the sweat glands, can be produced much more easily by hot baths or hot air. Sweating, therefore, is often useful in chlorosis for it promotes concentration of the blood and hence better nutrition because each unit volume of blood contains more hemoglobin. In chlo- rosis particular care, however, must be exercised to prevent cere- bral anemia from sweating by heat, so that this treatment should never be instituted with the patient sitting up, and cold appli- cations should always be made to the head while the patient is being sweated. Leukemia and pernicious Leukanemia Causal treat- ment II. LEUKEMIA. Although the blood picture of leukemia differs altogether from that of pernicious anemia, the two classes of blood disorder, nevertheless, must be considered as pathogenetically related; for in both instances we have some noxious agency, presumably toxic in character, affecting the blood-forming organs and chiefly the bone-marrow. Occasionally individual cases are seen in which both the red and the white cells are simultaneously affect- ed, so that a disease is produced that occupies an intermediary position on the border line between pernicous anemia and leuke- mia. This has been called leukanemia (Leube). The causal treatment of leukemia is therefore the same as that of pernicious anemia, in both cases unfortunately equally LEUKEMIA 87 unsatisfactory, because iu neither case do we know where to concentrate our attack. In leukemia, in fact, we know even less what indicatio causalis to meet than in pernicious anemia. Nevertheless, every effort should be put forward to look for a possible cause and particular attention should be bestowed above all upon bowel antisepsis and the removal of intestinal parasites. Free evacuation of the bowel contents, and treatment directed towards any systemic disorder (syphilis) that may be present and that might even remotely be accused of causing the leukemic blood picture, should be energetically instituted. The treatment, causal and symptomatic, of the different Splenic, forms of leukemia is the same. The old pathogenetic differ- iymphatic ences between splenic, lymphatic and myelogenous leukemia that leukemia have been formulated have only an anatomic interest and can no longer be recognized as useful for clinical differentiation. The preponderance, in individual cases, of lymphatic or of splenic swellings is nowadays considered to be of subordinate import- ance; for hyperplasia of the spleen or lymph glands, or of Both, occurs both with and without lymphocytosis (pseudo-leukemia, see next chapter). On the other hand, leukemia may occur with myeloid degeneration of the bone-marrow and no splenic or lymphatic swellings. We can conclude from this that in leukemia, as well as in pernicious anemia, the inflammation of the bone-marrow is after all the most important and presumably the determining factor. For clinical purposes it is simpler and more exact therefore merely to speak of a lymphocytic and a leucocytic leukemia, indicating in this way that in the former Lymphocytic case the lymphocytes predominate in the blood, in the latter the f^e^a 007 * 10 leucocytes, i. e., neutrophile, eosinophile, polynuclear and mast cells. Leukemia, as far as we know, is presumably never cured, but life can be prolonged, and long remissions with improve- Limitations of ment of the blood picture and great symptomatic relief can be ^u^emia* m brought about, by judicious treatment. The use of remedies in leukemia should be carefully instituted. "Whenever any drug is given the effect should always be carefully watched, for leukemic patients, possibly owing to the perversions of their leucocytic (antitoxic) function seem to be particularly suscep- tible to drug intoxications; moreover, they frequently suffer Care in giving from dyspepsia and diarrhea, all elements that render them espe- J^mic patients cially liable to drug poisoning and that should be included in the calculation both in prescribing drugs and in ordering the diet. The remedy that seems of the greatest value in leukemia is Arsenic arsenic. It should be given as in pernicious anemia (see page 73). Provided the gastric functions are normal it may, how- LEUKEMIA Dose and ad- ministration Sodium arsen- iate Sodium caco- dylate Injection of arsenic Quinine Phosphorus Iodine Extracts of spleen Lymph glands Bone marrow Oxygen ever, with care be given in somewhat larger doses at first in leukemia than in anemia. It is usually safe to begin with three times fifteen drops of Fowler's solution a day during the first week, giving three times twenty drops during the second week, three times twenty-five drops during the third week and, if no toxic symptoms appear, three times thirty drops during the fourth week. This dose should be continued for some time until favorable changes appear in the blood picture, and it may then be gradually reduced by stages. Several courses of arsenic should be given. It is occasionally good practice to change the preparation of arsenic and to alternate with the use of Fowler's solution, sodium arseniate and sodium cacodylate (see page 74). The injection of arsenic into the lymph glands or into the spleen is to be condemned in leukemia (see also page 89). The effects produced by this treatment have never been favorable and, per contra, much damage has been done. (Subcutaneous inflammation and necrosis; infarction and other mechanical injury to the lymph glands and to the spleen; rupture of the spleen; severe hemorrhages; have all been reported.) Quinine has also been recommended very warmly in the treatment of leukemia. It may be given as the muriate of quinine, in doses of five to fifteen grains (0.3 to 1.0 gm.) three times a day, preferably in combination with arsenic or iron. Phosphorus, too, is occasionally of value in leukemia. A very useful prescription is the syrup of iron phosphate with quinine and strychnia. It may be given in half or teaspoonful doses, three or four times a day. Iodine and the iodides are no longer used in leukemia although at one time they were considered to be efficacious. Extract of spleen, lymph glands and bone-marrow are ex- tensively used in leukemia. I have never been able to convince myself of their efficacy; nevertheless, there can be no harm in employing them, as some reliable authorities claim to have seen benefits accruing from their administration. All conclusions, however, in regard to the efficacy of these, or, for that matter, of any other remedy in leukemia must be very conservatively inter- preted, because the disease has a natural tendency to sponta- neous remissions. The inhalation of oxygen occasionally affords symptomatic relief, especially in cases with severe dyspnea and cardiac weak- ness. At least 100 to 150 litres of the gas should be given during twenty-four hours, if any good effects are to be expected. The fact that leukemia occasionally seems to improve if the subjects develop some intercurrent infectious disease, chiefly erysipelas and tuberculosis, has been utilized therapeutically. PSEUDO-LEUKEMIA 89 Tuberculin and erysipelas antitoxin have been injected in some Tuberculin cases with good temporary results. This method, however, is Erysipelas exceedingly precarious, and until further reliable data in re- gard to its efficiency shall be forthcoming it is best to suspend judgment in regard to its use. Local treatment is to be absolutely condemned. At one time it was fashionable to inject arsenic or ergot into the lymph Injections of glands or the spleen, to perform galvano-puncture or even to wniph. glands practise extirpation of large lymph glands or of the spleen. Galvano- Lymph gland excision has never produced any good results in P uncture < leukemia. The practice, moreover, is irrational, because, as stated above, the primary affection must not be sought for in the lymph glands, but rather in the bone-marrow. All the cases in which the spleen was excised died very shortly, probably sooner than they would have died without splenectomy, so that Splenectomy even this operation, however useful it may appear for the pur- pose of relieving great intro-abdominal pressure when the spleen obtains enormous dimensions, must be considered unjustifiable. The diet in leukemia should take into consideration the state Diet of the digestive apparatus, but, broadly speaking, should be abundant and highly nutritious, and should consist largely of nitrogenous material ; and every effort should be put forward to maintain adequate nutrition, in order that the patient may possess the greatest resisting powers to combat the inroads of the disease. Symptomatic treatment of the dyspepsias, of the hemorrhages, Symptomatic of cardiac weakness, are spoken of in the Sections on Diseases complications of the Stomach and Intestine, the Hemorrhagic Diathesis and Diseases of the Heart. For the profuse sweats that frequently torture leukemic pa- Treatment of tients alum applied to the surfaces of the body in one per cent, ^^j^f in solution; or camphoric acid, given by mouth, in closes of from fifteen to thirty grains (1 to 2 gm.) in capsule, or atropin one- •two-hundred-and-nftieth grain {% mg.) repeated, by mouth and hypodermically ; or the extract of belladonna, in quarter to one grain doses, or finally, agaricine, in doses of one-twelfth to one grain (5 to 60 mg.) in pills, repeated, may be used. III. PSEUDO-LEUKEMIA. The prefix "pseudo" placed before the name of a disease is Nomenclature intended to designate a special syndrome that differs from the and definition disease it simulates; pseudo means false. There cannot, how- ever, be a false leukemia but there can be a false name, and ■pseudo-leukemia is in fact merely a designation for a variety of 90 PSEUDO-LEUKEMIA Hodgkin's disease Splenic anemia Banti's disease Pseudo-leu- kemia Spleno-lym- phatica Recurrent glandular fever Tuberculous adenitis Scrofula Sarcomatosis of lymph glands Etiology Causal and prophylactic treatment im- possible Symptomatic treatment diseases that resemble leukemia in some of their manifestations but are not leukemia. Inasmuch as in leukemia swelling of the lymph glands and the spleen is common, many different disorders that lead to lymphatic and splenic enlargements without the characteristic blood picture of leukemia, have been grouped under the name of pseudo-leukemia. In some of these disorders the lymph swell- ings predominate; in others the splenic tumor. All show the blood picture of a simple anemia, occasionally also a lymphocy- tosis. Pseudo-leukemia rarely develops into true leukemia, then namely, as shown in the previous sections, when the bone- marrow becomes involved in the disease process. If the lymph swellings predominate we speak of pseudo- leukemia lymphatica (Hodgkin's disease) ; if the splenic tumor is particularly developed of pseudo-leukemia splenica, or splenic anemia; when it appears combined with hepatic cirrhosis and simple anemia, of Banti's disease. In all cases both the spleen and the lymph glands are probably involved to some extent; if they are both equally involved we speak of pseudo-leukemia spleno-lymphatica. Again, the lymphatic swellings may be accompanied by a remittent or intermittent type of fever, then we have recurrent glandular fever; this form is presumably a tuberculous adenitis, and as a matter of fact many cases of multiple tuberculous lymph gland swellings, as well as scrofula, are often included under the head of pseudo-leukemia. The same applied to multiple sar- comatosis of the lymph glands, that often cannot during life be distinguished from simple lymphadenomata. It will be seen, therefore, that the term pseudo-leukemia covers a multitude of different clinical entities, many of them of unknown etiology. Some of the cases seem to develop on the basis of tuberculosis or malaria, others after diseases of the ton- sils and pharynx, after measles, whooping cough and especially influenza. Given an inherited or acquired syphilis, vulnera- bility of lymphoid tissue, then a variety of noxious agencies seem capable of producing general lymphadenitis and splenitis. What factors determine this disposition and what noxious agencies become operative to cause the swellings, whether they are infec- tious or toxic, endogenous or exogenous, we do not always know. It is clear, therefore, that effective causal treatment and prophylaxis of the various forms of pseudo-leukemia is, in the obscurity of our present knowledge, impossible. Symptomatic treatment is, however, often efficacious in re- ducing the glandular swellings and the splenic tumor, especially early in the disease, and in correcting the anemia that usually PSEUDO-LEUKEMIA 9l complicates this disorder. With, the reduction of the tumors most of the pressure symptoms produced by them promptly yield so that the latter rarely call for special treatment. The chief remedy, again, is arsenic, employed as described Arsenic under Leukemia, i. e., either in the form of Fowler's solution, or as arsenious acid, or in the form of the Asiatic pill (see page 73). All these arsenic preparations, if given by mouth, should be administered after eating. In pseudo-leukemia sodium caco- dylate (sodium dimethyl arseniate) is also a useful remedy. It contains nearly two-thirds parts of arsenious acid and seems Sodlun * . J * cacodylate to be less irritating to the stomach than Fowler's solution or the ordinary arseniate of soda. It should be administered in pill form, each pill containing from one-sixth to one grain (0.01 to 0.06 gm.). From one to six pills a day may be safely ad- ministered, or a watery solution may be employed in the strength of one to fifteen, from five to twenty-five drops a day being given of the latter. After the use of cacodylate of sodium the patients very soon develop a characteristic odor of garlic on the breath. Whereas, in leukemia, the sub-cutaneous or intra-parenchy- i n t ra -paren- matous administration of arsenic in any of its forms is to be con- chymatous in- demned as useless, irrational and dangerous, in pseudo-leukemia arsenic it occasionally acts beneficially. One may either give Fowler's solution or sodium arseniate. If Fowler's solution is used, Technique either for injection into lymph glands or into the muscle tissue, Fowler's solu- preferably of the gluteal and anterior abnominal region, it is best 10n to administer it diluted in the proportion of one to three with water to which one-half per cent, of carbolic acid is added as an antiseptic. Of this solution about V2 cc - should be in- jected at a time in the beginning, and the dose gradually in- creased later on if no untoward symptoms develop. Better than Fowler's solution for injection is sodium arseniate. This is Solution of prepared as follows: 1.0 gm. of arsenious acid is boiled with 5 sodium arsen- cc. of normal sodium hydrate solution until a clear solution is obtained, and 600 cc. of distilled water are then added. In using this solution for injection a Pravaz syringe is filled one- half with water and one-half with sodium arseniate solution and about 1 cc. of this mixture is injected into the enlarged lymph glands. Still another useful preparation for hypoder- mic use is a 10 per cent, solution of sodium cacodylate of which Sodium caco- half a Pravaz' syringe full is injected at a time. The indications for the use of quinine and phosphorus are Quinine-phos- the same as in leukemia. These remedies act as general tonics and occasionally do some good. Iodide of potash also has a Iodide of place in the treatment of pseudo-leukemia; it should be given in the form of the saturated solution, in gradually increasing 92 PSEUDO-LEUKEMIA Local appli- cations Sapo kalinus Iodoform doses. In general tuberculous adenitis I consider this drug dangerous; one should, therefore, always be quite sure of one's diagnosis before employing it. For local application the best remedy is green soap (sapo kalinus viridis) or sapo kalinus. Of this about a teaspoonful is daily rubbed into the skin over the affected glands. Occa- sionally the addition of iodoform to this soap is of use ; for the alkali in the soap loosens the epidermis and permits the free entrance of iodoform into the tissues surrounding the affected gland. A very good mixture is : i* Iodoform, Sapo kalinus, Vaselin, M. 5 gm. aa 20 gm. Iron and ar- senic for the anemia Indications for gland ex- tirpation Treatment of splenic anemia In view of the simple anemia that is generally present, iron, as described in the part on The Anemias, is indicated. One can conveniently combine iron and arsenic by giving the cacodylate of iron, thus : Cacodylate of iron, 1.0 gm. Cinnamon water, 25. cc. M. S. Fifteen to fifty drops three times a day, after meals. In case all these medicinal measures, combined with proper feeding and ideal hygienic conditions, fail to cause the disappearance of the glandular swellings, and especially if cer- tain glands, by . mechanically compressing important nerve branches or blood vessels, produce disagreeable secondary symptoms, then extirpation of the glands becomes necessary. Some clinicians go so far as to claim that the excision of a few of the enlarged glands exercises a beneficial effect upon the whole disease process. Others, again, claim that excision per contra occasionally produces an aggravation of symptoms and accelerated growth of the remaining glands. For the purpose, therefore, of influencing the disease process, gland extirpation is probably a doubtful, possibly a precarious, procedure, and the only real indication for performing this operation is the relief of pressure symptoms. In cases of splenic anemia, i. e., pseudo-leukemia in which the spleen enlargement predominates over the lymphatic swell- ings, arsenic, iron and the other medicines recommended above X-RAY TREATMENT — PSEUDO-LEUKEMIA AND LEUKEMIA 93 are also indicated. Injections of arsenic, however, into the spleen itself are always a dangerous procedure and have so far never produced results sufficiently favorable to warrant their recommendation. On the contrary, disagreeable and dangerous results have often followed this practice so that it is to be con- demned as useless and unwarranted. The application of green soap, or of any other remedies, over the splenic region, excepting as counter-irritants to relieve pain, is useless. Electrization of the spleen, which has also been rec- ommended, is altogether without effect. Cold continuously ap- Cold to the plied to the splenic region occasionally produces at least symp- sp een tomatic relief and has been known to reduce the splenic swell- ings. The ice bag intermittently applied is probably the best and simplest method of producing this result. A variety of remedies have, at different times, been recom- Q umme mended for reducing the splenic tumor, chief among them being uca yp u quiniue and eucalyptus. These remedies, however, presumably exercise their good effect only in cases of large malarial spleen, and they should therefore only be used if the existence of malaria can be determined by examination of the blood; otherwise they are useless. Excision of the spleen has been frequently performed, and Splenectomy in some cases this operation has been followed by very favorable results, especially if splenectomy was performed relatively early in the disease. The main indications for splenectomy in ad- vanced cases are pressure symptoms due to the often enormously enlarged organ; if many lymph glands are involved at the same time the results are far less favorable. The operation, of course, is not without dangers, especially if adhesions have formed in the region of the spleen. The existence of a cirrhosis of the liver is always a contra-indication to splenectomy; consequently in Banti's disease this operation should not be performed. THE X-RAY TREATMENT OF PSEUDO-LEUKEMIA AND LEUKEMIA. (Dr. W. A. Pusey, Chicago.) In pseudo-leukemia the glands may be made to disappear un- p seu a _i eu . der X-rays. This happens not only with superficial glands, but kemia it also happens with glands in the pelvis and in the mediastinum. Where there is cachexia this gradually disappears as a rule pari passu with the disappearance of the glands. The improve- ment is prolonged, but recurrences are apt to take place. Of the first two cases treated with X-rays, one has had two serious re- currences in this time, but these have promptly yielded to X-rays, 94 X-RAY TREATMENT — PSEUDO-LEUKEMIA AND LEUKEMIA Leukemia Spleno-megaly and he has been able to pursue an arduous occupation with the loss of not more than two months' time in the last four years. The other case had a recurrence within a few months, for which an operation was performed, and he died of aspiration pneu- monia. Most of the cases of leukemia treated were spleno-myelogen- ous; a few were lymphatic. The results in both types have been about the same. The effect on the glands, including the spleen, is practically the same as in pseudo-leukemia. In numerous cases spleens filling a large part of the abdominal cavity have diminished until they were hardly palpable. In other cases, however, the diminution in the spleen while marked was not so great. The changes in the lymphatics may or may not be accom- panied by corresponding improvement in the blood. As a rule the blood rapidly improves, and may return to normal in its cellular composition. The cells which are slowest to disappear are the myelocytes; in some cases their percentage will remain high even after the blood otherwise has become normal. In most cases the improvement in the cachexia is more rapid than the improvement in the condition of the blood, and in many cases, in which the changes in the blood was relatively slight, the im- provement in physical vigor has been great. The persistence of the results in leukemia is not as long as in pseudo-leukemia. The disease may be expected to recur, but in many instances the relapses may be treated successfully. There are on record at the present time several cases which, with periods of treatment at intervals of a few months, have remained in a fair state of health for two or three years. I have treated one case of spleno-megaly without blood changes other than anemia, In this case the spleen extended from the brim of the pelvis to the diaphragm, and a hand's breadth to the right of the umbilicus. This spleen diminished with great rapidity so that within six weeks it was just palpable under the border of the ribs ; the patient 's general physical con- dition improved so greatly that he was able to resume his occu- pation and remained in good condition a year later and has, I believe, thus far had no relapse. THE HEMORRHAGIC DIATHESIS 95 IV. THE HEMORRHAGIC DIATHESIS. There are a number of diseases of obscure origin that are ciassifi t' characterized by the occurrence of hemorrhages in various or- Scurvy gans. The chief representatives of this group are scurvy, hemo- Hemophilia philia, and purpura. This classification is more or less Purpura arbitrary and the three disorders are closely related and occasionally merge into one another. Hemophilia, in the overwhelming majority of cases is due to a transmitted hereditary taint and is a permanent con- dition, whereas scurvy and purpura rheumatica are acquired, the former often occurring endemically, usually as the result of mal- nutrition with severe general disturbances ; the latter always oc- curring sporadically, generally without severe systemic disturb- ances and rarely dependent upon definite external conditions. Even in scurvy and purpura, however, one is almost forced to the conclusion that a congenital predisposition to hemorrhages exists by the occasional appearance of scurvy or purpura in subjects who are healthy and in whom none of the predispos- ing or determining factors that are usually incriminated with producing these diseases are operative. The diseases grouped un- der the name of the hemorrhagic diathesis, especially, nowa- days, scurvy, are fortunately very rare, so that their treatment is relatively of subordinate importance and may hence be dis- cussed very briefly. SCURVY. A number of theories in regard to the causes of scurvy Causal treat' exist. There seems to be no doubt that food factors play an men important role in its production. The absence of potassium salts, the excessive ingestion of salted foods, the lack of suffi- cient vegetables and fruits, the lack of fat in the diet have all been accused of producing the disease. At all events, in the practical treatment of the disease fresh vegetables containing potassium salts, viz., chiefly potatoes, cabbage, spinach, water- Diet cress, carrots, turnips, onions, artichokes, asparagus, oranges, and in addition milk, fresh meat, containing the blood, and meat extracts should above all thing's be immediately supplied. As a rule a scorbutic patient if placed at rest and fed on a diet Rest of this character will recover without further medicamentous interference. As a prophylactic measure the use of lemon or orange juice Prophylaxis has been recommended, especially in children who are fed upon artificial foods lacking so-called anti-scorbutic elements, and 96 Hygiene lorseradish Aromatic tonics Yeast Treatment of the gums Surface hem- orrhages Styptics by mouth in individuals, like sailors or arctic explorers, who are forced to live for long periods of time npon a diet consisting largely of preserved foods. In the English navy, for instance, it is a compulsory rule that the sailors be given every day a lemonade- consisting of 14 gm. of lemon juice, 429 gm. of sugar and 112 gm. of water, at dinner. The establishment of ideal hygienic conditions is also of great importance. There seems to be no doubt that lack of light and fresh air, exposure to cold and dampness and lack of proper exercise all contribute towards the outbreak of scurvy,, especially when many subjects are massed together in one dwell- ing for long periods of time. Of remedies that have been recommended herba cochleariae (Horseradish) was for a long time the most popular one. Aro- matic tonics, tannic acid, quinine and many other remedies have- been recommended, but it is generally unnecessary to give these medicines excepting to stimulate the appetite, or as general tonics. Yeast, too, is advised in doses of 200 to 300 gm. daily. Particular attention must be paid to the laceration of the- gums, for this is one of the most distressing symptoms of the disease. Here certain washes are necessary. Peroxide of hydro- gen may be applied directly to the gums, or a permanganate solution, 1 to 300, or a solution of silver nitrate, five grains to the ounce, or chlorate of potash solution, 1 to 50, or equal parts of the tincture of myrrh and catechu. In addition the teeth should be carefully looked after and mechanical irregularities corrected. For the gum hemorrhages adrenalin, in 1 to 1000 solution, or cocaine (10 per cent solution), or iron perchloride (concentrated solution), or gelatine 10 pep cent [sterile) are probably the best remedies. The same local treatment may be used in surface hemor- rhages in other parts of the body. In bloody infiltration of muscles the application of a hot mixture of vinegar, one part, and water, two parts, is frequently very grateful. Occasion- ally ice applied to the bleeding area, or swallowed, in case of gastro-intestinal hemorrhage, is useful. The internal adminis- tration of styptic drugs like ergot, chloride of iron, etc., is useless. Occasionally pressure bandages or tamponade become neces- sary to stop hemorrhages. Surgical measures are always dan- gerous owing to the hemorrhagic tendency that exists. Great care should also be exercised in the use of drastic purges or other drugs that stimulate violent peristaltic movement, for bowel bleeding may occasionally be produced by their admin- istration. HEMOPHILIA 97 HEMOPHILIA. In view of the hereditary character of this disease and the Prophylaxis transmission of the disorder through the females of the family, immaterial whether they be hemophilic themselves or not, mar- riage of the women of "bleeder" families should always be for- Marriage bidden. Male members who are not hemophilic, however, may marry. If it is known that at one time in the family history of a hemophilic man hemophilic children were born from a hemophilic father, then the male members of such a family likewise should be advised against marriage. Individual prophylaxis in all members of a bleeder family Individual is very important, especially during childhood and early adol- prop y axis esence. Thus all operative inroads, however slight they may be, should be avoided during childhood, as circumcision, the re- moval of moles, cutting of the frenum of the tongue, perforating Danger of the ears. Vaccination, however, seems to be without danger in minor oper- ations hemophilia, so that the children can be given the benefit of pro- tective inoculation against smallpox. The care of the teeth is, of course, of the greatest importance Care of the and even slight defects should be treated with the object in teetn view to prevent the necessity of tooth-extraction. Leeching, cupping and vesication should never be practised in children from hemophilic families. The toys that they are permitted to play with should be of such a character that the children cannot injure themselves. Violent gymnastic exercises, in fact, any pursuit that can lead even to slight surface abrasions or other bodily injury should be forbidden. In choosing a calling some occupation should be selected that does not necessitate contact with machinery or the use of sharp tools. The diet in hemophilia should consist largely of vegetables Diet and should be selected approximately on the same principles as the diet in scurvy (see page 95). Alcoholics, tea and coffee, condiments and spices should be reduced, in fact, nothing should be eaten that can irritate the cardio-vascular apparatus. A great number of remedies have been recommended for Medicamen- the cure of the hemophilic tendency, while but few of them have tous treatment vindicated the claims advanced for them by the different clini- cians who have advised their use. The laity have great faith in the use of large quantities of lemons or of other citrous Lemons fruits, and some clinicians report good results from the continued use of citrates. Mineral acids, too, deserve a trial, preferably Mineral acids sulphuric acid, either as acid sulph. dil, ten to thirty drops sev- 98 PURPURA Sulphates Ergot Lead acetate Hydrastis Opiates Treatment of hemorrhages by surgical means Subcutaneous injection of gelatine Calcium chloride Surface hem- orrhages and bleeding into cavities eral times a day, or as acid sulph. aromat., five to fifteen drops. Magnesium and sodium sulphate are also spoken of favorably, the latter remedies possibly acting beneficially from the sul- phuric acid they contain, and through their effect upon the bowels; that is, by promoting watery evacuation and hence pos- sibly greater concentration of the blood and also by counter- acting the absorption of bowel poisons. Ergot, lead acetate, hydrastis, opiates, have all been rec- ommended, but opinion seems to indicate that they are of no value in hemophilia. Hemorrhages, when they occur, must be treated chiefly me- chanically and according to surgical principles, i. e., the bleed- ing part must be elevated, compression applied above the bleed- ing area and occasionally a ligature placed about the afferent artery; thus a case of severe hemorrhage in a hemophilic fol- lowing the extraction of a tooth is reported in which the com- mon carotid had to be ligated before the bleeding stopped. The subcutaneous injection of gelatine may also be tried. A 2 to 3 per cent, neutralized solution of sterile gelatine in physio- logical solution should be heated to body temperature and from 5 to 200 cc. injected under the skin (technique, see Aneurism of the Aorta, page 58). This occasionally stops the bleeding. Calcium chloride, to judge from the case reports that have been published, is of no value. Surface hemorrhages should be treated as described under Scurvy. Joint hemorrhages and hemorrhages into the various serous cavities of the body (pericardium, pleura, peritoneal cavity) epistaxis, etc., call for special treatment, the details of which are described in their appropriate places. PURPURA. Nomenclature Various forms of purpura have been distinguished under the names of purpura simplex, purpura hemorrhagica, purpura rheumatica, syn. peliosis rheumatica or Schoenlein's disease, and Morbus Maeulosus of Werlhoff. All forms of purpura are closely related and the clinical differences are very artificially con- structed. At the bottom of all these disorders is a hemorrhagic diathesis, i. e., generally a pale, tender, vulnerable skin with a tendency to bleeding, and usually an anemic condition of the blood. Such individuals are particularly susceptible to tem- perature changes and hence to rheumatoid disorders, so that the simultaneous appearance of hemorrhages, joint exudates and muscle pains is not to be wondered at (hence the name "pur- pura rheumatica"). Causes The cause of these disorders is not definitely known. Some purpura yy cases seem to be due to an infectious agent (bacillus purpura?, Letzerich) ; in others a ferment intoxication is probable causing chemical blood changes; in still other, more chronic forms, the blood vessel walls seem to be particularly affected (endarteritis with hyaline or fatty degeneration of the muscular layers and fragility of the walls). Some cases seem to accompany chronic nephritis, especially with pronounced cardio-vascular manifesta- tions ; here again a weakening of the vessel walls engrafted upon the hemorrhagic diathesis may be incriminated. From a therapeutic standpoint it is very important to dis- Symptomatic tinguish true purpura from symptomatic multiple hemorrhages Phases due" due to sepsis or accompanying a variety of infections or intox- to sepsis ications (small pox, petechial typhus, cholera, plague, yellow fever, anthrax, acute yellow liver atrophy, phosphorus poison- ing, icterus gravis, snake poisoning, pernicious anemia, etc.). In the septic form of multiple cutaneous hemorrhages one fre- quently finds ulcerative endocarditis with secondary multiple septic emboli in the capillaries of the skin and other portions of the body ; there is also a so-called purpura gonorrheica closely related to the above. None of these forms constitute true pur- pura, although this name is often falsely given them. The treatment here must be directed principally against Causal treat- the underlying disorder of which the hemorrhages are merely an n ^ ent of tne unimportant, and by no means a constant, manifestation. The treatment of true purpura, in view of our ignorance in regard to its etiology, must unfortunately be largely sympto- matic. During the periods of remission that occur, the patient Symptomatic should, above all things, be protected from catching cold ; hence SjJJlSjJJJ 1 * ° f life in a warm climate is to be recommended whenever feasible. Hygienic conditions should be perfect, and above all nervous or emotional shock or over-strain should be strenuously avoided, for in some cases sudden fright or anger have been known to precipitate attacks. The treatment of the attack always calls for rest in bed. The diet should be bland and should be similar to that described ie in the other manifestations of the hemorrhagic diathesis. Cof- fee, tea, alcoholic liquors, spices, condiments and all other articles that can excite the vasomotors should be omitted. For a time, especially in the beginning, milk and cream with some bread or cereal and a little lemonade or orangeade should constitute the food. Particular care should be devoted to the regulation of the Regulation of . the bowels bowel function, and the stools should be carefullv examined for , , ., , Intestinal the appearance of blood, denoting intestinal hemorrhage, which hemorrhage 100 Sulphuric acid Fowler's solu- tion Ergot 01. terebin- thinae Chloride of iron Hydrastis Anti-rheu- matic treat- ment Hemarthrosis Serous hem- orrhage Epistaxis would require special treatment (see index). Intestinal para- sites, that have been accused of some role in the production of the disease, should always be looked for and should be removed, if present, as described in the Chapter on Intestinal Diseases. There is no specific remedy but, according to most authorities, sulphuric acid has been declared a very useful drug. It may be given as acid, sulph. dil. in ten to thirty drop doses, or as acid, sulph. aromat. in iive to fifteen drop doses, in water, sev- eral times a day. Fowler's solution is always indicated and should be given as described under Pernicious Anemia. Ergot, in the form of the fluid extract, in the dose of ten to thirty drops, repeated, is warmly recommended, especially in children. Oleum terebinthinse rect. (dose ten to fifteen drops) is endorsed by no less an authority than Litten. Chloride of iron in doses of one to five drops a day, in milk, or the extract of hydrastis, in doses of twenty to thirty drops every three or four hours, are also spoken of favorably. In all cases of purpura with marked rheumatic manifesta- tions (peliosis rheumatica) an anti-rheumatic treatment should be instituted, as mentioned in the part on Rheumatism (see page 169). It will generally be found that the pain in the muscles and tendon sheaths as well as in the joints stops as soon as the hemorrhages into the joints occur. The special treatment of the hemorrhagic joints (hemarthrosis), of blood extravasa- tions into the serous sacs, of nose bleed, etc., that occasionally occur in this, as in all the other manifestations of the hemor- rhagic diathesis, are discussed in full in the sections on the dif- ferent organs affected. CHAPTER III. DISEASES OF THE DUCTLESS GLANDS I. DISEASES OF THE THYROID GLAND. MYXEDEMA AND CRETINISM. The function of the thyroid gland is either nutritive or antitoxic, i. e., it either supplies something to the blood that is necessary to normal life or it removes something from it that is harmful. Effect . s °/ * e " moval of the Removal of the thyroid is followed within a few days, or thyroid after a longer time (as late as nine months), by anemia and oligemia. There is often an initial rise of temperature, usually followed by a descent to subnormal. In young animals the growth of the bones is retarded and various trophic disturbances develop, the rate of respiration increases, a variety of nervous phenomena are observed that may be either irritative or de- pressive in character, viz., about the motor sphere, fibrillary twitching of the muscles followed later by tetany, contractures or paresis; and in the sensory sphere, first hyperesthesia and later diminished sensibility; and about the heart palpitation and tachycardia. Myxedema Clinically, a similar syndrome is presented in myxedema (synonyms, sporadic or endemic cretinism) and in cretinism (synonyms, infantile or fetal myxedema, myxedematous idiotism, athyreosis chronica,), as well as in operative removal of the thyroid gland {cachexia thyrcopriva if the normal gland is re- moved, cachexia strumipriva if the diseased gland is removed). The conclusion is, therefore, self-evident that these diseases are due to suppression of the thyroid function. Here, therefore, the administration of thyroid gland is the sovereign remedy and the results obtained from this treatment are among the most brilliant achievements of modern medicine. Thyroid ther- ° . . apy m cre- The best results are seen in cretinism. Here the skin soon tinism becomes soft and moist, the bloating disappears, healthy growth of the bony structures, of the hair and of the soft tissues is stimulated, normal development of the teeth sets in and the mental condition improves, so that the patients change from apathetic semi-idiotic children to energetic and active indi- viduals. The younger the subject, the better apparently the result, although all ages seem to react favorably. In a very ♦Portions of this chapter are quoted from my article ou Orgaiio- Therapy in "The Reference Handbook of the Medical Sciences" 102 MYXEDEMA AND CRETINISM In operative myxedema In endemic cretinism Administration of thyroid Distressing symptoms fol- lowing" thyroid medication Thyroidism small proportion of cases thyroid is without result, and one or two cases are recorded in which the disease was aggravated. The unsuccessful cases constitute not quite two per cent, of all those reported in the literature. As it is not excluded that in many of these instances the thyroid preparations employed were worthless, this is a remarkable showing and one that war- rants the use of thyroid in all cases of myxedematous disease in children. Similarly good results are seen in operative myx- edema; and in many instances the disagreeable phenomena fol- lowing ablation of the thyroid gland could be prevented by the administration of thyroid preparations. In the endemic cretin- ism of adults the results are not quite so uniform, for in a cer- tain proportion of the cases only the main symptoms are re- lieved while the minor and probably secondary manifestations persist ; thus the edemas may promptly recede while the cachexia and the phenomena that are consecutive to the anemia in va- rious organs remain uninfluenced by thyroid medication. It is usually necessary to continue the administration of thyroid for some time; if the remedy has to be stopped tem- porarily, for reasons that will be presently discussed, then its use must be resumed again, from time to time, otherwise a recurrence of the symptoms is apt to supervene. This is due to the fact that the use of thyroid is merely a substitution therapy. In cases in which improvement is maintained for considerable periods after the administration of the remedy has been stopped, we must assume that the organism has stored away a certain reserve amount of the organ material. As soon as the latter becomes exhausted, symptoms of myxedema reappear and the recurrence of typical phenomena again calls for the administra- tion of thyroid. In the infantile form a course of thyroid carried on for a sufficient length of time, either continuously or intermittently, often leads to a permanent cure, so that the drug can ultimately be discontinued. This must be attributed to the fact that the substitution of thyroid, by relieving the defective thyroid of an amount of labor that it was unable to perform, has enabled it to develop up to the demands of the growing organism and ulti- mately to assume its normal function; such a favorable result, however, is exceedingly rare. Not infrequently, as indicated above, a congeries of dis- tressing symptoms follows the prolonged use of thyroid that may call, for an interruption of the treatment. The manifold effects that are attributed to thyroid feeding have been grouped under the name of thyroidism (or hyperthyroidism). They are charac- terized in extreme cases by pronounced tachycardia, palpita- MYXEDEMA AND CRETINISM 103 tion, sweating, tremor and emaciation; the latter being due to increased intracellular oxidation ■ and "accelerated" (?) meta- bolism, concerning chiefly the proteids and fats of the body, and manifesting itself by an increased excretion of nitrogen, phos-- phorus and chlorine. Fever and glycosuria are also occasionally observed. The patients develop an enormous appetite and thirst and often complain of headache, nausea, vomiting and weakness. It is doubtful whether these symptoms are due exclusively to the thyroid or whether they are due in part to certain toxic products contained in most thyroid preparations; for especially dried thyroid powder frequently contains ptomapeptones and pepto- toxins that are highly poisonous even in minute quantities. This assumption is borne out by the fact that thyroidin (see below) rarely produces these s} T mptoms, whereas dried extracts or the fresh ( ? ) gland often produce them. Fortunately, we are able in cases that develop symptoms of thyroidism thyroidism to counteract most of these disagreeable effects by the administration of small doses of arsenic, e. g., three to five drops of Fowler's solution given during the day. The results of this arsenic treatment are really remarkable, and it is prob- ably always a safe plan, if a prolonged thyroid treatment is contemplated, to give Fowler's solution in the above dose from the beginning. Various preparations of the thyroid gland are employed. Preparations Bircher, in 1889, first implanted a piece of human thyroid gland under the skin and in this way produced a prolonged thyroid effect with a brilliant result. Grafting of sheep's thyroid has been tried in operative myxedema with good effect, but none of these methods is, of course, practical. Different extracts of thyroid have been prepared with glycerin alone, or with glycerin and carbolic acid and thymol; these are administered hypoder- mically. Another hypodermic preparation is made by extracting thyroid with carbolized physiological salt solution and steril- izing the extract by filtering it through clay filters under high pressure with carbonic acid gas (method of d'Arsonval). Many clinicians advise the use of the fresh gland, raw, by mouth (one- eighth to two sheep's thyroids a day). Good results are also claimed from the administration of the boiled organ, which is more palatable than raw thyroid. Finally, thyroid gland may be finely chopped and given in a clysma by rectum. The most deservedly popular preparations, nowadays, how- ever, are compressed thyroid tablets made from the dessicated gland. These are less disagreeable to administer than the other preparations mentioned and, if manufactured by a reliable house, enable the physician accurately to determine the dose. True, 104 EXOPHTHALMIC GOITRE very little is known of the amount of active principle which they contain, but the same objection applies to all the other preparations. As it is essential to strictly individualize in thy- roid medication, it is at all events of advantage to know that the qualitative and quantitative composition of the tablets is approx- imately uniform. As the fresh gland furnishes about 27 per cent, of dry powder, each unit of powder corresponds to about four times its equivalent in fresh gland. Manufacturers of thyroid tablets usually indicate the amount of thyroid powder contained in each tablet. The common average dose of the des- sicated powder is from one to five grains three times a day. The active principle of thyroid gland is iodothyrin* or thy- roiodin (not thyroidin which is a name for the extract of the gland), a proteid body containing over 9 per cent, of iodine. It may be used in the place of the fresh thyroid extract but seems unable to replace it in all cases. The dose is from one-third to one-half grain (0.02-0.03 gm.) two or three times a day. Thyroidism and exoph- thalmic goitre EXOPHTHALMIC GOITRE. Many of the symptoms of exophthalmic goitre (Graves's dis- ease, Basedow's disease) resemble in their cardinal aspects the syndrome previously described (page 102) as thyroidism or hyperthyroidism, so that this disease is held to be due to ex- cessive activity of the thyroid gland. As a matter of fact many of the symptoms of Graves's disease are attributable to an in- creased secretion of the thyroid gland. Other features can be explained by a qualitative perversion of the thyroid function. In addition, however, there are a variety of signs in this disorder that can only be explained by some functional derangement of the cervical sympathetic and its ganglia, an idea that is borne out histologically by the occasional discovery of lesions in this portion of the nervous system as well as in the central nervous organ, especially in the corpora restiformia. The disorder of the thyroid in Graves 's disease is not due to a compensatory hypertrophy of the gland caused by relatively excessive demands for thyroid secretion as in simple goitre (see -page 109), but it is due to an absolute functional hyperactivity (and disactivity) with vascular engorgement which leads to the entrance into the blood stream of ah excessive quantity of the internal secretion of the gland. To supply thyroid extract in this disorder is, therefore, alto- *It would be of no practical value to discuss in this place the many other so-called "active principles" that have been isolated as, e. g., thy- reoglobulin, iodoglobulin, etc., etc. EXOPHTHALMIC GOITRE 105 gether irrational and paradoxical. It is unfortunate to record Fallacy of that this remedy is, nevertheless, extensively employed in this preparations disease either empirically or from ignorance of the physiological in this disease .action of thyroid extract. There can be no doubt that thyroid always does harm in this disease. There is no case on record of true Graves's disease in which thyroid medication was of benefit, and there are many cases on record in which it did serious harm. Of recent years, the serum and the milk of thyroidectomizecl animals has been utilized in the treatment of Graves's disease. Serum of thy- The principle underlying this method is at least based on more animals** 1126 * 1 sound physiological reasoning. The results obtained from the use of these preparations are for the present, however, ambiguous, And must be interpreted carefully and with great conservatism, especially as Graves's disease usually runs its course with many spontaneous remissions and intermissions. It is best, therefore, to suspend judgment for the present in regard to their efficacy. Thymus has been used in Graves's disease with some good Thymus results. Again, however, spontaneous remissions and intermis- sions must be included in the calculation. As no one has ever reported any bad effects from the use of thymus, the prepara- tions made from this gland may be tried in conjunction with other measures to be presently described. Raw thymus, from sheep, may be given, or thymus tablets. The dose of the latter should vary from five to fifteen grains two or three times a day. The most important general measure to be employed in the treatment of exophthalmic goitre is rest, both physical and psy- Rest chical, for the disease is frequently characterized by emotional -excitement or depression ; therefore the patients should live under conditions and among people where they are safe from emotional excitement, worry, anger and nervous strain. In most cases it is well to take the patient away from home, friends and rela- tions for a period of several weeks. A change of scene alone often works wonders. If a case of Graves's disease is sent to a resort, a low altitude climate and should be selected, for it is a common experience that elevations altitude over two thousand feet frequently induce severe palpitation. Life at a high altitude, moreover, stimulates the nervous system, and in view of the hyper-excitability of the whole nervous appar- atus in these cases, such stimulation should be avoided. The sea shore is never good for these cases, for life by the ocean is detri- mental both on account of its stimulating effect upon the nerves and on account of the deleterious effect it exercises upon anemic patients in general. There is much controversy in regard to the proper diet. Diet 106 EXOPHTHALMIC GOITRE Many clinicians recommend a diet consisting largely of vegeta- bles, cereals, fruit and milk, with the minimum of meat and eggs. Personally I have seen better results from an abundant meat and egg diet combined with the above. In Graves's disease the general metabolism is usually very active and many of these cases rapidly emaciate. The question has not definitely been decided by careful metabolic studies whether the disassimilation of the fats or of the proteids is particularly increased; at all events there is almost invariably a more active proteid metabol- ism than normal, as manifested by the increased excretion of nitrogen. Consequently, severe cases of Graves's disease should ingest more than the normal amount of albumen, otherwise they will attack the proteids of their own tissues in order to make up the deficit. Above all things in this as in any other disease the albumen of the body must be protected and this can only be done by supplying a sufficient quantity of albuminous pabulum by mouth. The patients, as a rule, feel better and stronger and retain their weight if abundant proteid is allowed. It is neces- sary, of course, to strictly individualize in this respect and to take into consideration the tastes of the patient, his previous, habits, the state of the digestion and of the kidneys in each case. The objection that a "meat toxemia" develops on such a diet is theoretically constructed and not borne out by facts. Electricity Electricity should always be given a trial in Graves's dis- ease, for considerable advantage accrues to some cases from its use. The galvanic current is preferably used, although general faradization is recommended by some clinicians, particularly of the French school. If the galvanic current is employed a small ball electrode, connected with the anode, should be applied below the angle of the jaw and slight pressure exercised upwards and inwards. The other electrode should be a flat sponge or plate applied to the back of the neck at the level of the lower cervical vertebra, that is, corresponding to the location of the lower cervi- cal spinal ganglia. Often it is of advantage to change the direc- tion of the current. The current in the beginning should not be stronger than one milliampere and should not be applied for more than three minutes at a time. Both sides of the neck should be galvanized at each sitting. Later, the strength of the current should be gradually increased to three or four milliamperes. At each sitting it should be slowly increased and then decreased. In this way not only the sympathetic, but also the various nerves of the neck that are in close proximity -to it, especially the vagus and probably, to some extent, the upper portions of the spinal cord are reached by the electric current. Very often it will be found that this treatment properly carried out reduces the gen- EXOPHTHALMIC GOITRE 107 eral nervousness of the patient as well as the palpitation and the tremor. Galvanization of the thyroid gland itself with a small sponge electrode is also often useful. Hydro-therapeutic means, unless they can be carried out Hydrotherapy under careful supervision in an institution, should be used guardedly. They have a place, however, in the treatment of Graves's disease. The exact choice of method will depend upon the presence or absence of severe degrees of anemia, of digestive disorders, of myocarditis or cardiac dilatation and upon the reactive state of the nervous system, notably the vaso-motors. At all events, severe hydriatic measures, i. e., extremes of heat or coid, should never be employed, but rather very mild, soothing measures. Most beneficial is immersion of the patient in water slightly below the body temperature, as described in the Chapter on Heart Disease (see page 26). Salt may be added or car- bonated waters may be used (see page 25). The patient should lie perfectly still for five or ten minutes in the water, should then be rubbed dry with a rough towel, the surface of the body treated with alcohol and the patient immediately put to bed. In cases that are not very severe, the patients may be wrapped in a towel wrung out of lukewarm water, covered with woolen blankets and left in this packing for half an hour at a time. It is always best to leave the arms out of the packing, as otherwise a sense of restraint or uneasiness may be created that in these nervous and excitable individuals is decidedly detrimental. A Priessnitz compress (see page 51) over the thyroid applied two or three times a day for an hour or two at a time sometimes acts beneficially. The medicamentous treatment of Graves's disease is not very Medicamen- satisfactory. If there is much anemia iron and arsenic should tous treat- be given, as described under Anemia. The nervous symptoms must be controlled with bromides, the best preparations being Iron the bromide of soda and the bromide of strontium, both given in Arsenic doses of from ten to thirty grains (0.65 to 2.0 gm.) preferably ™ m * es . Campnor in milk, three or four times a day. Monobromate of camphor, in Hyoscine ten grain doses (0.65 gm.) may also be given several times a day. hydro-bromate If there is much cerebral excitement, hyoscine hydrobromate, in Valerian doses of one-two-hundredth to one-one-hundredth grain, prefer- soda ably combined with bromides or with valerian, is useful. An- Aconite other remedy that seems to act beneficially in Graves's disease Digitalis is phosphate of soda. It should be given in thirty to sixty grain doses (2 to 4 gm.) two or three times a day, in plenty of water. This drug seems to exercise its effect especially upon the nervous mechanism governing the heart. The best remedy for palpita- tion and tachycardia, however, is aconite. It should be given 108 EXOPHTHALMIC GOITRE Iodine Surgical treat- ment Partial thy- roidectomy Resection of the sympa- thetic m intervals of from one to three hours and in doses of from one to three drops of the tincture until the desired effect is produced. Patients with Graves's disease may, to advantage, be kept on small doses of aconite for almost indefinite periods. Digitalis has no place in the treatment of this disease unless there is car- diac insufficiency. Even here great care must be exercised, for tne constant over-action of the heart in this disorder frequently produces myocarditis and here digitalis, as has been shown on page 30, is a dangerous drug. While it is possible with digitalis to reduce the number of heart beats, it should never be used in this disease for this purpose alone, i. e., it should never be given in doses large enough to appreciably slow the heart. Iodine is another remedy that is commonly used in Graves's disease. Just why has never become quite clear to me, unless it be that there is a vague idea in the heads of some that iodine has something to do with the thyroid. Its employment is men- tioned merely because this drug has been very popular in the treatment of exophthalmic goitre. Clinically, in my experience, iodine and iodides almost invariably do harm in this disease, and, as a rule, produce an exacerbation of all the symptoms. The surgical treatment of Graves's disease consists either in the extirpation of the gland, or of portions of the gland, ligation of the thyroid arteries or resection of the sympathetic or its ganglia. The results obtained from thyroidectomy in true ex- ophthalmic goitre are only partially satisfactory even in the most expert hands. The operation has not infrequently been followed by very disagreeable consequences, notably about the heart, and occasionally death. The operation, however, may become nec- essary as an emergency measure if the thyroid enlargement is so considerable that dangerous symptoms of pressure upon the trachea, the esophagus or adjacent blood vessels or nerves occurs and the patient's life becomes endangered from this source. Resection of the sympathetic is an operation that theoretically is well founded. I have never had an opportunity to follow a case of Graves 's disease before and after resection of the sympa- thetic or its ganglia in the neck. A critical review of the liter- ature and of the various case reports fails to convince me that the operation is indicated, because equally good results seem to be obtainable with other means.. The operation is certainly not without danger, as a number of fatal cases have been reported, and if the patients survive the operation, disagreeable symptoms, especially about the psychic sphere, seem to develop and to per- sist for a long time. Judgment in. regard to the advisability of SIMPLE GOITRE 109 this operation and of partial or complete thyroidectomy, as well as an expression of opinion in regard to the exact indications for surgical intervention, will have to be reserved nntil we know more about this subject. SIMPLE GOITRE. This disorder, especially simple parenchymatous hypertrophy of the thyroid, as frequently seen in juvenile individuals, often yields to thyroid medication. If, however, degenerative changes are present in the parenchyma of the gland, if the enlargement of the thyroid is due to vascular disturbances, as in Graves's disease (see page 104), or if it is due to hyperplasia of the in- testinal tissues, or to tumor formation, then thyroid treatment rarely exercises any beneficial effects. In the hypertrophic variety of thyroid swelling in adolescents Rationale for we must assume that the thyroid is endeavoring to meet the thyroid increasing demands of the growing organism by compensatory ov6r-activity. By supplying thyroid we relieve the gland of some of this excessive labor, and in this way spare the organ, prevent permanent functional inadequacy or degenerative changes, and thus enable it to regain its normal function and size. In this form very remarkable results are occasionally observed from the temporary administration even of small doses of thyroid or of iodothyrin. The largest statistics on the subject have been gathered by H. G. Wells, who reported 584 cases of struma simplex treated with thyroid extract, of which 62 per cent, were improved. The best results are obtained in recent cases, so that the treatment should be instituted as early as possible. The remedy must be continued in small doses (see page 103) for a long time, either uninterruptedly or with short intermissions, otherwise recurrences are apt to appear. Here, again, the simultaneous administration of Fowler's solution in small doses is of signal benefit in preventing the disagreeable symptoms of thyroidism. It is interesting to note that very good results are also occa- sionally observed in simple goitre from the administration of thymus preparations, preferably given in tablet form, in grad- Thymus ually increasing doses (see page 105). The indications for the use of other remedies than thyroid and thymus, and for dietetic, hydro-therapeutic and electric means of treatment, do not differ materially from those de- scribed under Exophthalmic Goitre. In extreme cases that do not yield to medical means removal of the gland, or a portion of the thyroid, often remains the nnlv resource. 110 ADDISON'S DISEASE Organo- therapy The use of supra renals II. ADDISON'S DISEASE. The treatment of Addison's disease, owing to our uncertain knowledge of its pathology, is in a very unsatisfactory state. No case of Addison 's disease has ever been cured. The patient 's strength must be supported during the attacks of weakness that so commonly supervene in this affection, preferably by rest in bed and the use of a nourishing diet containing an abundance of proteid foods. General tonics, notably strychnia and arsenic, may be administered. The anemia should be treated like any other anemia. The gastro-intestinal symptoms should be treated as described under Diseases of the Stomach and Intestine. Particular care should be taken in this disease to refrain from the administration of strong purges, as otherwise very intractibie diarrheas may be induced. Hydro-therapeutic measures, electricity and transfu- sion have repeatedly been tried without any determinable effect. The use of fresh suprarenal glands and of suprarenal extract is always indicated for, in the majority of causes of Addison's disease, marked organic changes, frequently obliteration, of the suprarenal glands have been discovered. The use of suprarenal preparations has, however, never cured a case. In many in- stances marked improvement followed the administration of this remedy; in an equally large proportion of cases, however, one must confess that no appreciable effect could be discovered from its use. In those in which the preparation seemed to relieve, withdrawal of the remedy was almost invariably followed by an aggravation of the symptoms; which demonstrates that the suprarenal treatment has some virtue. Here and there in the literature is found a case report in which the condition of the patient seems to have been rendered worse by the use of supra- renal preparations, but this fact should not militate against their use in view of the utter inadequacy of all other remedial meas- ures. It is difficult, moreover, to conservatively interpret either amelioration or aggravation from the use of any remedy in Addison's disease, owing to the spontaneous fluctuations in the condition of the patient that are so characteristic of this dis- order. When one considers that there are hardly one hundred well authenticated cases of Addison's disease recorded in the literature; that many of them were not studied with accuracy; that most of them came under observation at a very late stage; that finally some of the suprarenal preparations employed were inert; then the conclusion becomes unavoidable that the question of suprarenal therapy in this disease can in *»~ ^nse be con- sidered settled. ADDISON'S DISEASE « 111 When one considers further that the active principles con- tained in the suprarenal gland undergo very radical changes in the digestive tract within a short time ; that the percentage of hypothetical active principles varies greatly in the different glands; then some of these indifferent results may also be understood. The remedy should, at all events, be given a thorough trial. The earlier the disease comes under observation the more apt is one to obtain some therapeutic results, at least symptomatically. The best preparation to use is the powdered extract. The dose •cannot be specified; too much can, however, hardly be given, as no untoward effects, excepting some irritative phenomena about the stomach or intestine, are ever observed from the administra- tion of these preparations by mouth. Some authorities claim to nave obtained better results from the use of fresh gland, given in doses of two or three glands (from sheep) a day. Adrenalin has been used, but the results seen from this remedy are no better, probably less favorable, than those obtained from the use of the dry extract or the fresh glands. CHAPTER IV. DISEASES OF METABOLISM INTRODUCTION-THE LAWS OF NUTRITION. introductor That we may understand the pathology of a disease, and The . la . ws of that we may intelligently treat it, it is necessary to understand the function or functions a perversion of which it represents. In the case of the diseases to be discussed in this chapter it is therefore essential to appreciate the fundamental principles that underlie metabolism before attempting to treat its disorders. The manifold facts that constitute the sum total of our knowl- edge of this subject cannot be discussed in full within the com- paratively narrow limits of this book.* I will content myself, therefore, with describing those elements merely that have a direct practical bearing upon treatment. Composition of The food of man consists of organic and inorganic constit- uents. The former comprise water and a number of inorganic salts; the latter a variety of bodies containing carbon, oxygen, hydrogen, nitrogen and some phosphorus and sulphur, and classi- fied as proteids, carbohydrates and fats. The role of the inor- Inorganic and ganic and organic food elements differs; for, whereas the inor- J^ ni ts f0 ° d game constituents pass through the body unchanged, the organic constituents undergo a number of fermentative and oxidative metamorphoses so that they leave the body in the form of highly Terminal oxidized, inert, terminal products of which urea, water and car- P roducta bon dioxide are the main representatives. In this process of oxidative destruction, which can be crudely likened to a combustion, and the finer intermediary mechanism of which need not be discussed in this place, a certain amount The develop- of energy is developed by each organic article of food. To ^ e e ^g.° measure this amount of energy or its mechanical equivalent in heat or labor, the term calorie has been imported from the realm Definition of a of physics; a calorie being the amount of heat required to raise calorie the temperature of one kilo** of water one degree Celsius. It has been determined that each of the three food classes caloric value in process of metabolism (i. e., of assimilation, splitting and of proteids, oxidation) generates a definite number of calories, viz., fats ♦For details I refer to my forthcoming book on "Diseases of Metabol- ism" (1) **1 Kilo (kilogramme)=2 lb. 3 oz. 2 dr. (avoirdupois). 1 gramnie=15yo grains (15.432349 grs.). 114 DISORDERS OF METABOLISM Daily caloric requirement Law of isody- namics Proteid mini- mum Average adult requirement expressed in grammes per kilo Caloric value of different articles of food 1 gramme* of proteid furnishes 4.1 calories. 1 gramme of carbohydrate furnishes 4.1 calories. 1 gramme of fat furnishes 9.3 calories. It has further been determined that a normal adult requires from 30 to 35 calories per kilo of body weight a day in order to maintain nutritive equilibrium; i. e., assuming an average weight of 70 kilo, 70X30—35, or from 2100—2450 calories per diem. Theoretically this caloric requirement can be supplied vicariously by proteids, fats or carbohydrates ; actually, however, this "law of isodynamics" is not valid; for the pecu- liarities of our digestive and assimilative functions, as well as the character of our intracellular metabolism, render it impos- sible for an individual to subsist on one food class alone. Above all a certain amount of proteid is essential. The abso- lute minimum lies somewhere between 40 and 80 grammes for the twenty-four hours' period. The average amount ingested is, however, much larger; the daily quantity of food containing from 90 to 115 gm. of albumen (370 to 420 calories), 50 to 60 gms. of fat (465 to 560 calories), and 400 to 450 gms. of carbohydrate (1640 to 1850 calories) representing in round numbers a total of from 2500 to 2900 calories. The same ex- pressed in grammes per kilo of body-weight signifies that a normal average adult requires about 1.5 gm. of albumen, 0.8 gm. of fat and 7.1 gm. of carbohydrate per diem per kilo. The amount of rest and exercise, and the sex (women requiring less total calories than men) and many other factors influence these figures somewhat. In order to perform dietetic calculations that, as will pres- ently be shown, are of great importance in the proper feeding of sufferers from metabolic disorders, it is necessary to know the caloric value of the different articles of food; to do this the percentage of albumen, carbohydrate and fat each article con- tains must be known. The caloric value can then readily be determined by multiplying the grammes of albumen by 4.1, of carbohydrate by 4.1, and of fat by 9.3. The following table gives the approximate albumen, carbohydrate and fat content of the most important common foods. (2) *These figures hold good only for pure albumen, carbohydrates and fat. The actual amount of caloric value that is placed at the dis- posal of the organism by different foods depends, however, largely upon the physical properties of these foods, the amount lost in the feces ; i. e., their digestibility, assimilability, and a variety of other factors peculiar to each individual, so that actually these figures must be modified to read: 1 gramme of proteid furnishes 3.2 calories. 1 gramme of carbohydrate furnishes 3.8 calories. < gramme of fat furnishes 8.4 calories. DISORDERS OF METABOLISM 115 TABLE GIVING PERCENTAGE OF ALBUMEN, FAT AND CARBOHYDRATE IN COMMON ARTICLES OF DIET. Animal Foods. kind of food. Albumen %. Veal, lean, raw 20.0 Veal, fat, raw 19.0 Beef, medium, raw 20.5 Beef, fat, raw 21.0 Beef, boiled 38.0 Beef, roasted 32.0 Meat broth 10.4 Mutton, medium, fat, raw 17.0 Pork, raw. fat 14.5 Pork, raw, lean 20.0 Ham, lean, cured 21.0 Chicken 21.0 Duck 22.0 Goose 16.0 Piceon 22.0 Codfish 82.0 Salmon (fresh) 21.0 Trout 19.0 Caviar 32.0 Oysters 8.0 Kidney 18.0 Liver 19.5 Tongue (boiled) 15.0 Tongue (smoked) 21.5 Bacon 9.5 Suet 0.5 Lard 0.5 Frankfurter sausage 12.0 Egg (with shell) 12.5 White of egg 12.7 Yolk of egg 16.0 Milk 3.5 Milk, skimmed 3.1 Buttermilk 4.0 Cream 3.6 Butter 0.7 Cheese (Swiss. American) 34.0 Xeufchatel cheese 19.0 Camembert cheese 25.0 Vegetable Foods. Wheat flour 10.0 Oatmeal 13.5 Wheat bread 7.0 Rve bread 6.0 Carbohy- ^at %. drate %. 1.5 7.5 1.5 0.0 9.15 8.0 0.6 6.0 37.5 7.0 8.0 2.0 2.0 3.0 2.0 45.1 1.0 0.76 0.5 12.5 2.0 15.5 2.0 1.5 2.6 5.0 0.15 4.5 3.28 17.5 0.5 31.5 76.0 98.0 99.0 40.0 2.25 12.6 0.5 0.25 0.7 32.0 0.1 4.0 4.9 0.7 4.8 0.9 3.7 25.0 3.5 84.0 0.6 11.0 3.5 41.0 1.0 30.5 1.5 1.0 72.0 6.0 67.0 0.5 52.0 0.5 47.0 116 DISORDERS OF METABOLISM Albumen %. Zwieback 13.0 Macaroni and noodles 9.0 Rice 9.0 Potato 2.0 Carrots 1.0 Peas (green) 6.0 Cabbage 2.5 Cauliflower 2.5 Sauerkraut . . . 1.0 Spinach 3.0 Asparagus 2.5 Dried peas 23.0 Beans 24.5 Radishes 1.2 Lettuce 1.4 Cucumber 1.0 Sugar 0.5 Olive oil Fresh fruit 0.5 Mushrooms 2.5 Beverages. Alco- Fat %. 3.0 0.5 1.0 0.2 0.2 0.5 0.5 0.3 0.2 0.5 0.4 2.0 2.0 0.1 0.3 0.09 95.0 "6i' Carbohy- drate %. 80.0 77.0 78.5 20.5 8.0 11.0 6.5 4.5 4.5 5.0 2.5 52.5 52.0 3.7 2.2 2.2 96.5 10.0 4.8 hoi %.* Beer 4.0 White wine Claret 10.0 Madeira 20.0 Port 18.0 Sherry 17.0 Champagne 11.0 Brandy 70.0 Coffee Tea .... Cocoa Chocolate Albumen %. 4.3 0.2 0.2 0.18 0.2 0.2 0.16 0.16 14.0 5.0 Fat %. 0.5 .0.5 47.0 15.0 Carbohy- drate %. 0.8 1.6 11.0 3.0 5.8 5.0 12.0 1.4 1.4 18.5 75.0 This table is used as follows to calculate the caloric value of the diet that an individual is eating or to arrange a dietary in such a way that it will incorporate any desired quantity of calories. Assuming for instance that the individual is eating in the twenty-four hours the following articles of food, then the amount of albumen, fat and carbohydrate they contain can readily be gathered from the table as follows : Articles. Albumen. 50 gm. of roast beef 16.0 100 gm. of chicken 21.0 10 gm. of butter 20 gm. of potatoes 4.0 100 gm. of oatmeal 13.5 200 cc. of milk 7.0 Carbo- Fat. hydrate. 4.0 2.0 2.0 8.4 0.4 41.0 6.0 67.0 8.0 10.0 *One gramme of aicohol has a caloric value of 7 (see page 138). DISORDERS OF METABOLISM 117 50 gm. of lettuce 0.6 0,2 1.7 100 gm. of cauliflower. . 2.5 0.3 4.5 ,200 gm. of white bread. 14.0 1.0 104.0 2 eggs at 50 gm 25.0 24.0 1.0 100 gm. of rye bread.... 6.0 0.5 47.0 100 gm. of fresh fruit. . 2.5 1.0 55.0 50 gm. of sugar 0.1 48.0 50 cc. of madeira 1.5 (20% alcohol) Total 112.4 55.8 402.7 The individual, then, is receiving 112.4 gm. of albumen, 55.8 gm. of fat, 402.7 gm. of carbohydrates, and 10 gm. of alcohol. Expressed in calories : Albumen, 114.4X4.1= 460.84 cal. Fats, 55.8X9-3= 518.94 cal. Carbohydrates, 402.7X4.1=1651.07 cal. Alcohol, 10.0X7. = 70.00 cal. Total, 2700.85 Cal. On a mixed diet of this character the individual, therefore, is ingesting food of a total caloric value sufficient to more than adequately maintain nutrition ; for, assuming the subject to weigh as much as 70 kilo, he would be receiving 2700-^-70=38.5 calories per kilo, distributed as follows : 1.6 gm. of albumen 0.8 gm. of fat 5.74 gm. of carbohydrate per kilo of body weight. This, as shown above, would approxi- mate very closely normal requirements. Among the diseases of metabolism are included diabetes, The group of obesity, gout and the uric acid diathesis, osteomalacia, rachitis ™ S q S ° 1C 1S ~ and, in a special sense, chronic rheumatism. In many other dis- eases perversions of metabolism occur, but there the metabolic derangement is merely one more or less unimportant and, at all events, secondary symptom of definite and known underlying causes. In the diseases of metabolism proper the metabolic de- rangement is the primary event and the determining factor in the production of the disease. All the diseases of this group, especially diabetes, obesity Interrelation- and the uric acid diathesis, are intimately related to one another metaborc^d's- pathogenetically, chemically and clinically. In one the per- eases Version of the carbohydrate metabolism, in the other of the fat metabolism, in the third, of the proteid (nuclein) metabolism predominates, and each is characterized by an inability on the part of the organism to destroy sugar or fat or albumen (nu- cleins) in a normal manner. In this way sugar, fat or nucleins 118 DIABETES MELLITUS Inadequacy of causal treat- ment General thera- peutic indica- tions and their congeners accumulate and the pictures of diabetes, obesity and gout are created. The metabolism of the proteids, fats and carbohydrates is, however, so intimately concatenated that, as a rule, we witness combinations of diabetes and obesity, of diabetes and gout, of gout and obesity, or of all three together. Causal treatment, in view of our ignorance for the present of the etiology of the diseases of metabolism, and also in view of the intangible hereditary element that is so important a factor in all functional weakness or perversion of the protoplasm at large, is not satisfactory, so that the main therapeutic indica- tion is by dietetic means to compensate the defective intracellular nutrition, and, at the same time to maintain adequate general nutrition. This, as will presently be shown, can be done only by employing accurate methods. General hygienic and, above all, medicamentous means of treatment in this class of disorders play a relatively subordinate part. Loss of calor- ies in urinary sugar Dangers of routine treat- ment I. DIABETES MELLITUS. The most important element in the treatment of diabetes is the regulation of the diet. The main objects to be accom- plished are to maintain the general nutrition of the patient, to increase his tolerance for carbohydrates and, by implication, to reduce or prevent the loss of sugar in the urine. I have explained in the preceding section how the caloric value of the food can be determined and what amount of calories a normal individual requires in order to maintain adequate nu- trition. In case of diabetes with the loss of valuable unconsumed sugar in the urine, a diet that would adequately feed a normal individual does not furnish the body with a sufficient caloric value, and as a result the patient, once the deficit is not sup- plied, consumes his own tissues and emaciates. Here, therefore, whenever possible, a metabolic study should be undertaken in order to determine this deficit. Whenever this can be done it is of inestimable value, provided the figures obtained are in- terpreted with conservatism. With the introduction of calorimetric methods, however, into the treatment of diabetes the danger of substituting an ultra- scientific routine for the old-fashioned and venerable, though altogether unscientific, routine of feeding every diabetic on a diet containing no starches or sugars, has been created. For the clinician the proper treatment of the case has only begun when the metabolic study is completed; as, to him, individual pe- culiarities and divers complicating factors that determine devia- DIABETES MELLITUS 119 tions from the metabolic schedule must be included in the calcu- lation. It is well to realize, moreover, that the general prac- titioner cannot perform these metabolic studies in each case of Difficulties of diabetes that comes under observation. He has neither the metabolic °cal- time nor the facilities, nor possibly the training, nor, above all. culations in most cases the co-operation of the patient to do this work; for to properly carry out a metabolic study the patient should be under absolute and rigid control for several successive days, or better, weeks, preferably in a hospital. Nevertheless before discussing the practical methods that can be employed, and that have evolved from an immense number of accurate studies, the principles that underlie such a metabolic calculation may be briefly described, for they should be familiar to every physician. The following case report (quoted from the author's "Clinical Urinology, " page 73) may serve as an illustrating prototype of a metabolic study in a case of diabetes : Mrs. W. P. Weight 60* kilo. Calories required for adequate m etabolic° cat- nutrition, 60X35=2100. dilation in Average diet on six successive days : Proteids 150 150 gm.X4.1= 615.0 cal. Carbohydrates 190 gm.X4.1= 779.0 cal. Fats 110 gm.X 9.3=1023.0 cal. Total calorie intake=2417.0 cal. The patient's daily average sugar ex- cretion on four successive days on this diet was 160 gm. This amount calculated in calories must, therefore, be deducted as fol- lows : Average daily sugar excretion 160 gm.X4.1= 656.0 cal. Calories utilized=1761. cal. Instead of receiving, therefore, the full caloric value re- quired, i. e., 2100 cal., the patient, owing to the loss of sugar, only utilized 1761 cal., although the diet represented 2417 cal. This means a deficit of 2100—1761=339 cal. And these deficient calories unless furnished in additional food must be sup- plied from the destruction of the patient's proper tissues. One can further readily calculate what proportion of thi«. deficit was made good from the albumin of the patient's tissue. *The figures are given in round numbers throughout in order to facil- itate the calculation. 120 DIABETES MELLITUS Vicarious feeding Necessity of supplying some carbo- hydrate what from the fat (for the patient lost weight on this diet), and the diet can be regulated accordingly. All one has to do is to determine the nitrogen output in the urine and feces, and compare it with the nitrogen intake (food nitrogen). This patient, for instance, received in the daily diet 150 gm. of albumin, and as albumin contains 16 per cent, of nitrogen, this amount contained 24.0 gm. of nitrogen. On this diet the patient excreted a daily average of 23.7 gm. of N. in the urine, and 3.01 gm. of N. in the feces, making the total N. output 23.7-|-3.1=26.8 gm. of N. The nitrogen output, therefore, was greater by 2.8 gm. (26.8—24=2.8) than the N. intake, and this excess must have been derived from the patient's own albumin. These 2.8 gm. of N. are contained in 17.5 gm. of albumin ( 2.8 X 100-^16=17.5 ). As 17.5 gm. of albumin can produce only 7L75 calories (17.5X4.1=71.75), there still remain 268.25 (339—71.75= 268.25) of the 339 deficient calories to be accounted for. As these must have been derived from the patient's fat, one can readily determine by dividing 268.25 by 9.3 (the caloric value of one gramme of fat) that 268.25-^-9.3=28.8 gm. of the pa- tient's fat were consumed. The patient, therefore, on a diet valued at 2417 calories, i. e., considerably more than the calculated value necessary to adequately nourish a normal subject of 60 kilo (2100 cal.), lost 17.5 gm. of her own albumin and 28.8 gm. of her own fat. If it were true that a diabetic could use none of the sugar that enters the blood stream, the question of feeding such a case would be theoretically a very simple one. One would have to exclude the carbohydrates and replace them by proteids and fats of sufficient caloric value to make up the caloric deficit. In the case which is quoted, for instance, the patient would have to receive 17.5 gm. of albumin and 28.8 gm. of fat, in addition to the proteids, fats and carbohydrates enumerated in the above diet. As a matter of fact only a small minority of cases of diabetes are altogether unable to utilize any of the sugar. These are very grave instances that are fortunately rare, and would be still less frequent if many milder cases were not transformed into grave ones by injudicious dieting. The great majority of patients can utilize some of the sugar and it is generally bad practice to withhold this food permanently; for aside from the glycosuria, the digestive function, the comfort of the patient, and above all the formation of acetone bodies (see below) must be considered. DIABETES MELLITUS 121 In order to know how much sugar these patients can safely The boundary take without over-taxing their sugar metabolism, it is, however, ° r a s S iSlation necessary to determine, as a preliminary step, the tolerance of each case for carbohydrates, or the so-cal]ed boundary of assim- ilation, and to feed the patients accordingly. In order to do this the patient is given what may be called Diabetic test a diabetic test meal. This consists of a series of articles that are free from carbohydrates, plus a weighed portion of some carbohydrate food. The following table incorporates the most important carbohydrate free articles of food that can be used to arrange such a test meal. I give this diet list in this place in full, because, as will be presently shown, the articles included therein must often be utilized to the exclusion of everything else in the treatment of diabetes (see Table II). TABLE. II.* ARTICLES OF FOOD PRACTICALLY FREE FROM CARBOHYDRATES. Fresh Meats. — All the muscular tissues of mammals and birds, braised, boiled or roasted with their own gravy, with but- ter, with meal or flour ; fresh mayonnaise or other sauces made without flour — warm or cold. Inner Parts of Animals. — Tongue, heart, lungs, brain, calf's spleen, kidney, marrow. Liver of calf, game and poultry up to 100 grammes weighed after eooking). External Paris of Annuals. — Feet, ears, snout and tail of all edible animals. Conserved Meals. — Dried and smoked meats, smoked and salted tongue, pickled meats, ham. bacon, tinned meats. Sausage. — All varieties, if free from bread or flour. Fresh Fish. — All fresh and salt water fish, boiled or grilled or served with flour-free sauce. Fresh melted or browned but- ter may be taken at the same time. If the fish is cooked in bread crumbs, the latter should be removed before eating. Conserve el Fish. — Dried, salted, or smoked fish, such as cod, shell fish, herring, mackerel, sole, plaice, salmon, sprats, eels, etc. : also pickled herrings, sardines in oil, mackerel in oil, an- chovies, sardellen. tunny. Caviar. Mussels and Crustacea. — Oysters, mussels, lobster, crab. Eggs.— From all birds, raw or cooked in various ways, but without added flour or meal. Fats. — Of animal or vegetable origin, e. g., butter, lard, fat of roast meats, margarine, olive oil, usual salad oil, cocoa butter, goose fat. Cod liver oil. ♦Quoted in part from von Xoorden, "Diabetes." 122 DIABETES MELLITUS Cream. — Good fat, rich cream, sweet or sour, as drink or added to solid foods or to drinks up to about 200 cc. a day. For cooking purposes cream may be substituted for flour when making special dishes of meat, fish, vegetables and eggs. Fresh Vegetables. — Salads; lettuce, endives, cress, dandelion,, purslane. Aromatic Herbs. — Parsley, dill, thyme, pimpernell, mint,, leek, garlic, celery. Fruits, Roots and Stalks. — Gherkin, tomato, young green beans, vegetable marrow, onions, radishes, white and green as- paragus, hops, Brussels sprouts, celery (except the root), young rhubarb sprouts. Blossoms and Flowers — Cauliflower, Brussels sprouts, arti- choke. Leaves. — Spinach, sorrel, cabbage, red beet. Fungi. — Fresh mushrooms, truffles in usual quantities. Fruits. — Bilberries, unripe gooseberries, when prepared with saccharin instead of sugar. Conserved Vegetables. — Asparagus, haricot beans, cut beans,, salted gherkins, pickled gherkins, peppered gherkins, mixed pickles, sauerkraut, olives, champignons and any prepared vege- tables of those groups already mentioned. Condiments. — Salt, white and black pepper, cayenne, pap- rika, curry, cinnamon, clove, nutmeg, English mustard, saffron,, caraway, caper, vinegar, citron. Soups. — Meat soups prepared from fresh meats or meat ex- tracts, with the addition of green vegetables, asparagus, eggs,, fragments of meat, marrow, liver, Parmesan cheese or other foods contained in this fable. Sweets. — Prepared from eggs, cream, almonds, citron, gela- tine, saccharine being substituted for sugar. Drinks. — All varieties of spring and seltzer water. Good brands of brandy, rum, arack, whisky, and other fruit spirits. Wine. — All the well-known table wines (white and red) are almost sugar free — at all events those that have been kept for three or more years in casks. Bordeaux and Burgundy wines come under this category. White Rhine and Moselle wines are also free from carbohydrates. Tea, Coffee and Cocoa. — "With cream, but with saccharine substituted for sugar. Lemonade. — Seltzer water with lemon juice, sweetened with saccharin or glycerin (hevulose may be used especially if per- mitted). DIABETES MELLITUS 123 A very convenient diabetic test meal can be selected from the above articles. The following one I use almost as a routine in these determinations: TYPE OF DIABETIC TEST MEAL. For Breakfast — Two soft boiled eggs. 150 cc. of weak tea with a tablespoonful of cream. A beefsteak, weighing (cooked) 100 grammes. For Dinner — Bouillon with one egg. Boiled or fried fish and broiled chicken, the two together weighing (cooked) not more than 250 grammes. A little celery. Boiled onions. Cauliflower. Lettuce salad with plenty of oil dressing. A cup of weak tea or coffee with a tablespoonful of cream. About 30 grammes of Neufchatel or Camembert cheese. For Slipper — Two boiled eggs. Cold asparagus, or tomatoes, or lettuce salad with plenty of oil dressing. A little bacon. A cup of weak tea with two tablespoonfuls of cream. If a patient is placed upon this diet for forty-eight hours, and if at the end of that time the urine is sugar free, then one is dealing with a mild form of diabetes and it now becomes nee- Method of de- essary to determine how much carbohydrate food the patient v,o^^Jtf f can tolerate without excreting sugar. This is done by adding tolerance white bread to the above test meal, beginning preferably with 100 grammes during the first day, distributed over two meals in 50 gramme quantities, and increasing this bread ration each day by 50 grammes until sugar appears in the urine. Thus, if a patient on one day excretes no sugar after eating 3X50=150 gm. of bread, and on the next day passes sugar on 4X50=200 gm. of bread, then we say that the boundary of assimilation lies between 150 and 200 gm. of white bread. The diagnostic and therapeutic importance of knowing this boundary of assimila- tion, or the tolerance for carbohydrates, will presently be dis- cussed. 124 DIABETES MELLITUS The three de- grees of diabetes The first de- gree, mild diabetes Two categories of mild diabetes The second degree, dia- betes of medi- um severity Three groups diabetes of me- dium severity For practical therapeutic purposes it is convenient to dis- tinguish three degrees of diabetes that may be determined as follows : In the first category, the mildest forms of diabetes, the sugar should disappear within two days after complete withdrawal of carbohydrate foods, i. e., as soon as the patient is placed upon the carbohydrate-free test meal mentioned above. To the cate- gory of mild cases also still belong those instances in which the patients fail to excrete sugar when there are added to this carbo- hydrate-free diet from 100 to 150 grammes of white bread. From a clinical standpoint it is important to distinguish among these mild cases of diabetes two groups, viz., those form that occur in persons past middle age or old individuals and those that occur in very young people. The prognosis in the former class of cases is always better than in the latter. In- dividuals of the first type are usually moderately obese and commonly show some evidences of the uratic diathesis. In the young cases the neurotic type predominates, and unless great care is exercised in these individuals, they are apt to develop into the medium or the severe type of diabetes. To the second category of cases, diabetes of medium severity, belong those instances in which complete withdrawal of carbohy- drates is necessary for at least two or three weeks before the sugar completely disappears from the urine. Among these cases of medium severity several groups must be distinguished for practical reasons. There is one group of cases in which the withdrawal of carbohydrates not only causes the disappearance of sugar within two or three weeks, but also produces much general improvement in the condition of the patient, an increase of weight and a dis- appearance of acetone bodies from the urine (disappearance of Gerhardt's ferric chloride reaction). In a second group of cases, the withdrawal of carbohydrates again leads to the disappearance of sugar from the urine, but in the beginning there is considerable loss of weight, the patients feel weak and Gerhardt's reaction either appears for the first time or increases in intensity. Within a few days, however, after the disappearance of the sugar a change for the better occurs, the weight again increases, the patients recover their sense of well-being and the Gerhardt reaction disappears. In a third group of cases, finally, the condition becomes ag- gravated at once, and while the sugar may disappear the patients rapidly begin to lose weight and complain of great weakness ; it the same time the Gerhardt reaction appears and rapidly in- creases in intensity. In addition, such patients commonly de- THE LIGHT FORM OF DIABETES 125 velop digestive disorders and diarrhea. This last group of cases forms the transition to the third. or severe type of diabetes and should be treated accordingly. • In the third category, the severe type of diabetes, finally, The tnird de ~ the sugar does not disappear, even if the patients are placed diabetes for weeks or months upon a carbohydrate-free diet, showing that these individuals are unable to consume even that proportion of sugar which is generated within their own tissues from the dis- integration of their own albumens. Here the sugar does not disappear from the urine until the food albumens are consider- ably reduced, indicating conclusively that the albumens may be a very prolific source of sugar, a fact of great practical im- portance and one that is often overlooked (see page 128). In the most severe type of diabetes, finally, it is altogether impos- sible to cause the disappearance of the urinary sugar, even when the patients are starved, i. e., when all food is withdrawn. The prognosis and the treatment of these three classes of General con- diabetes varies radically and each type must be discussed sepa- relati^^to 5 rately. In the light cases, and in the cases of medium severity, prognosis and the main object of treatment must be to cause the disappearance t h e three de- of the sugar from the urine; for in this way the tolerance for ffrees of diabetes carbohydrates can ultimately, as a rule, be increased and com- plications removed ; whereas if the glycosuria, thanks to careless dieting, is allowed to persist, the cases almost invariably become aggravated. The complete withdrawal of carbohydrates is, however, rarely necessary as a permanent procedure, as will be presently shown. In the severe cases less attention should be paid to the glycosuria and more to maintaining the general nutrition of the diabetic patient. DIETETICS OF TPIE LIGHT FORM OF DIABETES. In this class the principle of sparing those organs that are "Besting" and concerned with the metabolism of sugars must be enforced exercism S" the sugar and here the plan can be adopted of first "resting" the metabolism sugar metabolism, so to say, for short periods of time by the complete withdrawal of carbohydrate food from the diet, and then gradually adding carbohydrate foods to the diet to "exer- cise ' ' the sugar-destroying functions back to normal. It is hardly necessary in most cases to keep such patients for long on a carbohydrate-free diet. They should be placed at first upon a diet containing no Technique carbohydrate foods (see Table II). During this period great care should, however, be exercised to furnish enough calories to adequately nourish the patient. This can usually be accom- 126 THE LIGHT FORM OF DIABETES plished without difficulty by supplying abundant fat. Should the patient begin to lose flesh upon the restricted regime, despite the ingestion of enough calories, or should very ]arge quantities of acetone and its congeners, oxybutyria and diacetic acid appear in the urine, then the restricted diet is to be abandoned and some carbohydrate must be administered. Even if no untoward symptoms appear, however, it is generally better after four to six weeks of restricted diet to allow the patients some carbohy- drate food for the sake of their appetite and general comfort; besides it is much easier to manage these cases, and above all to supply adequate caloric values in the food, if some bread, pota- toes, rice or other starchy food is allowed. Before the addition of carbohydrates to the diet of such cases the boundary of tolerance should be very carefully de- termined, as described above (see page 123). They should now be kept for a time upon a ration containing no more white bread than corresponds to an amount that is somewhat below the established boundary of tolerance. Should sugar reappear again, then the amount of carbohy- drate food should at once be reduced or stopped altogether until the urine becomes sugar-free again. If the patient bears the addition of white bread well for several weeks, and if no glyco- suria supervenes, then he may safely be kept on this amount of white bread, or its equivalent (see Table III), for many weeks or months at a time. From time to time a period of restricted diet should again be instituted and the boundary of tolerance re- established. Equivalents of The following table indicates various articles of food con- white bread taining an amount of carbohydrate that corresponds to that con- tained in 100 gm. of white bread. TABLE III. THE CARBOHYDRATE CONTAINED IN 100 GM. OF WHITE BREAD IS EQUIVALENT TO THE CARBOHYDRATE IN: 2 litres of milk or buttermilk. 120 gm. of rye or graham bread. 200 gm. of aleuronat or gluten bread.* *DIABETIC BREADS. — Most so-called diabetic breads contain ap- proximately 50 per cent of carbohydrate. The vegetable albumens (aleuronat, roborat, plasmon, gluten) all contain about 5 per cent of car- bohydrate. These breads are made from such flours plus a certain amount (one to four parts) of ordinary flour. They should only be used as equivalents for white bread in the proportion of about 2* to 1. Their indiscriminate use, which is so popular with the laity who imagine that these breads can be safely taken ad libitum, is therefore to be con- demned as dangerous. They fulfill a useful purpose, however, owing to the fact that twice as much of the various diabetic breads can be eaten as of ordinary white or rye bread and still no greater amount of THE LIGHT FORM OF DIABETES 127 70 gm. of zwieback. 100 gm. of chocolate. 80 gm. of chestnuts (peeled). 80 gm. of flour (wheat, rye, barley, buckwheat). 70 gm. of rice. 70 gm. of noodles or macaroni. 70 gm. of oatmeal. 120 gm. of dried peas, beans, lentils. 200 gm. of green peas. 360 gm. of new potatoes. 280 gm. of old potatoes. 240 gm. of fresh apples, pears, plums, apricots, cherries, grapes. 400 gm. of strawberries, raspberries, gooseberries, blackber- ries, cranberries, huckleberries. 100 gm. of figs. 6 bananas. 6 peaches. Two handfuls of walnuts, hazelnuts, almonds. 1-3 litre of Port, Sherry or Madeira. 1 1-3 litres of beer. It is clear that such large quantities of any one of these articles should rarely be eaten in place of bread. I have given these equivalents for one hundred grammes of white bread chiefly for the sake of convenience in calculation. Milk, bread, potatoes, cereals, diabetic breads, a little beer The different and the other articles enumerated above may be allowed spar- a rt ^ les of ingly, provided their carbohydrate content is included carefully in the calculation in such a way that for each gramme of thes^ articles that is permitted a corresponding amount of white bread is withdrawn. In this way one should succeed in keeping these patients permanently sugar-free and not infrequently in practically carbohydrate be administered. This is an advantage, inasmuch as the bulk of the bread satisfies the craving of the patient for bread, and, at the same time, enables him to ingest a larger amount of butter than if half the quantity of white bread were permitted. According to the same principle it is often of advantage to give diabetics very porous, fluffy breads on account of their bulk; for they satisfy the appetite if they are cut in thin slices and buttered freely, and, above all, they satisfy the eye and the mind without injuring the stomach or the carbohydrate metabolism. Still another bread for diabetics, that contains very much less carbohydrate than either ordinary white bread or bread made from gluten flour and wheat or rye flour, is almond meal bread made from ground almonds, containing about 7 per cent of carbohydrate, with the addition of butter, eggs, salt and spices. Unfortunately this bread is not very palatable, tastes more like cake than bread and hence is not well tolerated for an indefinite time by most diabetics. 128 DIABETES OF MEDIUM SEVERITY Substitutes for sugar curing them; at least to such an extent that they, at the expira- tion of a year or so, can exist upon a fairly liberal diet from which only a few articles are to be, for all time, rigidly excluded. Among the latter are pastry, honey, ice cream, preserves, candy and sugar. Unfortunately the various substitutes for sugar (see page 138) that we have do not seem to satisfy the majority of patients, so that for the sake of comfort it will nevertheless usually be- come necessary from time to time, as a concession to the patient but always with the exercise of careful control, to allow a little of sugar or of other sweets. Technique Low boundary of tolerance Danger of too much albumen Average meat and fat ration Addition of alcohol DIETETICS OP DIABETES OF MEDIUM SEVERITY. The cases belonging to this category must be handled with much more care than the light cases. The patients should at once be placed for at least two months upon a carbohydrate-free diet and after the degree of tolerance, provided they can tol- erate any carbohydrate, is established at the expiration of this time the addition of carbohydrate food made very gradually and kept up for a short time only. This rule is self-evident, be- cause sugar will almost invariably appear in the urine within a week or two after the use of starchy foods is resumed. Broadly speaking, this invariably constitutes an indication to return to the carbohydrate-free diet. It will usually be found that the boundary of tolerance in these cases is very low, i. e., that they cannot stand more than about 50 grammes of white bread, or its equivalent, without developing glycosuria. In such cases, moreover, particular care must be exercised that they, do not eat too much albuminous food. The fact is not sufficiently appreciated, as stated above, that albumen may become a very prolific source of urinary sugar and that the ad- dition of an excess of albuminous pabulum to a mixed diet un- doubtedly in many cases reduces the tolerance for carbohydrates, whereas the restriction of albuminous food often increases this tolerance. Excessive meat-feeding, besides, favors the devel- opment of acidosis. The average meat ration, therefore, should never exceed an amount containing 150 grammes of albumen (see Table I), whereas the amount of fat should approximate about 200 grammes. If a certain amount of alcohol (see page 138), about 70 to 80 grammes, is added to the diet, and this is usually a. very good plan in this type of diabetes, then the patient re- ceives approximately 3,000 calories in his food, that is, about DIABETES OF MEDIUM SEVERITY 129 500 calories more than the average requirement and enough usually to compensate for any slight loss of sugar that may oc- cur in the urine. If no alcohol is given the fat ration may be increased by 40 to 50 grammes. Occasionally it is impossible in this class of cases to produce complete disappearance of the sugar from the urine, even after the patients have been on a carbohydrate-free diet for nearly two months. In a case of this kind a very useful plan is the Starvation one suggested by Naunyn, viz., to starve the patients completely for a period of twenty-four hours, giving them during this time merely a little tea or coffee or bouillon, and plenty of water. After the fast the patient is placed for two or three weeks upon a carbohydrate-free diet, and it will frequently be found that now the sugar remains absent from the urine and that some tolerance for carbohydrates has been acquired. In view of the fact that no individual can, without great _ . ' to Intermittent suffering, great discomfort and some danger, exist indefinitely carbohydrate upon a diet consisting exclusively of albumens and fats, it gen- ee 1Iig erally becomes necessary, sooner or later, to administer, even here, some carbohydrate food, even at the risk of promoting glycosuria for the time being. This plan should, therefore, be adopted intermittently, immaterial whether the carbohydrate- free diet caused a complete disappearance of sugar from the urine or not. Such patients, however, should never receive more than 100 grammes of white bread, or its equivalent, in the twenty-four hours. The transition from the carbohydrate-free diet to the more G ra a ua i tran- liberal diet should always be very gradual and the patients sition from should receive each day a little more of the carbohydrate food until d \f j. the 100 gramme limit is reached. If it is found that the glycosuria rapidly increases, then the carbohydrates should be gradually reduced and finally stopped again. It is usually a good plan Chan g"e m kind to alternate the kind of carbohydrate food, i. e., to give for drate food some days bread, then its equivalent in potatoes or rice or oat- meal, etc., and to give onlv a single carbohydrate at a time; /» o ! t i i hit Tne advan- ior the mixture of several carbohydrates generally leads to a tag-es of sin- greater excretion of sugar than the administration of a single §^ + ^ a £k°ky^ one. Each individual, moreover, reacts differently to different carbohydrates, so that tolerance determinations with oatmeal or rice or potato often reveal peculiar relations that may be ad- vantageously employed in the treatment. Based on this fact so-called "cures'' for diabetes by feeding with large quantities of single carbohydrates have at different times been ad- vocated. Thus we have had the potato cure, of Mosse, the rice cure, of von Diihring, the milk cure, of Winternitz, and more recently the oat- meal cure, of von Noorden. All these observers are reliable clinicians drate feeding 130 DIABETES OF MEDIUM SEVERITY Oatmeal cure Uesults and good observers and all of them have reported a few cases that were decidedly benefited by this method of feeding. This is particularly striking, as the use of large amounts of carbohydrate food in diabetes is in itself paradox, and especially as the good results w T ere as a rule observed in cases that were of the severe type, and in which the ordi- nary methods of dietetic, hygienic and medicinal treatment had failed. The oatmeal cure seems to yield proportionately better results than any of the other plans of feeding, and as I, personally, have had experience witn the oatmeal cure alone, I will limit my remarks to it. The method of administering the oatmeal cure (as recommended by von Noorden) is the following: 250 gm. of oatmeal are cooked for several hours in water, to which a little salt is added ; while the por- ridge is boiling, about 100 gm. of butter are added and later, after the boiling is completed and the mess is cooled, about 100 gm. of egg albu- men, or a like amount of some vegetable albumen, may be added to the porridge while it is still on the fire. This soup is administered about every two hours during the day in such quantifies that the whole amount . is eaten in the course of twenty-four hours ; in addition, the patient is oermitted to take some brandy or claret and water or a little strong, black coffee. It will readily be seen that it is impossible to continue this mode of dieting for a long time; the patients naturally soon acquire a distaste for the oatmeal soup and when this period comes the treatment will have to be stopped, as it is worse than useless to force it. , The results from this treatment are either brilliant within tbe first few days after it is begun, as manifested by a great reduction or the complete disappearance of the sugar and the acetone bodies from the urine, or they are altogether negative from the start. Therefore, in my experience, if good results— striking results — are not seen within three days it is probably better to discontinue the oatmeal cure and to resort to other measures. I have seen one or two bad consequences that I think can be attributed to the prolonged use of the oatmeal cure after an appreciable effect failed to appear within two or three days. This group of patients suffered a reduction of their tolerance for other carbo- hydrates, and above all, developed alarming degrees of acetonuria. I am not as yet prepared from my own experience to state percent- ically how many cases are benefited, how many are not affected favor- ably, and how many are harmed by the oatmeal cure. I venture the statement, however, that if the rule is observed to stop the oatmeal cure if no good effects are seen within three days, the number of bad results will be reduced to insignificant figures. In about 35 per cent, of all my cases I have had good results, varying from a slight reduc- tion of the acetonuria and a considerable reduction of the urinary sugar during the time the oatmeal treatment was administered, to remarkable improvement in very serious cases in which the sugar prac- tically disappeared, the gain in weight was rapid and the reduction of the acidosis almost instantaneous, and in which, moreover, the after-effects of the "cure" were determinable for months after the patient had left the hospital. It is interesting and important to note, as well, that the best results are obtained in juvenile diabetes, a form that is particularly intractable to ordinary methods of treatment, and that is particularly damaged by the old-fashioned routine treatment of feeding on a starch- and sugar- free diet. No case of juvenile or adolescent diabetes should be deprived of the benefits of an oatmeal cure. At the least the trial should be made, and if the "cure" fails, no harm will have been done, provided it is properly carried out and not forced after the third day if no results appear within that time. THE SEVERE TYPE OF DIABETES 131 DIETETICS OF THE SEVERE TYPE OF DIABETES. In view of the fact that it is impossible in this form of diabetes to cause the complete disappearance of the sugar from the urine, even when the albumins of the diet are greatly reduced, espe- Technique cial care must be taken to compensate for the loss of sugar by increasing the ingestion of albumins and fats, for only in this way can adequate nutrition be maintained. For this reason less attention must needs be given to reducing the glycosuria than to maintaining the body weight, treating complications symp- tomatically and rendering these unfortunate cases comfortable. In this variety of diabetes, to which belong most of the juvenile cases, acidosis (and the excretion of acetone bodies) is usually Acidosis in very pronounced. This generally constitutes a danger, because tnis tyP e in a large proportion of cases coma seems to be more liable to occur when the acetone body excretion is great than when it is absent or small, although there are many exceptions to this rule. Exclusive meat-fat feeding seems to favor acidosis and it will be found that the addition of carbohydrates to the diet of such cases often, although not invariably, causes a considerable reduction in the acetone-body excretion. If, therefore, such pa- tients develop marked degrees of acetonuria, with oxybutyric and diacetic acid and much ammonia in the urine, then, above all, the exclusive meat-fat diet should be discontinued and, for the sake of safety and as a prophylactic measure against coma, carbohydrate food should be given even at the risk of increasing the glycosuria. In this class of cases carbohydrates, however, have practic- carbohydrates ally no food value, because they are promptly re-excreted in of little food the urine. They must be considered merely as a welcome addi- tion to the diet and one that enables the patient to eat enough of the necessary albumens and fats to maintain nutrition. It will often be found that the complete withdrawal of carbohy- drates not only destroys the appetite, but produces digestive dis- orders that are often fatal in their consequences. In general, these patients should be allowed considerable albuminous food The albumen up to 150 grammes, the maximum of fat, considerable alcohol and fat ration and, in addition, about 50 to 60 grammes of bread or its equivalent. This liberal feeding should be interrupted from time to time by placing the patients for two or three or more weeks upon a rigid diet; then the carbohydrate portion of the food should again be gradually increased. One will often be gratified even in these severe cases to find that their tolerance for carbohydrates is greater after such a period of carbohy- drate withdrawal than before. In this type of diabetes, par- 132 THE SEVERE TYPE OF DIABETES The liquid intake Smoking, chewing and atropine to al- lay thirst Fallacy of "forbidden" and "allowed" "diabetic diet." Inaccuracy of studies on drug effects in diabetes The sugges- tive element ticularly, careful metabolic studies, preferably carried out in an institution, are often of inestimable value in prolonging life. The amount of fluid in this class of cases should be regulated in such a way that the specific gravity of the urine, broadly speaking, is kept up to, or brought down to, 1025. The liquid intake should in general be proportionate to the ingestion of albumens and the corresponding excretion of urea; for the urea largely determines diuresis. Excessive water drinking is to be condemned in severe diabetes on account of the danger of gas- tric dilatation and of the strain upon the heart and arteries that results from the abundant ingestion of water. Very often diabetics acquire the habit of drinking large amounts of liquid. They should be educated to control this craving and if neces- sary may be advised to chew gum or smoke a little in order to deaden the sensation of thirst. Atropine sulphate in one-two- hundredth grain doses also, often fulfills a like purpose. It will be seen from all that has been said that the exact regulation of the diet in diabetes must vary according to the type and the degree of the disease, and according to individual peculiarities, the presence or absence of complicating diseases, the age of the patient and his ability or willingness to submit to rigid control. Consequently no mathematical formula, no "Diabetic Diet" giving "forbidden" and "allowed" articles can be arranged for feeding every case of diabetes. Until very recently the dangerous routine habit of placing each case of diabetes for indefinite periods upon a diet containing no carbo- hydrates was universal^ in vogue. As a result innumerable diabetics were literally starved to death. Nowadays we have learned, as shown above, that a diabetic not only can, but should, in the great majority of cases, at least from time to time, enjoy the benefit of carbohydrate feeding. MEDICAMENTOUS TREATMENT OF DIABETES. A large number and a great variety of remedies have at different times been recommended for the cure of diabetes. None, however, can exercise a curative effect upon the dis- ease proper and only a few appreciably influence the excretion of sugar. Most of the reports on the effect of the different medicines that have been used in diabetes have been made without sufficient dietetic control, and for periods of time that were far too short to rule out the uncertainties that always arise in regard to the effect of a remedy in a disease that is subject to so many spontaneous fluctuations as diabetes. In interpreting, furthermore, the efficacy of any drug in diabetes, a disorder that, especially in its milder forms, is so markedly influenced by emotional and psychic states (see page 146), the ele- ment of suggestion must always be considered, particularly, THE SEVERE TYPE OP DIABETES 133 when a new drug of much vaunted efficacy is tried for the first time. Some of the remedies that are actually capable of reducing the glycosuria act by curtailing the appetite and by interfering with the assimilation of food. As soon as a patient, owing to Remedies that such a drug effect, eats less food, especially carbohydrate or pgtife^and de- albuminous food, then the sugar excretion may very readily be- range the come reduced; incidentally, however, serious harm may be done lges 10n the patient, owing to the malnutrition and the irritation of the gastro-intestinal tract, or the liver, that is produced by the medicine. Other remedies, again, exercise a beneficial effect upon certain functions of the liver, the cardio-vascular appa- ratus, and, above all, the nervous system, so that they possibly General tonics improve the general condition of the patient, act as a general tonic and hence actually enable him to destroy more sugar than before. These effects are, however, as will readily be under- stood, very indirect and in most cases transitory. One should, therefore, be especially careful not to place too much reliance on drugs in the treatment of diabetes, nor to misinterpret a temporary reduction in the sugar excretion as due to the drug effect alone, for otherwise the temptation may be created to neglect the all-important dietetic treatment. The fact that there is not, so far as we know to-day, any proper anti-diabetic remedy should not, however, discourage us from using those drugs that we know to be capable of favorably affecting the general health of the patient, counteracting or remedying complications or, above all, removing distressing or dangerous symptoms, chief among them the glycosuria. To enumerate all the drugs that have been recommended would be futile, so that only those may be discussed in this place that have empirically vindicated their claims to usefulness in the treatment of diabetes. Chief among the valuable drugs are opium and its alka- opium and its loids. By the aid of opium the last traces of sugar can, with- alkaloids out doubt, often be removed from the urine in cases that do not become altogether sugar-free on a restricted diet. In cases of medium severity particularly, that are existing upon a re- stricted diet, but that still excrete some sugar, it often reduces the glycosuria. It does not, however, seem to exercise any ap- preciable effect upon the sugar excretion in diabetics who are eating carbohydrate foods. The effect of the drug can never be absolutely relied upon and its action is always uncertain; for occasionally it exercises no influence at all, even in the cases specified above. Its effect is never permanent; for when its use is stopped the glycosuria reappears and usually increases 134 THE SEVERE TYPE OF DIABETES Dose and ad- ministration Action of opiates Nervous seda- tives Bromides Chloral Phenacetin Sulphonal Valerian Salicylic acid preparations Mode of action Contra-indi- cations rapidly, only to disappear again, everything else remaining equal, when opium is resumed. Many patients rapidly wear the drug out, so that the dose must be continuously increased if its effect upon the sugar excretion is to be maintained. Herein lies the chief danger from the use of opiates, especially if the patients know what they are taking. The dose should be large from the beginning, i. e., at least half a grain (0.03 gm.) of the extract should be given three or four times a day, preferably in combination with the extract of belladonna, one-twelfth grain (0.005 gm.) or atropin sulphate one one-hundredth grain (1 mg\). Some clinicians prefer co- deine, others morphine in appropriate doses, but, in my experi- ence the best effects are undoubtedly obtained from the extract of opium administered as above. It is probable that opiates act chiefly by their sedative power and not by any specific effect upon the carbohydrate meta- bolism, although some investigations seem to indicate that opi- ates interfere with the disassimilation of the tissue albumens and hence prevent the organism from splitting off sugar mole- cules from the tissue proteids. This would explain their good effect in patients living upon a carbohydrate-free diet in which the urinary sugar is undoubtedly derived from the catabolism of the albumens proper. A number of other remedies have been given for their seda- tive effect upon the nervous system, chief among them, bromides, chloral, phenacetin, sulphonal, valerian, etc. Many of these drugs undoubtedly act beneficially in the neurotic or neuras- thenic types of the disease (see page 146), but in most cases they are inert and do more harm than good by irritating the gastric mucosa and deranging the digestion. Next in importance to the opiates are the preparations of salicylic acid, given either as sodium salicylate, in doses of from ten to thirty grains (0.6 to 2 gm.) or as aspirin, in doses of from thirty to forty grains (2 to 3 gm.) several times a day, after eating. These drugs act differently than the opiates, for their effect becomes apparent precisely in those cases that are eating some carbohydrate food; they seem to increase the boundary of tolerance for carbohydrate foods, and thus enable the patient to utilize more of the alimentary starches. These drugs, too, should be given in large doses, as indicated above, in order to do any good. They are strictly contra-indicated in diabetics suffering from gastric or renal disorders; and as many diabetics, especially of the severe type, suffer from these com- plications, their usefulness is limited. Some skeptics go so far as to claim that the salicylate preparations do good chiefly by THE SEVERE TYPE OF DIABETES 135 deranging the stomach and hence interfering with the proper assimilation of food, and that they reduce the glycosuria in this way, simply because, upon their administration, less of the ingested carbohydrate pabulum is absorbed. It is hard to disprove this criticism. Jambul occasionally acts very well in diabetes in a manner j an rt> u i similar to the salicylates, i. e., it aids in increasing the boundary of tolerance. Its action, however, is very uncertain and its effect transitory. One can never predict in advance, therefore, whether or not jambul is going to be effective. Patients, more- over, wear this drug out very rapidly, so that if it is adminis- tered at all, it should be given interruptedly, i. e., for two or three weeks at a time and then not again until after an inter- vening period of at least four or six weeks. Leading authorities report sufficiently good effects from the use of jambul to warrant its trial in every ease that does not satisfactorily yield to dietetic treatment, opium or salicylates. The drug may be given in the Dose and ad- form of the dry powder in the dose of five to thirty grains (0.3 to ministration 2 gm.) three or four times daily in capsules, gradually increas- ing the quantity until as much as an ounce (32 gm.) is given a day. A much more reliable and pleasant preparation is the maceration with water which may be prepared as follows:* 200 grammes of dried jambul fruits, including the seeds, are finely powdered and macerated in two litres of water (to which 10 gm. of salt and 4 gm. of salicylic acid are added) at 37° to 40° C. The watery extract is filtered off and 100 cc. of the fluid taken cold every morning on an empty stomach, and the same dose again in the evening before retiring. The salicylic acid is added merely as a preservative. Alkalies are always useful in diabetes and I have made it Alkalies a practice to give from five to thirty grains of sodium bicarbon- ate, or of calcium carbonate, two or three times a day to every case of diabetes for indefinite periods of time. Alkalies in the first place effectively aid in counteracting the acidosis that is so frequently met with in diabetes; in this sense a continuous alkali therapy may be considered a useful prophylactic measure against the development of severe acidosis, which notoriously Mode of ac ti n often leads to the development of coma. Aside from their effect upon the acid intoxication alkalies must also be considered an hepatic stimulant (page 496), and there is much experimental evidence to show that they increase intracellular oxidation and hence, we must assume, promote the destructive metabolism of circulating carbohvdrates. *Von Noorden. 136 THE SEVERE TYPE OF DIABETES Mineral waters Life in Carls- bad, Marien- bad, Vichy. Dangers of Re- sort treat- ment Iodide of potash Mercury The effects occasionally derived from the use of many of the mineral waters, natural or artificial, that are so popular in the treatment of diabetes, must in large part be attributed to the alkalies they contain. To this category belong especially waters like Vichy, Marienbad and Carlsbad. It is important, however, to appreciate that the benefits de- rived from a sojourn in Carlsbad or Marienbad or Vichy, or any of the other watering places, can only in part be attributed to the effect of these alkaline waters. The resort treatment of diabetes of certain types is without doubt highly beneficial; but this is due in great part to the careful regulation of the diet which can be carried out without hardship to the patient in such resorts; to the respite from worry and from the strenu- ous business life; to the out-door existence and the pleasure de- rived from a vacation in a pleasant watering place; not to speak of the benefits that accrue to the patients from placing them- selves under the care of resort physicians who are usually par- ticularly skilled and experienced in the management of this disease. There is one danger in the resort treatment of diabetes, viz., that many cases, particularly of the lighter type, imagine that a few weeks in Carlsbad, Marienbad or Vichy under a careful regime will neutralize the bad effects accruing from in- judicious dieting during the rest of the year, so that many pa- tients imagine that they can divorce themselves from all restric- tions, provided they return to the resort for some months each year. This form of optimism is to be seriously discouraged. That the drinking of the waters in these resorts alone does not produce the beneficial effects in diabetes is made very apparent by the indifferent results obtained from their use if they are taken at home, bottled, or in the form of artificial salts. Iodide of potash sometimes acts beneficially in diabetes, par- ticularly in two types, viz., those that are due to arteriosclero- sis, possibly involving the arteries of the pancreas, and those that are due to syphilis (central lesions, syphilitic pancreatitis or hepatitis). The remedial action of iodides in arterio-sclerosis has been fully discussed in the section on this disorder. Their good effect as antiluetics is self-evident. Every case, therefore, presenting evidences of arterio-sclerosis, or presenting a sus- picious syphilitic history, should be given the benefit of an energetic iodide treatment, care being taken, of course, above all things that the stomach and intestine are not deranged (see Syphilis). Mercury seems to act less beneficially in diabetes due to syphilis. This must be attributed to the fact that the diabetic manifestation in syphilis is always a late sign, presumably due THE SEVERE TYPE OF DIABETES 137 to arterial changes involving the central nervous system or the pancreas and producing degeneration of portions of these or- gans. Iodide of potash can here possibly be effective, whereas mercurials are usually without effect. Bichloride of mercury has been recommended, but the drift of opinion among reliable Bichloride of clinicians seems to speak against its efficacy. Given hypoder- mercur y mically it not infrequently produces disagreeable sequelae, owing to the vulnerability of the skin and subcutaneous tissues in diabetes and the tendency in this disease to the development of skin lesions. Its use, therefore, had better be eschewed. Various drugs have been recommended whose efficacy should Intestinal anti- be attributed to their action as intestinal antiseptics, and symp- se P tlcs tomatically they occasionally do good. To this group belong creosote lactic acid, creosote and other phenol preparations. Their effect Phenol prep- is very uncertain and very little benefit generally accrues from ara tions their use. General tonics, such as quinine, arsenic and iron, are com- Quinine monly used in diabetes. They occasionally improve the anemia Arsenic and possibly stimulate the nervous system to ^icreased activity, ron but I have never been convinced that they exercise any appre- ciable effect upon the course of diabetes nor upon the amount of sugar excreted in the urine. Organo-therapy on theoretical ""rounds should be efficacious Organo- therapy in diabetes. However seductive the use or pancreas prepara- tions or of combinations of pancreas with muscle- or with liver- or with salivary gland-extract may appear, practically nothing Pancreas alone of definite value has so far been observed from their adminis- with liver, tration. Pancreas is occasionally useful, as will be shown in muscle > sa j 1_ ^ 7 vary glands another paragraph, in the treatment of the steatorrhea of dia- betes, but it has no effect upon the glycosuria. I reported some oases in which the boundary of tolerance seemed to be raised by the use of pancreas-muscle extracts,* but observations made subsequently in a larger number of cases have failed to support the first observations. Liver extracts and brewer's yeast have Liver extracts been used, but the optimistic claims advanced in the beginning have never been vindicated, although yeast often favorably in- fluences the furunculosis of diabetes. Nevertheless organo- Brewer's therapy appears to be a very hopeful field and while nothing tangible has so far been accomplished, we may hope some day to discover an efficient organo-therapeutic method of combating diabetes. Among the drugs that may, finally, be used in the treat- Substitutes ment of diabetes may be mentioned some of the preparations that take the place of sugar. To this group belong chiefly ♦New York Medical Journal, 1904. 138 THE SEVERE TYPE OF DIABETES Saccharine Dulcin Crystallose Levulose Alcohol saccharine, dulcin and crystallose. Saccharine is the sulphonid of benzoic acid and is three hundred times sweeter than ordinary sugar. In very small quantities, therefore, it is often useful to sweeten coffee, tea and lemonade, preserves and other des- serts. It also forms an important constituent of a variety of diabetic relishes, wines, candies, etc. The patients, however, soon tire of this remedy and argue that while it is sweet it does not take the place of sugar; moreover, it has been shown that saccharine is not without effect upon the kidneys, for it not infrequently produces irritation of the renal epithelia. It should, therefore, be given carefully, occasionally stopped and replaced by crystallose or by dulcin. The latter remedy, para- phenol carbamid, is not so sweet as saccharine; moreover, it irritates the liver and occasionally produces icterus. Its taste, however, is more agreeable than that of saccharine. I have frequently used the drug without ever seeing any bad effects from so doing, provided it is not given in doses of more than 2 gm. a day. Occasionally a patient who is altogether intolerant to dex- trose can take levulose for a time with impunity. If this is the case the latter sugar is an invaluable aid in feeding diabetics. Before administering it one should carefully determine, how- ever, the boundary of tolerance of the patient for this sugar.* If alimentary glycosuria follows its administration promptly, then it must be considered as dangerous as dextrose and should be discontinued. Alcohol possesses a high caloric value, one gramme furnish- ing 9 calories. As a food, therefore, it can, to a limited ex- tent, replace other articles (see page 116). 100 calories are furnished by: 14.3 gm. of alcohol (lOO-f-7) 10.75 gm. of fat (100—9.3) 24.4 gm. of proteid (100-=-4.1) 24.4 gm. of carbohydrate (100—4.1) As the digestion of fats is usually improved by taking a lit- tle alcohol, preferably in the form of brandy or whisky, alco- hol is particularly useful as a stomachic in diabetes and as a substitute for some of the fat in cases that are living upon a meat-fat diet. As a general heart and nerve tonic it also has its place, especially in patients who have been used to some alcoholic stimulant all their lives. In such individuals, especially if they are advanced in years, the withdrawal of alcohol is decid- edly bad practice. More than forty to fifty grammes per diem, however, should rarely be allowed. *For the normal boundary of tolerance for different sugars see Croftan : "Clinical Urinology," pg. 65. THE SEVERE TYPE OF DIABETES 139 EXERCISE IN DIABETES. Importance of In addition to the dietetic and medicament ous treatment of ™?2 llar ex ~ ercise diabetes one should recognize that certain other elements in the general management of the disease are of great import- ance. Thus the amount of exercise that a diabetic takes should be carefully regulated. Muscular exercise by increasing the carbohydrate metabolism in the muscles is, in certain cases, capa- ble of reducing the glycosuria. Light muscular exertion, par- taking of the character of out-door sports, is always to be preferred to in-door calisthenics or forced exercises; for, in the former case, the pleasure derived from the exercise, i. e., the joyful psychic stimulation as well as the out-door life, both act beneficially. No violent exercise should be permitted, for in diabetes any over-strain is dangerous. The amount of exer- cise should be made altogether dependent upon the general nu- trition of the patient, the condition of the heart, the blood ves- sels, the kidneys and the nervous system. er5se°by thf" The urine should always be carefully inspected in order to urine control the effect of exercise. As soon as the nitrogen excre- tion increases muscular exercise should be reduced or stopped; for, whatever benefits are to accrue from muscular exercise should become manifest by an increased destruction of sugar, i. e., by a reduction of the glycosuria, and not by an increased destruction of body albumen, i. e., by an increased excretion of nitrogen (urea). In order to obtain the optimum effect from exercise it is best to administer the carbohydrate ration, in cases living on a semi-restricted diet, immediately before muscular exercise is indulged in, and to continue the exercise for an hour or two thereafter; for it has been shown that during muscular exercise more of the sugar is consumed and utilized than during periods of rest. Massage If gymnastics or out-door exercises are contra-indicated on account of complications about other organs, then massage occa- sionally produces a very beneficial effect upon the excretion of sugar and the general well-being to the patient, although its effects are not by any means so striking nor so reliable. Here, again, the carbohydrate ration can to advantage be administered before the massage treatment is applied. In the severe type of diabetes very active muscular exercise must be eschewed. Such patients should be advised to lead a quiet life, both physic- ally and psychically, for, in severe diabetes, as has been re- peatedly stated, any strain and unrest, either emotional, mental or physical, should be avoided. 140 COMPLICATIONS AND SEQUELS OF DIABETES Stomatitis Gingivitis Pyorrhea Caries of teeth Toilet of the mouth Fetor Bleeding 1 and painful gums TREATMENT OF THE COMPLICATIONS AND SEQUELAE OF DIABETES. Most of the complications of diabetes disappear with a re- duction of the glycosuria and an improvement of the general condition of the patient. Sometimes a more rigid diet must be ordered for a time, on account of complications, than would otherwise be administered, so that a mild type of diabetes, for instance, must be treated like a case of medium severity. Occa- sionally, however, it becomes necessary to employ special meth- ods for the relief of very obstinate, very distressing or particu- larly dangerous symptoms. The stomatitis gingivitis, pyorrhea, the loosening and caries of the teeth may be due either to localized infections or to tropho-neurotic influences. These mouth manifestations are among the most distressing symptoms of diabetes and it is im- portant that every case of diabetes should, from the beginning, be instructed carefully in regard to the possibility of mouth com- plications, and taught how to attain mouth asepsis and to per- form the proper toilet of the teeth and gums. After each meal a diabetic should rinse his mouth and cleanse his teeth, prefer- ably with a 3 per cent, solution of sodium carbonate in warm water to which may be added as a flavor a few drops of the tincture of eucalyptus or a little menthol. Mechanical irregu- larities of the teeth should be corrected early, by choice during the aglycosuric period. All articles of food that can mechan- ically scratch or injure the gums and very hot beverages should be forbidden. A hard tooth brush should never be used. Excessive fetor may be corrected by using the following mouth wash : 9 Beta-naphthol, Sodium biborate, Pepermint water, Distilled water, M. Sig. Apply locally. If the gums are painful and bleeding the following mouth wash is useful: 0.2 gm. 20.0 gm. 200.0 cc. 1000.0 cc. 3 Tincture of opium, 20.0 cc. Chlorate of potash, Biborate of soda, each, 10.0 gm. Decoction of marshmallow root, 1000.0 ce. M. Sig. Apply locally. COMPLICATIONS AND SEQUELS OF DIABETES 141 The care of the skin is always of great importance in diabetes Skin lesions on account of the tendency shown in this disease to the devel- opment of furunculosis,* erysipelatous infections, acne, eczema and gangrene. Lukewarm baths, preferably with the addition of soda or of salt, are exceedingly useful. Following such a bath the patient's skin should be carefully dried with soft warm cloths and treated with cocoa butter or oil. Severe rub- bing, owing to the vulnerability of the skin, should always be avoided. Patients with diabetes should frequently change their underwear and the greatest cleanliness of the surfaces of the body should be promoted. Pruritis, either general or localized, especially about the Pruritus genitals, is one of the earliest, most distressing and most ob- stinate symptoms of diabetes. General pruritus is presumably due to irritation of the cutaneous nerves by circulating sugar. In most cases its intensity fluctuates with the degree of glyco- suria and the symptom frequently disappears without further interference when the urine becomes sugar-free, only to reap- pear again, however, when more liberal carbohydrate feeding is instituted and the hyperglycemia increases. The best remedy for internal use and almost a specific is sodium salicylate, in doses of thirty grains (2 gm.) several times a day. Local appli- cations are of very little value in general pruritus. In pruritus around the genitals, due in many cases to the development of fungi {mycosis vulva) and usually due to leptothrix, the reduction of the glycosuria, sodium salicylate internally and anodyne powders or ointments applied locally usually relieve. A 5 per cent, cocaine ointment or a 3 per cent, eucaine ointment, or a dusting powder containing 10 per cent, of orthoform, combined with frequent washing of the parts without rubbing or scratching, usually promptly produce re- lief. Dyspeptic symptoms arising in the course of diabetes always Dyspeptic call for particular attention. First, because diabetics more s y m P toms than sufferers from any other disease are dependent for the maintenance of their existence upon an intact gastro-intestinal tract. Second, because dyspepsia, especially in severe types of diabetes, is frequently a precursor and a determining factor in the development of coma. Dyspeptic symptoms not uncom- monly arise from monotonous, one-sided feeding, e. g., from an excessive meat-fat diet, or simply from over-loading the stomach with food (polyphagia) or water, with resulting func- ♦Yeast internally is in some cases an efficient remedy against diabetic furunculosis. (See page 137.) 142 COMPLICATIONS AND SEQUELAE OF DIABETES Gastric irri- tation Catarrh of the bowel Fatty diarrhea tional over-taxation and mechanical dilatation of the stomach with all that entails. In very severe cases of gastric irritation the best plan of all is to withdraw food completely for a period of twenty-four hours, allowing merely a little broth or diluted milk or a little claret in water, at the same time feeding the patient by rectum (see p. 367). In order to allay the gastric hyperalgesia and the vomiting, cerium oxalate in ten grain doses, frequently re- peated, or cocaine, as described on page 19, or 2 per cent, chloro- form water should be given, while cold or hot applications, ac- cording to the likes of the patient, should be applied over the epigastrium. The severe thirst that usually appears during the period of food- and drink-restriction can, to some extent, be mitigated by allowing these patients to chew gum, to swallow small pieces of ice at frequent intervals, or even to smoke a little. After this rest cure for the stomach the patient should be put for a day or two upon milk and gruels composed of almond meal or gluten-flour and then gradually the broad dietary re- sumed, care being taken all the time that the maximum of food is introduced by rectum in order to maintain general nutrition. The more chronic dyspeptic disorders in diabetes call for careful analysis of the gastric function and for treatment that does not materially differ from that described in the Chapter on Diseases of the Stomach. Catarrh of the bowel is always serious in diabetes. Acute catarrh with profuse diarrhea should be attacked most energet- ically in every case; for the interference with food assimilation that results, rapidly weakens the patient and not infrequently directly precipitates coma. Bismuth subnitrate in doses of fif- teen to twenty grains (1 to 1.3 gm.), with extract of opium one- half grain, and tannic acid suppositories containing about three grains (0.2 gm.) of the drug, should be given at frequent in- tervals until the diarrhea is checked. An attempt should be made to feed the patient by mouth as soon as the bowel move- ments are controlled. During the diarrhea brandy and water should be frequently given by mouth, in small doses, by prefer- ence ice cold, both to support and, in a measure, to nourish the patient. Fatty diarrhea (steatorrhea) is not uncommon. Here pos- sibly the involvement of the pancreas and hepatic insufficiency can be held responsible for the condition. The fats in the diet should be reduced. Sodium carbonate or calcium carbonate, in ten grain (0.65 gm.) doses with pancreatin or ox-gall, of each COMPLICATIONS AND SEQUELiE OF DIABETES 143 five grains (0.3 gm.), should be administered at frequent in- tervals during the day. Obstinate constipation is also often a troublesome and a dan- Constipation gerous complication. It, too, not infrequently precipitates coma if allowed to persist. Here absorption of bowel poisons from stagnation and putrefaction of bowel contents must be accused of determining the attack of coma. Usually abundant fat-feed- ing and the restriction of carbohydrates suffice to counteract the constipation. . Saline waters or a lemonade made of Glycerin 3 parts, Citric acid 5 parts, Water 1,000 parts, the whole quantity to be administered in divided doses during the day, are all useful measures. The best medicines to counteract the constipation in diabetes are rhubarb and soda mixtures, either Mistura Rhei et Sodaa two drachms to three ounces (8 to 100 cc.) or the following powder: F> Rhubarb root, Sodium bicarbonate. Sulphur, precipitated, of each 10 grains (0.6 gm.) M. Sig: To be taken at night, preferably in milk. If these measures do not regulate the bowels, then castor oil or the Compound Infusion of Senna may be used to advantage. Complicating affections about the heart and arteries, the lungs (tuberculosis) and the kidneys that arise in the course of Complications diabetes must all be treated according to the principles described heart, arteries, in other chapters. It will rarely become necessary to deviate lungs, kidneys materially from the general dietetic schedule on account of these complications. The simple rules that should be occasionally ob- served have been mentioned in the text. If evidence of severe renal disease appears, especially if the cardio-vascular apparatus becomes involved, then the diabetes must be relegated to sec- ondary importance, and the treatment should be chiefly directed towards the cardio-renal disorder according to the principles laid down in the Section on Nephritis (see page 204f). The com- plication of diabetes with obesity, and diabetes with the uric acid diathesis, are discussed in their appropriate places. Obesity and Among the most distressing secondary symptoms of diabetes gou are the neuralgias, especially about the sciatic nerve and the brachial plexus; and a variety of other nervous disorders mani- Neuralgias festing themselves either as sensory or motor disturbances, or, 144 COMPLICATIONS AND SEQUELS OF DIABETES Trophic dis- orders Prevention of coma Treatment of the attack above all, as trophic disorders. Among the latter perforating ulcer and gangrene, herpes, pemphigus and glossy skin, brittle- ness of the nails, loss of hair and teeth and diabetic neuritis may be mentioned. The symptomatic treatment of the neuralgias is rather un- satisfactory, for the ordinary anti-neuralgic remedies rarely suf- fice to control the pain. The best combination of drags, in my experience, is quinine and opium, given as follows : Quinine sulphate, 10 grains (0.65 gm.) Extract of opium 14 grain (0.0015 gm.) M. Sig. In a capsule repeated three or four times a day. Antipyrin, in five grain (0.35 gm.) amounts, is also occasion- ally of service, especially as it seems to exercise some effect upon the glycosuria. Generally speaking, the majority of the nervous disorders yield spontaneously if the hyperglycemia can be re- duced, so that attention should chiefly be directed towards the treatment of the underlying diabetic disorder. coma. The administration of alkalies throughout the course of diabetes as a prophylactic measure against coma has already been mentioned (see page 135). With the appearance of the first signs of coma, especially in cases that have been living for some time upon a rigid meat-fat diet, some carbohydrate food should at once be administered. I have even occasionally practised the intravenous injection of levulose, a sugar that some diabetics can burn with facility (see page 134), and I can testify from personal experience to an occasional good sj^mptomatic result from this practice. Inversely, coma may sometimes be averted in a patient living upon a very liberal diet by great restriction of the carbo- hydrate food. The sudden withdrawal of carbohydrates from the diet, i. e., placing the patients at once upon a meat-fat diet is always dangerous ; for coma has many times been produced by this course. We are unable to explain these peculiar, apparently paradoxical phenomena, but empirically they are certainly true. In fully developed coma the patients are usually semi-con- scious or comatose; there is generally severe vomiting and other gastro-intestinal disturbance, so that dietetic rules, even if they would lead to any result, could not be carried out. The treat- ment here lies along different lines. Diabetic coma is always an exceedingly dangerous and usually a fatal complication, and almost all the measures that we can employ unfortunately merely fulfill the purpose of partially reviving the patient and post- poning the fatal issue for a short time. The patient in the first stages of diabetic coma should be put to bed and forced if pos- COMPLICATIONS AND SEQUEL/E OF DIABETES 145 sible to drink milk or large quantities of lemonade. At the same time the action of the heart should be supported, either by alco- hol, which acts also as a food, given by mouth, or camphor (10 per cent, solution in oil or ether), or ether injected subcuta- neously. Oxygen should be administered, for it often relieves the dyspnea. The most important remedy to administer, how- ever, is sodium carbonate. It should be given by mouth, by rec- tum, by hypodermoclysis and intravenously, in 3 to 5 per cent, solution in normal salt. However large the dose of soda the urine rarely loses its acidity, and whereas 5 gm. per diem nor- mally always suffice to render the urine alkaline, over 100 gm. may not do it in coma. A diabetic patient in coma cannot get too much soda. GANGRENE. It is one of the most distressing and dangerous compli- Gangrene cations of diabetes. When it is once fully established amputation of the affected member becomes necessary. Most surgeons recom- mend dressing the gangrenous extremity with a moist boric acid solution and awaiting the appearance of the line of demarcation before performing amputation. In a diabetic gangrene, partic- ularly, the amputation should be performed high up in the region of healthy arteries. With the appearance of gangrene the diet should never remain altogether carbohydrate-free. It is always better to allow from 50 to 100 gm. of white bread or its equiva- lent. Occasionally prophylactic treatment should be instituted, especially in old people or in alcoholics, or in individuals with marked arterio-sclerosis, who complain of certain premonitory signs like continuous pain, tingling or hyperesthesia in some extremity. Here everything should be done to promote the venous back-flow from the affected member. Hot foot-baths and massage should be energetically instituted, while, at the same time every effort should be put forward to reduce the glycosuria. PROPHYLACTIC AND CAUSAL TREATMENT IN DIABETES. A few words nmv be added in regard to prophylactic and ^ eredi t ar y element causal treatment in diabetes. In many cases of diabetes an hereditary element is very apparent. The disease runs in fam- ilies and if diabetes itself does not appear in the ancestry of a diabetic, then one will often discover one or several members of the family who suffer from obesity or gout. If several mem- bers of a family are diabetic, or if there is a tendency to obesity or gout, then all the members of such a family should be warned against over-indulgence in carbohydrate foods. Their urine should be examined at intervals of at least six months for the appearance of sugar. Particular care should be exercised in this direction in individuals of such families who are obese or 146 COMPLICATIONS AND SEQUELS OF DIABETES Test for ali- mentary gly- cosuria Clausal treat- ment Neurotic dia- betes Diabetes in or- ganic nervous -diseases are rapidly becoming obese, for in them frequently the deposit of fat in the tissues may almost be considered a precursor of diabetes; the sugar in such cases, one must assume, being con- verted into fat and deposited in the tissues instead of being wasted as sugar in the urine. In order to make quite sure that a tendency to diabetes is not developing in individuals with an hereditary tendency, the test for the presence or absence of an alimentary glycosuria may to advantage be made from time to time. This is carried out by giving such subjects 100 to 150 grammes of dextrose at one time on an empty stomach. In a normal subject no sugar should appear in the urine after this test; if the tolerance for sugar is reduced, then glycosuria will appear. This warning should never be neglected and as a prophylactic measure the carbohydrate foods should be somewhat restricted and the use of sugar and sweets temporarily reduced to a minimum. At the same time such individuals should be instructed to indulge in abundant muscular exercise and to live as much in the fresh air as possible. Very obese subjects should be submitted to a careful reduction cure, as described in the next section. Cases of this kind, in which diabetes is suspected from the family history and in which the test for alimentary glycosuria gives a positive reaction, are fortunate exceptions; fortunate, because at this early stage proper treatment generally quickly restores normal conditions and prevents the development of true diabetes. As a rule diabetes develops without warning or sugar is discovered by chance during a life insurance examina- tion or in the course of some ailment that calls for an analysis of the urine, so that an opportunity for prophylactic treat- ment is unfortunately rarely offered. Causal treatment is not very satisfactory in view of our ignorance of the precise nature of the disease and on account of the manifold character of the causes that determine its onset. There are certain cases of diabetes that develop on the basis of a neurasthenic tendency. This form, it appears to me, is particularly common among Jews. The sugar excretion of these cases is frequently increased by w T orry or emotional strain, and decreased by joyful emotions or success and happiness. Here causal treatment must clearly be directed towards the underly- ing neurotic taint, with the aid of certain nerve tonics and sedatives (see Medicament ou s Treatment, page 132) and those other means that are described in full in the Chapter on Gastric Neuroses. In organic disorders of the nervous system, that is, in tu- mors, hemorrhagic foci, cysts or other lesions in the region of the "glycosuric centre" in the medulla, and possibly in othet OBESITY 147 areas of the brain and cord, the prognosis is dependent alto- gether upon the nature of the underlying lesion; and treatment is successful only in so far as it can remove the mechanical cause producing the disorder. Provided the lesion in the nervous system is syphilitic, or s yP hllls if there is a suspicion of syphilitic interstitial pancreatitis or hepatitis, then energetic antiluetic treatment, as discussed in another portion (see page 594f ), is occasionally fraught with suc- cess. Inasmuch as syphilis of the nervous system, the pancreas and the liver, as well as arterial degeneration due to syphilis, may all occasionally produce diabetes (the latter by producing secondary nutritional, i. e., degenerative, changes in the pan- creas, medulla, etc.), every case of diabetes giving a syphilitic history should be granted the full benefit of long continued and persistent anti-syphilitic medication. The results obtained from such treatment are frequently exceedingly gratifying. II. OBESITY. The reduction of obesitv is an important therapeutic task, Importance of reducing" not so much when considered in the light merely of a tribute obesity to the vanity of the afflicted, but chiefly when regarded as a necessity in order to remove an over-growth of adipose tissue leading to disagreeable and dangerous complications about im- portant organs. It will often be found that these complications only disappear when the fat is reduced. We see here similar conditions as in diabetes, for there, too, many of the complica- tions rapidly disappear when the sugar is reduced. Whereas in diabetes the causes that determine* these complications are chemical, in obesity they are mechanical in character. The organs most frequently and most seriously affected in obesity are the heart and arteries, the bronchi, the digestive apparatus, the nervous system and the skin. ' Upon the heart is always thrown an enormous amount of ex- Complications cessive labor. First, because the body is heavier and locomo- ? boU f the tion requires more labor. Second, because a much larger vas- cular area than in a normal subject must be supplied, owing to the intricate labyrinth of new blood vessels that forms in the adipose tissue. Third, because the development of fat in the mediastinum and around and within the pericardium exercises mechanical pressure upon the heart and hence interferes with its action. Fourth, because fatty degeneration of the vessel walls very often occurs, with loss of elasticity and consequently p a tty deg-ener- an increased strain upon the heart muscle. Fifth, because owing ation of the b.63,rt (find to the development of abdominal fat the excursions of the dia- arteries phragm are seriously interfered with and there is a general con- traction of the thoracic space with a reduction of its suction 148 Complications about the re- spiratory ap- paratus Dyspnea Chronic bron- chitis action, and hence a general embarrassment of the venous circula- tion. Lastly, because either as a result of all this over-strain, or as a part phenomenon of the general obesity, fatty infiltration or fatty degeneration of the heart muscle itself occurs. As a matter of fact the affliction of the heart is probably the most serious consequence of obesity; for most obese subjects suffer from cardiopathy and die from heart failure. If, more- over, they should become affected with some intercurrent in- fectious disease, as pneumonia, typhoid fever, tuberculosis, etc., then the resisting powers of the heart are so slight that death commonly occurs from failure of the organ. The involvement of the heart in obesity leads to the clos- ing of a vicious circle; for the weak heart action produces an inadequate blood supply to various portions of the body with in- sufficient nutrition of muscular tissues and general lassitude, all factors that in predisposed subjects favor the development of obesity; on the other hand, as soon as obesity appears, it in its turn reacts unfavorably upon the heart. About the respiratory apparatus serious disorders are also very common. The fat in the mediastinum and the increased weight of the chest walls, the impediment to the downward ex- cursions of the diaphragm that is created by the over-growth of abdominal fat, all seriously interfere with the freedom of the lungs and the ventilation of the thorax. As a result rapid breathing, especially on exertion, dyspnea, and above all, chronic bronchial catarrh are very common in obesity. The bronchial catarrh is due in part also to the venous stasis that results from the cardiac insufficiency. The mucus is, as a rule, very tough and difficult to expel. The patients cough terrifically, usually without much relief, as expulsion of the mucus is rendered hard by the emphysema and the venous stasis in the lungs and by the difficulty of expanding the chest as a preliminary to the coughing effort. This condition again imposes a severe strain upon the heart, especially the right heart. The bronchitis in obesity rarely yields to the ordinary remedies, but is promptly bettered if the obesity is reduced and the condition of the heart improves. In obesity there is, therefore, also from this source again, danger of pulmonary infections and many of these cases succumb to catarrhal pneumonia, and, notably, to tuberculosis. There is a popular prejudice to the effect that obese subjects are not very susceptible to tuberculosis; if tuber- culous infection occurs, however, it usually goes very hard with fat patients, and they constitute a large proportion of the in- stances of so-called "galloping" consumption. The disorders about the digestive apparatus are manifold in OBESITY 149 character. Most of them are due to the venous stasis that re- Digestive dis- sults either directly from the heart weakness or indirectly from orders portal stasis. The most common intestinal symptoms in obesity are hemorrhoids and constipation; both are almost invariably Hemorrhoids present, the former due either to the portal stasis or to gen- Constipation eral interference with the venous backfiow into the abdomen, the latter due to the pressure of the fat masses within the abdomen upon the bowel, causing interference with their per- istaltic action ; besides there is always much difficulty in volun- tarily raising the abdominal pressure sufficiently to promote nor- mal defecation. The one-sided diet with the elimination of much fat and carbohydrate pabulum may also have something to do with constipation in obesity. Fatty infiltration of the liver, combined with stasis and Fatty infiltra- later cirrhosis, is not uncommon. Cholelithiasis and dislocation liver of the liver are not common during the stage of obesity, but Cirrhosis frequently follow rapid reduction cures, owing to the fact that ^epatis the support of the abdominal fat is rapidly withdrawn, and malposition of the liver and bending or knuckling of the gall- ducts is produced. About the skin a variety of irritative disorders, complicated s . kin affec- by secondary infections, are frequent. They are due both to the friction of abnormally enlarged adjacent parts of the body and to the profuse sweating that most obese subjects are afflicted with. The sweating is attributable presumably to an effort on the part of the organism to get rid of surface heat by water evaporation from the skin, especially as normal radiation is interfered with on account of the thick adipose layer that con- ducts heat so badly. Obese subjects frequently suffer from inter- trigo, eczema, furunculosis, carbuncles and sudamina; besides, the skin often becomes torn in its lower layers leading to the formation of stria?, while, at the same time capillary hemor- rhages, venous ectases, are frequent and varicose veins in various parts of the body make their appearance. About the nervous system, finally, a great variety of func- Nervous dis- tional disorders, many of them of a neurasthenic type, are com- orders mon. Most of them are due to the inadequate blood supply to the brain that results from the heart weakness. Apathy and a phlegmatic temperament are notoriously common in obesity, phlegmatic These psychic attributes, combined with what is popularly in- temperament terpreted as a good-natured disposition, are presumably a re- sult of the bulk of the individual ; for, with the difficulty of moving about freely, and an inability to speedily carry the dic- tates even of an energetic will into rapid execution, habits of listlessness, laziness and indifference are easily . engendered, so 150 Obesity and joint affections The three forms of obesity- Diet and ex- ercise that after a time the bodily condition becomes reflected in the temperament. More serious manifestations about the nervous system are apoplexies, especially in patients with a weak heart and arterio- sclerotic arteries, who are suffering from such conditions as bron- chitis, constipation, etc., which call for violent straining efforts. I have summarized the various complicating disorders in obesity somewhat at length, because from a therapeutic stand- point it is exceedingly important to recognize the etiologic role of obesity in these various states. Treatment directed towards them symptomatically is usually futile and intelligent thera- peutic effort must concern itself chiefly with removing the un- derlying cause, namely, the obesity. I will have occasion to refer to this form of treatment again in the different sections when discussing diseases of the heart and bronchi, of the bowel and the liver. The importance of reducing obesity in a variety of chronic joint disorders may finally also be mentioned; for here the re- duction of the bulk of the patient by relieving the joints of the labor of supporting a large mass acts in the same way as a mechanical support. Thus the reduction of obesity is a par- ticularly grateful procedure in chronic rheumatic and gouty forms of arthritis. As in diabetes, one can conveniently distinguish three de- grees of obesity that have been aptly characterized by a Ger- man writer as the enviable, the comical and the pitiable stages. The first presenting itself as a pleasing rotundity: the second, as a jovial embonpoint of the Falstaff type; the third as a sad, unwieldy, and to our Caucasian tastes, disgusting deformity. Each of these three forms requires particular treatment. In the first form no attempt need be made to reduce the amount of fat but every effort should be put forward to prevent its further development, particularly if premonitory signs of com- plications about the thoracic or abdominal organs begin to make their appearance. In the second and third forms, however, it becomes necessary to institute more or less energetic restrictions with the object in view of causing a loss of fat. The methods at our disposal for accomplishing this purpose are chiefly dietetic. Second in importance is the regulation of the muscular exercise. These two means, singly or combined, usually suffice to accomplish the desired purpose, for with a decrease of the intake of fat-forming pabulum, and an increase of its destruction by exercise, the fat content of the body must needs dwindle. These measures may to advantage be enforced by certain hydro-therapeutic and medicinal means, the latter THE DIETETIC TREATMENT OF OBESITY 151 finding their chief sphere of application, however, in the symp- tomatic treatment of the complications of obesity. ' THE DIETETIC TREATMENT OF OBESITY. Physicians until recently, and the laity to this day, have directed their attention chiefly to the quality or the preparation of the food in reducing obesity. Certain articles were said to form fat and others not. This idea is erroneous. Broadly speak- ing, carbohydrate and fat foods should be reduced, and not the albumens. This rule is to be observed not because albumen the food and "forms" less fat than carbohydrates or fats, but because the its mod e of reduction of the albumen below certain normal average require- ments, as will be explained below, is a dangerous and precarious procedure, whereas the fats and carbohydrates can be much re- duced without detriment to the individual. One may say, axiomatically (but with certain restrictions that need not be discussed in this volume),* that any article of food can form fat according to its caloric value (see page 114), that if more calories are introduced either in the form of albu- nf thp U ^/? y mens or of fats or of carbohydrates, than are required to main- tain normal nutritive equilibrium, then fat will be deposited in the tissues; and if less are introduced, that then the organism will promptly attack first its fat reserve to make up the caloric deficit. THE SCIENCE OF REDUCTION CURES. The initial procedure in instituting a reduction cure should be to determine the normal caloric requirement of the individual, assuming that he wen not obese. This can be done by consult- ing the following table on which will be found the normal aver- age weight for individuals of a certain height, both men and of the food women : (Quetelet.) Men. Women. Age, Height, Weight, Height, AVeight, Years. (In Meters).*-' (Kilo- grammes).*** (Kilo- grammes). 0.5 3.2 0.49 2.91 1 0.7 9.45 0.69 8.79 2 0.77 11.34 0.78 10.67 3 0.86 12.47 0.85 11.79 4 0.92 14.23 0.92 13.00 5 0.99 15.77 0.98 14.36 6 1.05 17.24 1.10 16.01 7 1.11 19.10 1.15 17.54 8 1.16 20.76 1.18 19.08 *See my forthcoming book oil "Diseases of Metabolism." **1 meter— 30.37 inches, or 1 yard 3 1-3 inches (English). ***1 kilogramme — 2 lb. 3 oz. 2 dr. (avoirdnpe.is). 152 THE DIETETIC TREATMENT OF OBESITY Men. Women. Age, Height, Weight, Height, Weight, Years. (In Meters). (Kilo- grammes). (Kilo- grammes). 9 1.22 22.65 1.19 21.36 10 1.28 24.52 1.25 23.52 11 1.33 27.1 1.30 25.7 12 1.39 29.8 1.35 29.8 13 1.44 34.4 1.40 32.9 14 1.49 38.8 1.45 36.7 15 1.55 43.6 1.49 40.4 16 1.59 49.7 1.54 43.6 17 1.63 52.9 1.56 47.3 18 1.66 57.9 1.56 , 51.0 20 1.67 60.1 1.57 52.3 25 1.68 62.9 1.58 53.3 30 1.68 63.7 1.58 54.3 40 1.68 63.7 1.58 55.2 50 1.67 63.5 1.53 56.2 60 1.63 62.9 1.52 54.3 70 1.62 59.5 1.52 51.3 Simplest form **J multiplying' this weight by 30 to 35 the approximate daily of reduction caloric requirement can b( i obtained, foi r, as shown on page 114, Three degrees of reduction Banting 1 , Oer- tel, Epstein, Hirschfeldt "cures." a normal subject requires from 30 to 35 calories per kilo a day to maintain adequate nutrition. Assuming that the patient were 1.67 meters tall, then according to the table he should weigh about 61 kilos and require 61X30 to 35=1830 to 2135 calories a day. The diet should now be arranged in such a way, with the aid of the tables on page 116, that this number of calories is furnished, not more and not less. This constitutes the mildest form of underfeeding for here the caloric intake is insufficient only relatively, i. e., as compared to the abnormal bulk of the patient. If now the patient does not lose weight on a diet con- taining the full normal caloric requirement, then it becomes nec- essary to reduce the caloric intake still further. It is convenient to follow the plan of von Noorden and to arrange three degrees of reduction cures. In the first degree the caloric requirements are reduced only to four-fifths of the normal, in the second to three-fifths and in the third to two- fifths. Calculating this for an individual, e. g., requiring 2500 calories as the normal, the first degree calls for the administra- tion of foods possessing a caloric value of about four-fifths of 2,500, or 2,000, the second of three-fifths of 2,500, or about 1,500, and the third of about two-fifths of 2,500, or about 1,000 calories. The popular diets of Banting, Oertel, Epstein, Hirschfeldt and others possess a caloric value lying between 1,100 and 1,600 only; they are consequently reduction cures of the third degree and, THE DIETETIC TREATMENT OF OBESITY 153 as will be presently shown, usually far more severe than is safe or necessary. The rapidity with which fat is lost in these three degrees of The first reduction cures varies. In the first degree the loss is usually de § Tee very slow, the patients rarely losing more than two or three pounds a month; and even this slight reduction can only be accomplished if they indulge at the same time in considerable physical exercise. The four-fifths diet is useful chiefly in pre- venting the further increase of fat in subjects who are showing a tendency to obesity. It is eminently suitable for continued use and does not require any great sacrifice on the part of the pa- tient. It is hardly ever necessary to calculate the caloric value carefully in this light form, all one has to do is to allow less meats, to reduce the amount of fat and starchy and sweet foods somewhat, to restrict or forbid alcoholic beverages, to give "filling" foods of small caloric value (see page 116) in abund- ance, to restrict the liquid intake to one to one and one-fourth litres of fluid a day, and to order abundant physical exercise. The second degree is also particularly useful for continued The second use. It should be adopted, first, for very strong and very fat de §" ree subjects who want to get rid of surplus fat and can safely in- dulge in very active physical exercise; second, for individuals who not only are fat but in whom complicating disorders about the heart, arteries, bronchi or digestive apparatus render it im- possible to "work off" fat by exercise; here the necessary reduc- tion of the fat must be brought about, in the beginning and un- til the complications improve or disappear, by dietetic restric- tions alone; third, for fat individuals who cannot at once toler- ate a third degree reduction cure without developing alarming symptoms of weakness, particularly about the circulatory and muscular apparatus. In the latter class of cases the three-fifths reduction cure is used as a transition diet to the third degree and is intended to gradually accustom the patients to restric- tions of a more severe order to be instituted as soon as some fat is lost and the complications have improved. This second degree, too, leads only to relatively slight and slow losses of fat, more than six to ten pounds rarely being sacrificed a month. The third degree, finally, is a rapid reduction cure. It The third must be carefully supervised and is best carried out in an in- de £ ree stitution. Here we frequently find that the loss of fat is rapid in proportion to the obesity of the individual, showing that it is the surplus adipose tissue that is being sacrificed and not the albumin of the body. Combined with systematic exercise and drink restriction (see below) as much as thirty pounds a month can be lost with safety. A reduction cure of the third degree 154 THE DIETETIC TREATMENT OF OBESITY Danger of re- duction cures in young and old subjects The kind of food Importance of protecting the tissue al- bumens should never be carried out for indefinite periods, and six weeks is the longest time during which this serious restriction of the patient's nourishment should be allowed. In many cases the in-, termittent plan will have to be adopted, i. e., the patients are placed for four to six weeks upon the rigid plan, then for a month or two upon the second degree, and then back again to the rigid diet until the desired loss of flesh has been produced. It will be seen that here very similar principles are adopted as in the reduction of diabetic glycosuria, where, too, three de- grees of diabetic diet can be conveniently arranged (see page 124). While it is true that energetic starvation often rapidly leads to a loss of weight greater than that which can be accom- plished by more gradual and more moderate means, such rapid reduction cures, as typified for instance by the Banting system, which is so popular among the laity, are rarely without" serious danger to the various organs that are commonly involved in ad- vanced degrees of obesity ; nor are the results, broadly speaking, permanent. In very young people and in very old people rapid reduction cures should be altogether eschewed; for in children and in adolescent subjects irreparable damage is often done, growth stunted and serious complications engendered; whereas, in old people, the results are usually very unsatisfactory and never without danger, while the effects at best are exceedingly transi- tory. THE ART OF REDUCTION CURES. The kind of food that should be allowed in instituting any reduction cure, and its mode of preparation, has been the subject of much controversy for many years. The greatest care should be exercised not to attack the albumen content of the body; hence it is important to give a certain amount of albuminous food to all cases in order that the patients may not be forced to consume the albumen of their proper tissues. As the known minimum necessary for maintaining adequate nutri- tion lies somewhere between 60 and 80 grammes a day, this amount at least should be invariably supplied. This corresponds to 400 to 600 grammes of lean meat (see below). No difficulty should be experienced in meeting this requirement. Notwith- standing the claims of some doctrinaires, excessive meat-feeding is not only unnecessary, but may be directly harmful in insti- tuting reduction cures. A great deal will depend upon the tastes and the previous habits of the patients. If they have not been excessive meat-eaters, there is no reason why they should be forced to eat much meat. If they have been abund- THE DIETETIC TREATMENT OF OBESITY 155 ant meat-eaters, they may safely continue meat-eating, provided the intake is not so large that the total caloric value of the food is increased above the prescribed and calculated limit. The next question to decide is whether the carbohydrates Restriction of or the fats are to be chiefly restricted. Here, again, a very ^hydrates* 1 " virulent controversy has been going on for many decades. This is not the place to enter into a discussion of the merits or de- merits of the different theories advanced. From a practical standpoint it is best to reduce the fats and to give relatively large quantities of such carbohydrate foods as possess bulk; for the latter, as a rule, incorporate a small caloric value, while, at the same time, fully satisfying the patient. The idea that fat forms fat in the body more than carbolrydrate lias been shown to be erroneous; as a matter of fact, carbohydrates seem to be more rapidly deposited as reserve fat in the tissues than the fat that is eaten. To summarize, therefore, the diet in reduction cures should Summary be arranged in such a way that the individual receives an amount of albuminous food incorporating at least 60 to 80 grammes of albumen. This is necessarj 7 in order to maintain nitrogen equilibrium and to protect the tissue albumen. The remaining number of calories that are to be supplied, accord- ing to the principles discussed above, may be vicariously furn- ished, either in the form of fats or carbohydrates. Of the two the carbohydrates, however, especially if they are voluminous, should be given the preference. The distribution of the meals is sometimes of importance. Distribution of The best plan is to give three meals during the day and, in meals addition, two or three small meals between, the latter prefer- ably consisting of articles like bouillon, coffee or a little fruit, that possess a small caloric value. They serve the purpose of keeping the patient comfortable, avoiding disagreeable sensa- tions of weakness and gastric emptiness, and, at the same time, preventing the patient from becoming too ravenously hungry at meal times and consequently from over-eating. One other important principle must be observed in the feed- Restriction of ing, viz., the liquid intake should be restricted. Nothing is easier than to rapidly reduce the weight of an obese subject by restricting the liquid intake to a minimum. This loss of weight becomes particularly apparent during the first four or five days of the cure. It is due, in the first place, to a direct loss of water from the tissues; in the second place, to the fact that an individual drinking very little water does not eat as much as one taking a normal amount of liquid. The restriction, Suggestion therefore, in the beginning is a useful procedure, more for 156 THE DIETETIC TREATMENT OF OBESITY psychic than for physiologic reasons ; for the patients when they notice how rapidly they are losing flesh, acquire that confidence in the method that is so important if they are to carry out the more or less disagreeable and stringent orders that must be given. No permanent effects, however, are obtained from this restric- tion of liquids, and the patients regain their weight as quickly as they lost it, as soon, namely, as they begin to increase water- drinking. Nevertheless, even in cases in which the restrictions are to be continued for a long time, a reduction of the total liquid intake to about one to one and one-half litres in the twenty-four hours is a useful adjuvant. It renders it easier for the patients to live up to their restrictions and it is also beneficial - in advanced cases of obesity with complications, be- cause it spares the heart and kidneys. In cases, finally, that suffer from excessive sweating, the restriction of liquids is also a very useful procedure to remove this disagreeable symptom. Alcohol Alcohol may be administered to obese subjects, provided the caloric value of each gramme of alcohol (1 gramme=7 calories) is carefully included in the calculation. It should be allowed particularly in cases- that have been accustomed to a little alco- hol all their lives ; for here withdrawal of alcohol is not only an unnecessary hardship, but may even constitute a source of dan- ger, especially if a weakened heart is suddenly robbed of its usual stimulus. A few words may not be amiss in regard to certain special articles of food that are of particular value in the dietetic treat- ment of obesity. In selecting meat for obese subjects lean varieties should be given the preference. Lean meat contains about 20 per cent, of albumen and 1.5 to 2.0 per cent, of fat, so that 100 grammes of lean meat, weighed raw, furnish about 100 calories. It is necessary, of course that the meat should be prepared in a very simple way, i. e., that it should be either stewed, roasted or broiled. All meats that are prepared by frying, or that are served as ragouts or with bread crumbs, sauces and gravies, of course contain incalculable amounts of fat, so that their caloric value may assume very large proportions. It is always best, therefore, to forbid the use of any but lean meats, plainly prepared. Delicacies Among the animal foods that an obese subject can eat with impunity are a number of delicacies that are taken only in small quantities and, on account of their flavor, are very agree- able additions to the diet ; thus according to a table published by von Noorden, 100 calories are contained in : Special ar- ticles of diet Meats THE DIETETIC TREATMENT OF OBESITY 157 45 grammes of caviar. 40 grammes of sardines. 100 grammes of boiled lobster. 160 grammes of crab meat. 120 grammes of oysters (equal to about 14 to 18 oysters of medium size). 25 grammes of pate de foie gras. Cheese also serves a useful purpose; for taken even in very Cheese small quantities it is very filling. Thus Swiss cheese, Ameri- can cheese, Cheddar and Chester cheese contain about 28 per cent, of albumen, 30 per cent, of fat and 2 per cent, of carbohy- drate, and 25 grammes of these cheeses furnish about 100 cal- ories. Milk is a very useful addition to the bill of fare, provided Milk its caloric value and the water it contains are included in the calculation. 100 cc. of milk furnish about 60 calories. This amount can safely be allowed with tea and coffee. Butter- Buttermilk milk is still more useful; for 100 cc. of this beverage only con- tain from 40 to 45 calories, and a whole quart about 250 cal- ories. Thin soups and bouillons and beef tea are exceedingly use- Soups ful articles, for their caloric value is practically 0. They ore very filling, they taste good, and the patient eating a large plate of bouillon imagines that he is getting something of value. Sauces Rich sauces, as stated above, should be absolutely forbidden, because they are made of large quantities of fat, flour, eggs and their caloric value can hardly be calculated. Articles made of flour or rice, like noodles and macaroni, puddings, etc., should not be allowed at all in the strict reduction cures. In Articles made the first and second degrees, however, small quantities may be permitted as a relish. If they are given, each tablespoonful of these articles should be figured as representing about 30 cal- ories. Potatoes are also permitted, provided they are given in Potatoes small quantities and are either boiled or baked or mashed and served without butter. One hundred grammes of potatoes pre- pared in this way contain about 1.5 per cent, of albumen and 18.5 per cent, of carbohydrate, and possess a nutritive value of approximately 80 calories. Among the vegetables those varieties that grow underground Miscellaneous as well as those that grow in pods should be forbidden or re- vege a es stricted, because they contain very large and varying amounts of carbohydrates. If they are permitted at all in the lighter reduction cures their caloric value should be carefully deter- 158 THE DIETETIC TREATMENT OF OBESITY Preparation of vegetables Pruit Bread Mineral waters Pvesort treat- ment mined. All the other vegetables are exceedingly useful articles of diet in obesity, for they possess a very small caloric value in proportion to their bulk and consequently fill the stomach and rapidly produce a sense of satiety; incidentally they act fav- orably upon the function of the bowel. They should be served only boiled in salt water, without the addition of cream, butter, flour, etc. If flour or fats are used in preparing vegetable dishes the amounts of these ingredients should be carefully weighed and their caloric value considered. Fruits of all kinds, with the exception of bananas, sweet grapes, figs, dates, raisins, are permitted without reserve; they, too, are very filling and act well upon the digestive apparatus and constitute a great relish without, at the same time, possess- ing a high caloric value. About 100 calories are contained in from 220 to 250 grammes of fruit. The use of bread is permitted in obesity, only however if the bread is carefully weighed and its caloric value considered. Here the same rules obtain as in the feeding of bread to diabet- ics, i. e., those varieties that are made of vegetable albumen (gluten breads, aleuronat bread, etc.), are particularly useful if they are baked so as to become fluffy and voluminous, for they, too, are filling without possessing a very large caloric value. I have already shown on page 126 how their caloric value is to be calculated. A great many mineral waters enjoy deserved popularity in the treatment of obesity, notably, the waters of Kissingen, Vichy, Homburg, Carlsbad and Marienbad. It is a futile task, how- ever, to attempt the reduction of obesity by the use of these waters alone. It is possible, of course, by producing profuse- watery diarrhea with the aid of these waters to cause a consid- erable loss of water from the tissues and hence a reduction in the weight of the patient. This practice is of some use for psychologic reasons, because the rapid loss of weight in the be- ginning of the treatment makes a great impression upon the patients and renders them more willing to follow directions later on. The indiscriminate use of mineral waters is, however, to be condemned; for if the diarrhea is allowed to persist too long the effect is without doubt weakening, and this practice, more- over, reacts unfavorably upon the blood pressure and the heart, especially in obesity. These patients do very well, as a rule, in resorts in which these waters are taken, but the effects are to be attributed only in a very small part to the drinking of the particular water, and much more to the careful dietetic regulations that are usually carried out in these watering places, and, above all, to the THE DIETETIC TREATMENT OF OBESITY 159 increased muscular exercise that these patients willingly undergo in a resort. This element of muscular exercise is second in importance Muscular ex- only- to the regulation of the diet in obesity. It can readily be ercise calculated how a definite amount of muscular exercise causes the loss of a definite amount of fat. Oertel, Avho has studied, more than anybody else, the effect of graduated exercise, espe- cially graduated hill-climbing, upon obesity and the action of the heart, based his original recommendations upon definite calculations.* In Nauheim and certain other watering places the Oertel- Terrain cure Terrain cure is given by instructing the patients to slowly in Naunemi climb a series of paths that are elevated at an angle of from to 20 degrees ; at the same time, certain other factors are care- fully considered (see page 23), as the heart's action improves and the fat is lost, more exercise is allowed each day. In this way it is possible to carefully grade the exercises and remarkably good results are obtained from this practice. Other useful exercises besides walking on a level or hill- Outdoor climbing, are bicycle riding, rowing and a number of light s P° rts out-of-door games. Rowing is especially useful, for the amount of exercise can be carefully regulated while, at the same time, full expansion of the lungs with improved oxygenation is pro- moted. In winter rowing machines fulfill the same useful pur- pose. Horse-back riding enjovs very good repute as a means Horseback * . . riding of reducing obesity ; this reputation, as a German writer states, is deserved as far as the horse is concerned, but not the rider; horse-back riding stimulates the appetite more than any other exercise, without leading to any reduction of the body fat. Massage is of no value whatever in the treatment of obesity. Massage Von Xoorden and his pupils have shown by very careful meta- bolic studies that long continued massage of the whole body exercises no greater influence upon metabolism than opening and shutting one hand energetically a few times. ♦Assuming that a man weighing GO kilogrammes ascends an eleva- tion each day of 100 meters, then the labor performed is equal to GOx 100— 0.000 kilogrammeters ; as a matter of fact, much more energy is expended, for the external labor produced represents only about 30 per cent of the total energy developed ; thus such an individual in a day develops fully 20,000 kilogrammeters of energy. As 425 kilogrammeters of muscle work require 1 calorie, 20,000 kilogrammeters require 47.0G calories, and this amount of caloric value is furnished by 47.06-^9.3= 5.0G of fat. It will be seen, therefore, that such an individual must con- sume 5.0G of body fat to raise his body 100 meters. It is immaterial, of course, according to the laws of the conservation of energy, whether or not this elevation is reached within a short time or within a long time, by a vertical path or by a long series of inclined paths. 160 THE DIETETIC TREATMENT OF OBESITY Hydrotherapy Medicinal treatment Thyroid therapy Hydro-therapeutic measures are useful for several reasons. Cold baths, especially when combined with, friction, cause a considerable loss of heat from the surfaces of the body and hence stimulate the organism to increased heat production with consumption of body fat. Hot baths act chiefly on account of their diaphoretic action and are synonymous in their effect with any other sweating procedure. The condition of the nervous system, of the circulatory apparatus and of the bronchi and the skin, must always be carefully considered when advising the use of hydro-therapeutic means, and the same contra-indica- tions to their employment in obesity exist as in any other case of cardio-vascular, renal or respiratory disease. ■ These contra- indications have been fully discussed in their appropriate places. The medicinal treatment of obesity is of very subordinate importance. The complications occasionally call for drugs, as described in the chapters on the heart, the arteries, the bronchi, the digestive organs, the nervous system. For the reduction of obesity only one remedy can be employed, namely, thyroid gland preparations. The use of thyroid in obesity at one time was very popular, and this remedy has been carefully tested for several years. Its effects are always uncertain, some obese subjects reacting to the administration of the drug by a rapid, sometimes almost alarm- ing, loss of flesh, others not reacting at all. The effect of the drug, moreover, is not permanent, for as soon as its use is dis- continued the patients rapidly regain the lost fat; besides, it is not without danger, especially when used indiscriminately by the laity; for the syndrome of thyroidism (see page 102) mani- festing itself in a variety of disagreeable symptoms about the nervous system and the circulatory apparatus is always to be dreaded. Cases are on record, moreover, in which the use of large doses of thyroid extract produced glycosuria, and in view of the fact that there is an intimate pathogenetic relationship between obesity and diabetes, this is particularly to be feared; for occasionally it has seemed that a true diabetes mellitus was precipitated by the use of thyroid extract. Generally speak- ing, the use of the drug is superfluous, because obesity can always be reduced if the dietetic regulations discussed in the preceding paragraphs are conscientiously carried out. The one real benefit that might occasionally accrue from the use of thy- roid would be to produce a rapid loss of flesh, in the beginning of a reduction cure, and in this way to exercise a strong sugges- tive effect upon the patient, thus giving him confidence in the efficacy of the measures employed for his relief; but even this suggestive effect can, as shown above, be equally well produced RHEUMATISM 161 by the restriction of water drinking or by sweating without, at the same time, doing the patient any harm. For the dose and administration of thyroid gland preparations see iudex. III. RHEUMATISM. The term rheumatism is a remnant of an ancient nomencla- Nomenclature ture and is loosely employed to designate a great number of mor- bid conditions, many of them related in no way to one another. Used originally by the humoral pathologists to indicate the cir- culation of disordered humors, it was later applied to a variety of fleeting pains in many parts of the body, i. e., to a symptom. As such pains were commonly produced by exposure to cold and dampness, many disorders that followed such exposure were called rheumatic, so that the term was used in an etiologic sense. As the joints were commonly affected in these disorders, the term rheumatism was later loosely used to indicate joint affections in general. Finally, a "rheumatic diathesis" was con- structed in which there was said to be a special predisposition to articular involvement (" Arthritism" of the French). From the clinical standpoint, and also from the standpoint of etiology, it becomes necessary to exclude as not belonging at all to rheumatism : Fust. Acute articular rheumatism, or rheumatic fever, a Rheumatic disease that is without doubt infectious in character. This dis- order will be discussed in the Chapter on Infectious Diseases. Scconel. A variety of articular inflammations that are Pseud °- rneu_ matism grouped under the unfortunate name of pseudo-rheumatism, that are of parasitic origin and due to infection of the joints with certain bacteria, or to inflammation of the joint membranes by their toxins. To this group belong gonorrheal, pneumococ- cus, diphtheritic, influenza, staphylococcus and tuberculous ar- thritis, also the joint lesions seen in scarlatina and measles. These, too, will be mentioned in the sections on the different diseases that produce them. Third. The acute articular lesions of gout. These are often Rheumatic confounded with rheumatic lesions but are not related to them. * out Hence they will be discussed separately in the Chapter on Gout and the Uric Aciel Diathesis. In fact "the words 'rheumatism' and 'rheumatic' are often so loosely employed that they have almost forfeited all claim to be regarded as scientific terms." (A. E. Garrod. ) Consequently I do not feel justified in discussing under the title of rheuma- tism the great array of symptoms involving almost every organ of the body, chiefly the nervous system, the peri- and endocar- dium, the pharynx, the tonsils, the eye, the skin and the perios- 162 RHEUMATISM Muscular rheu- matism Chronic rheu- matism teum that have been included under this term, but prefer to discuss the "rheumatic" inflammations affecting these differ- ent tissues in the Sections devoted to the diseases of the various organs involved. On account of the great frequency and clini- cal importance of rheumatic myalgia, and on account of the popularity of the term "muscular rheumatism" employed to designate this disorder, a special chapter may, however, for practical reasons be given to the treatment of this affection. There remain to be discussed separately a number of varie- ties of "chronic rheumatism." Some of them are consecutive to acuta articular lesions, others have an insidious onset and run a chronic, usually progressive course. They all have a tend- ency to involve several joints, with their tendons and muscle sheaths at once, and to appear symmetrically, although some mono-articular forms are known (malum coxa3 senilis and pseudo-arthritis vertebralis). In all of them are found ana- tomic changes about the fibrous tissues and synovial membranes, the cartilages of the joints, with osteophyte formation and os- seous atrophy. To be excluded from these forms, from the standpoint of anatomic classification, are those varieties in which urate deposits are present, i. e., that are manifestly due to the uratic diathesis ; also the syphilitic joint lesions and those forms that are due to some primary disorders of the spina] cord (spinal arthropathies) ; finally, those forms that are due to chronic suppuration. However interesting and important it may be with respect to the etiology, pathological anatomy and diagnosis, to differen- tiate between these manifold forms of chronic rheumatism, from therapeutic considerations it. is unnecessary; for the treatment of all these varieties, notwithstanding their origin and imma- terial whether the disease involves the joints, the tendons or the muscle sheaths, singly or together, is practically the same. In- asmuch as, on the one hand, the same term is often used to designate different disorders, and, as on the other hand, many terms are employed by different writers synonymously, to des- ignate the same lesions, 1 I will not undertake in this volume 2 ( 1 ) The most common and the most popular terms employed to des- ignate this large and heterogenous group of morbid entities are arthritis or pseudo-arthritis deformans, rheumatoid arthritis and chronic articu- lar rheumatism. The following terms, however, are all used to desig- nate chronic progressive "rheumatism" of different joints not due to acute infections (pseudo-rheumatism and rheumatic fever). Goutte Asthenique Primitive (Landre Beauvais, 1800). , Digitorum Nodi (Heberden, 1S04). Nodosity of the Joints (Haygarth, 1805). Chronic Rheumatism of the Joints (Todd, 1843). Arthrite seche (Deville und Broca, 1848 und 1850). Rheumatisme Chronique Primitif (Charcot u. Vidal, 1853 u. 1855). MUSCULAR RHEUMATISM 163 to bring order out of this chaos, especially as any classifica- tion, however refined and accurate it might be, would in no way render us more successful in the treatment of chronic rheuma- tism. It is my intention, therefore, in the following pages, under the heading of "Chronic Rheumatism," to discuss together the treatment of chronic articular, tendinous and muscular lesions that are either consecutive to any of the acute forms of arthritis, or that are due to trophic changes (spinal lesions), or that are of unknown etiology and run a chronic course. I am fully aware of the fact that this procedure must appear inexact, but I see myself regretfully forced into this necessity by reasons -*)f practical expediency, otherwise enaiess reiteration would be necessary. We can only hope that before long more light may be thrown into this obscure region. MUSCULAR RHEUMATISM. Muscular rheumatism or myalgia (lumbago, pleurodynia, Definition torticollis, etc.) is in all probability a neuralgia of the sensory nerves of the muscles involved and not an affection of the proper muscle structures. The term rheumatism, as explained in pre- vious paragraphs, is a misnomer. Uric acid has nothing whatso- ever to do with so-called muscular rheumatism, popular preju- dices to this effect to the contrary notwithstanding. In view of our ignorance of the real nature of myalgia and of its exact causes, treatment can, of necessity, be only symptomatic. As the disorder generally follows exposure to wet and cold Protection the same rules in regard to clothing and the general hygiene and^et 00 ^ of the patient should be observed that are mentioned in detail under Rhinitis and Anemia. An attack of muscular rheumatism can occasionally be abort- Abortion of ed. Upon the appearance of the pain the patient should take the attack Usure des Cartilages Articulaires (Cruveillier, 1858). Chronic Rheumatic Arthritis (Adams, 1857). Rheumatisme Noueux (Trousseau, 18G0). Arthritis deformans (Virchow, 18G9). Rheumatoid Arthritis (Sir A. Garrod, 1876). Osteoarthritis (Spencer, 1888). Pernicious Arthritis (Brahazon, 1896). Rheumatisme chronique infectieux (Chauffard und Ramon, 1896). Rh. chr. infectieux et diathesique (Pierre Marie). Rhumat. chr. progressif (Charcot, Le Gendre). Polyarthritis villosa und Arthritis deform. (Schueller). Arthritis nodosa (Schuchardt). Osteoarthritis deformans (Schuchardt). Rhum. chr. deformant (Teissier und Roque). [Pribram.] (2) *For a detailed discussion of this part of the subject, see my forthcoming book on "Diseases of Metabolism." 164 MUSCULAR RHEUMATISM Anodynes and anti-neuralgics Salicylates Alkalies a Turkish bath, or a hot bath of 100° to 105° F., followed by a sweat between woolen blankets; internally ten grains of Dov- er's powder, or five grains of quinine with five grains of salol. Free catharsis should be promoted by a tablespoonful of mag- nesium sulphate. If these measures fail to abort the attack, then treatment with anodynes and anti-neuralgics should be instituted. This therapy is based on the following principles: Patients with muscular rheumatism have a tendency to voluntarily immobilize the affected muscles ; they do this in order to stop the pain. The arrest of the movement of the muscles undoubtedly re- tards the healing of the attack, for reasons that we do not un- derstand. To discuss the numerous theories that have been advanced to explain this phenomenon would serve no practical purpose. So much we know that active movements of rheu- matic muscles hasten recovery. Hence it is good practice to artificially stop the pain by the administration of medicines by mouth or by local applications, for then the patients are enabled freely to move their muscles and in this way to promote restitution to normal conditions.* Internally, therefore, opiates, phenacetin, acetanilid, preferably combined with salicylates and alkalies, should be administered either singly or in combination. The following prescriptions I have found very useful: n Codeine, % gr. (0.016 gm.) Phenacetin, 3 gr. (0.18 gm.) Salol, 5 gr. (0.3 gm.) M. or Extract of opium, % gr. (0.016 gm.) Acetanilid, 3 gr. (0.18 gm.) Sodium salicylate, Sodium bicarbonate, aa 5 grs. (0.3 gm.) M. S. One such powder to be taken every four hours with a full glass of water. If these remedies do not stop the pain, then it may become necessary to use morphine hypodermically, in quarter-grain doses repeated two or three times a day, and preferably injected *In the case of the intercostal group of muscles, however, that can- not be kept quiet at the patient's will, it may become necessary, pro- vided these remedies do not stop the pain, to artificially immobilize the affected area, in order to afford temporary relief, by strapping the chest with broad layers of adhesive plaster. MUSCULAR RHEUMATISM 165 into the sore muscles; if the drug is administered in this way both the narcotic effect of the remedy and the mechanical effects of the puncture are utilized; for puncture alone of the affected muscles with a long sterile needle often acts marvelously in stopping the pain and in a sense in aborting the attack. In case of rheumatism of large muscles, and particularly in lumbago, acupuncture should be performed in the beginning of the attack, as a routine measure, by inserting an ordinary Acupuncture sterilized hat pin for four or five inches into the affected muscle and leaving it in place for from five to ten minutes. In addition to internal remedies heat is useful, applied by Local appli- means of hot water bags or a thermophore (see page 39), or ca 10ns by poultices made of flaxseed or bread, medicated with a few drops of the tincture of opium or tincture of belladonna. High degrees of heat applied by means of hot air and sand, as de- scribed in the next section (see page 171) are exceedingly use- ful, especially in rheumatism of the muscles of the legs and Arms. Mustard, belladonna or capsicum plasters may be used ocally over the affected area. Iodine may be painted over the sore muscles. Such measures as cupping, blistering or cauteri- zation of the skin over the rheumatic area are rarely necessary. Liniments, as chloroform liniment, or the following application, are also sometimes effective in relieving the pain : Tincture of aconite, Tincture of opium, of each, 2 drachms ( 4) Soap liniment, 3 ounces (96) m; I have never been convinced that particular dietetic regular Diet tions or restrictions exercise any determinable effect upon the course of muscular rheumatism, nor that the abundant drinking of plain water, or of any of the numerous medicated mineral waters, in any way shortens the attack or prevents the recurrence of mus- cular rheumatism. However important, therefore, the regula- tion of food and drink may be in gouty forms of musculo- articular affections, in simple so called muscular rheumatism the patient need not be unnecessarily burdened with dietetic restrictions. The constant galvanic current, by causing contractions of Electricity the affected muscles, and massage by mechanically moving the Massage muscles about, are useful adjuvants to the treatment. 166 CHRONIC RHEUMATISM AND RHEUMATOID ARTHRITIS Prophylaxis Dwelling and general hygiene Clothing Diet CHRONIC RHEUMATISM AND RHEUMATOID ARTHRITIS.* In this disorder prophylactic treatment is occasionally ef- fective in preventing the development of irremedial disorders about the joints. It seems well established that most of the cases develop in individuals whose vitality is low, consequently it is of paramount importance to counteract ail extraneous in- fluences that can reduce their vital powers. If an individual, therefore, who comes from a rheumatic family, begins to com- plain of fleeting pains in muscles, tendons and joints, and tran- sitory stiffness of the fingers or the knees, his mode of life should be carefully regulated. Among the most important elements to be considered are the dwelling, the clothing and a variety of psychic factors. The patient should be instructed to seek a domicile that is dry, well- ventilated and light, for moisture and lack of sunlight undoubt- edly predispose to the development of the disease under dis- cussion. Living in a gloomy dwelling, moreover, exercises a depressing psychic influence, and this, as well as any other emotional strain or worry, should be most carefully avoided. The patients should, above all, be protected against exposure to wet weather or sudden temperature changes; consequently, it is often important to induce individuals whose occupation forces them to undergo such exposures to change their mode of liveli- hood. The clothing is, of course, of great importance. Many of these people are anemic and react badly to temperature changes. Linen or cotton should never be worn close to the body; for these textures favor rapid radiation of heat, become wet and cling to the body when the patient perspires and hence oblit- erate the layer of immovable air that should intervene between the skin and the first garment. Wool or flannel, or silk, are best of all for Reasons that have been fully set forth under the head of Anemia. If the individual is strong enough it is al- ways well to attempt to harden him (see Rhinitis), i. e., to render him less susceptible to temperature changes. The diet should be especially nourishing without over- loading the stomach. The error is frequently committed of feed- ing these individuals according to the principles that are outlined under the Uric Acid Diathesis. This is always dan- gerous; for underfeeding, with its inevitable result malnutri- tion, is very apt to follow from this practice. It is useful, there- *Definition see page 1G1. CHRONIC RHEUMATISM AND RHEUMATOID ARTHRITIS 167 fore, to appreciate that the uric acid diathesis, so-caJled, has nothing whatsoever to do with" chronic rheumatism. The patient should be instructed to drink plenty of water, Water drink- preferably some alkaline mineral water that possesses slightly laxative properties. This plan is always indicated, for, in many of the cases the alkalinity of the blood is slightly reduced. The infectious character of some varieties of chronic rheu- Treatment of cEL'ts.rrlis.l con™ ■ matism cannot be denied, consequently great care should be ditions about exercised in removing catarrhal conditions about the orifices t J ie o ri fi ces of the body of the body, for they undoubtedly constitute an open port of entry for any micro-organisms that might be incriminated with producing the disorder. Inasmuch as women seem to be par- ticularly liable to chronic rheumatism, special care should be bestowed upon diseased conditions in the female sexual appa- ratus. The disease occasionally starts in with more or less acute Treatment of arthritic manifestations, or acute manifestations appear as exa- cations** 106 *" cerbations during the chronic course of the disease. Whenever the joints are acutely affected the patients should be put to bed on a restricted diet consisting largely of milk, alkaline wa- ters and some fresh fruits or vegetables, and the joints should be immobilized. Great care, however, should be exercised not to immobilize the joints too completely or for too long a time; immobiliza- for otherwise, irremediable adhesions and ankylosis may form, tion of the The chief object of the temporary immobilization is to reduce m S the pain by preventing contact and friction between the in- flamed, opposing structures within the joints. Permanent ex- tension has also been recommended. It acts beneficially by causing relaxation of the muscles and tendons, thus separating Ext ension the condyles and again preventing friction and pressure upon the joint cartilages. In order to reduce the swelling and stop the pain linen Moist dressing- bandages dipped in salt water may be applied. The bandages need not be changed every day but may remain in place for three or four days in succession, provided they are kept moist during all this time. The application of bandages moistened with 2 per cent, carbolic acid was formerly very popular, but a number of cases of gangrene from this source have been re- ported, so that this practice must be considered dangerous. A 20 per cent, alcoholic solution of salicylic acid with a few drops of chloroform occasionally aids greatly in relieving the pain. Very good formulae for local applications of this kind are the cations following: 168 CHRONIC RHEUMATISM AND RHEUMATOID ARTHRITIS Injections into the joint Ointments Salicylic acid, Alcohol, Castor oil, M. 10 gm. 50 cc. 100 cc. A teaspoonful of this mixture is rubbed into the joint and the member then covered with silk or rubber and wrapped in cotton or flannel. Or an ointment may be applied, consisting of: I> Salicylic acid. Oil of terebinth, Lanolin, Paraffin, M. 10 gm. 10 cc. 30 gm. 50 gm. Or a medicated collodion may be painted upon the joint, pre- pared as follows : i? Methyl salicylate, Spirits of menthol, Elastic collodion, M. 10 cc. 5 cc. 5 cc. One of the most popular preparations, finally, is guaiacol mixed with equal parts of glycerin, or with the tincture of iodine, in the proportion of one part of guaiacol to six parts of the tincture of iodine. Injections into the joint of iodoform emulsions of guaiacol have also been used; the formula recommended being: 3 Iodoform powder, Glycerin, Guaiacol, M. o gm. 60 to 100 cc. 20 drops In case the pain about the joints is very violent, then opium or belladonna ointments or chloroform liniments must be ap- plied, or hypodermics of morphine must even be administered. Counter-irritation with iodine frequently relieves. If there is very much swelling, then paracentesis of the joint, followed by the injection of the above iodoform-guaiacol preparation may be practised. CHRONIC RHEUMATISM AND RHEUMATOID ARTHRITIS 169 For internal use innumerable remedies have been recom- internal medi- mended, but none of them has fully vindicated the claims to catlon real efficacy in this disease. Guaiacol preparations should al- ways be tried. The carbonate of guaiacol is better than pure Guaiacol guaiacol as it is less irritating to the stomach and kidneys. The carbonate should be given in doses of five to fifteen grains {0.3 to 1 gm.) three or four times a day. Next in popularity Beta-Naphthol to guaiacol carbonate is beta-naphthol. Salicylic acid prepara- tions are of subordinate value in the treatment of chronic rheu- Salicylates matism. In view of the difficulty, however, of distinguishing clinically between the various forms of sub-acute rheumatism, it is often worth while to give salicylate preparations, either in the form of salol five to ten grains (0.03 to 0.65 gm.) three or four times a day, or as aspirin in the same doses. The so-called Salol .alkaline-quinine treatment, that is, the combination of quinine As P erm two to five grains (0.1 to 0.3 gm.) and sodium carbonate five to ten grains (0.3 to 0.6 gm.) may also be employed, if all other Alkaline- measures fail, for occasionally good results are seen from this nient medication. As soon as the acute and sub-acute stages are over, or if the Treatment of •case comes under observation for the first time with a fully de- full y devel- oped stage veloped case of chronic rheumatism, then treatment should be -directed almost exclusively towards promoting absorption of the exudates that may be present, towards preventing the forma- tion of ankylosis and contractures, or towards loosening the .ankylosis and relieving the contractures if they have already formed. In order to fulfill these objects dietetic and medicamentons measures are of very subordinate importance. What remedies Subordinate are given should be administered as general tonics, or in order ^ue-s aUC6 to correct any anemia that may be present, or, symptomatically, to relieve pain or other disagreeable local symptoms; thus strychnine, quinine, iron, arsenic and occasionally guaiacol car- bonate, salol, beta-naphthol, and the other remedies that have been enumerated above when discussing the drug treatment of the acute and sub-acute arthritic manifestations of chronic rheu- matism, may all be utilized. The chief reliance, however, should be placed upon external measures. Neither diet nor drugs can Value of ex- accomplish much in this disease. Local external treatment can te ^ na l appli- ^ cations accomplish everything that one can reasonably expect to see brought about. Heat in various forms must be applied to the affected joints. Heat Hot baths, plain or medicated, mud baths, sand baths, steam baths, sun baths, hot air baths, may all be used. All of these baths act by accelerating the circulation of lymph and blood in 170 CHRONIC RHEUMATISM AND RHEUMATOID ARTHRITIS Besort and institution treatment Extravagant claims of pro- moters of re- sorts and waters the diseased joints, and hence promoting absorption of liquid,. semi-solid or solid exudates that may have formed., The temperature of the bath and the length of time during which the hot applications are to be made vary in each individual case and no fixed rules can be formulated. One cardinal ride should always be observed, however, viz., that, in the beginning of the treatment, very high temperature should never be em- ployed. If the individual is suffering from nervous disorders or from disturbances about the circulatory apparatus, then any bath treatment should be begun with great care and under care- ful supervision of the nervous reaction, the blood pressure and the condition of the heart and arteries. Inasmuch as the bath treatment must be carried out con- sistently for long periods of time, sometimes for months, before- very appreciable effects become noticeable, and as proper facili- ties for this treatment are only with difficulty procured at home,, it is usually necessary to have such patients undergo their bath cure in certain watering places or institutions that are espe- cially equipped for these treatments. The number of these re- sorts is legion and in selecting an institution or a watering place one should be governed by the circumstances of the patient, the time at his disposal, and many other extraneous factors that need not be enumerated. The chemical composition of the water at different resorts has very little to do with the good effects of these waters, nor is there anything to indicate that the addition of various medicinal substances as pine needles, turpentine, car- bonate of soda or potash, sulphid of potassium, arsenate of soda,, formic acid, etc., to the bath water exercises any specific effect upon the disease process that could not be obtained by the use of plain hot water. The addition of salt and other slightly irri- tating ingredients to the water may enforce the action of the heat, inasmuch as they produce increased hyperemia of the skin and hence more active and prolonged dilatation of the superfi- cial capillaries, with a correspondingly increased blood and lymph flow through the underlying joint structures. The slight advantage accruing from this effect is almost negligible, how- ever, so that the extravagant claims advanced by the promoters of different resorts and waters in this country and abroad, in regard to the wonderful efficacy of their particular spring in curing chronic rheumatism, may be dismissed without further comment. It all depends upon the regime at these different places, the facilities for securing proper massage and the method, of applying the hot water, but not upon the chemistry of the waters used. CHRONIC RHEUMATISM AND RHEUMATOID ARTHRITIS 171 A very convenient method of applying high degrees of tern- M ^d baths perature to the affected joints is by the aid of mud baths, for the mud particles irritate the skin and also exercise pressure upon the affected joint, in both these ways enforcing the action of the heat and promoting more rapid absorption of the patho- logic exudates. Here, again, it is the heat and the physical prop- erties of the mud and not the chemical constituents it may con- tain that exercise the good effects. For domestic application sand baths are exceedingly useful, Sand baths for very high temperature can be applied with the aid of sand. The hot sand (up to 150° F.) may be filled into little linen sacks and applied to the joints; in this way the benefits of both pres- sure and heat are obtained. The length of time during which the application is made varies according to the sensations of the patient. If the finger joints alone are involved it is a very useful plan to have the patient put on a cotton glove and immerse his hand in the sand, holding it there for fifteen minutes to an hour at a time, several times a day. The most effective way of applying heat, and the one that Hot air permits the use of the highest temperature, is by means of hot air. Special apparatus of different makes are on the market which enable the patients to carry out this treatment at home. Temperature as high as 300 to even 400 degrees F. can be borne without discomfort. Dry heat used in such an apparatus makes it possible to treat one joint at a time while the rest of the body is protected from the heat; this prevents disagreeable and dan- gerous phenomena about the nervous and circulatory apparatus. Sun baths and electric light baths are also employed in cer- Sun baths tain institutions and occasionally fulfill a useful purpose. Here, Electric haths again, the heat is the active agent and not, as far as we know, the chemical rays of the light. In some institutions the mechanical effect produced by a Douches stream of hot water directed against the joints is utilized to advantage to promote the circulation in the joint and to en- force the effect of the h^at. One of the best plans is the so- called "Scotch douche." Here the temperature of the stream of water which is directed against the affected joint with con- siderable force is rapidly changed from hot to cold and back again, and a very marked effect is generally produced in this way. A method that has recently come into deserved popularity Bier's method is the production of passive hyperemia in the affected joint. of passive This is the so-called Bier method. In order to produce passive hyperemia a bandage is wrapped around the limb above the 172 CHRONIC RHEUMATISM AND RHEUMATOID ARTHRITIS Massage and movements Electricity- Orthopedic and surgical treat ment Reduction of obesity joint. It is applied so tightly that the region about the joint becomes bluish-red in color and swollen. The application of the bandage should never produce pain in the affected articulations. Occasionally a little throbbing is complained of in the begin- ning, but even this disagreeable sensation should disappear within a short time. The constriction should at first be continued for several hours at a time, later for all day ; still later, the band- age is applied only during the night. No harm has ever been known to follow this method of treatment and some of the re- sults reported are exceedingly satisfactory, so that it certainly deserves extended trial. The application of heat by any of the means mentioned above can usually be supplemented to advantage by proper mas- sage and by active and passive movements of the affected joints. Here, too, the improvement of the circulation that follows the massage aids in the absorption of the pathologic exudates. Inas- much as this treatment should be performed by a skilled opera- tor it is needless to discuss the technique of massage. Electricity has been used in many cases of chronic rheuma- tism with good results, either alone or combined with heat and mechanical treatment. The electric current undoubtedly exer- cises a distinct effect upon the circulation in the skin and the underlying parts, and may, in this way, aid in promoting a more rapid flow of lymph and blood through the affected area. This method of treatment, too, should be carried out by an expert, otherwise it is usually futile. The faradic brush and the sol- enoid current are particularly recommended. Recently good re- sults have also been reported from high frequency currents, but this question is still in abeyance. In the later stages of the disease when ankylosis and deformi- ties have occurred, orthopedic and surgical treatment often be- comes necessary. In this connection the importance of reducing obesity in sufferers from chronic rheumatism of the joints may again be referred to (see page 150) ; for the reduction of the weight of the person of necessity relieves the joints of much pressure and saves them the labor of supporting a huge bulk; hence a reduction cure acts in the same sense as the mechanical supports that are given these patients by orthopedic surgeons. The various surgical procedures that have to be instituted in deformed cases cannot be discussed within the compass of this book. GOUT AND THE URIC ACID DIATHESIS 173 IV. GOUT AND THE URIC ACID DIATHESIS.* Of the primary causes of the uric acid diathesis we know introductory- nothing. Theoretically, I place myself without equivocation Th ® principles upon the neuro-humoral viewpoint so ably denned by Duck- treatment of worth in the following words: "It is incumbent, I believe, to !? e t £ ri ? acld invoke not only a chemical and a physical basis for gouty dis- The neurosal ease, but to include also in a comprehensive review the marked e emen determining influence of the nervous factor in the problem." The neurosal element is vague and intangible, essentially hereditary and probably not remedial in one generation. The perversions of the uric acid chemism on the other hand are more definite and are amenable to considerable modification and to correction by treatment. There is immense confusion in this field. This may be due to the fact that the course of typical gout is per se irregular and subject to fluctuations, and that atypical gout* presents so protean a syndrome of functional disorders, involving almost every organ, that the doors are thown wide open to subjective misinterpretation. In seeking for a basis of treatment the fundamental per- versions characteristic of the uric acid diathesis must be de- termined. They are the following : 1. The uric acid of the blood is increased. 2. Crystalline deposits of sodium urate are found in cer- tain necrotic tissues. The former factor alone, however, by no means constitutes The increase the essential element of the so-called uric acid diathesis, for in ? f S5 1C , ? cld , ' m the blood several diseases, notably leukemia, the circulating and excremen- titious uric acid may be increased immensely without ever pro- ducing any of the symptoms or lesions of gout or goutiness. It is safe, on the other hand, never to include a case under the category of the uric acid diathesis unless the uric acid of the blood is increased. The increase of uric acid in the blood may be due to: (1) Increased formation of uric acid. (2) Decreased destruction of uric acid. (3) Retention of uric acid; or to several of these factors combined. The analytical formation of uric acid, i. e., the genesis uric acid de- of uric acid from the disassimilation of more complex com- rived from pounds, is the common mode of formation in man. The old view is that uric acid is an oxidation product of albumin and an inter- *Synonyms: Lithemia ; Uricheniia ; Atypical, irregular, incomplete or abarticular Gout. 174 GOUT AND THE URIC ACID DIATHESIS Endogenous and exogenous uric acid Transforma- tion of uric acid Retention of uric acid mediary product in the formation of urea; the new view is that uric acid is a specific metabolic product of a special kind of albumin, viz., nuclein. Nucleins are the chief constituents of all cell nuclei and are hence contained in many articles of food and also in the tissues of our own body; uric acid may therefore be derived from either. As a matter of fact, the administration of nuclein or nuclein-containing foods by the mouth is followed by an in- crease of the uric acid excretion in the urine. On the other hand, a subject fed for a long time on a diet containing no nu- cleins (see below), or a subject after a prolonged period of fasting, still excretes appreciable quantities of uric acid. In the former instance the urinary uric acid was derived from the food nucleins; in the latter the excreted uric acid was derived from the tissue nucleins. The formation of uric acid from the food nucleins we can control; the formation of uric acid from our tissue nucleins we cannot control. Whereas the former factor is constant and independent of the individual, in the sense, namely, that a definite quantity of food nuclein invariably leads to the excre- tion of a definite and calculable quantity of uric a^id, the lat- ter factor is inconstant, varies in different individuals, and cannot be calculated in advance, The theory has been advanced, and has been supported by some evidence, that in subjects suffering from the uric acid diathesis the individual catabolism of nucleins is high; the ad- herents of this view consider the diathesis a "nucleolytic auto- intoxication" — which proposition it is difficult to prove. Uric acid is normally in part destroyed or transformed in the mammalian organism. Extracts made from liver, muscle and kidney in certain lower animals possess the power of con- verting uric acid into more highly oxidized and more soluble nitrogenous bodies. The author has shown that the same ap- plies to human liver, kidney, muscle, and blood.* We also know that only a portion of the calculated amount of uric acid is excreted after feeding with nucleins or uric acid, and that a part of the nitrogen appears in the urine in other forms. I am inclined to believe that non-destruction is a more prolific cause of uric acid accumulation than over-production. Whether or not uric acid is retained in the uric acid diathe- sis cannot, I believe be definitely ascertained until we gain more comprehensive data in regard to the uric acid ex- cretion before, during, and after attacks of gout, and in re- * Medical Record, 1903. GOUT AND THE URIC ACID DIATHESIS 175 gard to the average uric acid excretion in those cases that never progress to the stage of gouty seizures. We have only recently learned to understand the influence The effect of ■of diet on the uric acid excretion, and above all the influence a ^ c ^ id ® x _ -of the food nucleins on this function. It is clear that uric cretion acid determinations are of value only if the patient is kept on a diet free from nucleins during the time of observation, or if at least the exact nuclein content of the food is known; in •addition, the individual (endogenous) uric acid excretion must be known. Failure to comply with these fundamental postu- lates must be made responsible for the colossal confusion obtain- ing in regard to the plus or minus excretion of uric acid in the disease. In that small minority of cases of gout in which there is distinct granular atrophy of the kidneys some retention may occur. I am also inclined to believe that renal insufficiency ob- tains in a much larger proportion of gouty cases than is usu- ally assumed. I refer to those patients in whom we find in- creased arterial pressure with an accentuated second aortic •sound and signs of cardiac hypertrophy, together with certain retinal changes, nitrogen retention without increase of bodily weight, and other evidences of renal inadequacy; these cases appear to me to be cases of "latent" nephritis, and the absence of albumin from the urine does not necessarily militate against this diagnosis. Urate deposits are a characteristic finding in the uric acid Urate deposits diathesis, even though cases of gout occur in which no urate deposits are found post-mortem, and though urate deposits are occasionally discovered on autopsy without a history of gouty seizures during life. It appears that urate concretions can only occur if the blood contains an excess of uric acid in solution; the reverse, is not true, for in many other states (leukemia, pneumonia, lead nephritis, etc.) in which the blood contains abnormal quan- tities of uric acid no concretions develop. Definite factors must therefore be operative in the uric acid Tlie factors de- diathesis that not only favor the deposit of urates, but also de- ura te deposits termine certain definite points of predilection for the precipita- tion of sodium urate crystals. These locations are the joints, the tendon sheaths, the muscle fascia?, the kidneys, the external ■ear and the bone-marrow. These factors must necessarily be local. It is very prob- able that the poor vascularization of the particular parts can largely be made responsible for the deposit of concretions in these special places. 176 GOUT AND THE URIC ACID DIATHESIS Blood alka- linity Proportion of salts Necrosis in the vicinity of urate con- cretions General con- siderations re- lative to treatment based on the above prin- ciples Chief indica- tions for treatment Much has been written in regard to the influence of reduced alkalinity of the blood. It does not appear, however, from ex- act determinations that the alkalinity of the blood is abnor- mally low in the uric acid diathesis. Changes in the relative proportion of salts (chiefly mono- and di-sodium phosphate) in solution in the serum are a much more important factor. If several salts are present in solu- tion the more soluble salt will precipitate the less soluble one even if the solution is not saturated with the latter. Given, there- fore, an increase of urates in the blood, with local stasis of blood and lymph, then a slow interchange between two relatively concentrated solutions occurs, and precipitation of the least soluble salts, the urates, obtains. Senile cartilages are relatively rich in salts, and the circu- lation in these tissues is particularly poor; hence possibly the- tendency of older subjects to uratic deposits in the joints. The significance of the necrosis found in the vicinity of urate concretions is still obscure. Either the urates produce the* necrosis or the necrosis is the primary event and prepares a suitable nidus for the secondary deposit of urates; the cause- of the necrosis in the latter event would remain unexplained; it may be tropho-neurotic or may be due to the action of the alloxuric bases, chemical congeners of uric acid. As the primary cause of the uric acid diathesis is unknown and as the neurosal element that enters into its pathogenesis is intangible, we are limited in our treatment to a correction of the perversions of the uric acid economy that we have outlined above. We find ourselves here in a similar position as in the treat- ment of diabetes and obesity, for in these diseases, too, we are limited in our endeavors to the removal of excessive sugar and fat and to a correction of the secondary disorders that follow the abnormal accumulation of these products. Unfortunately, we have in the uric acid diathesis no such definite index of the progress of the disease and the success of our treatment, as the disappearance of sugar from the urine or changes in the con- tour of the patient. The two chief indications for treatment are: 1. To prevent the increase of uric acid in the blood; this accomplished the precipitation of urates as we have seen is rendered difficult. 2. To promote the solubility of uric acid in the blood; in this way its precipitation may also be prevented. As the accumulation of uric acid may be due to increased formation, decreased destruction, or retention, treatment should GOUT AND THE URIC ACID DIATHESIS 177 he directed towards reducing the production of uric acid, in- creasing its destruction, and accelerating its elimination. To reduce the production of uric acid is one of the most important, and at the same time one of the most feasible, tasks of dietetic treatment. We know that the uric acid is chiefly Limited use of formed from disintegrating cell nuclei and that the restriction ^" c fo^g" orm ~ of articles of food containing many cell nuclei or nuclein or uric acid, or its chemical congeners, the alloxuric bases (purin bodies), must needs decrease the formation of uric acid. And even should it be shown that the accumulation of uric acid is due to retention or non-destruction, and not to over-production, the limited use of uric acid-forming foods must nevertheless be considered altogether rational. We know too little of the normal mechanism of uric acid The destruc- destruction to enable us satisfactorily to regulate this process. ™^ ° uric What means we possess to accomplish this end are not dietetic. The withdrawal of articles of food that are more readily oxi- dized in the body than uric acid was at one time considered to be good practice, for it was argued that in this way the oxidiz- ing powers of the organism would not be directed toward a destruction of these articles, but to the destruction of accumu- lating uric acid instead. Since it has been shown, however, that uric acid is not destroyed by a proper process of combustion, but by a more delicate process of intracellular disassimilation (probably fermentative in character), this argument has been rendered altogether invalid. Certain dietetic regulations can finally directly and in- Elimination directly aid in the elmination of uric acid; directly, by exer- of uric acldL cising an effect on the circulation and the renal excretion; in- directly, by sparing the heart and kidneys and enabling them to perform their functions in a normal manner. As the latter organs are frequently involved in the uric acid diathesis, it is particularly important that the diet should contain nothing that can injure them. The following considerations, therefore, based on the prin- The diet ciples just predicated should govern the selection of the diet in the uric acid diathesis. There is much disagreement and misunderstanding in regard Meat to the use of meat. One group of extremists interdicts the use of meats altogether; another makes artificial distinction be- tween dark and red meats; and a third insists on a diet con- sisting almost exclusively of red meat ("Salisbury diet"). In "Salisbury''" this country the red and dark meat fad is particularly rampant. I see the matter as follows: The use of a moderate amount of 178 GOUT AND THE URIC ACID DIATHESIS Red and dark meats Nuclein con- taining foods Internal or- gans Meat extracts Hed meats Towl Mode of prep- aration Dangers of meat restrro- '"'on meat is not only permissible but necessary. Some care must be exercised in selecting the kind of meat and in determining its quantity and its mode of preparation. The administration of nuclein or extractives (uric acid and the pur in bases) should be reduced; hence all meats containing many cell nuclei, i. e., all internal organs (liver, kidneys, sweet- breads, brain, thymus) should be rigorously excluded. All meat extracts, broths, sauces, and gravies contain the extractives and are consequently bad. Raw meats, smoked and cured meats, sausage, etc., because they still contain the extractives, should also be limited. To exclude the flesh of fowl because birds produce more uric acid than mammals is based on the erroneous conclusion that consequently their muscles are also particularly rich in uric acid. There is no reason to exclude poultry. It has also been shown by exact analyses that there is no difference in regard to their uric acid content between the dark and the white meat of birds. This distinction is therefore also unnecessary. Boiled meat is better than roast or fried meat, because the extractives have been removed from the former. Some writers maintain that the quantities of extractives introduced with meat are so small that they cannot possibly exercise an appre- ciable effect; there is, however, some evidence to show that these bodies, administered in small quantities for a long time, may exercise a cumulative effect. It is safer, therefore, to adhere to the foregoing rules until evidence to the contrary is forth- coming. We are unable, of course, to directly control the nuclein economy of the organism proper by restricting the use of nu- cleins, for the body is capable of building up its tissue-nucleins from any proteid- and phosphorus-containing pabulum. We know, for instance, that whole peoples live on a vegetable diet free from nucleins; (these by the way are remarkably free from gout!). The albumin of the meat exercises no direct effect on the excretion of uric acid and may therefore be considered an essen- tially indifferent constituent of flesh as far as the uric acid economy is concerned. The quantity of meat should, however, be limited, although not reduced too much. The organism re- quires a definite quantity of nitrogenous material, and while it is possible to supply all the nitrogen required in articles of food other than meat, this procedure necessitates feeding the patient with large quantities of bulky material leaving much residue and taxing the digestive apparatus very severely. It is GOUT AND THE URIC ACID DIATHESIS 179 more natural and more rational to supply a portion of the nitrogen in meat, especially as the withdrawal of meat consti- tutes a great hardship to many patients and it would be unneces- sarily cruel to stop its use. One pound of meat, moreover, contains as much nitrogen as several pounds of most other nitro- genous articles of food. Unless the caloric value of the diet is carefully calculated there is always danger of under-feeding the patients when meat is withdrawn. This is a dangerous possibility, for it favors the development of gouty cachexia, lowers the tone, and there- with reduces the activity of the oxygenation powers of the body. If nitrogen is deficient the organism, moreover, compensates for this deficiency by increasing catabolism of its own (nuclein- containing) tissues. On the other hand, too much meat is certainly bad, for, in Dangers of too the first place, meat produces a distinct digestion leucocytosis, much meat followed by the disintegration of leucocytic nuclei; in the sec- ond place, meat reduces the alkalinity of the blood owing to the sulphur and phosphorus it contains, for these elements, as we have seen, are oxidized to sulphuric and phosphoric acids, and as the bases (potassium, sodium, calcium, and magnesium) liberated from the meat at the same time are incapable of com- pletely neutralizing these acids, acidulation of the bodily fluids occurs (corned beef is particularly bad in this respect because all the basic salts are leached out in its manufacture and replac- ed by neutral sodium chloride) ; in the third place, meat taxes the eliminatory powers of the kidneys very much and these or- gans must be spared and protected in the uric acid diathesis. Eggs in moderation may be permitted. True, the yolk of Eggs egg contains abundant nuclein (vitellin), but this nuclein is different chemically from the nucleins of meat and cannot split off uric acid. Nevertheless, I restrict the use of yolk of egg. The white of the egg exercises no effect on the uric acid excre- tion even when given in large quantities; of course, it, too, like meat albumin, can reduce the blood alkalinity. Where it is well borne, it is, however, a very convenient form in which to supply nitrogen. An exclusive milk diet, as advised by some, is always bad, Milk particularly in old people; for the ingestion of large quantities of water incident to abundant milk drinking must needs over- tax the heart, the arteries, and the kidneys (see page 208 f). Milk as an addition to a mixed diet is good if it can be borne; here we must individualize. The nucleins it contains are paranu- cleus and do not produce uric acid. Milk slightly reduces the 180 GOUT AND THE URIC ACID DIATHESIS alkalinity of the blood, owing possibly to the generation of lac- tic acid and to the oxidation of its proteids. All these theoretical disadvantages are, however, over- compensated by its highly nutritious character and its powers to stimulate diuresis. Cheese In the manufacture of cheese the basic alkali salts contained in the milk are dissolved in the whey ; hence cheese is poor in these salts. The same objections can therefore be formulated against its use as against corned beef (see above), viz., that it acidulates the blood owing to the formation and incomplete neutralization of sulphuric and phosphoric acids; in addi- tion, the free fatty acids that cheese contains may enforce this effect. As a matter of fact the urinary acidity increases after a cheese diet. Empirically, cheese has been known to precipi- tate gouty attacks, and in certain regions of Germany where much cheese is eaten urinary calculi are said to be very fre- quent. I consequently usually exclude cheese from the dietary, although there is no compelling scientific reason for doing so. Fats It has been argued that fat should be omitted from the diet in uratic cases because it is so readily oxidized and hence pre- vents the oxidation of the nucleins. Withdrawal of fat does not, however, exercise any effect on nuclein catabolism nor on uric acid excretion. Excessive feeding, with fat has, on the other hand, been known to cause an increased excretion of uric acid. Paradoxical as it may sound, fat is particularly indicated in those cases that are inclined to obesity; for if fat is added to the diet, the appetite is more rapidly appeased, the patients con- sequently do not eat so much, and are above all not so apt to gormandize. As uric acid patients should be instructed to take much phys- ical exercise, the addition of some fat to the diet is almost in- dispensable to maintain full nutrition. If, therefore, certain individual idiosyncrasies, and also the state of the digestive apparatus, are duly considered, there is no valid objection to the use of fat in moderation. Carbohydrates Carbohydrates exercise no appreciable effect on the uric acid excretion nor do they irritate the kidneys. They do, however, favor the development of dyspeptic disorders, because they readily undergo fermentation and because they are so bulky. As all carbohydrates are quite soluble and are easily ab- sorbed patients living on a carbohydrate diet are very apt to ingest too much nutrient. Many persons, for instance, could without difficulty master 1,000 grammes of carbohydrate in the form of bread, cake, potato, etc., a day, whereas no one would GOUT AND THE URIC ACID DIATHESIS 181 be tempted to eat an equivalent quantity of fat (440 grammes) or of albuminous food (1,000 grammes). Carbohydrates, moreover, favor alimentary glycosuria and, indirectly, the development of diabetes and obesity, both com- plications that are not infrequently seen together with the uric acid diathesis. Carbohydrates should therefore be restricted. In cases com- plicated with diabetes or obesity they should be temporarily for- bidden altogether or replaced by fat. In patients suffering from dyspeptic complications, or in persons inclined to over-eat, their use should also be restricted. Certain of the bulbous vegetables, viz., potatoes, cabbage, Fruits and vegetables etc., contain a very large percentage of carbohydrate and very little proteid; as they, therefore, possess all the disadvantages of carbohydrate foods, and only very slight nutritive value in proportion to their bulk, they should be used sparingly in the uric acid diathesis. They are also apt to undergo fermentation and to produce dyspeptic disorders. Salads and all green vegetables, on the other hand (with the exception of young germinating plants, such as asparagus, that contain much nuclein), may be given freely. They con- tain relatively little carbohydrate and a large proportion of salts. The large residue of cellulose they leave in the digestive tracts stimulates peristalsis and aids in keeping the bowels open ; this is a desideratum in gouty cases. Celery and onions are to be forbidden on account of the irritating oils they contain. All spices and condiments should be avoided; they irritate Spices and the digestive tract and the kidneys and above all stimulate the con imen s appetite and in this way encourage over-eating. All fruits, either deciduous or citrous, may be permitted. The acid salts they contain are converted into carbonates and render the urine alkaline; they contain very little carbohy- drate. Empirically, too, we know that they act beneficially in the uric acid diathesis (so-called "fruit cures"). Fruit acids Fruit cures exercise no distinct effect on the excretion of uric acid, with the exception of tannic acid which seems to decrease it. Water should be the chief beverage. Forced water-drink- Water ing, however, is unnecessary, even harmful, although it is advised by some authors. Excessive water-drinking does not in- crease the excretion of uric acid; nor does increased diuresis by any means signify increased excretion of urinary solids. Water in a sense is a distinct irritant of the renal epithe- lium; in gouty nephritis, therefore, and in cases of beginning renal insufficiency water in excess may do harm. Where there 182 GOUT AND THE URIC ACID DIATHESIS Mineral waters Tea, coffee, cocoa Alcohol is much arterio-sclerosis, with a weak heart muscle, the flooding of the circulation with water can only be detrimental. On the other hand, the amount of water should not be re- duced too much, for we know from clinical experience that this practice favors the formation of urinary calculi. A uric acid patient should therefore drink from one to one and one-half litres of water a day, not much more nor less. It is better to order the frequent drinking of small quanti- ties than the drinking of large quantities at long intervals. It is a good plan to have the patient drink one-fourth of a litre of warm water immediately before going to bed; this practice occasionally, I believe, prevents the occurrence of nocturnal attacks of gout. In fact, owing to the frequency with which gouty seizures appear in the night, it is advisable that patients as a routine measure should eat a frugal evening meal and should drink warm water before going to bed. The favorable effects that are said to be derived from the use of numerous well advertised mineral waters are probably due to the water, and not to the salt in solution; the so-called uric- acid-sclvent virtues of many of these salts seem highly prob- lematical to me (see below). Tea, coffee, cocoa are usually considered bad. I think their use should be greatly restricted in uric acid cases. They contain certain members of the group of alloxuric bases (caffeine, theine, theobromine, adenine, etc.), and as these bodies are direct precursors of uric acid some of them are presumably in part converted into uric acid in the organism; at all events the excretion of uric acid is increased after some of these substances are given by the mouth. There is, moreover, some evidence to show that these compounds may directly irritate the kidneys and the circulatory apparatus, also the digestive tract. While excessive tea or coffee drinking is, therefore, to be absolutely condemned, the moderate use of thin tea or coffee is, I think, permissible, particularly in persons who crave these beverages. Tea is by all means preferable to coffee, for it stimu- lates diuresis and is not indigestible. In patients accustomed to alcohol it is also much easier to limit or stop the use of the latter if a little tea or coffee is allowed. Alcohol-drinking has always been considered one of the chief causes of gout. In view of the almost universal preva- lence of the alcohol habit, however, this proposition is difficult to prove. There can be no doubt that an alcoholic debauch may occasionally precipitate a gouty attack in a predisposed subject, and that sufferers from gout as a rule feel better if they abstain GOUT AND THE URIC ACID DIATHESIS 183 from alcohol. Alcohol is a direct irritant of the digestive tract, of the circulatory apparatus, and of the kidneys. No distinct and uniform effect of alcohol on the excretion of uric acid has so far been determined, notwithstanding the fact that a verit- able flood of investigation has been published on this question. The food value of alcohol is of subordinate importance in goutiness, for here there is no loss of valuable pabulum in the urine as in diabetes. Alcohol, chiefly on empirical grounds, is, therefore, as a rule, to be forbidden. At the same time we occasionally encoun- ter a patient who does better if a small quantity of some alco- holic beverage is permitted. Champagne, sweet wines, cider, liqueurs, and malted liquors are to be absolutely avoided; dilute Rhine or Moselle wine or claret or whisky with water, all in very small doses, may at times be allowed. As in all the other dietary regulations that I have outlined, the previous habits of the patient, his temperament and charac- ter, must be carefully considered. It is frequently easier to enforce rigid rules in one direc- tion if a little latitude is allowed in another, and if certain crav- ings and tastes — call them abnormal — are satisfied. ''By as sociation with rules that cannot be obeyed, rules that can bL' obeyed lose their authority." One of the most important elements to be considered in the Exercise treatment of the uric acid diathesis is the regulation of physi- cal exercise. Broadly speaking, every sufferer from manifes- tations of the uric acid diathesis, especially when afflicted with "rheumatic" and neuralgic symptoms, should indulge in abund- ant but light physical exercise, carried out as much as possible in the fresh air. In view of the fact that many of these cases are of a melancholy or irascible temperament, and usually suffer from Irypochondriasis, the exercises should partake of the character of sports, i. e., they should not be monotonous but should amuse and stimulate the patient. Moderate horse-back riding, golf, swimming, fencing, tennis, bicycling, rowing are all useful, and during the cold months, bowling, billiards and similar games. In view of the tendency to uratic nephritis and uratic myocarditis, that is always to be considered in these cases ; no violent exercise should be indulged in, nor should exertion ]yi assao . e ever be carried to the point of fatigue. If there are nephritic or cardio-vascular changes, then passive and resisting exercises and massage become exceedingly useful. Baths also occupy an important place in the treatment of s a ths the uric acid diathesis. If it is possible the patient should be 184 GOUT AND THE URIC ACID DIATHESIS Resort treat- ment Hot bathing Contraindi- cations Hydrotherapy in general [Medicaments Complications and sequelae Hepatic insuf- ficiency Dyspepsia advised, for a month or so of each year, to undergo a course of treatment in some watering place where he can have the benefit of hot baths combined with massage and exercises such as those specified above. The careful regulation of the regime, as it is generally carried out in resorts, combined with rest and respite from daily work and worries, usually exercises a most beneficial effect upon these cases. The choice of the bath is difficult and I am inclined to believe that the temperature of the waters and the mode of administering these baths are more important than the chemical ingredients the waters may contain; it is in most cases of small importance whether the water contains salt or carbonic acid or sulphids, or whether a mud or a fango bath is given. At home warm bathing should also be encouraged and the patient should, at least two or three times a week, take a hot bath, a few degrees above the body temperature, preferably lying still in the tub for ten minutes at a time. After the bath a vigorous rub with a rough towel, followed by a general mas- sage with cocoa butter or olive oil, is often of great value. Hot bathing of this kind, however, is distinctly contra-indicated in cases suffering from cardio-vascular or nephritic manifesta- tions of the uric acid diathesis, and immeasurable harm is un- doubtedly done in many of these cases by a routine treatment which ignores these elements. All hydro-therapeutic proced- ures, Turkish or Roman baths are, as a rule, too severe for these patients, particularly in view of the neurotic complications and also the changes about the heart and arteries that are present in the great majority of them. The medicinal treatment of the uric acid diathesis will be discussed in full in the Section on Nephrolithiasis Urica (see page 230), and I refer to those paragraphs for the use and abuse, the fallacies and inconsistencies of most so-called uric acid remedies, particularly the uric acid "solvents." Certain complications and sequelae of the uric acid diathesis require special treatment. Many of these signs disappear promptly upon the onset of a regular gouty attack and most of them are best treated, like the complications of diabetes and obesity, by correcting the underlying metabolic perversion. In view of the important part that the state of the digestive appa- ratus plays in the production of lithemic manifestations, par- ticular attention should be bestowed upon the gastro-intestinal tract and the liver. Here the syndrome of functional hepatic insufficiency must always be considered and treated, as de- scribed in the Chapter on Diseases of the Liver (see page 488). If the diet is arranged as outlined above gastro-enteric symp- toms are not very liable to supervene; if they should appear, RETROCEDENT GOUT 185 their symptomatic treatment differs in no way from that of other forms of gastric or intestinal dyspepsia, as elsewhere de- scribed. Constipation is very common and should be energet- Constipation ically combated. Intestinal putrefaction should never be per- mitted to go on unchecked. For this reason free evacuation of the bowel contents, either by the use of vegetable cathartics or preferably of salines, should be promoted, and, in addition, such remedies administered that we know can hold intestinal putrefaction in check. The latter have been discussed in full Catarrhal con- under the heading of Intestinal Antisepsis (see index). The dl tions chronic catarrhal conditions about the throat and respifatory apparatus; the skin affections; the "rheumatic" pains in the Anemia muscles; the anemia and cachexia; the nephritic manifesta- Diabetes tions; complicating diabetes and obesity, should all be attacked Q-beslt y by trying to correct the perversion of the patient's metabolism chiefly by diet, exercise and hydrotherapy, and, in addition, symptomatically as described under these different diseases. The tophi rarely call for special treatment. Particular care Tophi should be taken not to remove them surgically nor to allow pa- tients to try to squeeze or scratch the concretions out; for in the uric acid diathesis there is an increased vulnerability of the skin and subcutaneous tissues, so that even mild surgical procedures or surface injuries frequently induce erysipelas, cellulitis with ulcers and obstinate fistulas or even gangrene of skin lesions the parts. Before discussing the treatment of the acute attack of gout, Retrocedent the general principles that should govern the treatment of so- £ out called retrocedent or metastatic gout may ba briefly considered. RETROCEDENT GOUT. It is well known that occasionally the joint manifestations of Retrocedent gout will rapidly disappear and in their place a variety of dis- sont tressing and dangerous cerebral symptoms develop. The latter manifest themselves as cerebral gout by headache, vertigo and even apoplectic seizures (gouty encephalopathy) ; as cardiac gout by severe cardiac pain, syncope or collapse; as gastro- intestinal, vesical or cutaneous gout with corresponding mani- festations. The sovereign therapeutic indication in all of these cases is induction of to reinduce a regular articular paroxysm. This can best be done regular arti- either by placing the feet into hot mustard water or by rub- a parox y sm bing the dorsum of the foot, and particularly the large toe, with an alcoholic solution of turpentine f crowed by the appli- 186 THE ACUTE ATTACK OF GOUT cation of heat, and wrapping the parts in cotton. The cerebral symptoms, provided they do not promptly disappear when the articular paroxysm is produced, should be treated by the appli- cation of cold to the head and by venesection. If the stomach symptoms predominate, then vomiting should be produced by the use of emetics and counter-irritation over the epigastrium, preferably cold. The heart collapse calls for the use of analep- tics, scil. camphor, ether and the application of cold over the precordial region. Danger of aborting- acute paroxysms Local treat- ment Immobilization Lotions Anodyne ap- plications THE ACUTE ATTACK OP GOUT.* Any attempt to abort the acute paroxysm of gout is to be condemned ; for by suppressing local symptoms much danger can arise to the organism at large. The local treatment consists in the immobilization of the affected joint, the patient remaining in a recumbent position, at least in the beginning, with the diseased limb elevated and covered with cotton or flannel. No pressure should be exercised upon the affected joint. Cold should never be applied, because it retards the circulation and aggravates the local condition, and may even lead to the devel- opment of necrosis and to the permanent deposit of urates. A variety of lotions have been recommended for local use. Whisky and water applied on lint is very grateful, or a drachm of sulphuric ether in six ounces of water may be used. Lauda- num and water and belladonna liniment with morphia are rec- ommended by Garrod. The following liniment is advised by Duckworth: Atropin, 3 grains. Morphine hydrochlorate, 15 grains. Oleic acid, 1 ounce. M. S. To be painted over the painful joint with a large camel 's hair brush and carded cot- ton to be superimposed. Camphor-menthol, made by rubbing up together three parts of menthol with two of camphor, forms a useful anodyne applica- tion; or half an ounce of menthol may be dissolved in six ♦Acute paroxysms of gout are rarely seen in this country. Inas- much, therefore, as my personal experience with this manifestation of the uric acid diathesis is relatively limited, I submit in broad outline the combined authoritative statements of Duckworth, Gorrod, Roberts and Latham on the treatment of this disease. THE ACUTE ATTACK OF GOUT 187 ounces of spirits of camphor for a lotion. Any application that occludes the sweat ducts, like collodion or medicated powders, should be eschewed. Blisters and leeches should never be ap- Blist ers and leech.es plied, as the skin over the affected joints is usually very vul- nerable and there is always danger of producing obstinate ec- zema, furunculosis or even gangrene. Heat is always grateful, Heat preferably applied in the form of hot fomentations or poul- tices. Massage of the affected joint should be reserved until Massage the third or fourth day of the paroxysm, but had better not be administered in the beginning of the attack. Usually the pain produced by the massage, or by any movement of the joint, of itself forbids this measure. The internal treatment of the acute gouty attack consists Internal treat- in the administration at once of a purge. One or two grains of men calomel with two to six grains of the compound pill of colocynth and extract of hyoscj^amus (Pil. colocynth et hyoscj^ami, B. P.) should be given at night, followed in the morning by a Seidlitz Purging powder or some other saline aperient. As soon as the attack is fully developed colchicum becomes the sovereign remedy. This drug may be considered almost Colchicum a specific, at least for relieving the pain in a gouty paroxysm. In order to continue the laxative effect inaugurated by the cal- omel, colocynth and hyoscine, twenty grains of carbonate of magnesium may be added to each dose of colchicum. The fav- orite prescription employed in St. Batholomew's hospital is the so-called Haastus Colchici, containing: Magnesium carbonate, 10 grains. Tincture of colchicum seed, 20 minims. Peppermint water, • 1 ounce. This dose to be given every night; half the dose in the morn- ing. The treatment is continued for three or four days and then two or three grains each of the extract of colchicum, combined with a compound colocynth pill (see above), are given every night. The most satisfactory preparation of colchicum is the wine: for it does not possess such violent purgative properties as the Preparations preparations of the seed. The use of colchicine either by mouth or hypodermically is condemned as useless and not with- out danger by leading authorities. The symptoms of colchicine intoxication consist in depression, nausea and purging, and sweating, the stools assuming a characteristic green color. It is rarely necessary to give the drug in such large doses that 188 RACHITIS Sodium sali- cylate Anti-neuralgics Quinic acid Alkalies Diet Water Alcohol To prevent re- currences Iodides purging is produced. The appearance of severe depression and violent purging, and a great fall in the arterial pressure with profuse sweating, call for a reduction of the dose or temporary discontinuation of the remedy. Sodium salicylate also enjoys great popularity. In order to do any good it should be given in large quantities of from one to two drachms (4 to 8 gm.) a day, in doses of fifteen grains (1 gm.), repeated four or eight times during the twenty- four hours. Very frequently the good effects of salicylates persist only for two or three days, then the common anti-neuralgics, phenacetin, antipyrin, aspirin, etc. (see index), may be given. Urocine and sidonal, the former the lithium salt, the latter the piperazin salt of quinic acid, are also recommended, but they are by no means so effective nor so reliable as colchicum or the salicylates. Most clinicians speak very highly of the use of the alkalies, viz., sodium, potassium and lithium carbonate or citrate, in acute gout. The diet during the acute paroxysm should consist largely of milk, bread, toast, crackers and cereals, and broths. Fresh fruits and vegetable acid foods should be omitted from the dietary. The patient should drink large quantities of water, preferably some alkaline mineral water. Alcohol should be absolutely forbidden. In order to prevent the recurrence of acute attacks of gout during the stage of convalescence, the wine of colchicum, given in small doses, is the best remedy. Duckworth recommends five or six drops of the wine or tincture twice a day, or a grain of the extract in pill at night, to be continued for a long time after the subsidence of the acute attack. Occasionally the pain in the joint persists for a long time after the acute paroxysm is over ; here the iodide of potassium or of ammonium, in doses of five grains (0.3 gm.) three times a day, preferably combined with five to ten drops of the wine of col- chicum, is the best remedy. V. RACHITIS. Definition This disease, as the names rachitis and rickets indicate, is commonly interpreted to be a disease of the bony structures of the body. While the bony deformities are a prominent symp- tom they are by no means the determining manifestation of the disease. Rachitis must be regarded as a general nutritional, i. e., a metabolic, disorder. The diagnosis, it is true, is, as a rule, made from the bony changes, namely, the square head, the RACHITIS 189 open fontanelles, the beaded ribs, the enlarged bone ends, the curved arms and legs, the pigeon breast, the contracted pelvis, the deformed spine, and backwardness in teething. As import- ant as the osseous deformities, however, are the involvement of the lymph glands and the enlargement of the liver and spleen, the general muscular flabbiness, the anemia, the catarrhal con- dition of all the mucous membranes and the instability of the motor system with the well-known tendency to convulsions, tetany, laryngismus stridulus, glottis spasm, and tonic contrac- tions about the hands and feet. Intelligent prophylaxis can often prevent the onset of the prophylaxis disorder. That we may institute the necessary preventative measures and properly treat the disease after it is fully devel- oped, it is necessary to analyze the underlying etiological ele- ments that produce rachitis. A great number of factors have been accused of causing rickets. An inherited tendency has been incriminated, as well as congenital syphilis, poor general hygiene, lack of light and air, and, above all, a variety of food factors. A careful analysis of all these causes shows that the most important element of all is the food factor. As far as the hereditary element is concerned there is no Hereditary definite evidence to show that rachitic parents are more apt element to have rickety children than healthy parents. This is readily understood when one considers that rickets is a disease of child- hood and never persists into adult age so that the existence of rickets in the parent at one time may not be easy to determine. As a matter of fact, rickety children, as a rule, are the off- spring of healthy parents who never showed rickety tenden- cies during their childhood. Fetal rickets, so-called, is prob- ably not rickets at all, but a form of cretinism. Congenital rick- ets undoubtedly occurs, but only if the health of the mother is poor; here a nutritional and not an hereditary element is a1 play. Congenital syphilis, according to the best authorities, does syphilis and not produce rickets. In most cases of rickets the typical syph- rickets ilitic phenomena are absent and, on the other hand, most cases of congenital syphilis do not show rickety signs. The com- bination of the two undoubtedly can, and frequently does, occur, and in this way a peculiar disease picture is created in which it is often difficult to distinguish the syphilitic from the rachitic elements. That lack of light and air, and life in damp, dark dwellings General alone cannot produce rickets is made manifest by the frequent hy £ iene appearance of rickets in children of the well-to-do classes who live under ideal hygienic conditions. That malhygiene by fav- 190 RACHITIS Quantity of the food What elements are deficient? Lime salts Lactic acid Three elements lacking, viz., fat, proteid, and earthy . phosphates oring malnutrition and lowering the tone of the infantile or- ganism can favor the development of rickets, provided food errors are at the same time committed is, of course, self-evident. A child, however, may live in the most unhealthy surround- ings without developing rickets, provided it is fed according to correct principles. That the quantity of food, finally, does not produce rickets is made clear by the appearance of the disease in fat children, while, on the contrary, children in advanced stages of atrophy may not develop, in fact, rarely do develop, rickets. Broadly speaking the statement can be made that qualitative, and not quantitative, errors of feeding produce most cases of rickets. It is also important to note in passing that breast-fed children, provided the mother is healthy, hardly ever develop rickets, whereas, children who are fed on artificial foods, particularly of the farinaceous variety, are very apt to develop the disease, un- less a sufficient quantity of animal albumen and fat, as will be presently shown, is added to the diet. The question arises what elements are deficient in the food of children who develop rickets; and what elements must therefore be supplied in order to prevent the development of the disease? As the percentage of lime salts in rachitic bones is below normal, the theory has been advanced that the disease is due to deficient mineral matter, especially lime salts, in the food. This postulate is refuted by the observation that children living on farinaceous foods which contain an abundance of lime salts are particularly liable to develop the disease, and by the further observation that the addition of lime water to artificial foods is in no way capable of preventing rickets. Some clinicians believe that the lactic acid produced by the fermentation of imperfectly digested starchy foods in the stomach, can be made responsible for the development of rickets; they assume that lactic acid entering the circulation dissolves the lime out of the bones. This theory is opposed by the ob- servations that rickets develops in individuals who are not suf- fering from fermentative dyspepsia and who readily assimilate all the starchy food that is given them; besides, rickety chil- dren improve rapidly if the farinaceous diet is continued and if only sufficient proteid and fat is added to the diet. Finally, free lactic acid could never circulate in the blood, for it would at once combine with alkalies and circulate as lactate, that is, in a form that could not dissolve the lime salts of bones. The preponderance of all positive evidence submitted in- dicates clearly that in all cases of rickets three elemeots chiefly RACHITIS 191 are lacking from the food; namely, a sufficient quantity of ani- mal fat, of animal proteid and of earthy phosphates. Cheadle expresses himself as follows in regard to the deficit of fat, proteid and lime phosphate in rickets: "The depend- ence of rickets on the deficiency of these three elements of food would explain something more than the mere bone changes; it would clearly explain the imperfect nutrition of brain, muscle and nerve structure, which mere excess of lactic acid or absence of lime salts would not account for. It explains, moreover, why rickets is so prevalent in large towns and dense populations, where milk is so scarce and dear, deprived of cream and water- ed, and the poor driven to feeding their children on the cheaper farinaceous foods." One other etiologic factor must be mentioned, viz., chronic Gastro-intes- gastro-intestinal disorders, especially if they produce vomiting tinal disorders and diarrhea. Whenever such disorders are present the child practically becomes starved despite the administration of plenty of food; the proteids and fats chiefly are wasted under these circumstances because they must undergo certain preliminary changes, which require time, before they can be assimilated, whereas, the carbohydrates, being ingested largely in the form of sugar of milk, are promptly absorbed. This explains why cases of rickets occasionally develop in dyspeptic children who are fed on good cows' milk diluted in the proper proportion and containing all the elements that make up the correct diet for the child. From all that has been said the prevention and cure of rick- Prophylaxis ets is a comparatively simple problem, and in few diseases are so gratifying results obtained from proper feeding. In rickets, above all things, the gastro-intestinal tract, for reasons mention- ed in the preceding paragraph, should be treated in such a way that catarrhal conditions are corrected. The food, moreover, should contain an abundance of animal proteid, of animal fat and of phosphate of lime. In view of the fact that many children cannot digest large j law mea t quantities of milk casein, which would be the ideal proteid, the juice deficiency of animal albumen must often be supplied by raw meat juice. This is prepared as follows : Steak is finely chopped up and stirred with cold water in the proportion of one part of water to four parts of meat ; this mixture is allowed to stand for half an hour in the cold and the juice is then expressed through a cloth or through a meat press. The meat juice obtained in this way is very rich in albumen and extractives and consti- tutes an ideal means of supplying nitrogen. The meat juice 192 Cream and cod liver oil Lime Lacto-phos- phates can be mixed with milk without coagulating it and without per- ceptibly flavoring it. It also renders the milk coagulates fine and flocculent. The quantity of this raw meat juice that may be given in the place of casein is from one and one-half to three ounces in the twenty-four hours. In preparing an artificial mix- ture with meat juice the amount of casein, therefore, that is withheld should be calculated and an equivalent amount of meat juice added* That the meat juice should be prepared fresh every day and kept in a cool place need hardly be emphasized, for, otherwise, decomposition, with the formation of highly irritating poison- ous products, may occur. The deficit of fat should be made up by the addition of a sufficient quantity of cream. Cream is the best source of fat for the infant and is to be preferred to cod- liver oil. If cream cannot be borne codliver oil may, however, be found very useful; dose, a teaspoonful two or three times a day. Lime should not be supplied as lime water, for the lat- ter, as stated above, does not seem to fulfill the desired purpose. As a rule, if raw meat juice is given, or if plenty of good milk is used in the preparation of the artificial food, the addition of lime phosphates is rarely necessary. If lime salts, however, must be supplied artificially, then they can very advantageously be given in the form of the lacto-phosphate prepared as follows: Calcium phosphate, 12.5 Lactic acid, 15.0 Distilled water, 330.0 Sugar of milk, 630.0 Tincture aurant q. s., ad., 1000.0 M. Dose, two to four dessertspoonfuls a day. ( Ortner. ) Or the calcium lacto-phosphate may be given in water as follows: I* Calcium lacto-phosphate, Water, M. A dessertspoonful three times a day. 15.0 200.0 *The rules governiug the exact proportions of protcids, fats, carbo- hydrates and mineral salts that shoufd be contained in the different artificially prepared infant foods for different ages cannot be discussed within the narrow frame of this book. I must refer for information on this subject to text-books on Pediatrics. OSTEOMALACIA 193 Some very capable clinicians recommend the administration phosphorus of phosphorus in this disease; others, again, claim that its ad- ministration is unnecessary, provided the above dietetic rules are carefully carried out. Nevertheless, good results occasionally accrue from phosphorus treatment. The remedy is best given in combination with codliver oil, according to the following formula : Phosphorus, 0.01 Codliver oil, 100.00 M. This mixture contains about y 2 mg. phosphorus to the tea- spoonful ; one or two teaspoonf uls a day should be given. Hydrotherapy- Hydro-therapy, too, has a place in the treatment of rickets. Cold applications are dangerous in the fully developed stages of the disease. As a prophylactic measure, however, bathing the infant daily with warm water that is gradually cooled down to 20° C. is exceedingly useful. The extremities and the spinal column of the child should Orthopedics be protected against the development of deformities by forbid- ding standing and by carrying the child in such a way that no curvature of the spine or extremities can develop. The tech- nique of these self-evident precautionary measures, as well as the correction of the fully developed deformities, belong to the field of Orthopedics and Surgery and need not be elaborated upon in this volume. VI. OSTEOMALACIA. ~ i • • i i ! t . t -.i -,. Phosphorus Osteomalacia is closely related to rickets, and the medica- and codliver mentous treatment of the two diseases is practically the same. 0l1 Here the combination of phosphorus and codliver oil that has been mentioned above is particularly useful. Inasmuch as this disease usually develops in adult life, the dose of phosphorus may be larger than in an infant, as much as 4 to 6 mg. of phosphorus being administered during the day and continued for months. Sometimes codliver oil is not well tolerated and then phosphorus in the dose of 0.01 gm. may be given in the form of pills or in chocolate-coated tablets. Calcium has been „ , . _ Calcium frequently recommended in the treatment of osteomalacia, and it can do no harm to give these patients ten to fifteen grains of a mixture of calcium carbonate and calcium phosphate in 194 DIABETES INSIPIDUS Anemic medi- cation Atropine Diet and liygiene capsule several times a day. Inasmuch as many of these patients are anemic, the following capsule is useful : 5 1-100 gr. (1 mg.) 2 grs. (0.1 gm.) 5 grs. (0.3 gm.) 10 grs. (0.6 gm.) Arsenious acid, Reduced iron, Calcium phosphate, Calcium carbonate, M. One such capsule three times a day. A form of treatment that has been warmly recommended recently is the use of atropine. Its action in osteomalacia is altogether obscure. The dose should be regulated according to the appearance of symptoms of atropine poisoning. It is always well to begin with small doses of about one-two-hundredth grain three times a day, and gradually to increase the dose until atropine symptoms appear, as manifested by dryness of the mouth, dilatation of the pupils, etc. The diet in osteomalacia should be arranged according to similar principles as the diet in rachitis, i. e., there should be an abundance of albuminous and fat food. The state of the digestive apparatus should be carefully regulated, and ideal conditions as regards light and air and dwelling should be cre- ated. Here, too, during the florid stage of the disease the pre- vention of deformities and contractures must be considered. The orthopedic and surgical measures employed are the same as those in rachitis and cannot be entered into here. Definition Symptomatic polyurias VII. DIABETES INSIPIDUS. Diabetes insipidus is a name employed loosely to designate a variety of symptomatic polyurias that may be due to different causes. Provided one is dealing with a simple polyuria not due to cardio-vascular or renal disease, then the possibility of a cerebral or spinal origin, or of hysteria, must be seriously taken into consideration in every case and treatment instituted ac- cordingly. In view of the fact that a number of syphilitic le- sions of the cerebro-spinal axis are capable of producing symp- tomatic polyuria, every case of diabetes insipidus that does not yield to the measures to be presently described, should be given the benefit of an energetic antiluetic treatment. In such cases very large doses of iodide of potash, i. e., as much as two hun- dred or three hundred grains a day, preferably combined with mercury inunctions or Irypodermic injections of mercury salts, should be given (see Syphilis). DIABETES INSIPIDUS 195 The treatment of hysterical polyuria, which is often called Hysterical diabetes insipidus, is synonymous with the treatment of hys- po y^ 19 - 5 teria. Quite a few cases of so-called diabetes insipidus are on record for instance that were cured by hypnotism, others again by carefully carried out rest treatment or hydro-therapeutic measures directed against the underlying hysterical perversion. In view of the fact that most sufferers from diabetes in- Valerian sipidus are nervous people, valerian, bromide of potash, cam- Bromides phor, asafetida and antipyrin all have a distinct field of use- . S ^. e * . a fulness in this disease. I have never seen any good results follow the use of atropine or of other preparations of bella- donna that have been recommended for the purpose of "check- ing the secretion of the kidneys;" the dryness of the mouth, in fact, which atropine produces usually increases the thirst and hence favors rather than checks the polyuria. Ergot may be used and not infrequently produces good re- Ergot suits. Its exact mode of action is not understood, but it pre- sumably exercises its effect upon the blood vessels of the kid- ney. Its action can best be explained as follows: The amount of urine excreted depends upon the blood pressure in the glomerules and the more the renal arteries become contracted under the influence of ergot the smaller the amount of blood that enters the glomerules and the smaller consequently the flow of urine. A measure that is often useful is galvanization of the Galvanization sympathetic in the neck, as described under Exophthalmic of tne cervical S"VHlT)£L'fcllG'fcic Goitre (see page 106). It is not impossible that the galvanic cur- rent directed from the angle of the jaw to the back of the neck into the region of the lower cervical vertebra? actually exercises an effect upon the medulla itself which may reduce the polyuria. This assumption, however, is difficult to prove and the element of suggestion from the electrical treatment can never be ex- cluded, especially in a disease which is so so commonly combined with hysteria. Electricity, however, should be given a fair trial. The most rational procedure of all is to reduce the liquid „ , . . Reduction of intake, and at the same time to promote the elimination of water the liquid through other emunctories of the body than the kidney. Drink intake restriction, as a rule, exercises a pronounced effect upon the amount of excreted urine, in fact, some cures have been re- ported from complete withdrawal of liquids for a period of twenty-four or forty-eight hours. This procedure is exceedingly irksome to the patients and requires the exercise of much will power. The distressing thirst can be counteracted in a measure by smoking, chewing gum or swallowing small ice pills. In 196 DIABETES INSIPIDUS order to carry out the thirst treatment properly it is usually Sweating necessary to put the patients to bed and to treat them as one would an hysteric under restraint. If it is desired to sweat the patients, pilocarpine may be given to advantage, preferably hypodermically in the dose of 0.01 to 0.015, twice daily; or the hydro-therapeutic measures for promoting diaphoresis that have been fully described on pages 42, 43 may be utilized. CHAPTER V. DISEASES OF THE URINARY APPARATUS. I. NEPHRITIS. The classification of nephritis, if we are to follow orthodox Classification standards, is highly confusing. From the anatomic, i. e., de- scriptive pathologic standpoint, the matter is simple enough; from the clinical, i. e., the diagnostic and therapeutic stand- point, the anatomic classification is in a large measure useless. Clinically, we should distinguish (1), an acute nephritis; (2), a chronic parenchymatous or interstitial nephritis developing either consecutively to an acute nephritis or slowly and insid- iously from the beginning; (3), different types of "vascular" nephritis (cardio-renal disease), i. e., of nephritis due to im- paired circulation in the kidneys with resulting degenerative changes in the organ; to the latter category belong, e. g., the nephritis of Bright 's disease, in the modern sense, and the ne- phritis of arterio-sclerosis. The matter is further complicated by the fact that in all forms of chronic nephritis cardio-vascular signs develop sooner or later; so that it is often a difficult matter to determine whether the changes about the heart and arteries are the pri- mary event that produces the nephritis, or whether the nephritis causes retention of excrementitious bodies that poison the heart and arteries, or, finally, whether the same primary cause simul- taneously affects both the cardio-vascular apparatus and the kidneys. From a therapeutic point of view it is very import- ant to decide this matter, and I intend in the following dis- cussion of chronic nephritis to consider as belonging to the sec- ond category those forms in which the cardio-vascular signs appear after the nephritis, and to the third category ("vascular nephritis") those forms that are either directly preceded by, and traceable to, cardio-vascular disease or that develop simul- taneously with cardiac and arterial disturbances. As far as the further differentiation of nephritis into the parenchymatous and the interstitial forms is concerned, I con- sider that unimportant in the therapeutic sense, for there is never a parenchymatous inflammation without some interstitial changes, nor vice versa. The involvement of the renal paren- chyma or of the interstitial tissues of the kidney will depend altogether upon the kind, the virulence, the selective affinities of the various toxic and infectious agents that produce the 198 ACUTE NEPHRITIS nephritis, upon the length of time during which they irritate the kidneys and upon the path by which they reach them. Gener- ally speaking the more chronic the nephritis the more marked the interstitial changes. In the vascular type, too, interstitial changes usually predominate. Prophylaxis Abundant wa- ter drinking- Restriction of liquids Diet ACUTE NEPHRITIS. To the kidneys is relegated the chief disintoxicating func- tion of the organism, hence they are particularly susceptible to injury by any toxic or infectious material that may gain en- trance to the circulation. Recognizing this fact it is occasionally possible, in certain infectious diseases, to prevent the develop- ment of nephritis as a complication, first, by giving such abund- ant quantities of fluid early in the disease that whatever toxins are carried through the renal filter are thoroughly diluted and hence not so apt to irritate and inflame the renal epithelia in transit; second, by avoiding the administration of remedies that can irritate the kidneys.* In some diseases, moreover, energetic causal treatment instituted early may save the kidneys; thus in malaria an active quinine treatment may often prevent the de- velopment of nephritis, and in syphilis, paradoxical as it may sound, an energetic mercury treatment may also prevent renal complications, notwithstanding the fact that mercury in itself is capable of irritating the kidneys. The administration of abundant quantities of water in acute infectious diseases is a useful procedure, only, however, while the renal filter is still permeable for water and before pro- nounced nephritic changes have appeared. When nephritis has once set in the administration of water should be reduced con- siderably, at least during the period of acute inflammation, and the administration of large quantities of water should not be resumed until the nephritic process is in course of healing. One should be guided, in this matter, largely by the function of the kidneys ; when they stop excreting abundantly it is bad practice to try to force them to eliminate water, and one should wait with abundant water-drinking until the kidneys indicate by in- creased diuresis that they are again capable of excreting water. Of this more below when discussing the diet in acute nephritis. The diet, in acute nephritis, should, during the stage of in- flammation, be scanty and bland. The principle of sparing the kidneys by relieving them of the task of excreting much solid ♦Salicylic acid preparations, chlorate of potash, most of the bal- sams, tar, turpentine, cantbarides, etc. ACUTE NEPHRITIS 199 excrement is the prime indication and should be carefully ob- served. In certain infectious diseases of short duration it is not a bad plan to withhold food altogether for a period of two or three days, allowing the patient only enough water to allay the thirst and to compensate for the loss of water through the breath and the sweat glands. This treatment is heroic, but, starvation, especially in children, the results are so gratifying as to warrant its employment. The fact that the patients are forced to con- sume their own tissues and are inadequately nourished by this procedure need not militate against the starvation treatment, inasmuch as under-nutrition, lasting for two or three days only, can do no harm. In chronic forms of nephritis the starva- tion plan, or even continuous under-feeding, with the object of sparing the kidneys, is, of course, never permissible, as will be shown at length hater on. If one is justified in assuming that the acute nephritic in- flammation will last longer than two or three days, or if the renal complication does not rapidly yield to complete with- Milk drawal of food, then milk is the best nutrient. It should con- stitute, in acute nephritis, the only food until the nephritic pro- cess has entered into the sub-acute stage. Occasionally a patient cannot bear milk, either on account of an aversion to it, or on account of inability to digest it; in such cases the administra- tion of small quantities of milk, in tablespoonful doses, given ice cold and possibly with the addition of a little lime water or some flavoring extract, will often render its administration pos- sible. If there is complete intolerance or aversion to milk, then Buttermilk buttermilk or kefir or kumyss can frequently be borne, and Kumyss while these beverages do not possess the nutritive value of an equivalent of milk, still they serve a very useful purpose. The quantity of milk must vary according to the individual case, but more than one litre should rarely be given during the twenty-four hours. In order to increase the nutritive value of the milk cream may be added ; a tumbler full of milk-cream mix- ture, containing four parts of milk and one part of cream, with one tablespoonful of lime water, administered every two or three hours, suffices to adequately nourish the patient, and at the same time to spare the kidneys during the acute and sub- acute stages of the nephritis. During the stage of healing it becomes necessary to nour- Diet during ish the patient more generously. This can be done with safety the stage of by allowing soups made of oatmeal, rice and barley, a little bread or zwieback, some fresh fruit and boiled vegetables. Meat ex- tracts or bouillons exercise a beneficial and stimulating effect upon the appetite and the gastric digestion without, at the same 200 ACUTE NEPHRITIS Meat Hest Position in bed Catching cold Clothing dur- ing conva- lescence 'Symptomatic treatment Counter-irri- tants to renal region time, containing elements that markedly irritate the kidneys; nor do they, it is true, contain any elements that are particularly nourishing, hence they can hardly be considered a food, as their caloric value (see page 157) is very small. Later the ordinary mixed diet should be resumed, always under careful supervis- ion of the urine, in order to control the effect of a liberal diet upon the healing of the nephritic process. Meat should preferably be withheld until the healing is well advanced. I do not think that the kind of meat makes much difference, although possibly, in honor of an old fashioned prej- udice, light meats may be given the preference over dark meats. As soon as symptoms of acute nephritis make their appear- ance the patient should be put to bed and kept absolutely quiet until the inflammation of the kidneys subsides. As a rule nephritic cases lie on their back, but it is a very good plan, if they can comfortably do so, to have them lie on the abdomen, at least during part of the day. They should at all events fre- quently change their position in bed, for in this way, hypostatic congestion of the kidneys is prevented, and, in many cases, the pain in the lumbar region is markedly reduced. The pa- tient should remain in bed until the albumin has disappeared from the urine. Even after this stage has been reached, the patient should at first arise for a short time only each day, and never within an hour or two after a meal. The urine should be carefully controlled daily and the patient ordered back to bed as soon as albumin reappears upon exertion. Unless this precaution is taken chronic nephritis is very apt to develop. Nephritics or individuals who have just recovered from acute nephritis are very liable to catch cold. Possibly there is in such cases a lowering of the tone of the vaso-motor centres as a result of the renal intoxication. Particular precautions should be therefore taken to prevent taking cold, according to the principles discussed on page 266. Convalescents from acute nephritis should at all events always wear a flannel binder cov- ering the kidney region for many months after recovery, and should be warned particularly against exposing themselves to wet or cold. The symptomatic treatment of acute nephritis includes among other things the relief of the pain in the kidney region that is often quite distressing. Remembering always that no drug should be given in nephritis that can irritate the kidneys, care should be taken in selecting proper counter-irritants to be applied to the lumbar region. Thus cantharidal ointments or . plasters, or mustard poultices and plasters, that are very use- ful as revulsives, should never be used in acute nephritis. Cup- ACUTE NEPHRITIS 201 ping or the application of leeches is, however, a very useful treatment for the relief of renal pain. The galvano-cautery may be employed to advantage, especially when applied over Petit 's triangle,* for the veins in this area anastomose with the veins of the renal capsule so that congestion within and around the kidneys can be effectively relieved by counter-irritation over this particular point. Cups, leeches or the cautery may be advantageously applied throughout the whole duration of the acute stage, for they can never do any harm and frequent]} 7 seem to exercise a very beneficial effect, especially upon the pain and the reflex nervous symptoms of renal origin, viz., the headache, nervousness and vomiting. Different drugs have been recommended from time to time Drugs to re- for reducing the albuminuria. Aside from the fact that the ur [* a umm " excretion of albumin is a symptom of subordinate importance as far as any effect upon the nutrition of the patient is con- cerned, so that it hardly calls for special treatment, the various remedies used cannot be considered efficacious even to fulfill the purpose for which they are intended. They are mentioned merely on account of their historical interest. Thus tannin and tannalbin, methyl violet and methylene blue, strontium bromide and ichthyol and sodium benzoate, fuchsin and nitric acid all have their advocates, but none of them, in my experience, is of any benefit whatsoever in the treatment of acute nephritis. In case there is very much hematuria ergot may be given, Hematuria although the loss of blood is usually too insignificant to war- rant special consideration. Ergot should be given in the form of the fluid extract, 15 m. to 1 dr. (1.0 to 4.0) or the infusion 1 to 2 oz. (16 to 32 cc). The suppression of urine occasionally calls for treatment Anuria although as a rule it is best to allow Nature to take its course and to wait a few days without active interference until the kidneys spontaneously resume their function (see also page 210). To force the kidneys to pass water always means to irritate them; there is, moreover, no tangible evidence to show that the promotion of diuresis by drugs really promotes the elimination at the same time of large quantities of urinary solids, so that the slight advantages accruing from forced diuresis are, as a rule, more than counter-balanced by the damage inflicted upon the kidneys by the diuretics employed. The elimination of retained urinary bodies should, therefore, Vicarious be promoted not by crowding them through the kidneys but eliminatlon by favoring their vicarious elimination through the bowel, and, ♦Petit's triangle is the area bounded by the crest of the ilium below, the latissimus dorsi and the external abdominal oblique on each side. 202 ACUTE NEPHRITIS Milk as a diuretic Alkalies the only legitimate diuretic in acute nephritis Diuretics in dangerous edemas Heart tonics Digitalis and caffein Acetate of potash Calomel Diuretic teas so far as that is possible, through the sweat glands. It is more important, as shown above, to regulate the diet in such a way that only small amounts of excrementitious bodies have to clamor for elimination through the closed renal filter, than to feed in- judiciously and try to force urinary bodies through a barrier that Nature has closed for the time being. It is well to remem- ber that the chief task, in the treatment of nephritis, as of any other acute disorder, is to imitate Nature and to enforce her methods, viz., to spare the diseased organ and to keep it at rest, in order to enable it, as quickly as possible, to resume its normal function. Milk itself stimulates diuresis in a perfectly physiological manner, and if the patient with nephritis fails to pass a suffi- cient quantity of urine on an abundant milk diet, then this, in itself, is evidence that the kidneys cannot react to the stimulus even of mild diuretics. The reduction of the flow of urine, on a milk diet, is, therefore, prognostically, a bad sign and should induce us to be particularly careful not to irritate the in- flamed kidneys still further by the use of strong diuretics. The only legitimate diuretics, in the sub-acute stages of ne- phritis, are alkalies and alkaline mineral waters, preferably given in combination with milk. They act either by their effect upon the osmotic pressure of the blood in the kidneys and hence favor diuresis by their physical properties, or they pro- duce, as some authors claim, a reduction in the renal congestion, without in any way irritating the diseased renal cells. If the patient is suffering from severe edemas and an ac- cumulation of fluid in the serous cavities large enough to en- danger life mechanically by pressure, and if sweating and ac- tive catharsis do not relieve these dropsical swellings, then re- course must occasionally be had, as an emergency measure, to strong diuretics. As the heart in the great majority of these cases is affected (so-called nephritic edemas generally being cardiac edemas), heart tonics should always be administered in combination with a diuretic. No combination is more useful in such cases than the one described on page 43, in discussing cardiac dropsy, namely, digi- talis with caffein. The acetate of potash is commonly used; it acts as any other alkali for it reaches the kidneys in the form of potassium carbonate. Calomel, too, may be used for its diuretic properties in these extreme cases, and should be given as described under cardiac dropsies on page 43. Diuretic teas are very popular with the laity; it is doubtful whether the herbs that are used in their preparation possess very strong diuretic powers; the ingestion of large quantities of hot ACUTE NEPHRITIS 203 water, however, without doubt stimulates the function of the sweat glands and possibly also of the kidneys, while the herb infusion can do no harm. One of the best of these teas is com- posed of equal parts of Fol. Uva Ursi and Herba Hernearia Glabra; a cup of tea made with half a teaspoonful of this mix- ture of the two dried herbs and sweetened with sugar should be given every two hours; especially in sub-acute nephritis a profuse diuresis can usually be stimulated by this mixture while the sweat glands also become very active. Most cases of acute nephritis are benefited by the use of Hydrotherapy lukewarm baths given for fifteen minutes at a time and accom- panied by friction of the surfaces of the body. Such a bath should be given once a day. The effect of this practice upon the blood pressure becomes manifest, as a rule, by increased diuresis and sweating. If it is desired to produce profuse sweating, then hot baths of 35° to 40° C., should be given and sweating- by the patient afterwards wrapped in warm blankets. If a pro- hot baths fuse sweat is produced in this way, the patient should, at the same time, be given abundant quantities of water to drink, as otherwise concentration of the body fluids may be brought about, hence their toxicity be increased and the danger of uremia en- hanced. One might ask what benefit could accrue from sweating on Sweating and the one hand and giving abundant water on the other, especially abundant wa- if, as claimed above, little poisonous material is eliminated by the sweat glands. The main effect produced is an active cir- culation of the lymph which acts beneficially by increasing met- abolism, by preventing stagnation and accumulation of toxic material in certain portions of the body, where they might do particular harm, especially in certain areas of the nervous system. One of the most convenient methods for producing diaphore- sweating bv sis is by means of the hot air bath, as described under cardiac hot air dropsy (see page 42) or by the use of large Priessnitz com- presses covering the whole body. In promoting sweating by the sweating- by Priessnitz method, a sheet is wrung out of hot water, wrapped not com- presses around the patient and covered with two or three woolen blank- ets. In order to forestall dyspnea and reactive cerebral hyper- emia, the patient should be placed in a semi-recumbent position and the head kept cool with cold cloths or an ice bag. As the patients usually soon complain of thirst they should be given plenty of cold water to drink during the sweating. Pilocarpine, bv subcutaneous injection, also produces a „ • „ Sweating by profuse sweat, but this drug should only be used if the heart pilocarpine 204 CHRONIC NEPHRITIS AND BRIGHT S DISEASE is altogether intact. I consider pilocarpine dangerous in heart disease and generally superfluous in nephritis. Catharsis Mild catharsis may to advantage be promoted. Great care should, however, be taken not to administer drugs that can irri- tate the bowel, for upon the bowel chiefly is thrown the task of vicariously ridding the system of excrementitious bodies that the kidneys are for the time being unable to excrete. Any derange- ment of the bowel function, therefore, should be most strenu- ously avoided; the same applies to the liver, for it, too, assumes a disintoxicating and a vicariously eliminating function in ne- phritis. For these reasons calomel and all drastic purges should be used only as an emergency measure in extreme cases. To evacuate the bowel castor oil or cascara, of the extract two to eight grains (0.12 to 0.5 gm.), of the fluid extract ten to fifteen minims (0.6 to 1 cc), may be safely given. Saline purgatives are to be avoided, for most salts either irritate the kidneys or are eliminated with difficulty by the kidneys when they are dis- eased. Heart tonics That it may occasionally become necessary to supply digi- talis as soon as the heart begins to flag in acute nephritis, is self-evident. It is not good practice, however, to give digitalis in the beginning for the sake of its diuretic effect, because, in acute nephritis, a great strain is always thrown upon the heart sooner or later and it is decidedly dangerous to stimulate it with heart tonics before there is an urgent call for their em- ployment. Cardio-renal disease The newer con- ception of Bright's dis- ease CHRONIC NEPHRITIS AND BRIGHT 'S DISEASE. In addition to those forms of chronic nephritis that develop consecutively to acute nephritis, we have a variety of forms in which the involvement of the kidneys is merely one symptom of a general toxemia, and in which the disorder about the heart and arteries dominates the picture. In some forms the disease seems to affect the kidneys first, and later the heart and arteries; in others the toxemia seems to involve simultaneously the heart and arteries. The latter variety, according to our newer idea, is true Bright 's disease. It is unfortunate that the name Bright 's disease is retained at all in our medical nomenclature, for what we understand by this term, and what Richard Bright origin- ally described, are two very different things. It is still more unfortunate that the terms Bright 's disease and chronic ne- phritis are so commonly employed synonymously; for Bright 's disease, in the modern sense, is a systemic disorder that usually CHRONIC NEPHRITIS AND BRIGHT *S DISEASE 205 produces nephritis, but does not invariably do so, whereas chronic nephritis, while often due to Bright 's disease may also be due to a great many other causes. In Bright 's disease the determining feature is high arterial tension, with resulting cardio-vascular changes and nutritionaJ disorders in various parts of the body, and, particularly, in those organs that are supplied by end-arteries, viz., the kidneys, the retina, and the brain. The treatment of this so-called vas- cular type of nephritis is therefore practically synonymous with the treatment of the cardio-vascular apparatus ; for cardio- vascular disorders generally usher in these forms of nephritis or appear soon after nephritic signs become apparent; and cardio-vascular complications generally produce the death of these patients. Cases of this type of nephritis should be treat- ed, therefore, more as heart cases than as kidney cases, and for this reason the rules of treatment that have been laid down in the Chapter on Heart Diseases, particularly in the paragraphs on the treatment of valvular diseases of the heart in the stage of compensation, apply, broadly speaking, to this type of ne- phritis. Causal treatment of any variety of chronic nephritis must . concern itself primarily with combating or preventing the tox- ment emia that, in all probability, produces both the cardio-vascular changes and the nephritis. The character of this toxemia is still obscure. The preponderance of clinical evidence, however, points to a disordered gastro-intestinal tract and liver, on the one hand, and to metabolic derangement on the other, as the sources of the poisons. Treatment should, therefore, in many cases be directed towards correcting any digestive or hepatic disorders that may be present. The obscure metabolic perver- sions that sometimes underlie the disease unfortunately offer nothing very tangible to attack. A deranged bowel function leads to the abnormal disassimi- . . lation of albumins, chiefly because putrefactive bacteria gain f chronic unopposed sway. The toxic albuminoids and alkaloids gener- nephritis ated in this way flood the liver channels, where they should normally be arrested or disinfected. For a while the hepatic cells can withstand the stream of toxic matter that circulates around and through them and can properly exercise their dis- infecting properties; but an overwhelming mass of putrefactive material flooding them at one time, or small quantities of pu- trid excrement irritating them continuously, must needs impair their function and render them inadequate to protect the organ- ism as a whole from poisoning. When this occurs intestinal 206 CHRONIC NEPHRITIS AND BRIGHT S DISEASE Hepatic insuf- ficiency Intestinal an- tisepsis toxins filter through into the circulation beyond, and there can exercise their deleterious effect on the heart, on the arteries, and also on those organs that chiefly supplement the disinfecting function of the liver by eliminating poisons, namely, the kid- neys. Hepatic insufficiency produced in this way also leads to the incomplete elaboration of the afore-mentioned intermediary products of metabolism that reach the liver in the general cir- culation as poisonous bases, ammonium salts, etc., and should leave the liver more highly oxidized as innocuous uric acid, urea, etc. When the liver cells are inadequate to produce this conversion, then these intermediary bodies are returned un- changed to the general circulation, and thus cause auto-intoxi- cation. That some of these bodies can produce the cardio-vas- cular changes of Bright 's disease, and some of the renal changes, was shown by me in 1901/* Another important result of hepatic insufficiency is per- version of the physical and chemical character of the bile. Instead of flushing the bile channels in a broad stream the bile sluggishly oozes through the hepatic capillaries. The thick and viscid character of the bile favors diapedesis of poisonous bile ingredients from the bile channels into the blood capilla- ries and besides produces clogging of liver channels, with pres- sure on the hepatic cells and on the afferent blood capillaries that nourish them; as a result the function of the liver cells is still further impaired and self -intoxication is favored. Finally the absence of the proper quantity of normal bile from the intestine deprives the organism of its most important antiseptic secretion, so that intestinal putrefaction increases and a vicious circle is in this way closed. Causal treatment of Bright 's disease must concern itself, therefore, in the first place, with the prevention of intestinal putrefaction. Sterilization of the human intestine with its thirty feet, more or less, of warm, moist culture medium is man- ifestly impossible; nor is it desirable, for many of the micro- organisms that normally abound in the bowel aid the enteric ferments in the dis-assimilation of the food and produce certain physical changes in the bowel contents that favor the act of defecation. The human intestine is practically sterile at birth; later bacteria appear in the bowel contents, some of them pathogenic. Against the latter the organism normally protects itself by *Croftan — "The Role of the Alloxuric Bases in the Production of the Cardio-vascular Changes of Nephritis," Am. Jour. Med. Sciences, Feb- ruary, 1901. CHRONIC NEPHRITIS ^ND BRIGHT *S DISEASE 207 very efficient means; when these measures become inadequate, artificial intestinal antisepsis is called for. The object of in- testinal antisepsis, so-called, is not, therefore, to free the bowel from bacteria, but to prevent the pullulation of certain patho- genic species and to destroy their poisons. Remedies employed to this end may become operative in two ways : They may either act chemically by direct contact, or they may act physiologically by stimulating the natural defenses of the organism to greater activity. Most of the drugs employed as intestinal antiseptics fulfill both indications, inasmuch as they possess not only germicidal properties, but also act as hepatic stimulants. As the liver cells possess the power of arresting and of disinfecting many bowel poisons, and as the bile is a germicide, any remedy that causes increased activity of the hepatic cells and, by inference, acts as a cholagogue may be considered an intestinal antiseptic of the second variety. Chief among the remedies recommended as intestinal anti- Metallic salts septics are certain metallic salts, the bile acids and certain or- e aci s . . , x . „ . Organic per- ganic peroxids. It is necessary, 01 course, that these remedies oxides when given in doses sufficiently large to check intestinal putre- faction should be non-irritating and non-poisonous. For this reason I prefer the sulphocarbolate of zinc to other metallic Sulphocarbo- salts (mercurv, lead, silver, copper), and sodium glvcocholate „ a f. ° z \ nc • r *^ " & " Sodium glyco- to the free bile acids. A variety of organic peroxids under cholate various trade names are on the market and I consider them useful. Intestinal putrefaction may be considered checked when cer- Urinary and tain bodies that we know to be formed from the putrefactive d en ce of intes- disintegration of albumin disappear from the feces and from tinal putre- the urine (abnormal degradation products of the fats and car- bohydrates play a subordinate role in auto-intoxication). Chief among these are a variety of aromatic sulphur compounds and a complex group of substances that also contain the aromatic radicles that are split off from putrefying albumin (compound glycuronates and compound glycocolls).* For clinical purposes it is sufficient to study the sulphids of the feces and the aromatic sulphates (with indican as their prototype) of the urine. The intestinal antiseptics onould be given in small doses Dose an( i a a_ ( sulphocarbolate of zinc, one-half grain (0.03 gm.) ; sodium ministration glycocholate, one grain (0.06 gm.) ; the organic peroxids, one antiseptics grain (0.06 gm.), at frequent intervals, together with about ♦See Croftan : Clinical Urinology, Chapter VII. 208 CHRONIC NEPHRITIS AND BRIGHT S DISEASE Diet The quantity of food The dangers of an exclusive milk diet twenty grains (1.2 gm.) of bismuth subnitrate in the twenty- four hours. The latter is given merely as an indicator of the presence or absence of sulphids (sulphureted hydrogen or its salts) from the feces. H 2 S or its alkali salts form black bis- muth sulphid, and when the intestinal antiseptic is given in sufficient quantity to check the putrefaction of albumin, then no bismuth sulphid is formed and the stools are not colored black. It will be found in most cases that when the stools retain a light color, despite the administration of bismuth, the indican of the urine and the other aromatic urinary ingredients will also disappear or become greatly reduced. The proper dose, then, of the above-named intestinal anti- septics is enough to prevent blackening of the stools after the ingestion of bismuth subnitrate and enough to cause the dis- appearance from the urine of aromatic bodies. The Diet in Chronic Nephritis. In feeding patients suf- fering from chronic nephritis three conditions must be fulfilled. First, the diet must contain qualitatively and quantitatively all that is needed to maintain general nutrition (nutritive equi- librium). Second, the diet must contain as little as possible of materials that in their ultimate passage through the kidneys can irritate the renal epithelia or the glomeruli. Third, the diet, while sparing the kidney function, must not overtax or otherwise injure the function of the digestive or circulatory or- gans. One may say, in a broad sense, that the daily amount of food, expressed in caloric values should be inversely propor- tionate to the presumable duration of the nephritis. In acute forms of nephritis, as we have seen, under-feeding or even star- vation of the patient not only is permissible, but is good prac- tice; for the smaller the amount of excrementitious bodies the kidneys are forced to eliminate the more they are spared and the more rapidly can they resume their normal functions. The more chronic the nephritis, however, the more nutritive should be the diet, so that patients suffering from this disease should receive daily the full caloric value in their diet that is required to maintain nutritive equilibrium. For many years it has been fashionable to feed cases of chronic nephritis upon an exclusive milk diet. This method of feeding we owe chiefly to the French school of clinicians and to numerous imitators that this school has educated, including the laity. That milk is a useful article of diet in the manage- ment of nephritis, probably the most useful article we pos- sess, no one will gainsay. That a milk diet should be given persistently and should constitute a large proportion of the CHRONIC NEPHRITIS AND BRIGHT *S DISEASE 209 food to be administered to cases of chronic nephritis is also conceded. An exclusive milk diet, however, is directly harm- ful and dangerous in chronic nephritis, if carried out for too long a time. Milk alone cannot maintain the general nutrition for any Deficit of iron length of time unless enormous quantities are given. There is m milk always, in the first place, a deficiency of one all-important ele- ment, viz., iron. In regard to this deficiency of iron, one might argue that, as milk can nourish infants for a year or longer, the amount of iron in the milk should be sufficient to fulfill all the demands of the organism. As a matter of fact, however, i: has been demonstrated that milk while it contains exactly the same proportion of calcium, magnesium, potassium, phosphorus, etc., as the ash of the new born animal of the species from which it is derived, contains six times less iron. This anomaly is explained by the fact that the iron content of young suckling creatures decreases with the age of the animal and reaches its minimum at the time when iron-containing food is first eaten. The young animal, therefore, brings a surplus of iron into the world and is independent of the milk for his supply; but this does not apply to adult individuals. Here then, in the first place, is a qualitative deficit that must by all means be reme- died if an exclusive milk diet is to be given, or even if the patient is fed on a diet consisting largely of milk. This is best done by adding either chloride of iron solution to the milk or by diluting it with iron-containing mineral waters. It is not impossible that the lack of iron in the milk contributes in part to the anemia that is so common in patients with chronic nephritis who become martyrs of an exclusive milk regime. The second most important postulate in the proper feeding Excess of nitro- of chronic nephritics, viz., to spare the kidnevs, is also violated g^ 11 ? 113 waste- products if too much milk is given ; for it is a well known fact that albu- minous foods by leading to the formation of large quantities of nitrogenous end-products, chiefly urea, throw an excessive task upon the kidneys ; for urea and its congeners are eliminated with difficulty when the kidneys are diseased, and must be con- sidered as true irritants of the renal epithelia. It is for this reason that we reduce the albumens in the diet of chronic ne- phritis ; but if we give enough milk to adequately nourish these subjects then we also give an excess of albumen. A normal adult requires between two and three thousand calories to main- tain full nutrition. As one litre of milk has a total caloric value of only about seven hundred, it is clear that from three to four litres of cow's milk would be required per diem to meet 210 CHRONIC NEPHRITIS AND BRIGHT S DISEASE Excess of water the nutritional requirements of the subject. Such amounts of milk contain from one hundred and twenty to one hundred and fifty grammes of proteids, whereas the normal average quantity required by a healthy adult does not exceed eighty grammes per diem; in fact, recent investigations seem to show that ade- quate nutrition can very well be maintained on very much less albumen. This is particularly the case among individuals whose vitality is low and who, as will be shown presently, should lead a quiet life with the minimum of physical exercise. Finally, if the patient is fed upon milk alone and if enough milk is given to adequately nourish him, then too much water by far is forced through the cardio-vascular apparatus and the kidneys. The danger of stimulating diuresis by abundant water- drinking in acute nephritis has already been discussed, and at- tention has been called to the danger of trying to forcibly over- come the resistance that the diseased kidneys offer to the passage of water. In sub-acute forms of nephritis and in those cases that are on the border line between sub-acute and chronic ne- phritis, the intake of water can be increased; the object being to flush out the kidneys and to rid the kidney canals of accu- mulated debris. This is a useful practice, because by so doing mechanical obstacles to the flow of urine are removed, and the work of the kidneys is thereby somewhat reduced. If this pur- pose is to be accomplished, however, it is always better to re- strict the liquids for a time and then to institute so-called drink- ing days, during which very abundant quantities of water are ingested. If this is done the renal canals are flushed and at the same time accumulated waste products are washed from the blood through the kidneys and out of the body. Abundant wa- ter-drinking, instituted in this way possibly once or twice a month can do no serious damage, whereas abundant water- drinking continuously practiced undoubtedly injures the gastro- Mineral waters intestinal function, the cardio-vascular apparatus and the kid- neys. A warning may incidentally, therefore, be uttered in [his place against the indiscriminate use of the many mineral .waters that are broadly advertised for the cure of kidney dis- eases. In the Chapter on Acute Nephritis, the statement was made '.hat the water intake should be largely governed by the water output. In very chronic forms of nephritis the principle can hardly apply for, especially in the interstitial variety of the disease, large quantities of water are continuously eliminated containing a very small amount of solids in solution. Here, it is an easy matter to produce very copious diuresis by copious water-drinking, but nothing is gained by this and much damage Drinking days CHRONIC NEPHRITIS AND BRIGHT *S DISEASE 211 can be done to the heart and arteries which are particularly affected in the latter form of nephritis. One other objection to the indiscriminate use of an exclu- Excess of sive milk diet may be formulated. It is a well known fact that p osp a es phosphates are excreted with difficulty when the kidneys are diseased. Milk is very rich in phosphates, and in a healthy individual the urinary phosphorus excretion is greatly increased on an exclusive milk diet. If the kidneys are to be spared, there- fore, the urinary phosphate excretion should be reduced and not increased, as is done by feeding milk exclusively. The addi- Addition of tion of lime salts to the milk can somewhat obviate this diffi- ^^ water to culty, so that in nephritis, lime water should always be added to the milk; in this way, calcium phosphate is formed and this salt is absorbed with great difficulty from the intestine; con- sequently the bulk of the phosphates is excreted in the feces as calcium phosphate and is not at all absorbed into the circula- tion nor consequently eliminated in the urine. Again, an ex- cess of calcium in the milk leads to the formation of chloride of calcium in ' the stomach, which is absorbed and combines in part with the circulating phosphates, and the latter, it is well known, are always excreted, presumably through the bile ducts, into the bowel and not through the kidneys into the urine. There are still other objections to the exclusive milk diet Disgust and that may be briefly formulated as follows : Aside from the }?* s ? f a PP e ~ fact that feeding with milk alone, for a long time, becomes thor- elusive milk oughly distasteful and even disgusting to the patients, and that ee mff consequently the appetite is lost, and the normal psychic stim- ulus necessary to perfect digestion is perverted, the ingestion of large amounts of water mechanically does injury to the stomach and intestine ; for the stomach becomes dilated and the gastro-intestinal secretion constantly diluted. This, of necessity, impairs the digestive powers of the individual and may lead Gastric dila- to a variety of chronic digestive disorders that, as shown above, tatlon should be strenuously avoided in chronic nephritis. All these objections just formulated apply only to the use of excessive quantities of milk in nephritis. If certain pre- cautions are observed in regard to restricting the ingestion of milk to sensible limits, and if the deficit of iron is remedied by the addition of an iron preparation, and if the excess of phos- phates is neutralized by the addition of lime water, milk con- stitutes a valuable food. Broadly speaking, a case of chronic How to feed nephritis should receive from one to one and a half litres of milk milk a day; never any more and preferably less. The milk should be given in divided doses, at frequent intervals, by 212 CHRONIC NEPHRITIS AND BRIGHT S DISEASE choice in the form of a milk-cream mixture, consisting of four- fifths milk, one-fifth cream and two teaspoonfuls of lime water per tumbler full (nine ounces). Inasmuch as the function of the liver is frequently pervert- ed in chronic nephritis, and the character of the intestinal se- Pancreatin and cretion, especially in its upper portions, is consequently changed, it is very useful to give after each ration of milk and cream, a capsule containing pancreatin and soda, to which may be added with advantage the bile acid salts. A gelatine capsule contain- ing the following ingredients may therefore be given four or five times a day: soda ? Pancreas powder, Sodium bicarbonate, Sodium glychocolate, M. 2 grains (0.12 gm.) 1 grain (0.06 gm.) Y 2 grain (0.03 gm.) The kind of food and its mode of prep- aration Meats As one to one and a half litres of milk contain only about 600 to 900 calories, this amount of food is not adequate to main- tain nutrition, consequently it is necessary to make up the caloric deficit by the addition of sufficient proteids, carbohydrates and fats to meet the caloric requirements of the individual. The rules that should govern the arrangement of the diet, as far as the calculation of the caloric values are concerned, have been discussed fully in the Chaper on Diseases of Metabolism. In selecting the kind of albuminous, starchy and fat food to be administered and deciding upon its mode of preparation, the following principles should be observed : Albumen may be administered in the form of meats, eggs or vegetable albumens. Certain meats should be excluded alto- gether from the diet, chiefly those that contain extractives and toxic principles. To the former class belong all raw, rare, smoked, cured and corned meats, for they still contain the ex- tractives. Soups, bouillons and meat extracts, as well as most gravies, contain the extractives in solution and should be strictly eliminated from the diet of a chronic nephritic. In- ternal organs, like liver, spleen, kidney, brain, pancreas con- tain very abundant nuclein, and as nuclein in process of diges- tion is split up into the purin bodies, a group of substances that are distinctly toxic and can both . irritate the kidneys and the cardio-vascular apparatus, these articles, too, should be excluded. In addition, game, which usually contains ptomaines, especially if it has hung for some time and has "hautgout," is dangerous. Veal is said to be rich in toxic bodies and frequently produces CHRONIC NEPHRITIS AND BRIGHT 'S DISEASE 213 • acute digestive disorders, even in well subjects; it ought best, therefore, to be eliminated from the diet. Sea foods of all kinds should be absolutely fresh, and it would be a sensible rule to Sea foods forbid subjects living far from the seaboard to eat any salt water fish or crustaceans. To the category of forbidden articles also belongs caviar, for it contains a very large amount of nitro- gen and an abundance of nuclein, consequently" purin bases, and generally some ptomaines. There has been much discussion in the literature of recent years in regard to the use of light and dark meats. However Light and convincing certain purely scientific researches may be that are ar mea s intended to show that there is no difference between light and dark meats, I have never been able to convince myself that it is quite safe to depart from the old empiric rule to reduce the ingestion of dark and red in favor of light meats in ne- phritis. All spices and condiments should be forbidden, for they un- Spices and questionably irritate the kidneys. Con imen s Eggs were, for a long time, tabooed in nephritis; it seems Eggs established that raw eggs increase the albuminuria in certain forms of the disease; in view of the fact, moreover, that, espe- cially in all large cities, eggs are generally of the cold-storage variety, and there is consequently always danger of their con- taining ptomaines, they should be eaten sparingly. There is no objection, however, to the use of two or four fresh eggs a day. Some care should be exercised in the selection of vege- Vegetables to tables, thus all vegetables that contain irritating oils or other e av01 e pungent principles, like radishes, asparagus and garlic, onions, celery should be excluded from the diet. Mushrooms, too, should not be permitted; for, in the first place, they contain a very large percentage of nitrogen for their bulk; and in the second place, as is well known, frequently contain poisonous alkaloids, which, even in small quantities, would be particularly dangerous in nephritis, because their elimination from the body is in- terfered with. All other vegetables may be eaten with im- punity. Preference should be given, on account of their su- perior nutritive values, to vegetables growing under-ground. Salads, too, are very useful, both on account of the slight laxa- tive properties that they possess, and because they are usually eaten with a dressing containing abundant oil, so that in this way considerable fat can be introduced in a pleasant and pal- atable form. All articles of food made of flour, rice, cereals, may be eaten starchy foods with freedom and should be given in abundant quan- tities, for they enable the ingestion of a sufficient amount of 214 CHRONIC NEPHRITIS AND BRIGHT 'S DISEASE Desserts Cheese Beverages Alcohol Light wines Cordials and liqueurs Beer Tea and coffee Cocoa Imitation cof- fee Lemonade carbohydrate material and also permit the addition of much fat to the diet in the form of butter or cream. This also solves the problem of desserts, and patients with nephritis can eat puddings, sweets, stewed or fresh fruits, ice cream, etc., with impunity. Cheese is permissible, with the exception of those varieties that contain spices or that are in an advanced stage of putre- faction; thus especially Roquefort, Camembert and Parmesan cheese should be forbidden. A few rules can be formulated in regard to the beverages that may be permitted a case of chronic nephritis. The amount of liquid permitted has already been discussed above, and the relative advantages of drink restriction and abundant water- drinking explained. Alcohol should be eliminated, as far as possible, from the diet of nephritics, chiefly on account of the effect that this drug has upon the cardio-vascular apparatus; for, as has been repeatedly mentioned, irritation of the heart and arteries and elevation of the blood pressure should be avoided in chronic nephritis. If any alcoholic beverage at all is to be permitted, and this may be necessary among subjects who have been used to a little alcohol all of their lives, then light Moselle or Burgundy or Claret diluted with some alkaline mineral water may be allowed. Cordials, liqueurs and absinthe should be absolutely forbidden, not so much on account of the alcohol, but on account of the essences and flavors (aldehydes, etc.) that all these beverages contain, and that are excessively irritating to the liver and the kidneys. Beer is best omitted from the diet of chronic nephritics, espe- cially if they are taking large quantities of milk. Among subjects who have been used to drinking beer all of their lives, the occasional use of a glass of beer can, of course, do no great harm, but it is always safer to forbid it altogether. If beer is to be taken at all, Stout and Porter are better than German beers. Tea and coffee are theoretically contra-indicated in chronic nephritis. As the withdrawal of these beverages constitutes a severe hardship, however, to most persons, a little weak tea or coffee thoroughly diluted' with milk may be allowed, especially in the morning. One must be governed in the restriction of tea- and coffee-drinking somewhat by the individual tastes and peculiarities of the case. A very useful beverage, and one that can frequently take the place of tea and coffee, is cocoa. Some of the imitation coffees, which are black and sweet and hot, also have a useful place ; they certainly can do no harm. Lem- onade and orangeade are useful beverages, for the citric acid CHRONIC NEPHRITIS AND BRIGHT *S DISEASE 215 they contain is converted into carbonate in the bod} 7 and elim- inated as such. The importance of withdrawing chlorids from the diet may be mentioned in this place. In nephritis the elimination of so- Withdrawal of dium chlorid (common salt) is often reduced. It is retained in the tissues, and in order to remain there in a solution that equals the molecular concentration of the blood and tissue juices, it must draw water from the blood (the less concentrated solu- tion) into the tissues (the more concentrated solution) by a process of osmosis. This idea may in part explain the edemae of nephritis. On the basis of this theory the ingestion of sodium chlorid, i. e., common table salt, has been restricted in order to enable the kidneys slowly to eliminate the retained chlorids. If the theory were correct the edemas should disappear. As a matter of fact, in common with many others I have repeatedly seen nephritic edemas disappear (and, incidentally, albuminuria decrease) when the chlorids were excluded from the food, and reappear when salt was again given. As one hundred grains of common salt require about three pounds of water to form the proper physiologic solution (i. e., a solution exercising the proper osmostic pressure) in the body, any sudden increase in the weight of a nephritic patient, other things being equal, may mean salt retention and hence water retention (deep edemas), and should be an indication, tenta- tively at least, to withdraw the chlorids from the food. The medicamentous treatment of chronic nephritis is of very Medicamentous subordinate importance, for we know of no remedy that can treatment exercise a direct effect upon the nephritic process itself. What remedies are given should be administered in order to prevent constipation and to render the gastro-intestinal tract as nearly aseptic as possible (see index), to exercise an effect upon the heart's action and the blood pressure and symptomatically to relieve drops} 7 and internal edemas. Most of this drug treat- ment it will be seen is directed towards improving the condi- Indication? tion of the cardio-vascular apparatus ; it is in all essentials iden- or rugs tical with the treatment described at length in the Chapter on the Heart and Arteries. The symptomatic treatment of renal dropsy differs in no way from that of cardiac dropsy (see page 42). Drugs that can be given to relieve symptoms about the stomach, the lungs and the central nervous system are either discussed in the Sections on Gastro-intestinal or Pul- monary Diseases or in the Chapter on Uremia. It is useless, therefore, to describe all these remedies again in this place. 216 CHRONIC NEPHRITIS AND BRIGHT ? S DISEASE Necessity of giving 1 drugs sparingly Hydrotherapy Effect on heart's action and blood pressure Physiology of blood pressure Changes in peripheral re- sistance Drugs should, at all events, be used sparingly in chronic nephritis, for the continuous administration of drugs is always fraught with many inconveniences. In the first place the pro- longed use of medicine is bound sooner or later to injure those organs that are concerned with their absorption and elimination, notably, the stomach, the liver and the kidneys ; and in addition the effect of most drugs that we might give for the sake of re- ducing the blood pressure or stimulating catharsis or diaphore- sis is exceedingly transitory and the organism soon becomes ac- customed to them. It is much safer to undertake symptomatic treatment by hydro-therapeutic means, for, if the patient has been treated largely by such measures, then he always has drugs to fall back upon in emergencies should alarming symptoms develop that require energetic treatment. And as a rule it will be found that much smaller doses of the different medicines will be re- quired in such cases to produce the desired effect than in pa- tients who have been habituated for long periods of time to the use of cardiac tonics, vaso-dilators, cathartics, diuretics, dia- phoretics, etc. This is a great advantage. Hydro-therapy is the most efficient means for influencing the heart's action and the blood pressure. Three elements en- ter into the physiology of arterial tension, viz., the amount of the blood, the force of the contraction of the heart, and the de- gree of peripheral resistance. From the heart emanates the force that propels the blood into the arteries and causes the tension of their walls. The peripheral resistance, by creating an obstacle to the evacuation of the arteries, causes an accumula- tion of the blood in these vessels and tension of their walls with a reactive elastic pressure that propels the blood onward. The mass of blood finally is the intermediary agency that driven from behind and compressed from in front distends the arteries to such a degree that the elastic powers of their walls can be- come operative. Increased or decreased, these three factors de- termine variations in the blood pressure, and all three factors can be profoundly influenced by hydriatic measures. Changes in the peripheral resistance can be brought about both by cold and by hot applications. In chronic arterial dis- eases the latter, however, should have the preference, for this reason: The application of cold always at first produces a contraction of the peripheral vessels, followed very shortly by a dilatation called "the reaction." This physiological reaction that leads to reduced blood pressure cannot be utilized with safety in most cases of chronic nephritis; (1), because the pri- mary contraction of the peripheral vessels causes a sudden in- CHRONIC NEPHRITIS AND BRIGHT 'S DISEASE 217 •crease of the arterial tension and may, in predisposed subjects, produce rupture of the weakened blood vessel walls in the brain, the retina or otherwise; (2), because the cold causes an increase of the heart's action by a nervous reflex that is transmitted directly to the cardiac ganglia; (3), because, in chronic ne- phritis, the reaction may fail altogether owing to lack of tone or possibly to anatomic changes in the musculature of the peri- pheral arteries, or on account of myocardial changes. The method of choice, therefore, for reducing the peripheral Hot hydriatic blood pressure is the application of heat to the body surfaces, cold for hot applications, provided the degree of temperature is not too high, produce from the beginning cutaneous hyperemia without preceding contraction of the peripheral blood vessels, and if continued, true relaxation of the muscular coats of the peripheral arteries with a corresponding fall in the blood pres- sure. Moreover, heat causes a long-lasting loss of tone on the part of the peripheral blood vessels, in other words, a prolonged vaso-dilator effect, whereas the reaction following cold appli- cations leads to what may be called a tonic congestion of the peri- pheral vessels during which the tone of the blood ves- sels is fully preserved so that contraction soon follows. Heat, furthermore, if applied for a sufficient length of time produces dilatation not only of the cutaneous vessels, but also of the deep blood vessels; whereas, the dilatation of the superficial vessels produced by cold is usually accompanied by intense contrac- tion of the deep vessels, an effect that leads rather to high than to low blood pressure. The fall of blood pressure, therefore, following hot applications is much more permanent and its pro- duction fraught with less dangers than the decrease of arterial tension produced by cold or by medicinal vaso-dilators. The simplest way of applying heat to the surfaces of the Hot baths body for the purpose of reducing blood pressure is to give the patient what may be called a ''hot soak," i. e., the patient is instructed to once or twice a day (for practical purposes best •early in the morning and late at night) lie perfectly still for five or ten minutes in a bathtub filled with water a few degrees "below the temperature of the body. If it is desired to increase the effect friction may be applied for a time by an attendant while the patient is immersed in the bath. The addition of a few pounds of salt to the water, or im- Salt or car- mersion in warm carbonated water, is very useful because the 5°?^ c acid salt and the carbonic acid both assist in relaxing the peripheral •capillaries. The bathroom should always be kept very warm The bathroom for the capillaries of the skin are relaxed after the bath and should be kept so as long as possible ; if the- room is cold sud- 218 CHRONIC NEPHRITIS AND BRIGHT S DISEASE Danger of col- lateral hy- peremia Cold to the head Effect on vol- ume and com- position of the blood Electric light and hot air baths Danger of sweating by dry heat den contraction of the cutaneous vessels occurs and therewith a rapid rise of blood pressure and an increased strain upon the heart — all effects that one is precisely trying to avoid. In cases, moreover, in which the vaso-motor tone is below par, and this is common in cardio-nephritics, there is always considerable danger of catching cold. The best plan of all is to have the patient lie down in a warmed bed for a time after the bath. One other important point must further be considered in using this plan, viz., the occurrence of collateral hyperemia in various parts of the body, especially the brain. For this reason the head should always be covered with cold cloths or an ice bag during all the time the patient is in the water. It will be found that this plan not only reduces the blood pressure for many hours thereafter, but also slows the heart and reduces the force of its contractions. Occasionally the rapidity of the heart action is slightly increased, especially after the patient leaves the bath. In such cases the application of the ice bag to the precordial region, or of cold cloths to the nape of the neck, may be employed to reduce the number of heart beats. A marked effect can further be exercised by hydro-thera- peutic measures upon the composition and the volume of the blood. From all that has been said above, it is clear that cold applications are absolutely contra-indicated in any case of ne- phritis owing to the sudden initial rise of blood pressure and the nervous shock to the heart that they engender. It is useless, therefore, to discuss in this place the interesting effect that cold applied to the surfaces of the body can exercise upon the per- centage of leucocytes and of red corpuscles, and upon the specific gravity and the volume of the blood; and we will con- cern ourselves therefore exclusively with the use of hot applica- tions in order to see what effects, that may be beneficial in ne- phritis and that we usually attempt to produce by drugs or diet, can be produced by heat. Dry heat, i. e., the electric light bath or hot air, applied in different ways, always produces a greater concentration, i. e., a decrease in the total volume of the blood. This is due, of course, to the loss of water through the sweat glands, and while this practice by accelerating the current of lymph may act bene- ficially in the absorption of edemas, I have never been satisfied that sweating produced in this way is beneficial in cases of ne- phritis without edemas; for while some solids are lost through the sweat glands, the loss of water is immeasurably greater, and the concentration of the blood is so much increased by this practice that whatever toxic bodies may be circulating can un- doubtedly exercise a more deleterious effect in a concentrated CHRONIC NEPHRITIS AND BRIGHT 'S DISEASE 219 than in a diluted form. The reduction of the blood pressure that might result from a decrease in the volume of blood is off- set by the greater toxicity of the circulating fluids, for the pressor principles they contain are not eliminated via the sweat Copious water drinking* dur- glands. If dry heat is applied, then the patient should at all i ng . the sweat events at the same time be given very copious draughts of water to compensate for the loss of water by diaphoresis, but as this practice undoubtedly throws a great strain upon the heart and arteries that have to pump this water from the stomach to the emunctories of the body, I have always felt that the benefits accruing from sweating by dry heat are more than neutralized by all these disadvantages. For this reason if sweating is to be produced at all it should Sweating by- be done by means of moist heat, and here the method moist heat of choice is without doubt immersion for five, ten or fifteen min- utes in water heated slightly above the temperature of the body. It will be found that when this plan is adopted, the con- centration of the blood does not increase, as manifested by de- terminations of its specific gravity, freezing point, and electric conductivity. It is possible, as Wick has suggested, that the loss of water through the sweat glands is compensated by the absorption of water from the tissues, superinduced and aided by the pressure exercised from without by the water of the bath; at all events, immersion in hot water, aside from lower- ing the blood pressure by prolonged vaso-dilatation, causes a certain loss of excrementitious solids through the sweat glands without causing great concentration of the body fluids, in other words, greater toxicity of the latter, and without consequently necessitating the administration of much water by mouth. If properly carried out immersion in hot water really aids the body in getting rid of both solids and water with safety. In all diseases complicated by high arterial tension and an Hydriatic irregular and excitable heart action, and to this category belong means to allay '• ■ 11 n * i -. • • • • n '' nervous un- practically all cases 01 chronic nephritis, it is a matter of great tability importance to allay the nervous irritability. We should always endeavor to do this psychically by quieting the patient's fear, trying to keep him from worrying about his condition, and ad- vising him not to lead too strenuous a life, and we usually en- force this effect by sedative remedies. Much more can be accom- plished in this direction with complete safety by hydro-thera- peutic means. This fact is so well-established that nowadays Psychic treat- the standard treatment of neurasthenia, and of many psychoses ment complicated with excitement, consists in the use of hydro- therapeutic means. As a rule it is impossible to carry out such treatment at home. Certain simple measures that a^e of great 220 CHRONIC NEPHRITIS AND BRIGHT 7 S DISEASE Effect of hy- driatic means on the general metabolism Effect on di- gestion value in quieting the sensibility of the whole nervous system, including the vaso-motor nerves, can, however, be carried out in one's house, and chief among these, again, is the use of warm water and, by preference, the prolonged warm bath. Upon the general metabolism the use of hot water also exer- cises a very profound influence that is particularly valuable in nephritis. For immersion of the body in hot water for some time, by preventing the loss of heat by radiation, and, inci- dentally, by causing dilatation of the blood vessels supplying the muscles, causes an acceleration of metabolism, particularly of the non-nitrogenous constituents. This is a valuable effect in nephritis as it prevents to a certain degree the accumulation of waste products in the blood and relieves the kidneys of the necessity of excreting them. In obese subjects a considerable loss of fat can be brought about in this way, especially when judiciously combined with proper exercise treatment, and that this is invaluable in any form of cardio-renal disease need hardly be emphasized. The use of dry heat is again not safe on account of its effect upon metabolism, because the body at once consumes an in- creased amount of its own nitrogenous constituents to make up for the loss of heat by radiation; in this way flooding of the blood stream with urea and bodies that are intermediary be- tween albumen and urea is brought about. Whenever this oc- curs increased labor is thrown upon the kidneys, as they must rid the organism of this circulating waste material. Upon the digestion, i. e., upon the secretory and motor func- tion of the stomach and bowels, hydriatic procedures also exercise a profound influence. Unfortunately, however, the measures that are most efficacious in promoting increased secre- tion and improved motility are cold hydriatic means, and these we cannot employ. The one cold measure that is useful and that can be applied with safety is the application of cold locally over the liver, either in the form of a Priessnitz compress or by means of a cold stream of water directed against the hepatic region with the rest of the body protected. This process stimu- lates the hepatic function and promotes an increased flow of bile. In view of the presumably hepatic origin of many forms of Bright 's disease (see page 206), this is a useful adjuvant to treat- ment, especially since the entrance of much bile into the upper portion of the bowel reduces intestinal putrefaction. This is one of the most desirable effects that can be obtained in nephritis, an effect that we usually attempt to bring about by dietetic and medicinal means. CHRONIC NEPHRITIS AND BRIGHT 'S DISEASE 221 In conclusion a word should be said in regard to the effect of Effect on the hydriatic procedures upon the flow of urine. Cold applied to ow ° urme the surfaces of the body, as is well known, stimulates diuresis both by raising the blood pressure and presumably also by a re- flex action upon the musculature and the sensory nervous appar- atus of the bladder. This becomes manifest by the almost in- stantaneous desire to urinate that patients develop as soon as cold measures are applied. As cold is inadvisable in nephritis, we cannot make use of this procedure, but I do not consider this a disadvantage, for I have never been convinced that the stimu- lation of diuresis is a desideratum in nephritis. Any measure that increases the flow of urine by implication stimulates, even irritates, the kidneys, immaterial whether the stimulus be a drug acting directly upon the secretory mechanism of the kidneys or upon the blood pressure within the kidneys. When the kid- neys become diseased they at once fail, as shown above, to elim- inate certain bodies properly, but to force them to eliminate, nevertheless, is a precarious procedure for it violates one of the fundamental principles of the treatment of a functionally inad- equate organ, viz., that this organ should be rested rather than irritated and forced to work. For rest alone will enable Nature to institute the necessary reparative processes and to hasten re- covery. Consequently heat is again useful for it lowers the blood-pressure in the kidneys and consequently may somewhat reduce diuresis, but it also spares the kidneys by soothing rather than irritating the nervous apparatus that superintends the man- ufacture and excretion of urine. It will be seen, therefore, that such simple measures as hot signal ad- bathing, properly administered, and the application of hot or van tages of & ' * * J ' ** proper hydro- cold to various portions of the body, can accomplish much in the therapy in the treatment of the nervous, metabolic, gastro-enteric and cardio- chronic n ne°n- vascular manifestations of nephritis that we ordinarily attempt ritis by drugs. In selecting a climate its effect upon the skin should be con- Climate and sidered, preference should be given to a climate in which the daily temperature fluctuations are very small, in which the alti- tude is low and the atmosphere dry; for such a climate stimulates insensible perspiration, so that the kidneys are relieved of some of the labor of excreting water; moreover, the surfaces of the body are not alternately heated and chilled, consequently there is less danger of catching cold and less probability of disturbing the vaso-motor equilibrium and hence causing congestion of the diseased kidneys. Otherwise the choice of a resort or a climate should be governed by the condition of the heart and arteries (see page 24). In Europe, chronic nephrotics are sent to Egypt, 222 PYONEPHROSIS AND PYELITIS Exercise Massage Surgical treatment of Bright's dis- ease Algiers, Corsica and the Riviera. In the United States, Southern California, Arizona and New Mexico furnish the most ideal loca- tions for this class of cases. The regulation of exercise and the administration of massage likewise are dependent on the state of the cardio- vascular appar- atus more than of the kidneys. For a discussion of this part of the treatment I refer, therefore, to the Chapter on Diseases of the Circulatory Apparatus. One word may be said in conclusion concerning the so-called surgical treatment of Bright 's disease. Splitting of the kidney capsule, or decapsulation of the organ, for the cure of Bright 's disease is altogether irrational. The temporary relief of tension may improve the blood supply to the kidneys, and hence restore, i'or the time being, some functional activity to diseased epithelia ; nrid this improvement in the renal function may become mani- fest by a reduction of the edema, by a transitory decrease in. the albuminuria, the disappearance of formed elements (casts, etc.) from the urine, and an increase in the excretion of solids and of water. Bright 's disease, however, as we have seen in the pre- ceding paragraphs, is a systemic disorder and the nephritis is merely one of its symptoms. Any treatment of the kidneys alone, whether surgical or otherwise, is, therefore, purely symp- tomatic, and can in no sense be regarded as curative. One might as well amputate the rose spots in typhoid fever and expect to cure the disease. It is not surprising to find, therefore, that no true case of Bright 's disease has even been permanently bene- fited by operations on the kidneys. The procedure is mentioned in this place merely to be condemned. Causal and prophylactic treatment II. PYONEPHROSIS AND PYELITIS. Pyonephrosis and pyelitis are rarely primary disorders. As a rule they are consecutive either to calculus disease, or they develop by ascending infection from some disorder of the lower genito-urinary passages. Occasionally they are blood-borne as, for instance, in tuberculosis, typhoid, pneumonia, scarlet fever, diphtheria and small-pox. Carcinoma and sarcoma, and occa- sionally syphilis, also produce pyelitis, possibly by weakening the resistance of the tissues and thus rendering them susceptible to infection. The causal and prophylactic treatment of pyelitis must take all these pathogenetic elements into consideration. Thus in some cases the same rules apply as in the treatment of nephro-lithiasis, disorders of the bladder, urethra and female genitalia. Treat- ment directed towards preventing pyelitis in infectious diseases PYONEPHROSIS AND PYELITIS 223 consists in promoting a copious diuresis and advancing every effort to reduce the toxicity of the urine and increasing the re- sisting powers of the renal and pelvic tissues. The inflammation within the renal pelvis can be favorably influenced by the appli- Counter-irrita- -cation of leeches or cups over Petit 's triangle, i. e., that area petit's tri- which is bounded by the crest of the ilium, the latissimus dorsi an S le And the external abdominal oblique muscles, for the veins of this region connect directly with the veins of the renal capsule, so that counter-irritation, bleeding or cupping over Petit's tri- angle can exercise an important effect upon congestion within .and around the kidney. In addition the bowels should be kept Catharsis freely open by the use of laxatives, preferably of a vegetable character. In this way revulsive action is promoted and at the .same time the absorption of bowel toxins that might be irritating to the kidneys in their passage into the urine prevented. The diet should be bland and non-irritating and consist Diet largely of milk. Here the principle of sparing the kidney that is so important in most renal disorders of an acute and sub-acute •character, obtains with particular force, for the kidneys must be enabled to put forward every effort towards combating the local inflammation. The diet should consequently be arranged in the same way as outlined under Acute and Subacute Nephritis. There is one exception to this rule, viz., cases of pyelitis without nephritis should always drink plenty of water in order to dilute the urine and thus flush the kidney channels and the pelvis, prevent ascending infection and stagnation and mechanically, in •case the presence of calculi is suspected, promote their expulsion. In the latter case, provided it is possible to determine the composition of the concretions from fragments that may be passed or from other urinary signs, the same dietetic rules should be observed as described under Xcphrolitliiasis. In the more chronic varieties astringents, chiefly tannigen, in Astringent? doses of from ten to thirty grains (0.6 to 2 gm.), or catechu, preferably in the form of the compound catechu powder, con- taining catechu, kino, krameria, cinnamon and nutmeg, in doses of from ten to seventy grains a day (0.6 to 2.4 gm.) may be given. In this disease, finally, urinary antiseptics have the widest Urinary anti- field of application. Best of all is urotropin, which may be given se P tlcs in doses of from three to ten grains (0.2 to 0.6 gm.) in a full glass of water, three or four times a day. Benzoate of soda, in Urotropin doses of from five to thirty grains (0.3 to 2 gm.) in water; the Sod i um ben " oil of copaiba, in doses of from ten to fifteen minims (0.6 to 1 cc.) Copaiba in capsules; the oleum cadinum (empyrheumatic oil of juniper) Juni P er 0l1 in the same doses, are all useful. Finally, salol, in doses of from five to fifteen grains (0.3 224 LAVAGE OF THE RENAL PELVIS Salol Sod. sulpho- carbolate Methylene blue Pain Surgical treat- ment lntra-pelvic medication to 1 gm.) in capsule or powder or, the sulphocarbolate of sodium in from five to fifteen grain (0.3 to 1 gm.) doses three or four times a day can also be employed. Methylene blue is without effect. All of these remedies should be taken with abundant water and in using any of them great care should be exercised not to produce renal irritation. Their prolonged use is, as a rule,, somewhat dangerous, hence the urine should always be carefully examined for casts or other evidence of nephritis. As soon as such signs appear the administration of these drugs should be interrupted or stopped. The pain in pyelitis should be treated in the same manner as the pain in nephrolithiasis and renal colic (see page 232). In cases of very severe suppuration that do not yield to medicamentous treatment, combined with the proper diet, hy- giene and rest, surgical intervention may become necessary, con- sisting in drainage of the kidney, removal of concretions that may be present, or even nephrectomy. Of recent years still another method of treating pyelitis has been devised, consisting in the introduction of a ureteral catheter and the injection of various astringents and antiseptics directly into the renal pelvis. THE TREATMENT OF PYELITIS BY LAVAGE OF THE RENAL PELVIS. Instruments employed Technique (By Dr. F. Kreissl, Chicago.) Lavage of the renal pelvis is performed by injecting medi- cated fluids into the pelvis through a ureter-catheter, introduced by means of a cystoscope. The direct or indirect view catheter- izing-cystoscope may be employed. In the male the direct view cystoscope no doubt causes more tension and traumatism to the prostatic urethra than the indirect view instrument. The former,, also, will be found inadequate where the ureteral os, as quite frequently happens, is located close to the vesical sphincter. On the other hand it will generally be found that the passing of the catheter into the ureter is more readily accomplished with the direct view cystoscope, for here the curve from the instru- ment to the ureteral os is eliminated. For the purpose in ques- tion a cystoscope should be employed which can be removed without disturbing the position of the catheter in the renal pelvis. The catheters used should have moderately blunt points, and should be introduced without undue haste in order to avoid traumatism. Renal lavage, if carried out carefully, and under strictly aseptic precautions in every detail is a harmless pro- cedure. LAVAGE OF THE RENAL PELVIS 225 The solutions most commonly employed are a warm solu- Solutions em- tion of boric acid, 4 to 100; oxycyanide of mercury, 1 to 4000: y nitrate of silver, 1 to 2000 to 1 to 1000 ; protargol 1 per cent, and argyrol, 5 to 20 per cent. Of the silver solutions mild concen- trations should be used at first, gradually increasing their strength from treatment to treatment. The quantity to be injected must vary with the capacity of Quantity to be the renal pelvis in each individual case ; however, so much should mj never be injected as to cause over-distension and colicky pains. In the majority of cases I have found injections of 4 to 8 cc. at a time sufficient. The intervals that should elapse between each application de- Frequency of pend on the nature and the extent of the local trouble. If there applications is much debris in the renal pelvis it will be necessary to perform preliminary irrigation with a warm boric acid solution until the fluid returns fairly clear, and then to inject the antiseptic ; while in cases with little pus in the urine, the antiseptic may be de- posited at once without a preceding cleansing irrigation. Where the conditions require daily renal lavage in male Leaving the patients I always prefer leaving the catheter in situ for a few catneter m days at least ; this permits frequent topical application without unnecessary and inevitable traumatism to the prostatic urethra incident to repeated introduction of the instrument. The extravagant claims which have been made for this Limitations of method of treatment are not supported by facts, but it cer- tne method tainly has a definite, though limited, sphere of usefulness. To appreciate this the following points may be considered : Etiolog- ically pyelitis, or rather pyelonephritis, is more frequently caused by a descending or hematogenous, than by an ascending or urogenous, infection. If the suppuration be of hematogenous origin, the kidney parenchyma must have been first infected, and it is hard to understand how a topical application to the renal pelvis can effectively reach the focus in the kidney proper. And the same objection must reasonably be made to the efficacy of the method in the ascending type of pyelonephritis. At best one can expect some relief of those symptoms which are due to abnormal conditions in the renal pelvis and are directly trace- able to the infection and inflammation existing in that locality as, e. g., retention of pus and urine arising from inflammatory swell- ing or blocking of the ureteral openings, renal colic from dis- tension of the pelvis and fever. Cases of suppurative pyelitis without involvement of the Suppurative kidney proper constitute only a small fraction of the cases of P velitis pyelitis that come under observation ; this is partially explained 226 NEPHROLITHIASIS Complications Spontaneous healing of un- complicated pyelitis Gonorrheal pyelitis Renal lavage not effective in mixed infec- tions Summary by the generally accepted fact that hematogenous infection is the more common cause of pyelitis than urogenous infection ; per- haps also by the absence or the mildness of perceptible symptoms in initial stages of the disease that render its early discovery rare. This also explains the fact why we do not often see cases before the kidney parenchyma has been invaded. Another point to be considered is that many of these cases either are caused by or complicated with calculus, malforma- tions of the renal pelvis, strictures or other obstructions in the ureter and urethra, tuberculosis, tumors, etc., so that renal lavage can, at best, give only temporary relief, while suitable and well directed surgical measures will usually obviate the necessity of any topical application. Furthermore, the vast majority of uncomplicated cases of pyelitis heal spontaneously, or under the use of the internal agents discussed in previous paragraphs of this section. Almost the only exceptions to this rule are ascending gonorrheal in- fections of the renal pelvis. These eases are not so rare as is commonly believed and they do not yield to conservative treat- ment, while renal lavage with efficient silver solutions has gen- erally given me surprisingly good and rapid results. Fre- quently, however, especially in older cases the gonococcus ap- pears associated with bacterium coli, staphylococcus and other germs; if properly treated the gonococcus in such cases dis- appears permanently from the renal pelvis, but I have never succeeded in a single case of this kind in clearing the urine thor- oughly or permanently of the other bacteria. This leads me to the conclusion that renal lavage is not effective in mixed in- fections of the pelvis, or else that the gonococcus has a tendency to locate in the pelvis, while the other germs invade the kidney proper where topical applications do not reach them. Summing up my experience with renal lavage in many cases of divers types of pyelitis and pyelonephritis, I recommend its use as a curative agent in pyelitis uncomplicated by nephritis, stones or strictures, and then only when the ordinary means of internal medication fail to remove the suppuration. Indications for treatment III. NEPHROLITHIASIS. The treatment of nephrolithiasis must concern itself, first, with preventing the deposit of concretions in cases that are pre- disposed to the formation of renal stones; second, with facili- tating the passage of the concretions after they have once formed; third, with preventing secondary infections and, lastly, NEPHROLITHIASIS URICA 227 with symptomatically relieving the pain, the renal colic, the hematuria and other phenomena. The prophylactic measures that we can employ vary accord- Prophylaxis ing to the character and the composition of the urine. Thus an individual voiding an acid urine, with occasionally a little gravel or sand composed of uric acid, urate or oxalate crystals, must be treated differently from a subject whose urine is alka- line and possibly purulent; for, in the latter, we have every reason to dread the formation of phosphatic deposits. Of the many concretions that can form in the urinary passages the most important varieties, and those that, alone, in the light of our present knowledge, are amenable to causal and prophylactic treatment, are uric acid and urates, oxalates and phosphates. NEPHROLITHIASIS URICA. To prevent uric acid or urate deposits the solubility of the Four factors urinary acid must be increased ad maximum. The factors that sohibinty r ?f ne chiefly* determine this solubility are the concentration of the urinary uric urine, the percentage of uric acid it contains, its content of sodium chloride and above all its reaction. The more concen- trated the urine and the more uric acid and sodium chloride it contains percentically the greater the tendency to the precipi- tation of nric acid and urates in the urinary passages. For these reasons the urine should always be rendered dilute by abundant ingestion of water; the urinary excretion of uric acid should be reduced as much as possible by proper dietetic Diet and medicinal means, as described in full in the Chapter on Diseases of Metabolism (page 177), and, finally, the intake of sodium chloride, i. e., of common table salt, should be restricted. The most important element in the prophylactic treatment of nephrolithiasis urica, however, is the regulation of the reaction of the urine, for it is a well established fact that the alkaline urates are more soluble than acid urates or uric acid itself. To Alkalies render the urine less acid and to promote the solubility of uric acid, alkalies, i. e., chiefly sodium carbonate and bicarbonate, or alkaline mineral waters, are commonly given in nephrolithiasis urica. It must be remembered, however, that the action of alka- lies in cold urine, or even in normal urine, as studied in the test tube, differs materially from their effect on a highly con- centrated urine, such as we find it in nephrolithiasis urica, in which the gravel deposits at body temperature. The changes in *Iu all forms of nephrolithiasis there must also be a cementing ma- terial (mucus fibrin, pigments, etc.) that makes a concretion out of a fine sediment. NEPHROLITHIASIS URICA Effect of alka- lies on propor- tion of dif- ferent urinary- phosphates The decrease of phosphoric acid in the urine Calcium as a remedy the reaction of the urine, moreover, that are seen after the admin- istration of alkalies must be interpreted with great care if urinary titration methods are employed, for here many sources of error creep in that need not however be discussed in this place. The most important influence undoubtedly exercised by the administration of alkalies upon the solubility of uric acid in the urine is the change in the relative proportion of acid, neu- tral and basic phosphates in the urine that they bring about. For uric acid is readily soluble in basic phosphates (di-sodium phosphate), but insoluble in acid phosphates (mono-sodium phos- phates) ; the addition, in fact, of mono-sodium phosphate to a solution of uric acid in di-sodium phosphate will cause the pre- cipitation of uric acid. It is clear, therefore, that the solubility of uric acid in the urine is enhanced by the presence of di- sodium phosphate, and that the tendency to the formation of uric acid concretions increases in proportion to the amount of acid phosphate that is excreted through the kidneys. It is also clear that any effort directed towards preventing the precipi- tation of uric acid in the urinary passages must be concerned with increasing the amount of basic, and decreasing the amount of acid, phosphates. The ideal would be to cause the complete disappearance from the urine of mono-phosphate and, at the same time, to produce an elimination through the kidneys of a 4uantity of di-phosphate sufficiently large to hold all the uric acid excreted in solution. This can be accomplished in two ways, viz., either by decreasing the phosphoric acid in the blood that enters the kidneys or by increasing the sodium in this blood. The latter object can be accomplished by sodium salts but better still, as will be presently shown, by calcium salts. To decrease the phosphoric acid its source must be consid- ered; it may be derived from preformed phosphates ingested with the food or from the phosphorus contained in the albumins (chiefly nucleins) of the food or the body tissues proper that is converted, by intra-cellular oxidation, into phosphoric acid. By eliminating from the diet, on the one hand, pabulum containing preformed phosphates or nuclein-containing food, and by re- moving, on the other hand, from the blood and tissues, through other channels than the kidneys, the phosphoric acid that must inevitably be formed from the degradation of our own tissues, ^ we can reduce the urinary phosphate excretion. We possess a remedy that can both directly and indirectly regulate the phosphoric acid content of the blood and hence of the urine, viz., calcium salts.* For, in the first place, calcium *Croftan: The Use of Calcium Salts in Nephrolithiasis, etc. Jour. A. M. A., 1904. *See Croftan: "Clinical Urinology." NEPHROLITHIASIS URICA 229 forms insoluble salts with the alkaline phosphates contained in our normal food, and in this way prevents the absorption of this moiety into the blood. In the second place calcium, owing to the great affinity it possesses for phosphoric acid, combines with the phosphoric acid encountered in the blood stream, and causes the elimination of this proportion in the form of calcium phosphate — not, however, through the kidneys, but in great part through the intestine. This is an important point, for, in contradistinction to sodium, potassium and magnesium, all elements that are chiefly eliminated through the kidneys, cal- cium is principally (85 to 95 per cent.) eliminated through the bowel. It will be seen, therefore, that calcium given by mouth can, Mode of action first, prevent the entrance of a certain proportion of preformed of calcium phosphoric acid (phosphates) from the food into the blood, and can, secondly, prevent some of the phosphoric acid formed in the organism from passing into the urine by causing its elimina- tion through the intestine. In order to increase the sodium (or potassium) in the renal Dangers of blood, sodium (or potassium) salts, as stated above, are com- ^°^ 1 ?^ e ^ D al " monly administered ; but this practice is not without its dangers, for it may produce alkalinization of the urine and therewith create a tendency to the formation of x>hosphatic deposits (see below) upon the uric acid or urate stones. When this occurs the concretions usually grow rapidly and more harm is done than good. Whenever an alkali therapy is employed, therefore, care should be taken above all things to keep the urine faintly acid. This is difficult when sodium (or potassium) salts are given for long periods of time; their continued use, moreover, exercises a deleterious effect upon the gastric digestion and is not without effect upon the corpuscular elements of the blood. Calcium salts, on the other hand, never render the urine alkaline Advantages of and are fully as efficacious as sodium or potassium salts for they, calcium salts as shown above, cause a illative increase of the sodium and potassium and hence of the sodium (potassium) di-phosphate of the urine. They are, therefore, the best prophylactic reme- dies in nephrolithiasis, either alone or in combination with small quantities of sodium carbonate and, above all, with plenty of water. The best calcium preparation is the carbonate. This may be given in doses of fifteen to twenty grains, three times a day. Dose and ad _ More may be given with impunity. It is necessary to individ- ministration ualize. The smallest efficient quantity of any drug is always salts the best dose. The urinary calcium, phosphorus and uric acid excretion can to advantage be determined in the beginning (the 230 NEPHROLITHIASIS URICA Mineral wa- ters containing calcium Uric acid solvents Fallacy of giv- ing" uric acid solvents Lithium patient being on a fairly constant nuclein-free diet) and the dosage regulated accordingly. A more convenient method of administering calcium, and one that is preferred by most patients, particularly if the treat- ment is to be carried out indefinitely, is to give calcium in the form of natural mineral waters or as an addition to some pure water. Among the better known European mineral waters Con- trexeville, Wildungen and Fachingen contain the largest propor- tion of calcium salts. Among domestic waters the choice is diffi- cult. The exploiters of the majority of them make such blatant and extravagant claims in regard to wonder cures that it is not safe to place any reliance on this essentially commercial propo- ganda. Personally, I prefer adding the necessary amount of calcium salt or lime water to some pure water. A word may be said in this connection in regard to certain other remedies that have been recommended from time to time as so-called uric acid solvents. In most cases these remedies are given because they possess the property of dissolving uric acid in the test tube. One is not justified in deducing from this fact that they can also dissolve uric acid in the body, especially after urates have crystallized out or concretions have once formed. This applies with particular force to the alkalies that have just been discussed. They do not possess the power of dissolving urate concretions in the renal passages or otherwise in the body, but they act prophylactically by increasing the solubility of the circulating acid and preventing its deposit. They may also act beneficially by promoting general oxidation, and they finally possess a certain diuretic effect which is useful. It is preposterous to give alkalies or any other remedies with the idea that they will dissolve urate concretions. One might as well give ether to dissolve the fat of the body in obesity, or min- eral acid to dissolve the calcium out of osteophytes, on the ground that ether or acids can dissolve fat or calcium salts in the test tube. The amount of ingested alkali, moreover, that actually reaches the uric acid deposits (which are usually covered with a thin layer of mucoid material that protects them from " sol- vents") is so small that a solvent effect can impossibly be accomplished. This criticism applies with particular emphasis to lithium preparations that are so popular in the treatment of uric acid diseases. In the first place so-called lithia waters contain only a few decigrammes of lithium carbonate to the litre. As they always also contain large quantities of other alkalies only a very minimal amount of uric acid (according to Barthollet's law) would at best combine with the lithia, the bulk with the sodium NEPHROLITHIASIS URICA 231 and potassium salts, while, at the same time, most of the lithium would be promptly excreted as chloride, phosphate and sulphate. Finally, lithium carbonate, which actually does readily dissolve uric acid in the test tube, is immediately converted in the stomach into lithium chloride, a salt that possesses only slight uric acid dissolving properties. Other preparations that have been recommended as uric acid Lysidin, sido- sol vents are lysidin and sidonal (the quinic acid salt of piper- nal > piperazin. azin). I have never been able to convince myself that either of these remedies exercise any solvent effect whatsoever in nephro- lithiasis urica. Urea too is considered a uric acid solvent, and it urea actually possesses the power to a very marked degree of dis- solving uric acid outside of the body. Clinically, however, the results obtained from the administration of large amounts of urea have been, on the whole, unsatisfactory. What beneficial effect it occasionally exercises in ridding the renal passages of small concretions must presumably be attributed to its marked diuretic action. Benzoic acid in the form of sodium benzoate, in Sodium ben- doses of five to thirty grains (0.3 to 2 gm.) in water has been zoate extensively used. It does not dissolve urate concretions, but it acts as a urinary antiseptic and hence may prevent infection of the urinary passages, with disagreeable secondary conse- quences like pyelitis. Other urinary antiseptics have been dis- cussed in the part on Pyelitis. Urotropin (hexamethylentetramine) is probably the only rjrotropin remedy that in a measure has vindicated its claim to being a uric acid solvent in nephrolithiasis. It splits off formaldehyde in the body and the latter combines with uric acid to form a soluble compound. It has also been shown that the urine of patients who have taken large doses of urotropin acquires the power to a marked degree of dissolving uric acid. Urotropin is, besides, a very effective urinary antiseptic, so that it truly de- serves extended trial in nephrolithiasis urica. It should be given in five to ten grain doses, in a full glass of water, two or three times a day. One of the most useful remedies to promote the expulsion Glycerin of concretions that we possess, aside from diuretics and abundan t water-drinking, is glycerin. It should be given in large doses of 50 to 100 cc, in lemonade or water. Its mode of action is not well understood, but symplomatically it certainly sometimes aids in the expulsion of small concretions. The urine should, how- ever, always be carefully examined for evidence of renal irrita- tion, for in certain subjects glycerin produces hematuria; so that 232 NEPHROLITHIASIS URICA Olive oil The relief of renal pain Heat and cold Local applica- tions of tur- pentine and belladonna Opium Chloral hy- drate Chloroform Renal hem- orrhage Ergot Erigeron Tannigen Hydrastis Surgery as soon as blood appears in the urine, the administration of glycerine should be stopped. Olive oil, too, has been used for this purpose. For relieving the pain in nephrolithiasis either heat or cold or counter-irritants may be applied to the lumbar region. In the dull pain that is so characteristic of a large stone, heat is usually more grateful than cold, whereas in the acute paroxysm of pain in renal colic, cold usually affords greater relief than heat. Turpentine or tincture of belladonna (a few drops on flannel wrung out of hot water) applied locally in the lumbar region help the dull ache, but exercise no effect upon the colic. In severe renal colic opium will usually have to be given, either hypodermically as morphine, in doses of one-fourth to one-half grains, or by rectum in the form of a suppository or a starch enema. Chloral hydrate, ten to twenty grains (0.6 to 1.2 gm.) by rectum, also frequently relieves. The patient can to advantage also be placed into a warm bath or into bed with hot water bags to the lumbar region. If these simple measures fail to bring relief, then a few whiffs of chloroform will occasionally not only stop the colicky pain, but actually facilitate the passage of the calculus by producing relaxation of muscular spasm. Eenal hemorrhages, if slight, should be treated by rest in bed, while the bowels are thoroughly evacuated and the patient is kept on a milk diet. At the same time certain drugs may be given, especially if the hemorrhage becomes obstinate and very severe. The most useful drugs are the fluid extract of ergot in fifteen to thirty drops (1.0 to 2.0 gm.), or preferably the injection of ergot hypodermically, using ergotin, one part, and camphor water, two parts, in doses of three to ten drops (0.15 to 0.65 gm). The oil of erigeron, fifteen to thirty drops (1.0 to 2.0 gm.) in capsule may be used if there is no nephritis. Tan- nigen, ten to thirty grains (0.6 to 2.0 gm.) in powder; th^ fluid extract of hydrastis, fifteen to sixty minims (1 to 4 cc), or better the hydrochlorate of hydrastinin, given hypodermically or by mouth, in doses of one-half to two grains (0.03 to 0.1 gm.) repeated, are all useful remedies. In case the medicamentous and dietetic measures, combined with rest, fail to stop the pain and hemorrhage; if the attacks of renal colic persist or if severe suppurative pyelitis com- plicates the disorder ; or, finally, if a calculus becomes impacted in a ureter so that the patient's life is endangered from mechan- ical anuria, then recourse must be had to surgical means. NEPHROLITHIASIS OXALURICA 233 NEPHROLITHIASIS OXALURICA. Uric acid and oxalic acid are chemically closely related. Relation of There is also a peculiar relationship between dextrose and oxalic oxalic a <; id t0 . _ , . , n ' . . uric acid and acid that is not altogether understood; clinically we know, at dextrose all events, that many cases of mild diabetes develop oxaluria and, chemically, we know that dextrose can be converted into oxalic acid. The diet consequently should be arranged in such a way Diet as to take into consideration both the factors that may determine increased uric acid secretion and glycosuria. Besides all articles of diet should be excluded from the bill of fare, or greatly reduced, that contain preformed oxalic acid. Chief among the Articles of latter are tea, cocoa, spinach, gooseberries, rhubarb, figs and i n ^ d oxalic^ 11 " pepper; in addition, coffee, chocolate, chicory, red beets and acid tomatoes, the last named articles, however, containing only very small quantities. Champagne and beer also seem to lead to an increased oxalic acid excretion. In cases, moreover, that show a decided tendency to oxalate deposits, sugar, sweets, cereals, vegetables growing underground, and all starchy foods should be reduced. Meat (with the exception of nuclein-containing organs, i. e., special articles raw, rare and cured meats, meat extracts and bouillons), eggs, of diet green vegetables, salads, plenty of milk and fat, in any form, should constitute the chief articles of diet. In addition much water should be taken, preferably between meals, on rising and on retiring. The addition of a little soda to the water, or drink- ^drSkixJ*" ing alkaline mineral waters, is a useful adjuvant to the treat- ment. As many cases of nervous dyspepsia, chiefly hyper-acidity of P epJia U and yS " the stomach, seem to develop oxaluria, particular attention should oxaluria always be paid to this condition according to the rules that are discussed in another chapter. The symptomatic treatment of oxaluria is the same as that treatment 1C previously discussed under the heading of Nephrolithiasis Urica. NEPHROLITHIASIS PHOSPIIATICA. Phosphate concretions occur only when the urine is alkaline. Etiological As a rule they form upon a pre-existing urate or oxalate calculus, rea men •or upon some organic debris in the kidneys, the pelvis, the ureters or the bladder. Phosphate concretions are consequently most commonly found in inflammatory, purulent disorders of the urinary passages, particularly if there is some stagnation of urine. Treatment, especially in this form of nephrolithiasis, 234 FLOATING KIDNEY Diabetes phosphatide Muriatic acid Phosphoric acid Symptomatic treatment should hence be directed principally towards rendering the urine aseptic, towards preventing its stagnation and towards com- bating the existence of pyelitis or cystitis, according to the methods spoken of in appropriate sections. Phosphate stones cannot be dissolved by any known means after they have once formed. There is also an indistinct metabolic perversion which leads to an increased excretion of phosphorus, so-called Diabetes Phos- pkaticus, in which basic phosphates are excreted in great excess. This, in the obscurity of our present knowledge, we are unable to influence. An attempt should always be made in phosphate lithiasis to render the urine less alkaline and this can best be done by admin- istering by mouth muriatic acid (Acid Hydrochlor. dil. — dose five to thirty drops in water t. i. d.), or, paradoxical as it may sound, phosphoric acid (Acid Phos. dil. — dose five to twenty drops, twice or three times a day in water). The symptomatic treatment of pain, colic, hemorrhage, etc., and the indications for surgical intervention are the same as in other forms of nephrolithiasis. Causes Interpretation of the symp- toms of float- ing kidney IV. FLOATING KIDNEY. Unless the dislocation of the kidney is due to trauma or spinal curvature, abnormal motility and abnormal location of the organ are generally a part symptom of a general gastro- and enteroptosis. Floating kidney is found much more frequently in women than in men. This is due to a number of causes ; the wearing of corsets and tight waistbands ; pregnancy with result- ing sudden changes in the intra-abdominal pressure; dislocation of the uterus and its adnexa exercising a direct pull by continuity upon the ureters and kidneys. The right kidney is more fre- quently dislocated than the left, both in men and women, first, because it is normally somewhat more motile than the left; sec- ond, because the left renal artery is shorter than the right and is more intimately connected by the suprarenal vein with the suprarenal gland than on the right side ; third, because the pan- creas gives some support on the left side, and, fourth, for the reason that tight lacing is more apt to loosen the right than the left kidney, as on the right side the solid and unyielding liver lies between the waist and the kidney, whereas on the left side the hollow stomach forms a yielding and elastic cushion that does not transmit the pressure exercised from above. In the great majority of cases the increased motility of the kidney per se makes no symptoms. In some of the cases the general gastro- and enteroptosis may produce a variety of dis- tressing phenomena that are often, though falsely, attributed to FLOATING KIDNEY 235 the floating kidney. In still other cases, and these form the ma- jority, a general neurasthenic state exists, either altogether inde- pendent of the abdominal conditions or possibly remotely de- pendent upon the digestive disorders and the abnormal traction or pressure on the nerve plexuses that the abnormal position of the various abdominal viscera, including the kidneys, produces. From a therapeutic standpoint slight degrees of floating kid- Therapeutic ney are a negligible quantity; whatever treatment may be di- mdlcatlons rected towards the general symptoms of the patient should be directed more against the abdominal ptosis than against the float- ing kidney as such. Whenever symptoms are produced, how- ever, that are directly traceable either to a tugging of the kid- ney on its attachment, or to twisting of the pedicle of the kidney, with resulting congestion of the organ and possible hydro- nephrosis and pain, then special treatment of floating kidney becomes necessary. In view of the mechanical conditions existing the remedy The remedy must needs also be mechanical and directed towards causing a must °e me - chanical restitution of the kidney to its normal position and holding it there. Occasionally rest in bed in a recumbent position for weeks at a time, especially combined with a Weir Mitchell fattening treatment (see index) may lead to an increase of the abdominal fat and hence furnish a support for the movable kidney. There Rest and fat- is no evidence to show that this plan leads to the formation of tenm §' cure a new fatty capsule around the kidney, nor is there for all that any proof that in floating kidney the fatty capsule is lost. The plan is particularly useful however in thin, neurotic women, both because in these cases the increase of the abdominal fat and th.- resulting greater tension of the abdominal walls really supports the kidneys in conjunction with the other abdominal viscera, and because the rest-cure and the over-feeding act beneficially towards restoring nervous equilibrium. The result is that these Results of rest patients frequently arise from the rest and "Mast" cure with a cure kidney that is still somewhat motile but with a nervous system whose tone is restored to such an extent that it is no longer irritated by the abnormal excursions that the kidney occasionally undertakes. The use of pads and bandages is rarely of lasting benefit in the treatment of floating kidney and is generally disagreeable p a d s and to the patients. If any support is to be applied at all it should bandages be a general abdominal supporter intended to hold up all the abdominal viscera, possibly with a pad or pelotte, besides, below the kidney region. When this is done, the disagreeable symptoms General ab- dommal sup- that are attributed to the floating kidney, but that in realitv, as porter 236 Constipation and gastric distension to be combated The clothing- Indications for surgical treat- ment Relief of acule symptoms stated above, usually arise from the general abdominal ptosis, are frequently relieved. Care should always be taken that constipation, over-loading of the stomach and congestion of the liver are carefully coun- teracted by proper dietetic and medicinal means; for when this is done, the weight of the abdominal organs is reduced and less dragging permitted. The clothing should properly be worn sus- pended from the shoulders and not fastened about the waist. Lacing, of course, should be forbidden. If the degree of dislocation is so severe that the kidney occa- sionally becomes twisted, with resulting hydro-nephrosis and con- gestion of the organ with urinary signs that point to degener- ation and functional disturbances in the renal epithelia, or if the kidney becomes very sensitive to pressure or hurts sponta- neously, then, after all the other means have been tried, surgical intervention becomes justifiable ; but not before. There is unfortunately, nowadays, an exaggerated tendency to operate upon the floating kidney in cases of general abdominal ptosis; and while the operation rarely does any harm in this condition, and may occasionally even do good through the ben- efits derived from enforced post-operative rest in bed and proper feeding, still, a cure by surgery should never be promised nor the operation advised unless symptoms directly attributable to the kidney become unbearable, or unless nephritic changes in the dislocated organ make their appearance. A description of the operative technique lies without the limits of this article. In most cases a simple nephrorrhaphy is the operation of choice. The acute symptoms produced by twisting of the renal pedicle must be relieved by hot applications and morphine, with rest in bed, while attempts are made at the same time to correct the temporary dislocations of the organ by manipulation, if neces- sary under an anesthetic. Critique of current uremia theories V. UREMIA. In order to properly treat uremia it is essential to have a clear understanding of the causes that determine pre-uremic states and the uremic attack, or, as one might also express it, chronic, and acute uremia. Uremia is commonly considered to be due exclusively to inadequacy of the renal function, with resulting retention of excrementitious urinary bodies. If this current belief were correct, then complete anuria should always produce uremia, and the blood of uremic patients should always show an increase, and the urine a corresponding decrease, of urinary substances. , _ ^ UREMIA 237 As a matter of fact, many cases of complete anuria, due to Anuria does various causes, are recorded, in some instances persisting for n ot always . . produce uremia several weeks, in which none of the characteristic phenomena of uremia developed. On the other hand, uremia not unfre- quently occurs when the flow of urine is abundant and the excre- tion of urinary solids and water does not appreciably deviate from the normal. Similar results are seen in animals after experimental nephrectomy or occlusion of both ureters, or after the injection of urine. The animals die, but are not uremic. One must, therefore, distinguish, clinically at least, between uremia and urinemia. In uremia we witness the signs of Uremia and urinemia but also other signs besides. The latter, precisely, are urmemia the most characteristic symptoms of uremia and never occur in urinemia. This alone forces one to the conclusion that they must be produced by other factors than simple urine poisoning, a con- tention that is borne out by an analytical study of the blood and urine in uremia. Without going into the analytic data in detail the statement may be made that quite as many cases of uremia develop without as with an abnormal amount of nitrogenous or saline constit- uents in the blood. There also is much chemical and clinical Metabolic dis- evidence to show that in uremia the general metabolism and, in or er particular, the manifold functions of the liver, are perverted. Moreover we not infrequently encounter a condition of acidosis Acidosis that points to a severe auto-intoxication that cannot be attri bated to renal inadequacy alone.* That the kidneys are not always primarily involved is further The kidneys borne out by the clinical observation of an occasional case of pri m arTly y ln- uremia in which the kidneys are found practically normal after volved death, and in which essentially no evidence of renal disease, or even of functional inadequacy on the part of the kidneys, pre- sented itself during the life of the patient. This newer conception of uremia must induce us to depart from the orthodox method of treating uremia. We are wont to treat uremia by promoting vicarious elim- The orthodox ination, i. e., by stimulating the flow of urine, by purging and hernia and° its by sweating, with the intention or relieving the kidneys of the fallacies work of excreting retained urinary bodies. Occasionally we even attempt to force these bodies through the damaged kidneys by using diuretic drugs. In addition, we try to regulate the diet in such a way that there shall accumulate in the blood the smallest possible amount of residual excrementitious bodies. If, ♦For the details, see Croftan, "An Analytic Study of Uremia." Jour. A. M. A., January 6, 1906. 238 Prophylaxis of uremic attacks The diet in chronic uremia Carbohydrates Alkaline wa- ters and al- kalies Hepatic stim- ulants Calomel Bile acid salts Salol Warm bathing now, uremia is not clue to the circulation in excess of such bodies, nor to renal inadequacy alone, then the above treatment is wrongly directed. The chief object in chronic uremia, i. e., in pre-uremic states, should be to prevent the development of uremic attacks, i. e., of acute uremia, by giving attention to those organs whose func- tions threaten to fail; and in order to do this intelligently the renal idea should be somewhat relegated to the background and more attention should be bestowed upon the liver and the general metabolism. In chronic uremia the diet should be arranged in such a way that the function of the liver is not overtaxed; at the same time the existence of a chronic nephritis should be included in the calcu]ation. A diet consisting largely of milk and carbohydrate foods is the ideal. In view of the chronic character of the dis- order care must, however, above all things, be taken that ade- quate nutrition is maintained, and for this reason the addition of some albuminous food, preferably in the form of vegetable albu- mens, is very desirable. Carbohydrates possess a high nutritive value, and at the same time exercise a gentle stimulating effect upon the functions of the liver, without, coincidently, leading to the formation of end-products that irritate the kidneys in their passage. Alkaline waters are also very useful in this condition, for they too gently stimulate the liver, and, above all things, counteract the tendency to acidosis which not infrequently ap- pears in chronic uremia, as manifested by the increased ammonia excretion in the urine. Calcium carbonate, in fifteen grain doses three or four times a day, in powder or capsule, is a useful means to aid in maintaining alkalinity. The use of hepatic stimulants is also indicated, although great care should be exercised not to give remedies that can irritate rather than stimulate the liver; thus calomel I consider a dan- gerous drug in chronic uremia. Bile acids, preferably in the form of sodium glycocholate, in doses of one-fourth to one-half grains (0.0015 to 0.003 gm.), together with five to ten grains (0.3 to 0.6 gm.) of sodium carbonate, half an hour after eat- ing, are useful. They possess a distinct cholagogue action and also act as intestinal antiseptics. Salicylates, preferably in the form of salol, in one grain (0.006 gm.) doses, together with an alkali, three or four times a day, half hour after eating, act similarly and are also useful. In chronic uremia warm bathing is an excellent preventative measure. "The patient should be instructed to lie quietly, for five or ten minutes, in a tub of water slightly below the body tem- perature, with a cold cloth applied to the head to prevent reactive UREMIA 239 hyperemia of the brain. Such a bath should be given every evening and may, to advantage, be followed by an alcohol rub, «are being taken that the bath-room is warm and the patient does not take cold. This measure is very effective in reducing the blood pressure and in preventing acute uremia. If threat- ening cerebral signs of uremia appear, a hot bath, combined with friction of the surfaces of the body, is a useful means for abort- ing convulsions, and the patient, in uremic coma, may safely be placed in a hot bath while cold water is poured upon the head, provided the other means described below for combating acute uremic seizures are instituted at the same time. Chronic uremia principally manifests itself in a protean Symptomatic array of symptoms involving nearly every organ of the body, treatment While every endeavor is being put forward to treat the conditions thai, underlie uremia, it becomes necessary in addition to insti- tute symptomatic treatment for the relief of disagreeable sub- jective symptoms. In view of the fact that, in uremia, Nature Gastro-intes- puls forward every effort to promote vicarious elimination of tinal symptoms ace u ululating toxins through the different emunctories of the body, disagreeable symptoms about these organs, that are due largely to their irritation by the poisonous bodies that are clam- oring for elimination, occasionally require special treatment. Thus vomiting and diarrhea are very common symptoms in chronic uremia. In addition the heart is very frequently over- Heart svuid- stimulated and ultimately becomes fatigued, so that failure of toms the heart muscle makes its appearance with edema and stasis; these phenomena, too, occasionally require special treatment. Finally, cerebro-spinal uremia, of a chronic type, occasionally appears, presumably due either to edema of the central nervous Cerebro-spinal tissues or to irritation of these nerve elements by circulating urenua toxins that have a selective affinity for certain nervous tissues. The symptomatic treatment of these various uremic phenomena may now be discussed seriatim. Vomiting in uremia must, as a rule be regarded as an Vomiting endeavor on the part of the organism to rid itself of circulating poisons by way of vicarious emesis, and it is questionable whether it is good practice to check this vomiting at once. Vomiting may occasionally even be stimulated to advantage by giving the patients lukewarm water to drink. Only when the vomiting when to becomes so severe that the patients cannot retain any food, or check vom- if the heart and arteries, and, in particular, the cerebral vessels threaten to become seriously over-strained, or if the patients cannot sleep, should we actively interfere by giving symptomatic relief. For this purpose, we can use oxalate of cerium, in doses __„... Oxalate of of from two to ten grains (0.1 to 0.6 gm.), frequently repeated, cerium 240 Tincture of iodine Chloroform Cocaine Ice Lavage Diarrhea Saline laxa- tives Opium. Tannin Cardio-tonic medication Edema Pulmonary edema Atropine This remedy acts like bismuth, but is less toxic and frequently stops the nausea and vomiting. Or the patient may be given from one to three drops of the tincture of iodine in ice cold water or in a few ounces of cold milk. Chloroform, in doses of from five to ten drops, or a dilute solution of cocaine as described elsewhere, may also be given to advantage. If none of these means is efficacious, then the swallowing of small pieces of ice and the application of cold over the epigastric region may occa- sionally stop vomiting, and sometimes, in extreme cases, lavage of the stomach leads to the goal. Uremic diarrhea, which is often troublesome, should always at first, be encouraged; that is, a complete evacuation of the gastro-intestinal tract should be promoted by the administration of saline laxatives, for here we must again assume that the organ- ism is trying to get rid of irritating poisons by the bowel path. Saline laxatives are also advantageous in cases of uremia with failing heart and venous stasis and edema of the bowel wall, for the withdrawal of water from the edematous tissues by the saline acts beneficially. If the diarrhea persists so long that the nutri- tion of the patient is interfered with, then attempts should be made to check the bowel movement by the use of opium or tannin ;. the former given, preferably, as laudanum, either by mouth, in doses of from five to fifteen drops, repeated every hour or so until the desired effect is produced, or by rectum in thirty to sixty minim doses, preferably in starch enema and also repeated. Tannin is probably best given as tannigen (diacetyltannin), in doses of ten to twenty grains (0.6 to 1.3 gm.) repeated until effect. The heart is usually seriously affected in uremia, and cardio- tonic medication, as described in the Chapter on Heart Diseases, becomes necessary. Uremic edemas in various parts of the body are often due to cardiac failure and they should be treated pri- marily by cardio-tonic medication (see index). One of the most dangerous forms is edema of the respiratory tract, vjz., pulmonary edema and edema of the glottis. Here very active measures must at once be instituted if the life of the patient is to be saved, and energetic sweating and purging becomes neces- sary, even occasionally stimulation of diuresis with the main object in view, irrespective of anything else, of ridding the organism as rapidly as possible of the accumulated water. Atro- pine in doses of one one-hundredth to one one-hundred-and- fiftieth of a grain hypodermically, , may be administered if the patient threatens to drown in his own secretions. In edema of the glottis, ice applied to the neck and ice swallowed are useful. If necessary, scarification of the edematous laryngeal folds or UREMIA 241 <3ven tracheotomy may be resorted to. In pulmonary edema cold or mustard plasters to the chest also occasionally relieve. Uremic asthma is best treated by the use of ether given as Uremic asthma spirits of ether, in doses of ten to thirty drops several times a day; or in the form of pure ether, hypodermically, in doses of 1 to 2 cc, or by mouth, in teaspoonful doses, three or four times Ether during the twenty-four hours. If this treatment, which inci- dentally stimulates profuse diuresis, does not relieve the asth- Valerian matic seizure, then tincture of valerian, in doses of one to three Oxygen drachms (5 to 10 cc), oxygen inhalation, or a few whiffs of ° orm chloroform must be tried. As stated above it sometimes becomes necesary in chronic vicarious elim- uremia to stimulate vicarious elimination with the expectation m ation that together with much water some toxic material may also be eliminated, and in this way a purification of the blood and tissue juices be brought about. . A very useful measure is to stimulate the action of the saliva^ glands, and a case of chronic uremia should be advised to chew gum. For the sake of producing catharsis, very mild laxatives or dilute laxative water should stimulation of be used, remembering always that no drug that can irritate the salivary glands liver should be used, for this organ, as we indicated above, is commonly involved in the chronic uremic self -intoxication. Sweating,* if advised at all, should always be combined with water-drinking or the use of large, water enemas ; for unless this Sweating is done a concentration of the body fluids will be brought about and the intoxication be rendered more severe. An acute uremic attack, in fact, may be produced by injudicious sweating, partic- ularly as the blood, when it becomes concentrated by sweating without the simultaneous introduction of water, draws abundant toxic material from the edematous tissues in which the toxins are deposited and carries the poisons in a concentrated form to the higher nervous centres. Diuresis is best stimulated by digitalis combined to advantage D . with caffein (see formula, page 43), by the copious ingestion of hot water, preferably slightly alkaline, and by large alkaline — saline enemas. The treatment of the acute uremic attack is always an un- The treatment grateful task, for immaterial whether we are dealing with a dis- of the ac ^ te uremic attack, order that is primarily or in its ultimate consequences due to renal, hepatic or general metabolic insufficiency, we are in most cases concerned with a syndrome that is due to the crum- bling of the whole cellular edifice. To arrest this collapse essen- tially means to revive a dying organism. That this may occa- *See page 237. 242 CYSTITIS ^Bleeding Infusion of physiological salt solution TyTarcotics Chloral enemas TJrethan Xumbar punc- ture sionally be done, for the time being, cannot be denied; and as the recuperative powers of the human body border on the phe- nomenal no effort should be spared to bring an acutely uremic patient back to life. The acute attack usually sets in with fulminating symptoms simulating epileptic seizure (uremic eclampsia) and gradually leading to coma, occasionally preceded by a severe headache or a syndrome that resembles the aura of epilepsy. The appearance of cerebral uremia, manifesting itself by severe headache, neuralgia, psychic disturbances, insomnia, twitchings, amaurosis, etc., is usually a grave danger signal, generally constitutes a premonitory warning of an impending uremic attack and should be fought most energetically. Bleed- ing is the sovereign remedy, carried out as described on page 37. A considerable quantity of blood, if need be a quart, should be withdrawn. A uremic attack may often be prevented in this way. If large quantities of blood are withdrawn, venesection may be followed to advantage by the infusion of an amount of warm, sterile, physiological salt solution (0.8 gm. to 1000 cc.) corresponding to the quantity of blood abstracted. The symptoms about the nervous system unfortunately, as a rule, cannot be controlled by any other drugs than narcotics, i. e., morphine or opium. Occasionally enemata, containing ten to fifteen grains of chloral, repeated every two hours, or inhalations of chloroform, become necessary. Urethan also is useful here, given 4 by rectum in watery solution in large doses, i. e., about five drachms (about 20 gm.) in twenty-four hours. In severe spinal manifestations lumbar puncture should be done. It will often be found that the fluid in the cerebro- spinal canal stands under high pressure, and symptomatic relief is frequently obtained by drawing it off, thus reducing this pressure. Lumbar puncture possibly also relieves by withdrawing fluid that contains much toxic material in solution from intimate contact with irritable nervous tissues. VI. DISEASES OF THE BLADDER AND URETHRA-CYSTITIS. (By Dr. F. Kreissl, Chicago.) Definition ^ n the treatment of cystitis, irrespective of any conventional classification, we have to bear in mind that the disease is merely a symptom of some underlying pathological lesion, that every true cystitis is of mycotic origin and that "simple cystitis 7 ' is only a theoretical condition. CYSTITIS 243 Since the mode and avenues of the infection have become Prophylaxis better known and since it has become established that trauma- tism and infection by instruments is one of the most frequent contributing causes of cystitis, much has been accomplished in the way of prophylaxis. This source of infection can be and is successfully eliminated by extreme cleanliness, asepsis and anti- sepsis in everything that comes in contact with the urethra, in cleansing of the latter preceding and following the use of in- struments, in preventing stagnation of urine in the bladder, and in exercising better care of the urinary tract during labor and gynecological operations. The principal indications for the treatment of cystitis are: Indications for 1. To remove the cause treatment 2. To relieve pain and frequent urination. 3. To modify the character of the urine so as to make it an unfavorable medium for the development of pathogenic microbes, and 4. To check suppuration. In the acute stage, as in many other local inflammations, Rest rest in bed should be insisted upon until the symptoms are well under control. The food should be bland and should consist Diet largely of fluids in small quantities, milk, or milk mixed with Vichy being preferable. The still customary ingestion of large Liquids quantities of fluids in cystitis should be discouraged, as it only increases the congestion of an inflamed organ which is much in need of rest. Careful attention should be given to the bowel. A purge of calomel and pulverized jalap, 0.10 of each, followed Purgation by a wineglassful of magnesia citrate answers the purpose. A hot Sitz bath of 105° F., if necessary repeated several sitz bath times daily, will afford much immediate relief to the pain and tenesmus. Hot fomentations applied to the perineum and above Fomentations the pubes are almost as efficient; so is sitting over steaming water. An anodyne will often be necessary in addition to con- trol the vesical tenesmus, pain and irritability. The remedy par Opiates excellence is opium and its alkaloids. It should be given by mouth or rectum. If given by mouth, the addition of fol. uvae ursi, or the time honored linseed decoction with salol will be serviceable : Dose and ad- ministration Decoct, sem. lini. or (infus. fol. uvaa ursi), 10.0-150.0 Salol, 4.0 Tinct. opii spl., gtts. XX. Syr. spl., 30.0 Sig. A tablespoonful every two hours. 244 For suppositories the extract of opium should be combined with the extract of belladonna: Balsams Santal oil Pichi Pichi Gonosan Uva ursi Buchu Herniaria Internal anti- septics Salol Boric acid 9 0.18 0.06 6.0 Camphoric acid Benzoic acid Extract of opium, or (Morphine sulphate, 0.08) Extract of belladonna, Olei cacao, Ft. suppositories No. vi. Sig. One suppository twice to three times a day. The balsams, oleum santali, fluid extract of pichi pichi, Gonosan, a combination of kava kava and purified sandalwood oil, all have a sedative effect in acute cystitis. The folia uvae ursi, the folia buchu and the herba herniarige are also still in use. They are taken as infusions, either singly or in mixture of equal parts of these herbs, about a heaping tablespoonful to a large cup of boiling water. Gonosan is free from the disa- greeable effects of the sandalwood oil and to avoid the unpleas- ant eructations should be taken on a full stomach, and very little of fluids consumed during or soon after the meal. The dosage is two to three capsules, three times daily. It is especially efficient in gonorrheal cystitis. Sometimes it will be necessary to give internal antiseptics in order to attack the root of the evil. The most commonly em- ployed remedies of this class are salol, camphoric acid, boric acid, benzoic acid and last, but not least, urotropin. Salol is given in doses of 0.3 to 0.5 gm., three times daily; being a phenol derivative, it should not be prescribed where kidney lesions exist. Combining useful antiseptic and astringent qualities is the following formula: Salol, Extract of uva ursi sice, aa 5.0 M. ft. Pill, No. XXX. Sig. Two to three pills three times daily. Boric acid, to be effective, has to be taken in doses of 0.5 to 1.0 gm., several times a day; this occasionally, it must be re- membered, may cause toxic symptoms such as exanthema, albu- minuria and extreme weakness. The dosage of camphoric acid is 1.0 gm., three times a day, of benzoic acid 0.3 to 0.5 gm., three times a day. Both have CYSTITIS 245 a marked deodorizing effect on ammoniacal urine, but distress the stomach if given for a long time. In urotropin we possess the strongest urinary antispetic of Urotropin more recent date. However, it does not seem to have any effect on the gonococcus or the bacillus tuberculosis. It requires an acid urine in the renal pelvis in order to develop its active principle, formaldehyde, but the latter after being once liber- ated, acts alike in acid or alkaline urine. In the cystitis of typhoid fever it is, so to say, a specific. It is given in doses of Dose and ad- 0.3 to 0.5 gm. twice to three times daily and should always be mmistratl0n dissolved in a few ounces of water in order to avoid distressing stomach symptoms. It may be used for weeks and months with- out any ill effects. Occasionally albuminuria and hematuria may be observed, which rapidly subside when the drug is discon- tinued. It rarely causes dysuria, excepting occasionally in an ulcerated bladder. In these cases helmitol, another formalde- Helmitol hyde preparation, has been used, but with no better results. While in many cases the symptoms of acute cystitis dis- Local applica- appear under this treatment, it sometimes becomes necessary tions to the to make local applications to the bladder besides. The key to this treatment is given by the intolerance to tension of the in- flamed bladder wall. Therefore, large or even moderately large injections are objectionable and only soft instruments of small- est calibre should be introduced. The best method to employ is instillation, performed by Treatment by- applying locally drop by drop the active medicinal solutions to ms 1 a 10n the inner surface of the bladder wall. The strength of these solutions used, the small quantity of fluid instilled, and the slow- ness with which one by one they enter the viscus, are the import- ant points to be attended to. Instillations should not be hur- riedly given, or they then become injections; the solution, although by no means always a caustic one, is far stronger than could be used in the form of an injection, and this constitutes the chief virtue of instillations. The instruments required are a small, graduated syringe and the instillator, which is a perforated, gum elastic, olive tipped bougie. In Guyon's syringe the contents is one dram. In the first place, the bladder, as in all instrumentation of the urethra, should be empty. The quantity used should never exceed one dram. The strength of the solution that may be used is as great as its quantity must be small. While the bladder could not be irrigated with a nitrate of silver solution stronger than 1 in 500, instillations of from one to five per cent, may be used with perfect toleration. 246 Solutions of the strength of 1 in 20,000 of bichloride of mercury may be used for injections, but for instillations of solu- tions the strength of 1 in 5000 and 3000 may be used and some patients even support 1 in 1000. But as a rule the first instilla- tions should be still milder, the concentration of the nitrate of sil- ver solution not to exceed 1 in 1000 and the bichloride of mercury 1 in 10,000. "When increasing the strength the quantity should be decreased, as for instance of % to 1 per cent, nitrate of sil- ver solutions or of 1-2000 to 1-1000 bichloride solutions not more than 15 to 30 drops should be used. The substances that will be found most satisfactory may be divided into (1) anesthetics, and (2) antiseptics. Anesthetics 1. Anesthetics are very valuable as treatment in themselves and as a preliminary to instillations of more or less painful solutions. In mild cystitis, where there is no excessive tenes- mus to tension, antipyrin in ten times its weight of water ren- ders the mucous surface of the bladder less sensitive to the sub- sequent application of nitrate of silver. In very acute cystitis guaiacol is superior to antipyrin and cocaine, especially in the formula of Pirot, viz., iodoform, 1 part, guaiacol, 5 parts; steril- ized oleum benne, 100 parts ; of which solution one dram may be injected three times daily without any inconvenience. Great care has to be exercised in applying cocaine to the bladder cavum, on account of its ready absorption from raw surfaces. A good rule is never to exceed the injection of one and one-half to two grains of the drug. Antiseptics 2. Antiseptic Instillations. Perchloride of mercury in solu- tion of 1 in 5000 or 1 in 3000 will be found of great service, especially in the constant and prolonged agony of tuberculous cystitis. Its effect is still more pronounced if used alternately in two days' intervals with the iodoform guaiacol suspension given in the preceding formula. Another specific in tuberculous cystitis is "Gomenol. " Its analgesic action is equal to that of guaiacol while its antiseptic properties are more pronounced. It is used in the form of instillations of 10 per cent, and 20 per cent, gomenoloil, one dram of the oil being instilled into the empty bladder night and morning. Nitrate of silver is perhaps the most valuable local agent in the treatment of cystitis. The more acute, the more painful the cystitis, the more frequent the desire to micturate, the more clear is the indication for instillations with nitrate of silver, hence its effect is little short of astounding in acute gonorrheal cystitis. In recent years I have quite extensively used argyrol in acute and sub-acute cystitis, and it has given me much satis- faction. Being inferior to the nitrate of silver as a germicide it CYSTITIS 247 lacks the irritating quality of the latter, a point to be considered in the presence of so much pain and suffering in acute inflam- mation. For instillations 4 cc. of a 5 per cent, to 20 per cent, solution of argyrol may be used. In the more chronic state irrigations of the viscus become necessary when the viscid pus clinging to the bladder wall, or mineral deposits in a diverticle, call for a thorough cleansing preceding other topical applications. But even then one should never inject more than two ounces at a time, because the blad- der muscle reacts differently towards slow or rapid tension, a fact of which one may convince himself by rapidly filling a normal bladder with ten ounces of fluid. There will be tenes- mus for quite a while afterward, while the same bladder does not take notice of such a quantity if accumulated in the natural way and time. The result of such rapid filling of a diseased bladder is seen in renewed congestion and secretion and many a protracted cystitis is due to this procedure. Moreover, the cleaning of the bladder wall is much more thoroughly accom- plished by small and repeated flushings than a few large ones. For all these reasons a sterile piston syringe is preferable to the time-honored irrigation can. Chinosol and pyoktanin in a solu- tion of 1 in 4000 have a marked deodorizing effect on very offensively ammoniacal urine. One dram of a 5 per cent, iodo- form suspension most effectively checks ammoniacal decomposi- tion of the urine but the strong odor of the remedy prevents its general adoption outside of a hospital. Salicylic acid in solu- tion of 1 in 3000 dissolves phosphatic debris and renders an alkaline urine neutral or slightly acid. A saturated solution of boric acid, or a solution of 1 in 3000 of acetate of lead has a soothing effect in simple congestion of the mucosa associated with a mucous secretion, but it is of no antiseptic value. If with all these procedures no marked improvement becomes noticeable within a reasonable time, one has to resort to cysto- scopy to determine the real condition back of a sympto- matic cystitis, which is not amenable to a radical cure unless the original cause is removed. Stones will have to be crushed or removed by lithotomy. Cystoscopy Ulcerations must be curetted and cauterized through the opera- tion cystoscope, or excised through a suprapubic or a vaginal opening, as the case may require, and a rebellious cystitis dolorosa, where the whole bladder wall represents a large slough- ing ulcer, requires broad incision and drainage, like any other abscess. Topical applications and internal medication will fail when strictures, prostatic obstructions or a diverticle cause the 248 ACUTE URETHRITIS formation of a pool of stagnating residual urine in the bladder which forms an excellent culture medium for microbes. It is, of course, also impossible to restore normal conditions of the bladder wall if a continuous or interrupted stream of pus from adjacent organs or from the upper or lower urinary passages floods the vesical cavity. Neither will local treatment in secondary tuberculous cystitis be efficient, unless we support the reconstructive power of the tissues by a general hygienic treatment of the system, or by the removal of the primary seat of the trouble. Non-infectious urethritis Infectious ure- thritis VII. ACUTE URETHRITIS.* (By Dr. F. Kreissl, Chicago.) The treatment of acute urethritis depends upon its etiology. The discharges of non-infectious urethritis, as observed under various and different etiological conditions, show a marked tendency to a rapid cure, if the cause is recognized and removed. A urethral secretion following a traumatism like the use of in- struments, foreign bodies, a new-growth in the canal, masturba- tion or excessive coitus, will spontaneously cease when the cause of the trouble ceases to exist. This will also occur in discharges due to chemical irritations such as strong injections with bichlo- ride or silver solutions, frequently used as a prophylactic after cohabitation. Urethral secretions appearing as a part of the symptoms of general conditions such as gout, constipation, phosphaturia and oxaluria, will yield to the proper constitutional treatment of these ailments. The four best known types of infectious urethritis are, in the succession of their frequency : 1. Gonorrheal urethritis. 2. Infectious urethritis of non-gonorrheal origin. 3. Urethritis tuberculosa. 4. Syphilitic urethritis. 1. GONORRHEAL URETHRITIS. The efforts made for years to prevent the results of an inocu- lation with the gonorrheal virus, in short, to find an effectual prophylactic, seem to have been rewarded. In a two per cent, nitrate of silver solution, or in a four per cent, protargol solu- tion, we now possess a reliable preventive. To this end, a few Chronic urethritis is amenable to successful treatment only at the hands of the skilled surgeon-specialist and will hence not be discussed in this volume. GONORRHEAL URETHRITIS 249 drops of either solution are applied with a syringe or a glass dropper in the fossa navicularis and there retained for a few minutes, shortly after a suspicious cohabitation. This should be tried in every case of urethritis which is not At, ortive treat- ment older than three days. While, of course, the best results may be expected on the first day of the manifestation of the disease, there are sufficient proofs that the gonococcus does not always penetrate so rapidly into the tissues as to escape the influence of the germicide even after a few days; and as long as no harm can be done by this treatment, if judiciously applied, it is worth while to attempt an abortive cure within the above time limit. After irrigating the anterior urethra with a hot boric acid solu- tion, I constrict the urethra at the peno-scrotal junction with a rubber band, inject one drachm of a four per cent, protargol solution and have it retained for five to ten minutes. For the irrigation with the boric acid solution a piston syringe is used and a sterile elastic catheter. No pressure to distend the urethra should be applied and the fluid should commence flowing through the catheter before it enters the urethra; this prevents the dis- semination of infectious material. During the following eight days I irrigate the anterior Treatment dur- urethra in the same way with a pint of a 1 :5000 hot nitrate of d ^ s rs eig silver solution, once a day. The discharge, if there is any, is examined microscopically every day. If no gonococcus is pres- ent in the last five specimens, the treatment is discontinued; otherwise, the systematic treatment for gonorrheal urethritis is commenced. The use of alcohol is absolutely prohibited except in patients Systemic treat- in whom, from long continued habituation, grave nervous dis- turbances would follow its sudden withdrawal. In these cases Avoidance of some claret diluted with water may be allowed. Sexual excitement and physical exertion must be rigorously Sexual life avoided. The diet should be non-stimulating. Meats in excess, highly Diet seasoned foods, strong tea or coffee are to be avoided in the acute stage. A well fitting suspensory bag will relieve the sensation of Suspensory dragging on the spermatic cord when the patient has to be much on his feet. A piece of antiseptic gauze — not cotton — to catch the discharge should be placed around "the glans penis in such a way as not to constrict the urethra. Most convenient for this purpose are the little bags called gonorrhea bags. For women, a gauze sponge saturated with an antiseptic should be placed be- tween the labia? and renewed after each micturition. 250 GONORRHEAL URETHRITIS Local ment treat- The local treatment of the infected area should be com- menced at once, irrespective of the stage of the disease. The best results, the most rapid recoveries and hardly any compli- cations are observed under these conditions. In order to deal successfully with acute gonorrheal urethritis the following points should be remembered: 1. The acute symptoms are due to the irritating qualities of the toxins. 2. The tissues if slightly assisted are usually capable of taking care of the gonococcus, consequently the toxins will have to be frequently removed and the gonococcus as far as it can be reached destroyed by a remedy which does not increase the in- flammatory conditions already present. Therefore, injections and not irrigations under pressure have to be employed and even Janet, the sponsor of the irrigation method for acute gonorrheal urethritis, has come to my point of view on this subject as I expressed it many years ago. The syringe should have a capacity of three drachms, should have a blunt tip and may be made of glass, rubber or metal so that it can be thoroughly cleansed and sterilized. The quantity to be injected at a time depends on the capacity of the anterior urethra; however, enough fluid should be used to slightly bal- loonize the canal without any perceptible discomfort to the patient. It should also be borne in mind that the capacity of the urethra varies with the degree of inflammation. The remedy which has given me the most satisfactory re- sults for many years, and which now seems to be generally rec- ognized as the most valuable, is protargol. If judiciously used it promptly destroys the gonococci, where they can be reached by this specific; it shortly allays inflammation, and surely pre- vents complications. The strength of the solution, the frequency of the injection and the length of time it is to be retained depend on the stage of the disease. Generally speaking, I would say that in the acute stage with much inflammation the solution must be very dilute ; it should be injected at short intervals and retained but a minute. With the acute symptoms subsiding the strength may be increased, the frequency of the injections reduced and the solution retained longer. As a routine treatment for this class of cases I would rec- ommend the following procedure : Technique The patient should urinate before each injection so as to mechanically remove the secretion from the urethral wall. He should then inject a one-eighth per cent, solution of protargol and retain it for one minute, repeating the treatment every two Protargol in- jections Strength of the solution GONORRHEAL URETHRITIS 251 hours during the day and twice during the night. The latter importance of point is of the utmost importance for a speedy and safe cure, n ig" n t injec- tions and many complications and chronic cases are due to the neg- lect of this rule, which I have tried to impress upon the prac- titioner for many years. After three days a 14 P er cent, solution should be injected every three hours during the day and once during the night. At the end of the first week the strength of the solution may be Treatment dur- increased to y 2 per cent, to be injected every four hours and re- "J? second and tnird week tained five minutes and the night injections discontinued. At the beginning of the third week the same solution is injected three times a day and retained ten minutes at a time. At the be- ginning of the fourth week, when the secretion will be found to Fourth week contain mostly epithelial cells, none, or but a few, leucocytes and no gonococci, an astringent and mild antiseptic will be substi- tuted for the morning and noon injection with protargol, but the latter is still to be used before retiring. In the following two weeks only the astringents may be injected, if repeated examina- tions have shown the permanent absence of gonococci. The most commonly employed and the most serviceable astrin- Astringents gents are : Zinc sulphocarbolate, 0.60 Resorcin, 1.80 Aqua distill., 140.00 Fluid extract Hydrastis, 40.00 Sig. Inject mornings and noon. Zinc sulph., 1.0 Plumb, acet., 2.0 Aqua distill., 200.0 Sig. Inject mornings and noon. This is the old Ricord's formula. Cupr. sulph., 0.20 Alum crud., 1.00 Aqua distill., 200.00 Sig. Inject mornings and noon. The astringents should only be retained for a minute at a time. Fresh solutions of protargol, not older than three to four 252 GONORRHEAL URETHRITIS Preparation of solutions Female gon- orrhea Bougies Vaginal douches Toilet of ex- ternal parts Complications in women Acute posterior urethritis Gonosan days, should be used and they should, therefore, not be made from stock solutions and must be kept in stained glass bottles. They should be prepared slowly by spreading the powder on the surface of cold water and not by mixing, stirring, heating or by the addition of solvents. These small details seem to be overlooked quite frequently but are important to obtain good results. The female urethra is not suitable for injections nor is it possible to retain fluids therein for any length of time. Instead of these I have always successfully employed urethral bougies, one and one-half inches long, made of protargol and gelatin. They are inserted in the urethra once and, later on, twice a day and there retained for ten to fifteen minutes by a pledget of gauze or cotton slightly pressed against the urethral orifice. By squeezing the bougie for an eighth of an inch upward from the orifice oftentimes no artificial retention at all, in the recum- bent position, is necessary. After the gonococcus has disap- peared from the discharge, astringent, medicated bougies are in- serted on alternating days with protargol bougies for about two weeks. and, finally, the astringent alone for another week. Pre- cautionary hot vaginal douches with a quart of a 1 in 3000 pro- targol solution, or 1 in 10,000 nitrate of silver, twice and later once a day, are used. The vestibulum, the area around the vulvo-vaginal glands, the urethra and the clitoris should also be cared for in the same way. Occasionally, but rarely, it will be necessary to employ protargol solutions as strong as 1 per cent. ; they may not be used more than once a day and, if found inadequate, a 1 in 2000 nitrate of silver solution, injected twice a day, may be substituted with satisfactory results. Where this fails after it has been tried for a reasonable time, closer inves- tigation will reveal some complication, the most common being infection of a paraurethral duct; a periurethral or a follicular abscess; invasion of the Cowper glands; or the disease has crossed the external sphincter and invaded the posterior urethra with or without producing acute inflammatory symptoms. Acute posterior urethritis, which is characterized by symp- toms identical with those of acute cystitis, requires rest in bed for a few days, a strict milk diet, care for the bowels, in short, the same management as acute cystitis. Injections in the ante- rior urethra should be discontinued until the acute symptoms have subsided and the medication indicated for acute cystitis instituted. Gonosan, which I prescribe in these cases, has not the least specific effect on the gonococcus, as is claimed for it, but it renders the urine bland and helps to allay the inflamma- tory symptoms. With the improvement of these symptoms the GONORRHEAL URETHRITIS 253 injections may be resumed and local treatment of the deep urethra and the vesical neck added. Daily, deep injections with one drachm of a 1 per cent, to 2 per cent, protargol solu- Deep injections tion will answer the purpose. They are given like bladder in- W1 stillations (see Section on Cystitis), with the difference that the tip of the catheter or of the instillation bougie is placed in the vesical neck and the solution is deposited, drop by drop, over the whole inflamed area while the catheter is being slowly with- drawn to the external sphincter. Prostatitis. This complication of acute gonorrheal urethritis requires besides the treatment for acute posterior urethritis, appli- cations of cold to the posterior aspect of the prostate in order to prevent suppuration. This is best accomplished through the rectophore applied for fifteen to thirty minutes, several times Rectophore daily. The temperature of the water circulating through the apparatus should not be so low as to produce discomfort. Ice bags applied to the perineum add to the comfort of the patient. Ice bags Eetention of urine, as it occurs in some of these cases, may Retention of be relieved by catheterizing under the necessary and well-known antiseptic precautions. Only soft rubber catheters are permis- Catheterization sible for this purpose. If, in spite of antiphlogistic treatment, pus forms and a prostatic abscess can be palpated through the Prostatic ab- rectum, one should not be too hasty with an operation as the abscess frequently ruptures spontaneously into the deep urethra, an event that is announced by the appearance of much pus mix- ed with the urine and a remission of all distressing symptoms. If the abscess does not rupture spontaneously within a few days after it becomes palpable, it should be evacuated by a perineal opening to prevent serious complications, for, if not surgically Surgical relief relieved, the pus might break through the capsule and burrow its way beyond our control. Epididymitis. The indications for the treatment of this disorder are : 1. To relieve the pain and inflammation, and 2. To promote the absorption of the inflammatory products. The first indication is best accomplished by rest in bed, a Rest suitable support for the testicle and the application of heat in the shape of hot fomentations or a hot poultice. If taken in Heat hand before the acute symptoms have reached a climax the following procedure has always given me satisfaction: Apply a solution of equal parts of guaiacol and glvcerin with a brush Guaiacol and glycerin appli- or a gauze sponge all over the scrotum of the afflicted side ; this cations causes considerable smarting for several minutes. The whole 254 GONORRHEAL URETHRITIS Suspensory- Internal treat- ment Moist heat Scarification of the tunica vaginalis Abscess of epididymis Latent tuber- culosis scrotum is wrapped in a square of absorbent cotton, 12x12 inches, and one inch thick. This is covered with a piece of oil- silk or rubber protective tissue of the same size and the whole held in place by a large sized suspensory bag. The bag for this purpose must be extra large to accommodate the voluminous mass to be placed therein and should have a strong elastic abdom- inal band, the latter to be adjusted high enough to suspend the testicle as high as possible. The guaiacol acts as an antiphlo- gistic and an anodyne, the cotton, covered with oilsilk, as a dry poultice, and the suspensory, if properly adjusted, takes away all the dragging of the testicle on the tender and inflamed cord. The effect is a momentous one, patients whose features were dis- torted with pain, are able to walk briskly immediately after the testicle is immobilized in the manner described. One applica- tion of the guaiacol is sufficient but the cotton, being worn down, has to be renewed at least once in twenty-four hours. Three grains of salicylic acid with lemonade, taken twice daily, seems to assist in the acute stage. Within five to eight days the swelling of the epididymis is usually reduced by one- half and the greater part of the inflammatory effusion in the albugineal sac has become absorbed. Moist heat furthers the removal of the infiltration in the epi- didymis at this stage. Eight thicknesses of a piece of moist gauze, 12x12 inches, are wrapped around the whole scrotum, this is covered with oilsilk of the same size, over this is placed a layer of cotton, 12x12 inches and one-half inch thick, and the whole is supported in the suspensory bag, to be renewed morn- ings and nights. In a few cases the very profuse effusion in the albugineal sac causes so much tension that absorption becomes impossible. In this event Vidal's multiple scarification of the tunica vaginalis will be necessary to open an avenue for the escape of some of the fluid. In rare instances abscess formation in the epididymis occurs, in which event broad incision of the albugineal sac and evacuation of the pus will bring speedy re- lief. This pus ought to be carefully examined, as usually a latent tuberculosis is back of these suppurations. The same should be remembered in the ever recurring swellings of the epididymis without a palpable cause. All local treatments have to be discontinued in the acute stage of epididymitis and no balsams of any kind given in- ternally. Many a case of a persistent acute inflammation will readily disappear under proper treatment when this latter point is observed. INFECTIOUS URETHRITIS 255 2. INFECTION URETHRITIS OF NON-GONORRHEAL ORIGIN. Owing to the fact that very little is known about the nature Causes and origin of this peculiar form of urethritis, it is not surprising that we do not as yet possess any definite means to successfully deal with the trouble. Streptococcus, staphylococcus, pneumo- coccus, pseudo-diphtheria bacillus and coli-bacillus which are found in the discharge of these cases also exist in the normal urethra without producing any symptoms. From observations extending over a number of years it seems to me that these micro- organisms occasionally become virulent on a mucosa which by some provocation has lost its natural powers of resistance and has thus become transformed into a favorable culture medium; Predisposing in fact, upon inquirjr we can often trace the trouble to a pre- factors ceding sexual excess, prolonged and violent exercise, forcible urethral instrumentation, etc. I have seen such discharges ap- pear after sexual excesses carried on with the protection of condoms, and after instrumentation under all possible anti- septic precautions, so that a transmission of the infection was at least in these cases out of question. In others the infection occurred simultaneously with the inoculation with the gono- coccus, and in still others a chronic gonorrhea rendered the ure- thra more susceptible to the subsequent mixed infection. Regarding treament very little of value can be said. The few cases of coli infection which I have seen yielded promptly to internal medication with large doses of urotropin or other xj ro tropin formaldehyde preparations. In a few staphylococcus infections mercurol, in one-half to two per cent, solutions, proved very M , effective; also two per cent, ichthyol solutions, provided the patient could tolerate the smarting sensation caused by the med- icine. In one case in which the urethroscope showed several islands of pseudo-membrane, and the culture nothing but pseudo- diphtheria bacillus, I used antitoxin hvpodermically on two sue- ^. , A , ' ,. , t t-t Diphthena-an- cessive days, and the discharge disappeared. I have seen the titoxin case since then repeatedly. This is now over two years ago, and everything is apparently normal. Perhaps a urethral in- jection with the antitoxin might have had the same effect. En- couraged by this result I tried this treatment in other cases in which the diphtheria bacillus was found in company with staphylococcus and pneumococcus but without success. In a few cases I used electrolysis in apparently diseased pockets and Electrolysis follicles with good results. 256 URETHRITIS TUBERCULOSA Intractable character of the trouble Radio-active fluids Very few of these cases seem to improve under any method of treatment, but they get worse as soon as treatment is discon- tinued, and most of them even while under the treatment. A few recover without any treatment, some of them completely, some to that extent that the discharge ceases, but shreds are constantly present in the urine. Most of them seem to remain well for days, weeks, even months at a time, when with or without evident cause the secretion reappears. Several times I have seen the trouble permanently disappear after a reinfection with gonorrhea. One of my patients, who carried this infection for over two years, lost it permanently after a severe typhoid fever. Light having a deleterious effect on pneumococcus and bacil- lus diphtheriticus, I utilized injections with radio-active fluids, but with the same varying results. A specific has still to be discovered. Hygienic and symptomatic treatment 6. URETHRITIS TUBERCULOSA. As a rule, this is the local manifestation of the constitutional trouble or the partial symptom of a more or less generalized tuberculosis of the urogenital tract, and requires a hygienic and symptomatic treatment. Instrumentation is to be avoided. The same topical treatment as in cystitis tuberculosa may afford some relief, but a cure depends on the extent of the urinary lesion and the possibility of dealing successfully with the lat- ter, and in this respect the prospect is not very encouraging, as the disease is usually far advanced before urethral manifesta- tions are observed. Injections of bichloride so- lutions Bougies 4. SYPHILITIC URETHRITIS. If caused by the primary lesion of syphilis — the hard chancre — the proper local and constitutional treatment (see Section on Syphilis) is sufficient. The ulcus being situated near the orifice can easily be reached by local medication. This con- sists in injections with a drachm of a 1 in 5000 bichloride solu- tion, twice a day, followed by the insertion of a urethral bougie, one inch long and one-eighth of an inch thick, consisting of: h Olei cacao, Iodol, Ft. Urethral bougie. Sig. One twice a day. 0.30 0.06 SYPHILITIC URETHRITIS 257 If the healing is retarded, or bleeding due to flabby granu- lations is observed, the ulcer has to be exposed in a short ure- throscope and cauterized with a concentrated nitrate of silver, or sulphate of copper solution — from 10 per cent, to 50 per cent. Secretions, due to secondary syphilitic lesions in the urethra, readily yield to the constituional treatment supported by a few irrigations of the anterior urethra with a 1 in 1000 nitrate of silver solution. Cauterization Nitrate of sil- ver irrigations CHAPTER VI. DISEASES OF THE MOUTH AND UPPER AIR PASSAGES INTRODUCTION. Nearly all the diseases of this region of the body call for topical and surgical treatment. A few of the more acute varie- ties, especially those that are complications or part phenomena of general constitutional or infectious diseases, however, belong to the province of the internist. The more chronic disorders that are accompanied by advanced anatomic changes (hyper- trophies and atrophies, deformities, abscess, ulcer formation, etc.) should be treated by special surgeons alone. Whereas the latter should by all means be competent general practitioners, it is nowadays not necessary nor, for that matter, possible, for the general practitioner to be a competent specialist. It is, in fact, almost more important that the latter should recognize his limitations in this direction, than that he should attempt without adequate training to encroach upon the domain of the skilled, experienced specialist. It is due precisely to failure on the part of the general practitioner to recognize these limitations that there is so much promiscuous, uncalled-for, and generally harmful spraying and applying, cutting and cauterizing about the nose and throat. The diseases of the mouth and upper air passages that the internist is frequently called upon to treat, either because their onset is very acute or because they accompany various general disorders, are the different forms of stomatitis, acute rhinitis, including hay fever and pseudo hay fever, pharyngitis, acute ton- sillitis and acute laryngitis. The treatment of these disorders alone, therefore, will be discussed in this chapter. I. DISEASES OF THE BUCCAL CAVITY. STOMATITIS. Stomatitis complicates a variety of infectious diseases, gastro- intestinal and hepatic disorders, cachexias and anemias, certain Causes metabolic disorders as diabetes, the uric acid diathesis and acetonemia, the hemorrhagic diathesis. In children during the period of dentition, and especially in bottle-fed infants and children with rickets, mouth disorders are common. Finally, in all unconscious states the mouth is apt to become diseased; the stomatitis, in the latter instance, being due in great part to de- 260 STOMATITIS Prophylaxis in acute infec- tious diseases Mouth washes Glycerin Prophylaxis in cachectic conditions ficient salivary excretion and the inhibition of masticating and swallowing movements, causing the mouth to become dry and preparing a particularly favorable nidus for the development of bacteria and fungi about the gums, the mucous lining of the mouth and the tongue. In the acute infectious disorders it is particularly import- ant to prevent the development of stomatitis, so that tjhe patients during convalescence may not be hindered from eating on ac- count of soreness of the buccal cavity. The prophylactic meas- ures that must be employed in infectious and in comatose states are the following: In order to induce swallowing, to promote the flow of saliva and to prevent cracking of the tongue and lips, the mouth should be washed out every two or three hours with a linen rag dipped either in a saturated solution of boric acid, or a three per cent, bicarbonate of soda solution, or a two per cent, solution of chlorate of potash. The latter remedy should not be used if the kidneys are affected. In patients who are altogether unconscious the tongue should be painted with glycerin, or boric acid in glycerin in the proportion of one part of boric acid to four parts of glycerin, and so much should be ap- plied that a portion of the glycerin trickles down into the pharynx. Ice pills should be inserted into the mouth or tea- spoonful doses of lemonade poured in at frequent intervals. In order to force swallowing movements, pressure may be exerted upon the base of the tongue. On the lips glycerin should not be used because it is too hygroscopic. Here vaseline or lanolin are the proper applications. If all these measures are carefully carried out a sore mouth will rarely develop, even in so pro- tracted a disease as typhoid fever. In chronic cachectic conditions, in sufferers from the hem- orrhagic diathesis, in diabetes, the following mouth wash is very useful: ? Biborate of soda, Menthol water, Distilled water, M. Sig. Mouthwash. 30 gm. 150 cc. 950 cc. - ( Ortner. ) Fetor Of this mouth wash a teaspoonful in half a glass of water should be used as a cleansing solution after each meal. A useful prescription for the excessive fetor in diabetes has been given on page 140. The following astringent wash is also STOMATITIS 261 very useful, particularly if there is a tendency to bleeding from the gums: Bleeding gums r> Thymol, 35 gm. Benzoic acid, 3 gm. Tincture of eucalyptus, 15 cc. Absolute alcohol, 100 cc. Peppermint oil, 20 drops M. Sig. Mouthwash. —(Miller.) Of this solution a teaspoonful in half a glass of water should be used as a wash or gargle. In all forms of stomatitis, too hot, too cold, too hard or rough articles of food, spices, strong alcoholic beverages, and also tobacco should be carefully avoided. If the mouth disorder is once established the treatment differs somewhat according to the character of the stomatitis. For ^. . .. 3 , Five varieties practical purposes it is convenient to distinguish five varieties, of stomatitis First, simple catarrhal or erythematous stomatitis; second, aphthous (follicular or ulcerative) stomatitis; third, thrush (stomatitis due to oidium albicans) ; fourth, gangrenous stoma- titis (noma, cancrum oris) ; fifth, mercurial stomatitis and ptyalism. In the simple catarrhal form the measures described under prophylaxis should be employed for the sake of promoting Treatment of cleanliness and antisepsis of the mouth. At the same time any f iinp j e catarr ~ r J hal form underlying constitutional, gastro-mtestmal or hepatic disorder should be treated. No special local treatment is required. In the ulcerative or aphthous form each ulcer should be touched with a stick of silver nitrate, or cauterized with a Treatment of galvano-cautery or a Paquelin. The best liquid application in ulcerative and the ulcerative form is a mixture of potassium chlorate in gly- cerin in the proportion of one to two. Potassium chlorate is a particularly useful remedy in the ulcerative form, but should be used carefully in the aphthous, for, in the latter, it increases the pain. If kidney disease is present it should never be used. Potassium is excreted in part through the saliva, so that it usually grants a prolonged local effect in the mouth. A one per cent, sodium salicylate solution, or a one to one thousand permanganate of potash solution, may also be used for wash- ing out the mouth and touching up the ulcers. If the mouth is very sore and painful a few drops of opium tincture or cocaine 262 STOMATITIS may be added to the solutions, the following: A very useful preparation is Salicylic acid, Cocaine muriate Glycerin, Water, M. 1.0 0.1 10.0 10.0 Treatment of thrush Treatment of noma Treatment of mercurial stomatitis Potassium chlorate Peroxide of hydrogen Thrush is usually preventable if rigid cleanliness of the mouth is maintained. In nursing children particular care should be exercised to have the nipples clean. Gastro-intestinal disorders should be carefully treated and corrected. The best local applications are potassium chlorate in a two per cent, solu- tion, or potassium permanganate in a one pro mille solu- tion. These are best applied on rags that should be rubbed against the affected areas in the mouth. Internally, resorcin, one to one hundred, in teaspoonful doses, two or three times a day, is said to exercise an inhibitory effect upon the develop- ment of thrush (Baginsky). Gangrenous stomatitis is a very dangerous complication and one that always calls for energetic local treatment. The gan- grenous areas should be destroyed either by a galvano-cautery or a Paquelin cautery, or by the application of nitric acid or silver nitrate in stick form. If the line of demarcation does not form within a day or two an artificial line of separation should be produced by the use of these caustics and the gan- grenous areas excised. Mercurial stomatitis can generally be prevented by careful mouth asepsis carried out as described under prophylaxis. Cer- tain individuals, however, seem to have a peculiar susceptibility to mercury and become salivated upon the exhibition even of very small doses. As soon as the first evidence of stomatitis (usually soreness about the gums) becomes manifest, the ad- ministration of mercury should at once be stopped. Two remedies are particularly useful in the fully developed form, namely, potassium chlorate and peroxide of hydrogen. The former should be used in a mouth wash in a two or three per cent, solution, or a tooth brush may be dipped into powdered chlorate of potash and the teeth and gums energetically brushed with it. Peroxide of hydrogen should also be given in the strength of about two per cent. As the commercial preparations contain about 10 per cent., a teaspoonful to one-third of a glass of water approximates the proper concentration. TONSILLITIS 263 If mercurial ulcers develop they should be treated with a silver nitrate stick, or should be painted with tincture of iodine or touched with chromic acid. Free catharsis should be pro- Atropine moted, sweating induced, preferably by hot bathing, and the patient should be instructed to drink plenty of water. Intern- ally, atropine in one-two-hundredth grain doses given three times a day often beneficially influences mercurial stomatitis. TONSILLITIS. Classification Abortive treat- The mucous lining about the orifices of the tonsillar crypts may become involved in any catarrhal state of the mouth or upper air passages, or the crypts alone may be attacked (lacunar or follicular tonsillitis) or the whole gland, including its ade- noid tissues, may be diseased (parenchymatous tonsillitis), or the infection ma} r be suppurative in character (tonsillar or peritonsillar abscess). The treatment of these different forms does not vary materially. In the suppurative variety, of course, surgical evacuation of the pus becomes necessary. Upon the onset of the first symptoms the bowels should be ment thoroughly evacuated, probably best by the use of ten one-tenth grain doses of calomel given at ten minute intervals, followed by a tablespoonful of magnesium sulphate in water. The diet should be non-irritating to the throat, i. e., should contain no rough or hard particles nor spices, nor should it be too hot. Internally tincture of aconite, in drop doses, should be Aconite given at two hour intervals throughout the attack. The most useful remedies for internal use, possibly owing to the intimate relationship of tonsillitis to certain forms of rheumatism, are guaiac and the salicylates. Guaiac is useful both internally Guaiac and and locally, so that its administration in lozenge form is espe- a lcy a e cially appropriate in this disease. For internal use the tinc- ture of guaiac may be given in tablespoonful doses in milk, sev- eral times a day. Sodium salicylate is best given as salol in five to ten grain (0.3 to 0.6 gm.) doses, or in combination with some alkali, for instance, as ten grains (06. gm.) of sodium sali- cylate with ten grains (0.6 gm.) of sodium bicarbonate in some simple syrup. This quantity should be administered every two hours during the first two days, then every four or five hours throughout the course of the disease. The local treatment consists in the application of cold ex- Local treat- ternally either by means of a Priessnitz compress, i. e., a linen ment cloth wrung out of cold water and covered with flannel or, bet- ter still, by means of a. Leiter coil (see index) through which plications 264 TONSILLITIS Internal cations Gargles appli- ice water is flowing. Leeching or blistering the neck are rarely necessary and usually very disagreeable to the patient. Paint- ing the neck with iodine occasionally helps, but this form of counter-irritation is inferior to the use of the Priessnitz com- press. Sometimes cold applied to the neck is very objectionable to the patient; heat may then be applied either by means of hot cloths frequently renewed and covered with oiled silk or by means of linseed-, oatmeal- or bread-poultices. Cold is, how- ever, always more effective in modifying the course of the dis- ease than heat. The tonsils themselves should be treated by means of gargles or by direct applications to the affected glands. The different gargles should be used as follows: A small quantity is taken into the mouth, the head thrown back, the nose closed with the fingers and thumb, the mouth opened and a swallowing move- ment attempted. The following gargles are useful: A tea- spoonful of alum dissolved in half a pint of water, to which is added a teaspoonful or two of some flavoring syrup; or a two per cent, solution of potassium chlorate ; or again, the following : 3? Salicylic acid,. Glycerin, Carbolic acid, Water, M. 1.0 gm. 1.0 cc. 1.0 cc. 100.0 cc. Sodium car- bonate Ammoniated tincture of guaiac Inhalations Sprays Evacuation of pus by incision If there is pain a gargle of equal parts of lukewarm milk and water to which are added twenty drops of tincture of opium is very soothing. If the tonsils are very much swollen, or if they are very painful, gargling is difficult and disagreeable. Here direct ap- plications to the tonsils are useful. Dry sodium bicarbonate may be rubbed directly upon the tonsils with the fingers, or the tonsils may be painted or swabbed with ammoniated tincture of guaiac. Inhalations through a steam inhaler of a one per cent, solu- tion of sodium bicarbonate to which are added a few drops of tincture of opium; or spraying the tonsils with a solution of five grains of menthol in an ounce of alboline, are soothing measures. If there is much mucus from complicating pharyn- gitis, then ice cold lemonade sucked through a straw frequently aids in expelling it. If suppuration becomes established then nothing in the na- ture of lozenges, inhalations, sprays or local application should ACUTE RHINITIS AND PHARYNGITIS 265 be used. Here evacuation of the pus by incision becomes nec- essary. The indications for the surgical treatment of tonsil- litis are the following :* "First. Never to inflict unnecessary pain by useless scari- indications for fication of the surface of the tonsils undergoing general inflam- ^f^of tern-*" mation. sillitis "Second. Never to make deep incisions unless there is almost certainty of advanced suppuration. The instrument for making the incision should be a curved, pointed bistoury with not more than one inch of cutting edge, and the cut should be made from without inwards, so as to avoid the not impossible risk of injuring the artery. "Third. To recommend removal, on subsidence of the at- tack, of all tonsils chronically enlarged and liable to quinsy. "Fourth. To remove the tonsils as soon as they become suf- ficiently enlarged, in those cases of recurring quinsy in which there is not chronic enlargement, but in which the tonsil though diseased is too small for excision except on recurrence of the acute inflammation. By this means, the present attack is at once cut short and the chance of further recurrence is avoided." II. DISEASES OF THE NOSE AND THROAT. ACUTE RHINITIS AND PHARYNGITIS. Catarrh of the nose and pharynx can fitly be discussed to- gether because both these regions are commonly affected simulta- neously or consecutively, and because the general treatment of acute rhinitis and pharyngitis is in all essentials identical. Catarrh of the upper air passages is rarely produced by direct irritation of the mucous linings of the nose and throat, although what may be called chemical forms of catarrh occur. The treatment of the latter form, when the catarrhal condi- tion is once fairly established, does not materially differ from that of other forms that are due to constitutional causes. The most common cause of catarrh of the upper air passages Causes is exposure to cold. The nose and throat are a locus minoris resistenticB, partly on account of their exposed condition and partly owing to the fact that they are chronically in a state of irritation from the inhalation of dust or tobacco smoke, from contact with alcohol, hot foods, spices, or from irritation by ex- cessive use of the voice. Moreover, there is frequently present in these passages a condition of passive hyperemia due to ab- dominal plethora and tympanitis induced by errors of diges- tion and liver disorders, gastroptosis and chronic constipation; or due to the wearing of tight collars and neck bands. Inasmuch *Quoted from Lennox Browne. 266 ACUTE RHINITIS AND PHARYNGITIS Action of ex- posure to cold Prophylaxis "Hardening." as the blood vessels of these parts are, moreover, especially sus- ceptible to reflex vaso-motor influences that ma} 7 " originate in many different parts of the body, it is not surprising to find the nose and throat particularly liable to inflammation as soon as the body is exposed to any influence as, for instance, sudden temperature changes, that tasks the adjusting powers of the vaso-motor system. It is a well known fact that, normally, exposure of any part of the body to cold produces, first, a tetanic contraction of the capillaries of the exposed area; second, a reactive dilatation beyond the normal calibre of the blood vessels; third, a restora- tion of the vessels to their original calibre. Unless the vaso- motor apparatus is functionating in an altogether normal man- ner, the primary contraction may not occur at all or it may occur promptly, but last too long. In either case the secondary dila- tation, which fulfills the purpose of carrying an increased amount of blood to the exposed portion and hence maintaining its temperature, does not take place and the first stage of in- flammation is produced. This effect is frequently exercised in the nose and throat and a catarrh produced in this way. Be- sides, cold affecting certain remote regions of the body, espe- cially the feet, the back of the neck and the region between the shoulder blades, by a peculiar reflex mechanism that is not well understood, readily deranges the vascular supply of the mu- cous lining of the upper air passages and again catarrh is the result. Hence, as is well known, a draft about the feet, the back of the neck or between the shoulder blades, in susceptible subjects, rapidly produces congestion of the nose and the throat, in other words, a "cold in the head." In order to counteract this tendency to catch cold, the va- rious causes that determine it must be attacked. An intelligent and efficient prophylaxis can here be instituted by removing, primarily, local causes of chronic irritation and, next, by "hard- ening" the organism with an unstable vaso-motor system against abnormal reactions to cold. The first condition can be fulfilled by eliminating, as far as that is possible, all the factors that have been enumerated above and that are known to produce irritation of the nose and throat. Here, too, the correction of deformities, the removal of hypertrophies, adenoid tissue, etc., must be regarded as a useful prophylactic measure. The "hardening" process must be carried out carefully and with due consideration of individual peculiarities. It should properly begin in infancy, and babies from the first weeks of life should be accustomed to the use of cold water. In adults ACUTE RHINITIS AND PHARYNGITIS 267 suffering from frequent nasal catarrh it is never safe to begin at once with cold sponging or bathing, so that the best plan, especially in weak individuals, and in old subjects, is to begin with dry rubbing of the skin carried on for two or three min- utes every morning. Later alcohol may be employed to rub the surfaces of the body, then warm and lukewarm water and still later cold water. The best way to accustom weakly individuals to cold water is to place them into a warm bath of about the „ , „ , , ... Cold bathing body temperature and while friction of the body is being per- formed, to gradually cool off the temperature of the water. It will be found that from day to day the temperature can be re- duced a few degrees without discomfort to the patient until, finally, cold water can be employed from the beginning. Warm baths alone never harden. Strong and healthy individuals, in whom the reaction to cold is very energetic can, of course, with impunity begin at once with the use of cold sponging or cold plunges even in the coldest weather. Sea bathing, provided the individuals do not stay in the water more than two or three minutes, that is, until the first reaction appears, is also useful in strong people. The matter of clothing is of great importance. Most people ° msr dress too warmly. The underwear should consist of wool, silk or flannel, never of linen or cotton. Linen absorbs the moisture quickly and permits its too rapid evaporation; as soon as it be- comes wet, it clings to the body and obliterates the layer of warm air between the skin and the first garment that is so effective as a non-conductor of heat in preventing loss of heat from the body surfaces. Wool is a poor conductor of heat and gives off the absorbed water very slowly. The fine hairs it con- tains hold the material at some distance from the skin so that a layer of air is always present between the skin and the wool. Its rough texture, moreover, causes some friction and passive hyperemia of the skin, which is grateful to the patients and renders them less liable to catch cold when they pass from a warm room into the cold air. Silk and flannel do not absorb moisture so well as wool, but they are very poor conductors of heat and as they do not irritate the skin they do not produce quite so much perspiration as wool. Chest protectors and back protectors and mufflers should be eschewed. The throat can be accustomed to exposure to cold as well as the face. The most dangerous form of w T rap that can be worn around the throat is, of course, fur; for it produces profuse sweating without ab- sorbing any of the moisture and hence favors great radiation of heat wherever worn. The temperature of the living zoom should vary but little The room tem- from sixty-five degrees Fahrenheit. The individual who is sus- pera ure 268 ACUTE RHINITIS AND PHARYNGITIS Abortive treat- ment Camphor Opium Atropine Foot baths Dover's pow- der and qui- nine and aspirin Treatment of the established attack Symptomatic treatment ceptible to catching cold should accustom himself to sleep in a cold room, preferably wearing a flannel night-dress and a night-cap to protect himself from drafts, and should keep warm by using plenty of covers, sleeping between flannel sheets if necessary.* All the measures enumerated above are particularly useful if there is a congenital predisposition to catching cold, or if such a predisposition has been acquired by frequent attacks of catarrh, or after some infectious disease. In many individuals a general neurasthenic or hysteric condition will be discovered with abnormal sensibility of the nervous system, or there may be chronic anemia that must be corrected (see page 76), for in all these cases there is apt to be a perversion of normal vaso-motor reactions that must be incriminated with producing an abnormal tendency to react by nasal or pharyngeal catarrh to exposure to sudden temperature changes. TREATMENT OF THE ACUTE ATTACK. Upon the appearance of the prodromal symptoms such as headache, a feeling of fullness in the frontal region, a little chilliness or fever and oozing of a clear fluid from the nose, with conjunctival irritation, it is occasionally possible to abort the attack by the use of camphor, opium and atropine. It is always worth while to attempt this abortive treatment by giving three drops each of the tinctures of belladonna and opium in half an ounce of camphor water, at three hour intervals, for three or four doses. In addition to this internal medication the patient should take a hot mustard foot bath and apply a mus- tard plaster to the back of the neck. In the evening before re- tiring five grains of Dover 's powder with three grains of quinine and three grains of aspirin should be administered in capsule, together with a glass of hot lemonade containing two table- spoonfuls of whisky ; the patient should go to bed and be covered with woolen blankets until profuse sweating is produced. It is very difficult to abbreviate the attack after the catarrh is once fully established. After the first attempt at aborting the attack by sweating has been made it is useless to try to in- fluence the duration of the disease by further diaphoresis. Symptomatic relief may, however, be secured by using a mix- ture of one part of menthol to ten parts of chloroform and plac- ing a few drops of this solution into the hand and sniffing the vapors at frequent intervals. It is also well to thoroughly wash out the nose two or three times a day with some alkaline solu- tion, such as the following: *See also Open Air Treatment of Tuberculosis on pages 313-315. CORYZA VASOMOTORIA AND HAY FEVER 269 Bicarbonate of soda, 0.65 (10 gr.) Borate of soda, 0.65 (10 gr.) Water, 96.00 (3 oz.) M. Nasal wash. A spray containing five grains of menthol to an ounce of Menthol and albolene (0.3 to 32) is always very grateful in relieving the albolene sense of fullness and the headache. Cocaine, which should be used very carefully in the fully developed attack, may occa- Cocaine sionally serve a useful purpose if it is insufflated in the form of a powder in combination with menthol. A useful preparation of this kind is the following: Menthol, Cocaine, of each, 0.3 (gr. 4%) Zinc sozoiodate, Boric acid, of each, 10.0 (5 2%) M. Sig. For nasal insufflation. Adrenalin, in 1 to 1*000 solution, may also be employed Adrenalin locally to give relief. All these remedies, recommended for local use, should be used only if it becomes necessary to remove excessively distress- ing subjective symptoms for the time being; they should not, however, be given too energetically in any case, for their violent vaso-constrictor action gradually produces paralysis of the vaso- motor nerves, with permanent dilatation and serious injury to the nasal mucosa, leading in its ultimate consequences to a pro- longation of the acute attack and the establishment of sub-acute or chronic catarrhal conditions within the nose. CORYZA VASOMOTORIA AND HAY FEVER. Vaso-motor coryza is distinguished from catarrhal rhinitis Definition by the fact that the secretion always remains watery and never becomes purulent. To this category of rhinitis belongs hay fever and pseudo hay fever; the former being produced chiefly by the pollen of Ambrosia artemisi folia; the latter by a variety of other floating particles of vegetable origin. Vaso-motor Hay fever and coryza usually affects neurotic individuals. After exposure to a P seudo kay draft they suddenly begin to sneeze violently while a profuse amount of clear watery fluid pours from the nose. The attack is usually of short duration. Occasionally, however, unless rapidly aborted, it leads to true catarrhal rhinitis. To abort 270 CORYZA VASOMOTORIA AND HAY FEVER Abortive treatment Morphine and atropine Prophylaxis of hay fever Opium and belladonna Menthol-cam- phor the attack one-twenty-fourth grain of morphine with one-two- hundredth grain of atropine should be given every two hours for four or five doses. Local applications do no good what- soever. The treatment of hay fever and of pseudo hay fever is a very ungrateful task when the attack is once established. An intelligent prophylaxis, however, may aid very much towards preventing the recurrence of attacks of hay fever, or at least towards rendering the seizures less severe and less protracted. In the first place the mucous lining of the nose must be carefully treated during the winter, hypertrophies, varicose veins, deform- ities, etc., being corrected. More important than this, however, is the treatment of the underlying neurotic, i. e., neurasthenic or hysteric, temperament. Here, hydrotherapeutic measures, a course of arsenic or strychnia or phosphide of zinc, and all the measures described in detail in the Section on Gastric Neuroses have an important place. Sufferers from hay fever, as is well known, obtain the greatest relief, or even complete immunity from attacks, by a change of climate. Most mountain climates and the shores of Lake Superior, Lake Huron and the northern shores of Lake Michigan enjoy a well merited reputation as hay fever resorts. Symptomatically, in order to reduce the violent coryza, the conjunctivitis and the asthma in patients who cannot go away, opium and belladonna, in two or three drop doses of the tinc- tures, may be given three or four times a day. Often small doses of atropine, one-two-hundredth grain, are useful, also given three or four times a day. The menthol-cocaine mixture, described on page 269, may be inhaled, or smelling salts of the following formula be used with considerable relief to the patient : Carbolic acid, . 30 drops Ammonium carbonate, 1 ounce Charcoal powder, 1 ounce Lavender oil, 20 drops Compound tincture of benzoin, V 2 ounce M. Sig. Smelling salts. — (Lennox Browne.) Sprays Sprays of adrenalin, morphine, salicylic acid, cocaine, cap- sicum, etc., have all been recommended, but their effect is very transitory and, as a rule, injurious to the nasal capillaries, es- pecially if used continuously. Their use had best be eschewed EPISTAXIS 271 altogether or reserved for emergencies when it becomes neces- sary to grant temporary relief. The use of Dunbar's "Hay Dunbar's hay Fever Serum" is still in the experimental stage, but promises fever serum something. It is too early to render judgment in regard to its efficacy. EPISTAXIS. Nose-bleed is an important symptom of manifold origin that Epistaxis of the internist is frequently called upon to treat. Those forms ^^ nical of epistaxis that are due to mechanical injury of the blood ves- sels of the nasal mucosa of necessity call for topical or surgical treatment. To this category belong cases of epistaxis that follow trauma, especially fracture of the base of the skull, rupture of the sinuses, etc. ; epistaxis occurring as a complication of tumors, malignant or otherwise, of the nose or its accessory cavities whose surfaces within the nose undergo ulceration with result- ing erosion of superficial arteries; and epistaxis from ulcers of the nasal cavity due to syphilis, lupus and other causes. In addition to this mechanical form there are important Epistaxis of forms of epistaxis that are due to constitutional causes. In the origin* 1 10na first pluce any of the manifestations of the hemorrhagic diathe- sis, notably hemophilia, scurvy and purpura, as well as any of the severe anemias and leukemia, can produce hemorrhage from the nose. Here the hemorrhage is rarely profuse but generally consists of slow and continuous oozing with the formation of large clots and hematomata. In most of these cases one must assume that diapedesis of blood occurs through vessel walls weakened and rendered permeable to blood plasma and corpus- cles by nutritional disorders of their tissues ; now and then these degenerative changes produce fragility and rupture of arterioles with more profuse bleeding. To the same class undoubtedly belong those forms of nasal Epistaxis in hemorrhage that occur as a part phenomenon of various infec- intoxicSions tions and intoxications. Thus in typhoid fever, in most of the ex- anthemata and in yellow fever, nose-bleed is common ; in hepatic cirrhosis and acute yellow liver atrophy, also phosphorus liver, in gout and in diabetic acidosis epistaxis may occur. The exact explanation of this phenomenon is still forthcoming, presumably, however, one is dealing with degenerative processes occurring in the vessel walls superinduced by the action of circulating bac- terial toxins or of poisonous products of perverted metabolism. A third variety of cases of epistaxis occurs in diseases of Epistaxis in the cardio-vascular apparatus accompanied by high arterial cardio-vascu- pressure with fragility of blood vessel Avails or profound venous lar apparatus 272 Epistaxis and sexual dis- orders Topical treat- ment Ice compress and ice water injections stasis as, for instance, in arterio-sclerosis, in syphilitic arteritis, chronic alcoholism, and lead-poisoning. In valvular diseases of the heart in the stage of decompen- sation, or in tricuspid lesions before the balance of compensation, is broken, hemorrhage from profound venous stasis about the nasal mucosa is apt to occur. In this group of cases hemorrhage from the nose rarely takes place spontaneously but is usually superinduced by some straining effort; so that hiccough, bron- chitis, emphysema, nausea, vomiting from whatever cause, con- stipation and all other disorders that force the patient to strain must be considered determining causes of nose-bleed in predis- posed subjects. Finally there is an interesting class of cases of epistaxis re- lated to disorders about the sexual apparatus. It is well known that irritation of the sexual sphere can produce turgescence of the corpora cavernosa of the turbinates; that inversely stimuli applied to the nose influence the sexual sphere, so that certain odors exercise a peculiarly stimulating effect upon the libido sexualis; that treatment of the nose, especially cocainization of certain sensitive areas, can occasionally exercise a profound effect upon dysmenorrhea. It is not surprising, therefore, to find nose-bleed occurring not infrequently as a part phenomenon of disorders of the sexual sphere. Epistaxis is a common accom- paniment of excessive masturbation; it is especially frequent during the age of puberty in individuals of both sexes and it not infrequently accompanies menstruation or takes its place, so that it has been characterized in these instances as a vicarious form of menstruation. To treat epistaxis, especially chronic recurrent or particu- larly obstinate, continuous forms of the disorder, successfully all these causative factors must be thought of, the exact etiology determined and causal treatment instituted accordingly. Epistaxis due to purely local causes, violence, trauma, tumor, ulceration, chronic nasal catarrh with erosion of arterioles, calls for appropriate topical treatment. In post-operative and trau- matic nose-bleed it is a good general rule not to be in too great a hurry to stop the nasal hemorrhage by active interference, as most cases of traumatic epistaxis have a tendency to become spontaneously arrested, and the hemorrhage is rarely so pro- fuse as to endanger life; with the loss of blood, moreover, the coagulability of the blood increases. The simplest measures that should be tried, if the hemorrhage does not cease spontaneously within a reasonable time, are the application of ice to the out- side of the nose (pressing a piece of ice against the side of the nose near the bridge) and the injection of ice water into the EPISTAXIS 273 bleeding nasal cavity. If possible tampons should be avoided in these cases, as they are exceedingly disagreeable to the patient during the days they have to remain in place and may cause new bleeding from tearing of the clot or cicatrix when they are removed. If the hemorrhage is very profuse and the patient becomes Cauterization rapidly exsanguinated so that one is justified in assuming that g** 116 bleedm £" an artery has been ruptured or eroded, then every effort should be put forward to find the bleeding spot. If the bleeding area can be located, after cleansing the nose of blood, it should be touched with trichloracetic acid, a stick of silver nitrate, tannin powder or a strong solution of hydrogen peroxide or, if neces- sary, with the actual cautery, remembering always that the latter should be removed while hot, as otherwise the clot becomes ad- herent to the instrument and may be torn off again. If it is impossible to stop the hemorrhage in this Way, then Tamponade tamponade of the nose becomes necessary. The application of the simple aseptic cotton, or better still, of iodoform gauze, should be preferred to the use of cotton saturated with cocaine (5 per cent.) or antipyrin (10 per cent.) or ferric chloride solutions; especially the latter should be avoided for its styptic effect is slight, the clot that is formed is very fragile and, above all, the tampons become very slippery and are apt to drop out. Digital com- Provided simple packing of the nose with cotton or iodoform P ression gauze, combined with digital compression from without, do not stop the bleeding, then it becomes necessary to plug the poste- rior nares with a Bellocq canula according to the methods de- Plugging of scribed in special works on disorders of the nose and throat and P° sterior nares in text books on. surgery. While these local measures are being applied the general General man- management of violent nasal hemorrhage is the following: The a §' ement collar or neck-band should be loosened; the patient should not be allowed to stoop over and should be put to bed in a semi- Position recumbent position with the head high or thrown back. Often holding the hands over the head is a useful measure. It may become necessary to ligate off the extremities with bandages in order to reduce the volume of blood streaming to the head. If Ligating ex- the blood pressure falls from loss of blood and the pulse be- remities comes small and weak, a hypodermic injection of camphorated oil, or of camphor in ether, or of ether alone, must be given for Supporting the- their analeptic effect (see page 32). The management of post- heart hemorrhagic anemia is fully described on page 7b*. In the other forms of nose-bleed that are not due to injury Treatment of or erosion of larger blood vessels in the nose, the following plan fP^taxis in ar- of treatment should be adopted : In cases that are accompanied 274 by high arterial tension, notably in cases of cardio-vascular and renal disease, in syphilitic arteritis and arterio-sclerosis, an effort should always be made to discover the bleeding point in the nose. In the majority of cases the hemorrhage occurs from the septal artery at a spot near the anterior part of the sep- tum. In this region spurs are often found, so that here the mucosa is often attenuated and foreign bodies can also readily lodge and cause local erosions. While every attempt is being put forward to stop the hemorrhage locally by direct treat- ment of the bleeding spot (see above), by ice water injections, by packing with pledgets of cotton or iodoform gauze combined with digital compression and the application of ice externally; Aconite while the patient is instructed to hold his arms over his head Veratrum and to follow the other general rules in regard to position that have been described above; an attempt should also at once be made to lower the blood pressure by giving drop doses of the tincture of aconite or of veratrum viride every half hour for three or four doses, or better still by giving one single dose of three to five drops of aconite tincture in water at once, fol- lowed later by one-hundredth grain doses of nitroglycerin, re- peated once or twice, or by one dose of one grain (0.05 gm.) of erythrol tetranitrate. If the blood pressure is not high and if the epistaxis is due to simple oozing from congested veins or from rupture of venules or capillaries on the surface of the nasal mucosa, and if this venous congestion is due to decompensated heart lesions, or tri- cuspid insufficiency without decompensation, then the use of digitalis in five drop doses of the tincture, repeated three or four times at one hour intervals or, better still, of camphor, ether, ammonia or other analeptics (for exact mode of adminis- tration, see page 32), is indicated. Here the patient shouM sit up and place his feet in hot water medicated with mustard, about three or four teaspoonfuls to a gallon of water. The best internal remedy aside from cardiac tonics is hy- drastis in twenty to thirty drop doses of the tincture, repeated several times, or as hydrastinine hydrochlorid in doses of one- half to two grains (0.03 to 0.13 gm.), in watery solution, by mouth or hypodermically. Cotarnine (stypticine) in the dose of one- third to one-half grain (0.02 to 0.03 gm.) may be administered in the same way. Combined with these measures simple local treatment with ice water, digital compression and, if necessary, Venesection packing with cotton may be tried. Sometimes, too, venesection and the withdrawal of 200 to 300 cc. of blood is a very useful procedure. If the bleeding from the nose occurs frequently in such cases and if it is generally superinduced by some strain- Nitroglycerin Erythral te- tranitrate Treatment of epistaxis due to venous stasis Digitalis Analeptics Mustard foot "baths Hydrastis Cotarnine EPISTAXIS 275 ing effort then all the factors that determine the straining, i. e., coughing, vomiting, hard defecation, should be removed and Avoidance of appropriate treatment undertaken against any underlying efforts 115 chronic respiratory or gastro-mtestinal disorder that may be present. A word of warning may be expressed in this place against Dangers of the use of ergot in nose-bleed. This drug is commonly recom- erg,ot mended for the arrest of hemorrhage anywhere in the body, and while it is of marked value in the arrest of uterine hemor- rhage, it is doubtful whether it is efficacious in epistaxis. I believe it does more harm than good in nose-bleed, even in those cases in which it is desired to cause constriction of bleeding arteries; in all the other cases of nose-bleed in which the hem- orrhage occurs from bleeding veins and capillaries, or in which the hemorrhage is due to diapedesis of blood through degener- ated vessel walls, its use is at least superfluous, for ergot usually produces a slight rise of the blood pressure. Ergot, moreover produces blood vessel constriction only in certain definite areas and the nasal mucosa does not happen to be one of the regions in which the drug exercises this effect on the vascular supply. As a matter of fact I have never been satisfied that it acts beneficially in nose-bleed or in pulmonary hemorrhage (see also page 310). Opium and morphine and members of the chloral group opium should also always be avoided in treating cases of nasal hem- Morphine orrhage. The temptation to give these remedies is great as the Chloral not to patients are often restless and frightened and one might think of giving them as sedatives in order to quiet this excitement. Opiates, however, reduce the tone of the vaso-motor center in the medulla and hence cause vaso-dilation and consequently congestion, especially about the head. Witness the flushing of the face after the exhibition of opiates, that renders them de- cidedly harmful in hemorrhages from the nasal mucosa (see also page 310). The drugs of the chloral group exercise a simi- lar effect, for they too produce paralysis of the vaso-motor nerves and induce peripheral congestion. The causal treatment of nasal hemorrhage, due to anemia, causal treat- leukemia, various infections, auto-intoxication in hepatic and ment in infec- gastro-intestinal disorders and in poisoning by different drugs is t ]^l gpis- in all particulars the same as the treatment of the underlying taxis disorders and need not be discussed again in this place. It is frequently difficult to determine whether the nose-bleed is due to the toxemia direct, i. e., to changes in the composition of the blood, or to degenerative changes in the vessel walls of the 276 ACUTE LARYNGITIS Epistaxis often a useful oc- currence Bleeding as a prophylactic against vicari- ous epistaxis Leeches to the anus Sitz baths and drugs to pro- duce menstru- ation nasal mucosa, or to general cardio-vascular changes (high blood pressure, venous stasis, etc. ) produced by the circulating poisons. It is well to remember that occasionally nose-bleed is a useful means adopted by Nature to relieve plethora, especially in in- dividuals suffering from stasis due to decompensated heart lesions and in subjects of an apoplectic habit. Here the shed- ding of blood from the nose is a safety-valve action and one of Nature's means of defense against more serious injury. In such instances the physician must frequently exercise his best judg- ment in regard to the advisibility of stopping the hemorrhage at once or of allowing some blood to escape before endeavor- ing to arrest the flow. If the conditions are such that venesec- tion would have been indicated, then no effort should be made to stop the nose-bleed too soon. By the same sign bleeding the patient from the arm may occasionally be efficacious in forestalling disagreeable vicarious menstruation from the nose. In some of these cases hemorrhoidal bleeding occurs instead of epistaxis, so that if it is desired to stop or prevent the nose-bleed, leeches to the anus often accom- plish this purpose if leeching is performed immediately before and during the time of the menstrual period. Hot vaginal douches or a hot sitz-bath; free evacuation of the bowels by a saline laxative: tincture of cimicifuga, in five drop doses, every four hours, during the two or three days preceding the expected menstruation, Pil. Aloes et Ferri five grains (0.3 gm.) two or three times a day, or Pil. Aloes et Myrrha in the same dose, occa- sionally aid in overcoming the amenorrhea and in preventing vicarious epistaxis. Abortive treatment Expectorants ACUTE LARYNGITIS. The prophylactic and internal treatment of acute laryngitis is essentially the same as that of acute rhinitis and pharyngitis (page 265). Upon the first appearance of the prodromal symp- toms, sweating, mustard foot baths and the combination of quinine, Dover's powder and aspirin, as described on page 268, with hot whisky lemonade should be given. The bowels should be thoroughly evacuated upon the onset of the attack by the use of calomel given in one-tenth grain doses for ten doses in the evening, and followed in the morning by a tablespoonful of magnesium sulphate in water. As soon as secretion becomes established mild expectorants (see page 281) may be given. The following expectorant mixture is very useful : ACUTE LARYNGITIS 277 Ammonium carbonate, 5 grains Tincture of scilla, 10 drops Compound tincture of camphor, 15 drops Syrup of ginger, 1 drachm Infusion of serpentaria, q. s., 1 ounce M. Sig. Expectorant mixture. — (Browne.) A very practical adjuvant to the treatment and one that alone, better than any other means, often suffices to bring about quick relief and to hasten restitution to normal conditions, is cold about the throat applied by means of the Leiter coil or a hand- Cold compress kerchief wrung out of cold water, placed tightly about the throat and covered with a woolen or flannel bandage. It may be left on over night and renewed again in the morning; or, if the patient remains at home, applied several times during the day. The atmosphere of the room should be saturated with mois- ture from a steam kettle. Inhalations of steam medicated with equal parts of a mixture of oil of terebinth, juniper and eucalyp- Moist atmos- tus, or compound tincture of benzoin, may be used as follows: P nere A teaspoonful of the mixture of the three oils, or of the ben- zoin, is mixed with a quart of boiling water in a dish; the patient's head and the dish are covered with a thick cloth and the rising vapors inhaled deeply for five to ten minutes at a inhalations time, three or four times a day. Or the inhalations may be made through a paper cornucopia, the large end of which is held over the dish of hot water. Special steam inhalers may also be used to advantage and here any of the etherial oils men- tioned above, particularly oil of terebinth, the oleum pumilionis, or the oil of juniper are useful. In case of severe pain and dif- ficulty in swallowing ten to fifteen drops of opium tincture may be added to the inhaling fluids. In the later stage of the disease when the mucus becomes tough and difficult of expectoration, inhalations through a steam vaporizer of a 1 to 2 per cent, solution of common salt, or of sodium bicarbonate, are exceedingly useful, and here again the addition of a few drops of opium tincture will relieve the sore- ness in the throat better than any means that I know of. Intra-laryngeal applications are rarely necessary unless there intra-laryngeal is very great hoarseness, or much pain with burning and dry- applications ness and difficulty in swallowing. A useful laryngeal spray con- taining cocaine and bromide of potash, is the following: 278 ACUTE LARYNGITIS 3 Insufflation of alum Cleansing the nasal passages Muriate of cocaine, Bromide of potash, Distilled water, M. 0.03 10.00 300.00 Better still, however, is the insufflation of a powder consist- ing of equal parts of alum and sugar of milk. The latter should, however, only be used as an emergency measure to stop hoarse- ness and aphonia in an individual, for instance, who has to use his voice for two or three hours despite the existence of laryngeal catarrh. Symptomatically, the thorough cleansing of the nasal passages with an alkaline wash, followed by a menthol and alboline spray, as described under Rhinitis, is often followed by good effects upon the laryngitis. CHAPTER VII. DISEASES OF THE BRONCHI, LUNGS AND PLEURA I. DISEASES OF THE BRONCHI. ACUTE TRACHEO-BRONCHITIS. In acute catarrhal bronchitis there is always, first, hypere- mia of the mucous lining of the bronchial tubes followed by de- generation of the superficial epithelia, then an outpouring of a serous transudate with swelling of the mucosa and narrowing of the lumen of the bronchial tubes and, last, loosening and desquamation of the epithelia that have undergone degeneration. classlfi cation Clinically, it is convenient to distinguish two stages, viz., what may be called a dry and a wet stage, the former being the stage of hyperemia, the latter the stage of profuse exudation of serum and casting off of degenerated epithelium. The object of the treatment in acute bronchitis must be, if possible, to abort the attack while it is still in the dry, hyperemic stage, or, if this fails, to convert the first into the second stage as rapidly as possible. Prophylaxis can be exercised merely in rendering the indi- Prophylaxis vidual less susceptible to temperature changes or other ex- traneous influences that determine bronchial catarrhs. Here the same rules in regard to clothing, diet, bathing, exercise, etc., obtain as in the prophylactic treatment of catarrh of the upper respiratory passages, and I refer to the chapter on these dis- orders for the details. Upon the onset of the first signs of bronchial catarrh, viz., Abortive a sense of dryness, irritation or pain behind the sternum and along the distribution of the larger bronchial tubes, a saline lax- ative should be administered and the patient should take a dose of three grains (0.2 gm.) of quinine sulphate, and drop doses of the tincture of aconite every hour for five or six doses. Hot lemonade, with a tablespoonful of brandy or whisky to the tumblerful, should be freely taken. A general hot bath of 100° to 105° F., provided the patient can go to bed afterwards and sweat between woolen blankets, is very useful. Turkish baths, which are very popular, are dangerous unless the patient can remain in the bath establishment over night. It is rarely nec- essary to give pilocarpine to produce sweat, as the hot bath, with hot alcoholic drinks, possibly a ten-grain Dover's powder, suf- treatmeat 280 ACUTE TRACHEOBRONCHITIS The treatment of the dry stage Inhalations Bronchitis tent Opiates Atropine series Alkalies Counter-irrita- tion over the ■chest fice to produce the desired vaso-dilator and diaphoretic effect. After an hour or two of profuse sweating the patient should be carefully dried and put back to bed between dry, warmed linen sheets. If these measures do not abort the attack, then every effort should be put forward to soothe the inflamed mucosa and, at the same time, promote outpouring of fluid from the bronchi; in other words, to relieve the dryness and hasten the development of the second stage. This object can be accomplished by in- halations, the use of opiates and alkalies internally, and stim- ulating compresses externally. Inhalations of physiological salt solution, or of 2 to 3 per cent, sodium bicarbonate solution, through a steam inhaler are very useful. Instead of using a steam inhaler the patient may hold his head, covered with a cloth, over a dish of boiling water, to which may be added tincture of benzoin (one drachm to one pint), a few drops of opium tincture, or of extract of bella- donna; the latter especially if the cough or the retrosternal pain is very severe. In children the bronchitis tent serves a very useful purpose. It is constructed by hanging over the bed sheets supported either by a special rack or by a screen. Within the tent a kettle of water is kept boiling by means of an alcohol lamp. In this way the child continuously breathes air that is saturated with moisture, and a very soothing effect upon the inflamed mucous membranes of the bronchial tubes can be ob- tained in this simple manner. Internally some opiate will generally have to be given to allay the cough, preferably morphine, in the dose of one-thirty- second to one-twelfth of a grain, or codeine one-sixteenth to one-fourth grains. The numerous other opium derivatives, as heroin, dionin, peronin, etc., possess no advantages over mor- phine and codeine. Hyoscyamus, stramonium, belladonna and other members of the atropine series are best reserved for the stage of profuse secretion, for while they act as sedatives and relieve bronchial spasm they also check secretion and the latter effect is undesirable during the dry stage of bronchitis. Alka- lies, administered in the form of citrates, acetates or carbonates of potassium or sodium, in doses of ten to thirty grains (0.6 to 2 gm.) at four or five hour intervals, in milk or water, or in the form of mineral waters, act very beneficially at this stage. It is possible that they are in part excreted by way of the bron- chial mucosa hence causing some irritation with outpouring of secretion. Their exact mode of action is not all understood, but empirically we know that they act very beneficially. One of the most useful adjuvants to the treatment of this stage of bronchitis is counter-irritation over the chest, preferably ACUTE TRACHEO-BRONCHITIS 281 administered by the use of cold compresses. A linen bandage about three yards long and six inches wide is dipped into water Cold compress of room temperature and thoroughly wrung out. One end of the binder is applied to the right axilla, the binder carried across the chest to the left shoulder, across the back to the right axilla, across the chest to the left axilla, across the back to the right shoulder and then to the middle of the chest. A second cross bandage of dry flannel is then applied over the first one and the dressing left in place until it is dry, which usually requires four or five hours. A second wet pack may then be applied, or the skin may be washed with alcohol and rubbed dry. It is unnec- essary to apply an impermeable oil-silk or rubber dressing over the wet bandage; if the binder is to be left on all night the patient may wear a woolen shirt rather than a flannel bandage piaster, cup- over the cross bandage. Mustard plasters, dry cups, iodine and P in g"> lodine » camphorated oil, are not as effective as this simple means. As soon as the dry, hyperemic stage is over and an exudation Treatment of of mucus from the bronchial mucosa has begun, then the treat- the wet sta » e ment becomes radically different. Three main indications must now be met, namely, first, to promote liquefaction of the sputa; second, to aid their expulsion ; third, to allay excessive cough- ing and to relieve the pain in the chest. A number of remedies can be employed to produce liquefac- Liquefaction tion of the sputa. As already indicated above, alkaline or saline of the s P uta waters serve this purpose. They should be taken warm at fre- Alkalies quent intervals and in abundant quantities, either alone or mix- ed with milk. Probably the most useful remedy in this condition is chloride of ammonium. It is not improbable that this drug is in part Ammonium excreted via the bronchial mucosa, so that it acts locally as a chloride slight stimulus to the bronchial epithelia and produces a reac- tive outpouring of serum ; besides, ammonia salts exercise a stimulating effect upon the respiratory centres in the medulla and hence aid in the expulsion of the mucus. The dose of am- monium chloride varies from five to fifteen grains (0.3 to 1 gm.)and it should be given at three or four hour intervals. A very convenient and useful way of administering it is in solu- tion in Mist. Glycrrhiza? Comp. (see page 28o i. Emetics, given in small doses, produce a copious transuda- Emetics tion of bronchial mucus and of saliva. They are all very useful, therefore, if the bronchial secretion is tough and viscid and thus difficult of expectoration, but they should never be used when the secretion of the bronchial tubes is abundant. Nor should ipecac they ever be given to sufferers from heart disease (see page 282 ACUTE TRACHEOBRONCHITIS Apomorphine Tartar emetic Turpentine Terpene hy- drate Terpinol Balsams of Peru and tolu Sodium ben- zoate Volatile oils Copaiba Cubebs Santal oil Strychnia 38) or from catarrh of the stomach. The most useful mem- bers of this group are ipecac, most conveniently given in the form of Dover's powder, five grains, several times a day; or as syrup of ipecac in one-half to one teaspoonful doses; apomor- phine, given in doses of one-twentieth to one-tenth of a grain (.03 to .06 gm.) ; and tartar emetic, in doses of one-thirtieth to one-eighth grain, two or three times a day. Turpentine is also useful at this stage ; it should be given in ten to twenty drop doses in a tablespoonful of milk and half a glass of milk taken immediately afterwards. If the patients cannot take the milk, five to six drops of turpentine may be placed upon a piece of bread and butter and the drug taken in this way. The milk and the butter prevent the irritating effects of turpentine upon the gastric mucosa. Agreeable preparations of turpentine are terpene hydrate, which can be given in daily doses of 0.2 to 0.5 gm., acceptably in dilute alcoholic solution with some simple syrup; terpinol, in three grain doses, four or five times a day, in capsule with two or three parts of olive oil. The balsams of Peru and tolu are very popular in the treat- ment of bronchitis. They all contain benzoin or its derivatives, hence sodium benzoate belongs to the same group. Balsams of Peru and tolu should be given in an emulsion or as a mucilage in doses of five to fifteen grains (0.3 to 1 gm.) several times a day. The syrup of tolu is particularly useful as a vehicle for ammonium chloride, emetics or opiates, but it contains very little of the balsam so that it is itself practically inert. Ben- zoate of soda is generally very useful; it should be given in five to thirty grain doses (0.3 to 2 gm.) two or three times a day. Certain of the volatile oils, as copaiba, cubebs and santal, may also be given at this stage. Copaiba, in the form of the oleoresin, in capsule, in doses of ten to twenty drops (0.6 to 1.3 cc. ) ; cubebs also as the oleoresin, in doses of ten to fifteen minims (0.6 to 1) ; and santal oil in the same dose, several times a day. Turpentine and the balsams are apt to irritate the stomach and the kidneys and hence they should be administered with care and their use discontinued at once upon the appearance of signs of gastric or renal irritation. In order to aid the expulsion of the mucus strychnia is one of the most effective remedies, for it causes contraction both of the bronchial musculature and of the large respiratory muscles. Strychnia is particularly valuable in cases of bronchitis in which much tough mucus accumulates during the night, so that the patients awake with severe dyspnea. Here the administration of one-thirtieth to one-fortieth of a grain of strychnia before going to sleep frequently prevents these attacks of nocturnal CHRONIC BRONCHITIS AND BRONCHIECTASIS 283 dyspnea. Senega, finally, which may be given in doses of ten Senega to twenty drops (0.6 to 1.3 gm.) of the fluid extract, or in the form of the syrup of senega one to two drachms (4 to 8 gm.), may also occasionally be employed in this stage of bronchitis. If the cough is very severe and distressing then it becomes necessary to allay both the irritability of the coughing center and the local sensitiveness in the pharynx. This can best be done by Opium and small doses of opium or morphine, preferably given in combina- orp me tion with atropine or belladonna, especially if there is, at the same time, a very active and profuse discharge of bronchial Atropine secretion. One of the best standard preparations for internal use at this stage is the Compound Licorice Mixture containing opium, anti- Mistura mony, spirits of nitrous ether and licorice as its chief ingredients. C0 ^J TT It should be given in one to two teaspoonful doses, several times a day. In order to quiet the local irritation in the throat any Cough syrups demulcent or syrup is useful, and here the innumerable cough drops Irops and cough syrups that are recommended have their field of application. CHRONIC BRONCHITIS AND BRONCHIECTASIS. Chronic bronchitis may develop as a result of repeated at- tacks of acute bronchitis, or it may be a part phenomenon or complication of heart lesions, arterio-sclerosis, emphysema, obesity, gout, chronic nephritis and other disorders. The chronic inflammation of the bronchial mucosa generally yields to appro- priate treatment directed towards removing the underlying cause, as discussed in the section on these different diseases. If Causal and the primary affection is irremediable, or if mechanical destruc- treatment l ° tion, scil. atrophy of the mucous lining of the bronchi, has oc- curred, then the treatment of chronic bronchitis of necessity becomes symptomatic. The treatment of the different varieties of chronic bronchitis differs somewhat according to the charac- ter of the secretion. From a therapeutic standpoint it is practi- cal to distinguish a dry form of chronic bronchitis in which there is very little secretion; a moist form in which there is very abundant secretion; a form in which the exudate is fibrinous and in which casts of the bronchial tubes appear, and, finally, a purulent or putrid form of chronic bronchitis. In all kinds of chronic bronchitis the choice of climate is Climate exceedingly important. In the dry variety a moist, warm climate with the minimum of sudden temperature changes is the ideal, whereas in the moist variety a dry, hot climate is by far prefer- able. Whatever resort is selected the atmosphere should be free 284 CHRONIC BRONCHITIS AND BRONCHIECTASIS Mountains Seashore Hydrotherapy Alkaline and saline waters Sulphur waters Medicamentous treatment Treatment of putrid bron- chitis Inhalations from dust. If the subject is anemic, and if there is complicating lung trouble, especially of a tuberculous character, then a mod- erate altitude is advantageous (see page 318). If there is em- physema and the subject is not anemic, then the sea shore is better. The selection of a proper climate for chronic bronchitis is altogether an exceedingly difficult task, for it must be governed by many individual factors that vary in each patient. Hydrotherapeutic measures are of particular value in dry forms of chronic bronchitis and enough cannot be said in regard to their efficacy, especially of cold compresses applied in the form of crossed bandages, as fully described in the section on Acute Bronchitis (see page 281). These compresses allay the coughing, act as a general sedative to the respiratory centers, liquefy the bronchial secretions and aid in their expectoration. Alkalies and alkaline and saline waters are always of value; the latter both on account of their stimulating effect upon the bronchial secretion and their laxative properties; for they ef- fectively relieve abdominal plethora and hence save the right heart much labor, in this way improving the circulation in the lungs. Sulphur waters, too, have an important place in the treatment of chronic catarrhal bronchitis, for part of the sulphur is eliminated via the bronchi as sulphureted hydrogen, produc- ing in its passage active hyperemia of the atonic mucosa, hence improving the circulation in the bronchial wall and also acting to some extent as a local antiseptic. The drug treatment of chronic bronchitis varies according to the character of the secretion. In the dry variety remedies should be administered that can aid the liquefaction of the viscid mucus and, at the same time, stimulate the bronchial mucosa ; to this group belong ammonium chloride, turpentine, balsams of Peru and tolu, sodium benzoate, copaiba, cubebs, santal oil, ipecac, tartar emetic, apomorphine ; whereas in the moist variety drugs shou]d be used that can diminish the excessive secretion and simultaneously favor its expectoration, notably, belladonna, atropine, stramonium, hyoscyamus. All these remedies, with their dose and mode of administration, have been fully men- tioned under Acute Bronchitis. In purulent and putrid bronchitis, disinfection and deodoriza- tion of the foul bronchial secretion can be accomplished either by the inhalation of medicated vapors or by the internal admin- istration of different drugs that are in part excreted via the bronchi. The best method of treating the bronchial mucosa by inhalations is by means of a steam atomizer, using turpentine oil, tincture of eucalyptus, carbolic acid (1 to 3 per cent.), thymol (1 to 2.000), creosote or gnaiacol (1 to 2 per cent.), to medicate CHRONIC BRONCHITIS AND BRONCHIECTASIS 285 the vapors. For internal use the balsams of Pern and tolu, sodium benzoate, turpentine and its derivatives (see index), Drugs fluid extract of eucalyptus, fifteen to thirty drops, or eucalyptol, five to fifteen drops, repeated several times a day (or sulphur waters), may all be employed. In fibrinous bronchitis the most effective remedy is iodide Treatment of of potash, given in increasing doses, beginning with ten drops fibrinous bron- of the saturated solution in milk, three times a day, and grad- ually increasing the dose until sixty or more drops a day are i di ae f being taken. The good effects from iodide of potash may pos- potash sibly be attributed to the fact that many cases of fibrinous bron- chitis are due to syphilis. Inhalation of lime water through a Lime water by steam atomizer is the best remedy to produce loosening and ex- m a a 10n pectoration of the fibrous coagulates in the bronchi. In many cases of chronic bronchitis it becomes necessary at Narcotics some stage of the disease to administer narcotics in order to check the severe cough. This is necessary for the comfort of the patient and in order to prevent emphysema and dilatation of the heart, two complications that are certain to' supervene unless the coughing is controlled. In view of the chronic char- acter of the disease particular care should be exercised not to create an opium habit, and, for this reason, it is well to fre- quently change both the preparations of opium as well as their mode of administration, giving at different times opium in tinc- ture or extract, morphine, codeine, heroin, dionine by mouth, hypodermically, in suppository or as a rectal injection. The dose should always be small and it is best if the patient does not know what he is getting. The addition of belladonna or Atropine atropine to opium preparations is usually of value. Strych- nine also has a place in the treatment of chronic bronchitis, for strychnine it aids expectoration by its stimulating effect upon the bronchial musculature, the respiratory centre and the heart. BRONCHIECTASIS. Bronchiectasis may well be discussed in connection with chronic bronchitis, for the internal treatment and the treat- ment by inhalation is essentially the same as in the putrid bron- chitis. In bronchiectasis certain mechanical features that characterize this disorder must be considered; thus the evacua- tion of the bronchiectatic cavities is promoted by placing the patient every morning in such a position that the opening into the bronchiectatic cavity, provided there is only one large cavity, Position of pa- points downward. In giving inhalations with the different rem- in^iati^ns^ edies described above it is always well first to produce evacuation of the cavity in this way and then to let the patient remain in the proper position while inhaling ; if this is done, the medicated vapor can come into much more intimate contact with the dis- l>8(i BRONCHIAL ASTHMA Danger of narcotics Operative treatment eased cavity wall than if the latter is full of excretion. In bron- chiectasis narcotics should be withheld, for if the sensibility of the mucosa near the orifice of the cavity or cavities is dead- ened, the normal coughing effort that results from contact of the putrid material with this area is prevented so that stagna- tion of the material in the bronchiectatic cavities is favored and the disorder is apt to be aggravated rather than improved. The operative treatment of bronchiectasis is still in the ex- perimental stage. Aspiration of bronchiectatic cavities is feas- ible only if the exact location., of the cavity can be determined by physical examination and if the cavity is near the surface. Drainage of the cavity by aspiration, and injection of antisep- tic fluids into the cavity, is never without danger ; this procedure, moreover, is followed by very indifferent results, and as there is generally more than one bronchiectatic cavity, it is hardly prac- ticable. Opening t'he pleura for the purpose of producing col- lapse of bronchiectatic cavities has been extensively practised; but I have not been convinced in those cases in which I could study the patients before and after the operation, that the re- sults obtained were sufficiently satisfactory to justify so pre- carious an inroad. Cardiac, renal, uremic, lead, e*~ M asthma Bronchial asthma Causes BRONCHIAL ASTHMA. Many forms of dyspnea that are due to heart disease, ne- phritis, obesity, diabetes, goutiness and lead-poisoning are com- monly included under the name of asthma, with various pre- fixes such as cardiac asthma, renal asthma, uremic asthma, lead asthma, etc. These symptomatic forms of asthmatic dyspnea usually yield to proper causal treatment directed towards the underlying disorder. Bronchial asthma proper is a disease sui generis, of various etiology. It is characterized by spasm of the bronchial mus- cularis, generally accompanied by vaso-motor disturbance in the bronchial mucosa, manifesting itself by hyperemic swelling and narrowing of the bronchial lumen, and occasionally by the formation of an exudate in the smaller bronchioles. These conditions may be produced, first, by local agencies directly affecting the upper respiratory passages and the bron- chial mucosa, as certain forms of dust or pollen and, in pre- disposed subjects, emanations from certain animals, as well as other odors; second, by certain psychic factors, as a fright or an emotional shock, a loud noise, a flash of light and many bizarre causes, especially in hysteric and neurasthenic subjects; third, by reflexes starting from variuos organs of the body, BRONCHIAL ASTHMA 287 notably, the genital sphere, the gastro-intestinal tract (disten- sion of the stomach, constipation, meteorism and intestinal para- sites) and, above all, the nasal mucosa. Causal treatment should take all these elements into consid- Causal treat- eration. It is one of the fundamental rules in the treatment ment of bronchial asthma to carefully elicit from the patients state- ments in regard to those factors that seem to precipitate the attacks; and however ridiculous the determining elements may seem to be, to take the statements of the patient very seriously into consideration and to proceed accordingly. The element of suggestion is very strong in many cases, particularly in hysteri- cal women who have preconceived notions in regard to the ele- ments that produce asthma. To ridicule their belief is bad Suggestive practice and in such cases, suggestion, even hypnotism, is use- rea men ful; Christian Science has celebrated some of its greatest tri- umphs in the cure of such neurotic forms of bronchial asthma. In neurasthenic individuals judiciously applied hydrother- apeutic measures, as described in the Section on Gastric Neuroses, are exceedingly useful ; if possible such patients should be treated for a time in an institution, where any ovarian or uterine trouble may coincidentally be corrected. The diet should always be carefully regulated. Over- Diet loading the stomach, particularly with starchy foods, should studiously be avoided. Constipation and flatulency should be Constipation combated with the means that are discussed under Intestinal Diseases. Intestinal parasites should be sought for, and if found, Parasites removed. The patients should be advised against going to bed during the period of active gastric digestion, in other words, they should never take a heavy meal at night, nor indulge in late suppers. Treatment of the nose, while occasionally followed by very Nasal treat- gratifying results in bronchial asthma, is, by no means, the panacea that it is claimed to be by extremists. It . : s good prac- tice in every case of bronchial asthma to carefully examine the nose. The mucosa should be cocainized and sensitive areas, so- called 'asthma points," looked for by touching different intra- nasal areas with a probe. If marked respiratory reflexes can be elicited by touching such points, and especially if they are found upon a polypus or hypertrophied or turgescent tissues, then these over-growths should be removed. At all events the "asthma points" should be cauterized surgically. It is said that if true "asthma points" have been destroyed in this way, a febrile reaction will appear in the evening and persist for several days in susceptible individuals. If the patient will not give his consent to intranasal treatment t etween the attacks, then symptomatic relief can often be obtained during the paroxysm 288 BRONCHIAL ASTHMA Climate Interim, treatment Iodide of potash Arsenic Atropine by touching the "asthma points" in the nose with a five to ten per cent, solution of cocaine hydrochlorate. There is very little to say in regard to the selection of a climate for asthmatic subjects, for every patient is a rule unto himself. Some patients find relief at the sea shore, others at an altitude ; some in a moist, others in a dry climate ; a few people in the city and others in the country. It has been my ex- perience that most of the cases do well after any change of climate, so that they should be instructed to go to one place first, and to seek some other locality, high or low, wet or dry, hot or cold, as soon as the asthmatic paroxysms again make their appearance. Sufferers from hay fever asthma, of course, should select one of the resorts mentioned in the Section on Coryza Vasomotoria. It is very important to attempt by all means at our disposal to reduce the number of attacks; for in this way the affected centres are given a rest and are enabled to regain their normal tone. In the interim between attacks certain remedies should, therefore, be administered that may accomplish this purpose. The principal reliance can, I believe, be placed upon the iodide of potash, given in ten to thirty drop doses of the saturated solution in milk, three times a day, for three or four weeks con- tinuously, then omitted for a week and then again administered for a like period. Such an interrupted course of iodide of potash can be continued almost indefinitely, often with great relief to the patient. Next in importance to iodide of potash is arsenic, given either in the form of Fowler's solution, beginning with five drops, three times a day, in water, and increasing the dose until fifteen drops, three times a day, are taken; or in the form of arsenious acid, sodium arseniate or sodium cacodylate (see page 74). Arsenic, too, should be given interruptedly, the patient tak- ing the maximum dose for three or four weeks and then grad- ually reducing it, only to increase it again when the lowest dose is reached. Iodide of potash is the best remedy when there is much bronchitis, emphysema or arterio-sclerosis, or if there are manifestations of goutiness, whereas arsenic seems to yield bet- ter results in young, neurotic subjects without bronchitis or emphysema. Atropine is another useful remedy, provided the iodide of potash and the arsenic do not exercise the desired effect; it should be given in rather large doses, i. e., one-one-hundred-and- fiftieth to one-one-hundredth of a grain, two or three times a. day for a considerable period of time, care being always taken that symptoms of atropine poisoning do not make their appear- BRONCHIAL ASTHMA 289 ance. Atropine presumably acts by paralyzing the vagus ter- minations, thus reducing the spasm of the bronchial muscula- ture and suppressing the bronchial secretion. For the treatment of the acute attack a great many remedies Treatment of have been recommended. It is necessary in bronchial asthma, ta ck acu e a " owing to its manifold origin and the varying idiosyncrasies of many sufferers from this disease, to try a great many different remedies before finally one is discovered that seems to be spe- cifically active in the particular individual. The most generally useful remedy to abort an attack is probably chloroform, which Chloroform may either be administered in small whiffs or given internally as chloroform water in the dose of one to two teaspoon fuls, or as spirits of chloroform in twenty to sixty drops. If the par- oxysm is not promptly checked by chloroform, then morphine should be given hypodermically in one-eighth grain doses, com- Morphine bined with a one-two-hundredth grain of atropine and two to five drops of a ten per cent, solution of cocaine hydrochlorate ; Cocaine this dose to be repeated two or three times if necessary. As it is not practicable nor altogether safe to leave the hypodermic in the hands of the patient, this treatment should be reserved for use by the physician if he is called in early to a case of severe bronchial asthma. The patients may have on hand for internal use a solution of chloral Irydrate, which is best given in combina- Chloral tion with large doses of bromide of potash well diluted with some simple syrup and water. The following prescription I have Bromides found useful for stopping attacks of bronchial asthma : i* Chloral hydrate, 4 gm. Potassium bromide, 12 ec. Simple syrup, 32 cc. Water, 96 ec. M. S. A dessertspoonful every hour until relieved, or until four are taken. Chloral hydrate should, of course, never be prescribed unless the heart is altogether intact. A useful substitute for chloral hydrate in such cases is chloralamid (see page 36), which may Chloralamid be given in doses of ten to thirty grains (0.65 to 2 gm.) two or three times in succession at intervals of one hour. Very popular are asthma cigarettes made of the leaves of Asthma cig- stramonium, belladonna, hyoscyamus or lobelia, usually mixed with potassium nitrate or smoked through paper that has been soaked in nitrate of potash. Trousseau recommends the follow- ing cigarette: 290 CAPILLARY BRONCHITIS BRONCHO-PNEUMONIA V Cannabis indica Inhalations of potassium ni- trate, ammonia vapors, to- bacco smoke Steam Leaves of belladonna, Leaves of hyoscyamus, Leaves of stramonium, Phellandrium aquat, 0.36 0.18 0.80 0.06 The ribs are removed and the leaves cleansed, a trace of ex- tract of opium added and the mixture rolled up in paper treated with laurel water and dried. The mixture of these leaves may also be cut up fine and ignited on a plate and the fumes inhaled. Cannabis indica is also used in the form of cigarettes and very good results are claimed from its use. The following mix- ture is particularly recommended by Ortner: ? Stramonium leaves, Potassium nitrate, of each, Belladonna leaves, Herb, cannabis indica, of each, 2 10 The mixture may be used either in cigarettes or it may be mixed with nitre, ignited on a plate and the fumes inhaled. In order to be effective the smoke from these cigarettes must always be inhaled. It is impossible to predict in advance whether or not they will help, but it is certainly worth while to try them in every case. Other remedies that are used for inhalation are nitrate of potash, which may, in a simple manner, be vaporized on a hot spoon. Ammonia vapors also occasionally relieve. Strong ammonia water is poured into a glass and the patient after plugging his nostrils with cotton inhales the whiffs of ammonia that are carried to his mouth by fanning across the top of the vessel. It is finally worthy of mention that some pa- tients obtain marked relief from smoking tobacco. It is always good practice during the attack to develop steam in the room. Sometimes relief is obtained if the patients re- peatedly dip their hands or feet, or both, into hot water. Whether this is a reflex vaso-motor effect or pure suggestion is hard to determine; yet as the measure can do no harm, often does good, and is very simple, it should be advised. CAPILLARY BRONCHITIS— BRONCHO-PNEUMONIA. Catarrh of the smaller bronchioles (bronchitis profunda, bronchiolitis capillaris), especially in children and old people, frequently extends to the infundibula and ultimately involves CAPILLARY BRONCHITIS BRONCHO-PNEUMONIA 291 the lobules of the lungs. From a clinical point of view, there- fore, it is practical to consider capillary bronchitis and broncho- pneumonia together. Owing to the occlusion of numerous air channels and the Involvement ° . of the right narrowing of the bronchial lumen in either disease, the aeration heart of the lungs becomes deficient so that an excessive amount of labor is thrown both upon the right heart and upon the muscles of respiration. In most cases fever sets in that in its turn ex- ercises a deleterious effect upon the heart muscle. Most cases, therefore, as will readily be understood, die not from the bron- chial and pulmonary inflammation directly, but rather from embarrassment and failure of the right heart. One of the main objects of treatment, consequently, should be to support the heart, relieve the respiratory muscles of their excessive labor and reduce the temperature. Hydrotherapy Here lukewarm baths (90° to 96° F.) gradually reduced to 75° or 60°, or followed by cold sponging, are the sovereign rem- edy. The explanation of their action is the following: By immersion in water that is somewhat below the normal body temperature a preliminary contraction of the cutaneous vessels Lukewarm baths is produced, especially in febrile cases; this is followed by a reactive dilatation of these vessels which can be markedly en- forced by rubbing tiie patient while he is in the bath. The pri- mary shock and the sudden contraction of the skin vessels causes reflex stimulation of the heart and of the respiratory centres as manifested by a rise of the blood pressure and a few deep in- spirations. The passive hyperemia of the skin which follows, in its turn depletes the bronchial mucosa, relieves the heart, re- duces the blood pressure and quiets respiration. The effects of the primary shock are very transitory, whereas the reaction per- sists for a long time. A second reaction can be secured if the patient upon leaving the bath is rapidly sponged with cold water of room temperature and is at once put to bed between warmed linen sheets and given the benefit of an energetic dry surface massage. The duration of the bath should not exceed ten to fifteen minutes and two or three such baths may be given during the day. This bath treatment is particularly useful in cases of capillary bronchitis affecting strong individuals without pul- monary involvement and without high fever. In all cases it is good practice to give a teaspoonful or two of brandy before the bath. If myocardial or arterio-sclerotic changes are present such cool baths should, of course, never be given. Instead of cool baths the cold pack may be applied as fol- ° pac lows : A linen sheet is wrung out of water of from 50° to 65° F. and the patient quickly wrapped up in the sheet and covered 292 CAPILLARY BRONCHITIS BRONCHO-PNEUMONIA with a woolen blanket. Here, too, there is a preliminary shock, promptly followed by the desired reaction. It is best to cover only portions of the patient 's body at a time, applying the sheet once to the thorax, then to the abdomen and then to the legs. In very nervous subjects and in cases suffering from much dyspnea, I have made it a rule always to leave the arms free when administering a wet pack, for wrapping the sheet around the arms causes a sense of restraint and oppression that excites and worries the patients and reacts unfavorably upon the heart's action and the blood pressure — conditions which should be avoided. The cold packs should be repeated at short intervals until the temperature is lowered several degrees. As a rule, after the first pack the temperature at first falls quickly, but rises again as quickly, i. e., within a few minutes, so that it usually requires three or four applications of the wet sheet to keep the temperature permanently down. Hot bath In some forms of capillary bronchitis there is no fever, the patients even develop sub-normal temperatures with cyanosis and cold hands and feet; here cold hydrotherapeutic measures are altogether out of place and the hot pack or the hot bath should be given instead. Contra-indications to the use of hot hydrotherapeutic measures are myocardial changes and arterio- Hot pack sclerosis. In giving the hot pack the sheet is wrung out of water of 100° to 105° F. and the patient speedily wrapped into it and covered as above; or the patient may be placed into a bath of 100° F. for ten or fifteen minutes. In either case an ice bag or cold cloths should be applied to the head. As soon as the hot cloth is removed or the patient leaves the hot water, the skin should be energetically rubbed with a warm rough towel and the patient placed to bed and covered with linen or cotton bed-clothing. The good effects of the hot bath must be attributed to the passive hyperemia of the skin that sets in promptly, for the dilatation of the superficial capillaries that is produced is prac- tically synonymous with bleeding the patient into his own ves- sels ; the fall in the blood pressure that resuljbs herefrom greatly relieves the heart without depressing it. Here, too, as in the case of cool bathing, the first contact with the hot water stimu- lates deep respirations and aids expectoration. The prolonged exposure to heat, besides, exercises a very desirable sedative in- fluence on the nervous system, most patients promptly falling asleep after such bath. The temperature occasionally rises slightly while the patient is immersed in the hot water, but in febrile cases it generally drops 2 or 3 degrees as soon as the patient is back in bed. CAPILLARY BRONCHITIS BRONCHO-PNEUMONIA 293 The air in the room should always be kept moist. This is Moistening best done by hanging sheets wrung out of hot water in the the air room, or by developing steam from a kettle or pan. In children the bronchitis tent described elsewhere (page 280) may be used and steam developed underneath it. Cases that set in with high fever, and all cases of capillary Rest in bed bronchitis developing in children and old people, should be kept in bed, preferably in a semi-recumbent position; the pa- tients should be ordered to frequently change their position so ^ ha .^f e of as to prevent hypostatic congestion of the lungs. Little children with capillary bronchitis should be frequently lifted out of bed and carried about. The diet should be very strengthening but not bulky. No I)iet articles of food should be given that can dilate the stomach or produce gaseous distension of the stomach or bowels, as, other- wise, the heart's action may be mechanically interfered with and full excursions of the diaphragm downward prevented, so that coughing and expectoration would be rendered difficult. The diet should, therefore, be largely albuminous, consisting of scraped meats, broth, milk, eggs, with a little fresh fruit and fresh vegetables and a minimum of starchy foods and fats. Little food or drink should be taken at one time, the patient preferably eating small meals at frequent intervals. A little alcohol in the form of dilute claret, Rhine wine or whisky throughout the disease can do no harm ; the alcohol acting bene- ficially both on account of its food value and on account of its general stimulating and supporting effect upon the heart. If symptoms of heart weakness appear, alcohol is by far the best stimulant in this disease. The bowels should be kept open throughout the course of Regulation of the bowel the disease. Constipation and intestinal flatulence or meteorism function are to be carefully avoided in order not to interfere with the movements of the diaphragm. In the beginning free catharsis should be promoted by a tablespoonful of castor oil, or by calo- mel best given in one-tenth grain doses repeated ten times and followed by a tablespoonful of magnesium sulphate in water. Later a mild saline laxative or wine of cascara may be given in doses sufficiently large to produce one or two free evacuations of the bowels every day. The medicamentous treatment of the bronchitis per se does Medicamentous not differ very materially from that advised in other forms of acute bronchitis (see page 281). If the disease sets in suddenly with high fever, drop doses of the tincture of aconite every two Aconite or three hours should be given. Narcotics should be used very 294 PULMONARY EMPHYSEMA Stimulating expectorants Emetic expec- torants Heart tonics Narcotics sparingly, as it is self-evidently always dangerous to suppress the cough and stop the expectoration. If the cough is very dis- tressing, if it is wearing the patient out, preventing sleep or straining the heart, as manifested by an irregular heart action after each coughing effort, then a five-grain dose of Dover's powder, or one-eighth grain of morphine with one-two-hun- dredth grain of atropine, or a one-fourth grain of codeine, may be administered several times a day. Stimulating expectorants as strychnine, senega or ammonium chloride, and small doses of the emetic expectorants, ipecac, tartar emetic, apomorphine, may be given with the reservations and precautions outlined in the Chapter on Valvular Lesions (see page 38) and the Section on Acute Bronchitis (page 282). As soon as alarming signs of heart weakness appear, heart tonics must be given (see page 32). I have made it a practice to give very small quantities of digitalis or strophanthus, i. e., two or three drops of the tincture several times a day from the very onset of the disease. In this way the heart's action is rendered more regular, while, at the some time, no over-stimulation is produced. I have never seen any ill-effects from this practice. If small doses are given larger doses always remain available for emergencies. If signs of heart failure appear suddenly (and if the case is carefully watched from the beginning and treated with small doses of heart tonics this failure is not apt to appear unexpectedly), camphor, ether, ammonia must be given hypo- Analeptics dermically (see page 32) and the patient sponged or douched with very cold and very hot water alternately. On rare occa- Oxygen sions it may become necessary to resort to inhalations of oxygen, combined with the use of strychnia in one-twentieth to one- fortieth grain doses, given hypodermically in order to overcome cyanosis, excessive dyspnea and lividity. The treatment of the convalescent stage is the same as in any other form of bronchitis. Limitations of treatment II. DISEASES OF THE LUNGS. PULMONARY EMPHYSEMA. On account of the mechanical and destructive character of the lesion in pulmonary emphysema a cure of this disorder is manifestly out of the question. We are dealing with a rarefac- tion of the intralobular septa either throughout the lung or in certain circumscribed regions (as in compensatory or traumatic emphysema) with atrophy of the alveolar walls, obliteration of capillaries and loss of elastic tissue and, in many cases, anatomic rigidity of the chest wall with ossification of costal cartilages. PULMONARY EMPHYSEMA 295 When one considers further that in many cases of em- Hereditary physema, especially when occurring in young people (with or element without the co-operation of factors like over-exertion and vio- lent respiratory efforts incident to various occupations), a dis- tinctly hereditary element, manifesting itself by abnormally high intra-pulmonic blood pressure and congenital weakness of the alveolar walls must be included in the question, then it becomes clear that even prophylactic treatment directed towards check- ing the progress of emphysematous changes when they first make their appearance is generally a futile task. For all these reasons the treatment of emphysema is of Treatment necessity largely symptomatic. Our efforts must be directed t ^® t f c ^^-'P" chiefly towards counteracting the bronchitis that complicates and aggravates most cases of the disease; then towards prevent- ing or correcting the dilatation and hypertrophy, especially of the right heart, that generally precede or follow emphysema ; and towards relieving the signs of venous stasis about various organs that develop consecutively to the cardiac insufficiency. Finally the asthmatic seizures and the attacks of dyspnea that render the existence of advanced cases of emphysema so hard to bear must be energetically treated and if possible relieved. In undertaking to treat the bronchial catarrh in anj case The cornpli- of emphysema of the lungs it is very important, as a preliminary chiS 8 cat' r 1 li step, to determine whether the bronchial catarrh preceded the emphysema or whether it developed consecutively to emphyse- matous rigidity of the lung. This point can usually be deter- mined with some degree of accuracy from the history. If the bronchitis preceded the emphysema then it is pre- Expectorants sumably of the simple catarrhal variety, and here the various cough remedies, sedatives, expectorants, etc., that have been described in full in the Section on Chronic Bronchitis (page 284) have their field of usefulness. If the bronchitis developed after the emphysema, then it Cardiac tonics is generally due to venous hyperemia of the bronchial mucosa produced by the impeded pulmonary circulation and the weak action of the right heart that so commonly supervenes in pul- monary emphysema. If a careful examination of the heart re- veals dilatation of the right half and marked accentuation of the second pulmonary sound and if, at the same time, evidence of venous stasis, due to cardiac insufficiency, is discovered in other regions of the body, then venous stasis can be charged with producing the bronchial catarrh, and the treatment should be largely cardio-tonic, as described in the section on Valvular Diseases in the stage of failing compensation. Unfortunately the exact determination of the heart bounda- 296 PULMCNARY EMPHYSEMA Significance of bloody sputum Catarrhal asthma Dyspnea Climate and resorts ries is frequently a very difficult matter in emphysema because the superficial heart dullness is commonly obliterated in emphy- sema of the anterior margins of the lungs, and because deep percussion does not yield very positive information in advanced degrees of emphysema. The presence of a little blood in the sputum may aid in the differential diagnosis between hyperemic catarrh of the bronchi, due to venous stasis, and simple bron- chitis, slight degrees of hemoptysis speaking for hyperemia of the bronchi. A therapeutic test, finally, with heart tonics may aid in the decision ; for venous stasis in the bronchi, i. e., hyperemic catarrh, yields readily to the judicious use of these tonics, whereas catarrhal bronchitis is in no way influenced by cardio- tonic medication. There is still another variety of bronchial catarrh in em- physema that assumes the characteristics of catarrhal asthma. The dyspnea is paroxysmal and spasmodic and the sputum in many cases contains eosinophile cells. Here, too, the catarrhal asthma may have preceded the emphysema or it may have fol- lowed it, the former being the more common event. The treat- ment of this variety of bronchial catarrh must be carried out as described in full in the Section on Bronchial Asthma. It will usually be found that if the bronchitis, soil., the cough, expectoration and the asthmatic paroxysms, are held in check the patients notwithstanding their emphysema will feel relatively comfortable, in fact, rarely suffer from their em- physema per se unless the latter is so far advanced as to ma- terially reduce the breathing surface of the lung and to cause marked insufficiency of the right heart with all that that en- tails. Hence it is a matter of greatest importance to determine the exact cause of the bronchial trouble and to attack it energet- ically. The dyspnea that emphysematous patients suffer from calls for the same careful analysis as the bronchial catarrh. It may be due either to the emphysema itself, i. e., it may result from the reduction of the breathing surface of the lung, or it may be paroxysmal in character, i. e., an asthmatic dyspnea, or it may be due to cardiac insufficiency. In the latter case appro- priate cardio-tonic treatment is usually effective; in asthmatic dyspnea the treatment is the same as given in the Section on Bronchial Asthma. In view of the chronic character of emphysema the choice of a resort or a climate and of the proper altitude is exceed- ingly important. Here, as in the selection of all the other PULMONARY EMPHYSEMA 297 remedial measures that are to be employed, the exact causes that determine the complications, chiefly the bronchitis and the dj^spnea, must be considered and advice rendered accord- ingly. Thus in the selection of an altitude everything will depend Altitude upon the condition of the heart, the severity of the bronchial catarrh and the degree of emphysematous dilatation of the lung. If the emphysema predominates and the bronchial catarrh Moderate al- is relatively slight and the cardiac insufficiency not far ad- tltudes vanced, then a moderately high altitude should be selected, for these patients complain chiefly of difficulty in getting rid of the air, that is, of expiratory dyspnea ; so that the low barometric pressure at an altitude and the rarefied air render expiration •easier and hence help the patient. Incidentally slight degrees of bronchial catarrh are not unfavorably influenced by an alti- tude. If, on the other hand, the catarrhal condition of the bronchi Southern low predominates so that there is abundant irritating secretion and climates much cough with resulting strain upon the heart, then these patients should be advised against seeking high altitudes and should live in a Southern climate at a low barometric pressure with the minimum of temperature changes, a maximum of clear, sunshiny days and little humidity in the air. The latter require- ments can frequently only be met in semi-tropical arid regions; here however the dust and alkali in the air usually constitute a serious irritant to the bronchial mucosa and produce violent coughing efforts — therefore the climatic advantages are often neutralized in this way, so that emphysematous patients should be sent by preference to moist: warm, rather than to dry, warm Sea sn <> re and climates. For such cases the seashore in Southern regions, or an ocean voyage through Southern seas, is of signal benefit. Patients who cannot seek a proper climate occasionally derive Pneumatic benefit from the use of pneumatic chambers at home and in re- chamber sorts located not too far from home. A great many different kinds of apparatus have been constructed by means of which the patient breathes under pressure; all of them improving the bronchial catarrh of emphysema provided it is due to hyper- emia of the bronchial mucosa. Symptomatically, too, breathing compressed air helps many cases of emphysema; the exact scientific explanation of this clinical fact is still forthcoming. In choosing a resort for an emphysematous case the charac- Laxative ter of the waters may be advantageously considered in addition waters to the altitude and climate and the facilities for breathing com- pressed air. Resorts furnishing laxative water should be given 298 PULMONARY EMPHYSEMA Diet Little albumen No large meal Reduction of obesity Venesection the preference for by the judicious use of saline laxatives ab- dominal plethora is corrected and hence the right heart re- lieved of much labor and breathing thus facilitated. On the same principle catharsis by saline laxatives should be promoted at home. The diet should be selected with the object in view chiefly of preventing abdominal plethora and over-loading or disten- sion of the stomach. Consequently the diet should not contain too much albuminous pabulum, for the latter produces engorge- ment of the mesenteric veins during digestion, i. e., abdominal plethora, more than other food. The use of aerated beverages and of fermenting foods chiefly of the starchy variety, should be interdicted. If necessary anti-fermentative remedies (see Meteorism) , may be given from time to time to prevent flatu- lency and distention of the stomach and bowel. In cases with a tendency to dyspnea large meals should never be allowed; the patient should be instructed to eat small meals at fre- quent intervals. All these dietetic rules are intended to pre- vent pressure upon the diaphragm from below by a distended stomach or bloated bowel and hence interference with free res- piratory excursions. If the patient with emphysema is obese, then a reduction cure- is an exceedingly useful element in the treatment; for the presence of large quantities of intra-abdominal fat interferes, with the respiratory movements of the diaphragm downward and hence increases the dyspnea, an effect that is enforced by the weight of large fat masses upon the thorax. Obese patients,, moreover, as a rule suffer from abdominal plethora, constipa- tion, flatulency, all factors that should be counteracted in em- physematous dyspnea. Finally, the heart, as is well known, is- particularly over-strained in advanced degrees of obesity. This, is due in part to the presence of fat masses around the organ and infiltration of the heart muscle by fat, or to fatty degenera- tion of the heart muscle; in part to the great resistance offered to the flow of blood by the fine network of capillaries that forms in new adipose tissue ; and to many other causes that have been discussed in full in the Section on Obesity on page 148. Some of the most gratifying results are obtained precisely in obese em- physema cases suffering from much dypsnea, bronchitis and symptoms of stasis in various organs as soon as the bulk of the- patient is reduced by a carefully carried out cure. For the choice of method and the technique of the latter I refer to the Section on Obesity. Occasionally a patient with advanced emphysema suddenly develops quite alarming degrees of dyspnea and cyanosis that PULMONARY EDEMA 299 endanger his life. In such cases without regard to what the exact pathogenesis of these phenomena may be in the individual case (and time will rarely be given to make a careful analysis of all the contributing factors) bleeding is the sovereign remedy. From two to three hundred cc. of blood should be removed at Oxygen in- once from the median basilic vein, as described on page 37 At the same time inhalations of oxygen may be given; two or three gallons of oxygen being administered every two or three hours. If the excitement is great and the patient very restless, then an hypodermic injection of an eighth of a grain of mor- Morphine phine with a two-hundredth of atropine frequently furnishes prompt relief. While these measures are being carried out the heart should be supported by the hypodermic administration of Analeptics analeptics, camphor, ether, ammonia, strychnia, given as de- scribed in detail in the Section on Valvular Diseases of the Heart in the stage of failing compensation (see page 32). PULMONARY EDEMA. There is an inflammatory pulmonary edema due to local pro- Collateral pul- cesses and occurring in the neighborhood of acutely inflamed onar y e ema areas, infarcts, tumors, etc., of the lungs, mediastinum ana pleu- ral cavities. This so-called collateral pulmonary edema is due either to local injury produced in the vessel walls of a given vicinity by bacterial toxins, or it may be due to plugging of blood-channels and lymph spaces, or to mechanical compres- sion of the latter in circumscribed areas of the lung. This local pressure or plugging, with or without degeneration of the vessel walls by toxins permits diapedesis of serum and probably also of corpuscles into the air cells and the alveolar tissues of cer- tain circumscribed regions of the lung and, in this way. pro- duces localized pulmonary edema. This variety is rarely amenable to treatment other than that directed towards the underlying cause. In fact, the edematous area is often so small as to cause little discomfort and produce few symptoms. If large areas of the lungs become edematous from this source, then the symptomatic treatment is the same as that of any other form of acute pulmonary edema. Edema due to paralysis of the musculature of the pulmonary An^io-neu- arteries may be a part phenomenon of hysteria (angio-neurotic rotlc edenla edema) or it may occur in the course of chronic intoxications as, e. g., in uremia, acute alcohol poisoning, lead-poisoning, Toxic edema iodide-poisoning, etc. The most common form of pulmonary edema, however, is 300 PULMONARY EDEMA Edema due to stasis Pulmonary edema usually due to several factors Condition of the heart im- portant Cardiac tonics Catharsis Diuresis Diaphoresis Cupping 1 Avoidance of iodids and bromids that produced by stasis in the pulmonary veins. This is an edema of the lungs that accompanies general disorders involving the competency of the heart, hence it often constitutes a terminal phenomenon in a variety of infectious and chronic cachectic disorders; it also occurs in valvular diseases of the heart and in cardiac disorders of manifold origin, fatty heart and myo- carditis. In most cases of pulmonary edema several of the above fac- tors are operative; thus, for instance, in uremic edema occur- ring in cardio-renal disease there is at the same time chronic intoxication from renal insufficiency, and a weakened heart and weakened blood vessels. In pulmonary edema occurring in infectious diseases, as typhoid, measles, influenza, pneumonia, etc., there is a general bacterial toxemia and often, at the same time, myocardial degeneration as a result of the infection. In pulmonary edema occurring in the course of anemia and cachec- tic states there is usually injury to the structure of the blood vessel walls from malnutrition and, at the same time, a heart with a weakened myocardium and self-ovidently with a tend- ency to dilatation and insufficiency. It will be seen, therefore, that in almost all cases of chronic pulmonary edema the condition of the heart must, above all things, be seriously taken into consideration, hence the treatment differs somewhat according to the condition of the heart. One can for therapeutic purposes distinguish between cases of chronic pulmonary edema in which the heart's action is good and the myocardium apparently intact, and cases in which the heart's action is weak and in which evidences of myocar- ditis, dilatation, fatty degeneration, etc., are apparent. The latter variety of cases is by far the most common of the two. Here the judicious use of cardiac tonics and of all the other hygienic, dietetic and hydrotherapeutic measures that have been described in full in the Section on Valvular Diseases of the Heart in the state of broken compensation must be em- ployed. Here, too, active catharsis and the stimulation of diure- sis and diaphoresis, with all the precautions and reservations that have been discussed at length in the above section, have a useful field of application. Dry cupping over the chest (see page 39) is a useful adjuvant to the treatment, especially in those peculiar cases of cardio-renal edema of the lung in which the edematous effusion seems to occupy circumscribed regions of the lung only. In all cases of chronic pulmonary edema particular care should also be exercised to avoid the administration of certain drugs that can produce hyperemia and congestion of the bronchi, PULMONARY EDEMA 301 notably iodids and bromids. This warning is appropriate be- cause in many cases of chronic pulmonary edema insomnia, due to the difficulty of breathing and possibly to circulatory disturb- ances of the brain that result from the cardiac insufficiency, is a very distressing symptom. Here the temptation is always given to administer bromids. On the other hand many cases of cardio- renal disease develop on the basis of a syphilis, so that a course of antiluetic medication with large doses of iodids might. seem indicated. Acute edema of the lungs developing as an exacerbation of Acute edema chronic edema or occurring suddenly and independently, im- material what its origin, calls for rapid interference, for this disorder always constitutes an emergency that threatens the life of the patient. The best remedy in any case is atropine or its congeners, Atropine hyoscine (scopolamine). These remedies should be given hypo- y° scine ,.,,., , ,.. n P . . Scopolamine dermically in large doses, that is, m doses or one-sixtieth to one- thirtieth of a grain (1 to 2 mg.) repeated two or three times, or oftener at intervals of one hour. To give smaller doses is, in my experience, a waste of time. The after-effects of the large doses of atropine or hyoscine are disagreeable, but one is dealing with a life and death question in which unpleasant sensations affecting the patient should not be considered. The action of atropine and hyoscine is to stimulate both the respira- tory centers and, at the same time, the vaso-constrictors ; in this way, in all probability, counteracting the mechanical dilatation of the vessel walls and rendering them less permeable to blood serum. In acute edema occurring in the course of chronic cachectic diseases and in disorders accompanied by malnutrition and degeneration of blood vessel walls no ready response to vaso- constrictor influences will be obtained; but cases advanced to this point are almost invariably fatal and as no harm can be done by giving atropine in large doses a trial, one need not hesi- tate to begin the emergency treatment, even in such cases, with large doses of atropine or hyoscine. Second in importance to atropine is ergot. This drug also Ergot is given on account of its power to cause constriction of blood vessels in certain areas of the body. Ergot does not produce general vaso-constriction, otherwise it would raise the general blood pressure much more than it does. It causes constriction merely of the blood vessels in certain areas of the body ; we know positively that it exercises this effect about the female adnexa, whether it exercises the same effect upon the pulmonary blood vessels we do not know positively, but some experimental evi- dence seems to indicate that it does. Empirically and clinically 302 PULMONARY EDEMA Action of ergot Mode of ad- ministration we know, at all events, that it raises the blood pressure in the pulmonary circulation and hence we are justified in concluding that it also exercises a local vaso-constrictor effect; for this rea- son the remedy is useful in pulmonary edema, and for the same reason it is so dangerous in hemoptysis (see page 310) ; for if there is rupture or erosion of blood vessels within the pulmonary area the beneficial effects that might accrue from the vaso- constriction are more than neutralized by the rise in blood pres- sure that is at the same time produced. If given in pulmonary edema it should.be given either in the form of the Injectia Ergota Hypodermica in the dose of three to twenty drops, or by mouth as the solid extract of ergot in doses of three to sixteen grains (0.2 to 1 gm.). It can, to advant- age, be combined with atropine and the following combination I have found useful and safe : ? Atropine, 1-50 gr. (0.0013 gm.) Extract of ergot, 10 gr. (0.6 gm.) M. Sig. One capsule every hour until relieved or until four are taken. Cacodylate of soda Analeptics Still another remedy that may be used as an emergency meas- ure in pulmonary edema is cacodylate of soda. This prepara- tion of arsenic should be given in large doses in order to be effective. It exercises a most remarkable influence upon exu- dates and edematous effusions without, to my knowledge, pos- sessing any disagreeable after-effects. It is perfectly safe to give sodium cacodylate hypodermically in one grain doses, in watery solution, every three or four hours, for four or five doses. A convenient way to administer the remedy is to have a solution of fifteen grains of cacodylate of soda to the ounce of water made and to inject a Pravaz needle full subcutaneously or in- tramuscularly every three or four hours. When one consid- ers that one grain of cacodylate of soda contains as much arsenic approximately as three-fifths of a grain of arsenious acid, the absence of symptoms of arsenic poisoning after the administra- tion of this drug is very remarkable. If there is much cyanosis in acute edema with other evi- dence of embarrassment of the right heart, then active cardio- tonic medication becomes necessary. Here the character of the pulse, the size of the heart, the strength of the apex beat and its reaction must all determine the dosage of the various analep- tics and cardio-tonics that are to be administered. The same PULMONARY INFARCT, ABSCESS AND GANGRENE 302 principles should govern us here as in the treatment of cardiac stasis due to decompensated valvular lesions. Ether, ammonia, camphor, camphor in ether, camphor in oil, champagne and, in less acute cases, digitalis, strophanthus, caffein, all have their application (see page 32). Venesection may be practised in extreme cases and very Venesection marked relief is frequently obtained from the withdrawal of two or three hundred cc. of blood. It is always safe and good treat- ment, if none of the above emergency medicines are immediately available, or if they do not act very promptly, to bleed the patient Leeches to as a preliminary measure. In the same sense the application of leeches to the anus, i. e., bleeding from the hemorrhoidal veins occasionally helps (see page 40). In advanced cases of cardiac incompetency with venous Paracentesis stasis in the portal area and abdominal ascites, paracentesis of i n p0 rtal the abdomen and withdrawal of some of the ascitic fluid fre- stas is with quently exercises a very beneficial effect upon the pulmonary edema edema. This effect must be attributed to the relief of pressure produced within the abdomen which enables the veins of the por- tal area to expand more readily and consequently to harbor more blood within their lumen. Abdominal puncture in these cases is, therefore, in a sense, bleeding the patient into his own blood vessels. PULMONARY INFARCT, ABSCESS AND GANGRENE. In view of the mechanical character of the lesion in pulmon- ary infarct the treatment is largely symptomatic. Prophylaxis is in a sense possible ; for given on the one hand Prophylaxis a phlebitic process about one of the extremities, the brain sinus, uterus, the hemorrhoidal veins, about recent fractures, or on the other hand, a weak right heart with endocardial disease, or both, and the possibility of embolus formation and pulmonary infarc- tion must always be remembered. Hence the existence of any of the above named conditions should put us on the alert for pulmonary infarct and the attempt should be made to prevent its development. The principles that should govern this prophylactic treat- Principles of ment are the following: We know from experience that there is P ro P n y laxis less probability of embolus formation in the marantic variety of phlebitic thrombi that develop as a late phenomenon in chronic cachectic disease, cancer, severe anemias, phthisis, etc., than in thrombosis due to acute phlebitic processes. This is owing to the fact that marantic thrombi develop slowly and are consequently better organized, i. e., more solid and more adherent 304 PULMONARY INFARCT, ABSCESS AND GANGRENE Rest and im- mobolization in acute phlebitis Danger of mas- sage and in- unctions in phlebitis Treatment of sudden infarc- tion Artificial res- piration Oxygen Hot compresses Analeptics Morphine to the vessel walls than thrombi that develop rapidly as the re- sult of acute phlebitis; and also to the fact that sufferers from marantic thrombosis are usually very weak and of their own inclination remain quiet, while patients with acute phlebitis are strong, apt to be restless and to move about a good deal, hence favoring the breaking off of emboli from the thrombus. In acute phlebitic disease consequently every effort should be made to favor- slow development of the thrombus and to keep* the patient quiet, in this way rendering the breaking off of frag- ments of the thrombus and hence embolization and infarction in remote regions of the body less probable. Every patient with phlebitis should therefore be put at rest in a recumbent posture and should be warned against perform- ing any sudden movement. If the phlebitic process is going on in some extremity of the body then the latter should be immobil- ized with loose bandages or splints and kept perfectly quiet in a horizontal position. Massage of the affected limb should not be given nor inunctions, that are so popular in phlebitis, be admin- istered. Rest of the body and of the affected extremity should be maintained until all the sequelae of blood vessel occlusion have disappeared, that is, until the extremity has regained its natural red color and temperature and size. As long as the limb is swol- len, pale, cool and edematous there is danger of embolization. In phlebitic processes, involving the pelvic or the hemorrhoidal vessels, straining at stool, violent coughing efforts and hiccough should be avoided as much as possible. If in spite of these precautions, that cannot unfortunately be carried out successfully in every case, the patient suddenly experiences a pain in the chest, begins to cough violently, becomes dyspneic, possibly spits some blood and faints, then infarction of the pulmonary vessel with extravasation of blood into the pul- monary air cells and the interstitial tissues of some region of the lung may be suspected. The treatment of this syndrome is the following : If the pa- tient is in syncope, as a result of the infarction, he should be placed in a horizontal position. If there is much dyspnea arti- ficial respiration should be practised and oxygen inhalations given. At the same time hot compresses should be applied over the chest. If the heart is weak, the pulse feeble and rapid, then analeptics should at once be administered beginning with a hypo- dermic of thirt}^ minims of ether and following with an injection of camphor in ether or camphor in oil, as described on pa^e 32. As soon as the patient revives from his faint an injection of a quarter-grain of morphine with two-hundredth of a grain of atropine is given in order to allay restlessness and excitement. PULMONARY INFARCT, ABSCESS AND GANGRENE 305 If, shortly after the infarction, evidence of pulmonary edema begins to appear, then two or three hundred cubic centimeters of blood should be withdrawn by venesection from the median cephalic vein as described on page 37. If the hemoptysis is very abundant then this complication should be treated as de- Venesection scribed in the Section on Hemoptysis. The bleeding from the lung is rarely very profuse or persistent in pulmonary infarct and it is well to remember that infarction of the lungs may occur without any hemoptysis. If the infarction in any particular case is attributable more to thrombosis of branches of the pulmonary artery from the right auricle than from embolization originating in some phle- bitic process in a remote portion of the body, and if there is tangible evidence of cardiac dilatation and insufficiency, then cardiac tonics, digitalis at their head (see index) should be administered, an ice bag should be applied to the precordium and cardiac tonics venesection performed. If, however, the hemorrhage from the lungs is very severe, then venesection is contra-indicated. ice bag PULMONARY ABSCESS AND GANGRENE. In connection with the treatment of pulmonary infarct a few words may be said in regard to the treatment of pulmonary abscess, for this lesion not infrequently develops as the result of pulmonary infarct due to occlusion of a pulmonary ves- p u i m0 nary sel by a septic embolus. The symptomatic treatment of pulmon- abscess ary abscess dependent upon this cause in the beginning corre- sponds to that of any other form of pulmonary infarct. In fully developed pulmonary abscess due to septic infarct from septic phlebitis or endocarditis, or to any other cause as the aspiration of a septic foreign body, purulent breaking down of a pneumonic or tuberculous focus, etc., or in abscess occurring as a part phenomenon of a general pyemia, internal treatment is practically of no avail and the case becomes a surgical one, i. e., the indications are created for opening the abscess by pneumot- omy and establishing drainage. If there is only a single abscess pneumotomy cavity, and if it can be definitely located, the injection of anti- and drainage septic fluids, as carbolic acid, iodoform emulsion, menthol, may injection of be tried, but this treatment is very uncertain, never without dan- antiseptic ger and essentially surgical in character, so that the injection treatment of pulmonary infarct need not be discussed in this volume. If the abscess cavity ruptures into a bronchus the treat- ment becomes synonymous with that described in the Section on Bronchiectasis (page 283), if it ruptures into the pleural cavity Rupture of the an empyema is created which should be treated according to abscess the rules laid down in the Section on Pleuritis (page 331). Gangrene of the lungs, finally, may occasionally follow em- Gangrene of bolism of the pulmonary artery and infarction of certain areas of e ^ 306 HEMOPTYSIS Injection of antiseptic fluids Fetor of the breath Internal rem- edies Turpentine Myrtol Eucalyptol the lungs. This development, however, is relatively rare and, as a rule, gangrene follows pneumonia, bronchiectasis or invasion of the lung by a foreign body either via a bronchus or the pleura. Here, too, internal treatment is unsatisfactory. Surgery has a definite field in the treatment of this disease, as in the treatment of abscess of the lung, and here, too, if it is possible to circum- scribe the gangrenous area, the injection of a certain antiseptiG solution (by a surgeon!) has a place. The internist is often called upon to treat certain symptoms. The horrible fetor of the breath is an especially disagreeable ac- companiment of this disorder. Inhalations of turpentine, laven- der oil and tincture of eucalyptus are especially useful, employed either singly or combined. From five to ten drops of any of these preparations should be poured on hot water and the vapors in- haled through a paper cornucopia as described on page 284, or a few drops of the various oils may be inhaled through a steam atomizer. A two per cent, solution of carbolic acid inhaled in the same way is also frequently efficacious in correcting the bad breath. For internal use the rectified oils of turpentine, myrtol and eucalyptol are especially useful. If given in sufficiently large doses the expired air soon acquires an odor of turpentine, myrtol or eucalyptus, showing that a portion of these remedies is ex- creted through the lungs. Whether they act merely as deodor- izers or also as disinfectants it is difficult to say. Their adminis- tration never does harm and often seems to aid materially in restoring healthier conditions. Rectified turpentine oil, myrtol and eucalyptol are best given in capsules in two minim doses every two or three hours until the breath smells of the drugs. It is well, in order to protect the stomach, to give some fat after these oils have been taken, or the patient should be ordered to drink a glass of milk with cream or to eat a piece of bread and butter after each capsule. A very simple plan, too, is to admin- ister oil of turpentine directly on bread and butter. That the general health and the nutrition of a patient suffer- ing from circumscribed pulmonary gangrene should be raised to the highest possible standard by plenty of fresh air and a nutritious diet, suitable to the functional powers of the patient's digestive apparatus, is self-evident. HEMOPTYSIS. Definition Hemoptysis properly speaking means hemorrhage from any portion of the respiratory tract, i. e., the pharynx, trachea, bronchi, or the lungs. The hemorrhage may either be due to HEMOPTYSIS 307 rupture or erosion of one of the large blood vessels lining the respiratory tract, or to rupture of an artery adjacent to the air passages into the lumen of the latter, or it may be due to capil- lary oozing, that is, diapedesis of blood through the weakened walls of congested veins and capillaries in the respiratory mu- cosa. Hemorrhage from the lungs may occasionally be a protective Hemoptysis process and one that does not call for any interference. This p^ect?ve ly * applies particularly to three varieties of hemoptysis, viz., first, process hemorrhage occurring before and during the period of menstrua- tion; second, hemorrhage occurring in certain heart lesions, notably mitral and tricuspid insufficiency; third hemorrhage occurring in apparently healthy subjects, usually in adolescents. The treatment of hemoptysis occurring before and during Vicarious the menstrual period, i. e., vicarious menstruation through the nemo Pty sis respiratory passages, is the same as that described under vica- rious epistaxis (page 272). An effort should be made to bring about bleeding from the uterus by hot vaginal douches, hot mustard foot baths, catharsis and the use of emmenagogue rem- edies, chief among them Pil. Aloes et Ferri, five grains (0.3 gm.) two or three times a day, or cimicifuga, which should be given in doses of five drops of the fresh tincture every four or five hours for two or three days preceding the expected menstruation. Hemoptysis due to pulmonary stasis from valvular disease may usually be considered in the light of a "safety-valve" action Hemoptysis in inaugurated by Nature to relieve engorgement of the right heart g^ s J and embarrassment of the pulmonary circulation. It has its analogue in the hemorrhoidal bleeding so frequently seen in portal stasis due to obstructive processes (cirrhosis or stasis within the liver from heart disease). As a rule this form of hemoptysis calls for no intervention. In frequently occurring pulmonary or bronchial hemorrhages, however, due to heart Cardiac tonics disease with the loss of large quantities of blood, cardiac tonics, as described in the Section on Decompensated Heart Lesions are the chief remedies to be employed ; and the results from this therapy are always satisfactory. As a prophylactic measure against such hemorrhages it may Pro P n y laxis become necessary to administer some opiate in order to reduce the straining effort incident to violent or persistent coughing. In other cases if the hemorrhage is so severe as to fill up large areas of the bronchial tree so that there is danger of suffoca- tion, or if the patient after the hemorrhage experiences great difficulty in expelling the blood clots, so that there is danger o? secondary infection (pus germs and other bacteria finding a suitable nidus for their development in the stagnating and dis- 308 HEMOPTYSIS Expectorants Ipecac Hemoptysis of adolescence Rest and avoidance of heart tonics Hemoptysis from ulcera- tion in the upper air passages Topical treat- ment Hemoptysis from aortic aneurism integrating blood), then it may become necessary, as an ex- treme measure, to choose the smaller of two evils and to admin- ister expectorants. The best remedy in these cases is ipecac root, given either in three or four large doses of fifteen grains (1 gm.), each, every hour, until vomiting occurs (Trousseau), or in small doses of one and one-half grains (0.1 gm.) every ten minutes to the point of nausea (Jaccoud). It will rarely become neces- sary, however, to adopt this somewhat precarious procedure and it must always be considered as a violent emergency measure adopted as a last resort to save a suffocating patient. Closely related to hemoptysis from valvular disease belongs the hemoptysis occurring in healthy adolescents. The patients rarely feel any serious discomfort from the hemorrhages, which are generally slight. The explanation of these hemorrhages is difficult to give. It is probable that in rapidly-growing adoles- cents there develops a relative inadequacy of the heart's capac- ity due to the fact that the heart cannot keep up with the in- creasing labor that is imposed upon it when the body grows rapidly. As a result temporary insufficiency with dilatation of the ventricles, chiefly of the right heart, relative muscular in- sufficiency about the mitral and tricuspid valves occurs with ven- ous engorgement in the pulmonary circulation and hemorrhage from the lungs. This theory is borne out by the frequent dis- covery in such cases of systolic murmurs at the apex and over the tricuspid area. The best treatment for this form of hemop- tysis is rest and careful administration of heart stimulants and heart tonics (see page 38). The young people should be warned against excessive exercise and should be instructed to lead a quiet life, physically, mentally and emotionally. As a rule the heart soon adjusts itself to the increased demands upon its pow- ers and the hemoptysis disappears never to return again. Hemorrhages from ulcers in the larynx and trachea are amenable to the same treatment as hemorrhages in any other ex- posed region of the body, provided the bleeding spot can be seen through the laryngoscope. Here the same rules apply as in the treatment of epistaxis due to similar causes. The hemorrhages can often be arrested by the application of a silver nitrate stick or of alum powder or, best of all, of the actual cautery, care being taken, if the latter is applied, to withdraw the point of the cautery while it is still hot, as otherwise the eschar may be torn off when the instrument is removed. Hemorrhages from aneurism of the aorta are in most cases very profuse and rapidly fatal so that no opportunity is given for aiiy treatment. If the patient does not succumb at once to the loss of blood or to suffocation from flooding of the bronchial HEMOPTYSIS 309 tree with blood, then the treatment becomes the same as that in any other form of pulmonary hemorrhage from an eroded blood vessel (see below). Hemoptysis not due to vicarious hemorrhage nor to heart ^ftm^t 7 f lesions and not occurring in an adolescent, under the conditions hemoptysis outlined above, but resulting from erosion of an artery (the protoype of such a hemorrhage being the hemoptysis of pul- monary tuberculosis) should be treated as follows: Upon the occurrence of the hemorrhage the patient should immediately be put to bed and kept in a sitting or semi-recumbent position, as P 0551 * 1011 it is easier to expectorate the blood w T hen in this position than when lying down. If the loss of blood is so severe that the pa- tient faints, then no effort should be made at first to revive him by the use of stimulants, as clotting is favored when the patient is unconscious. If the loss of blood is not so severe as to pro- duce fainting, then above all things the patient's excitement Famtm g should be allayed, if necessary by the hypodermic injection of a Morphine quarter of a grain of morphine with one-two-hundredth grairi of atropine. In some cases it is best to refrain from the use of hypodermic medication, especially if the patient is afraid of the needle ; in others it is well to insert a hypodermic needle if for no other reason than to give the patient the assurance that energetic measures are being instituted to save his life. The physician in such an emergency must be guided by the tempera- ment of the individual patient. If a physical examination, rapidly made, or if previous knowl- edge of the patient's lungs enables the physician to suspect from what part of the lungs the hemorrhage has occurred, and especially if there is pain in a circumscribed area of the chest, then an ice-bag should be applied over this point. If the bleed- Ice bag ing spot cannot be definitely localized in a tuberculous case, then it is always safe to apply small ice-bags over the apical region. At all events an ice-bag should be placed over the heart in order to quiet its reaction and reduce its frequency. A very good plan is to apply the ice-bag intermittently over the suspected lung area and over the precordium, leaving it in place for an hour. Rest in bed, morphine and the application of ice to the re- gion of the heart are intended, above all things, to reduce the rapidity of the heart's action and to lower the blood pressure. The latter purpose can also be fulfilled by the use of aconite or of sodium nitrite, the former to be given in drop doses until the character of the pulse reveals that the blood pressure has been Aconite reduced; the latter in doses of one to two grains (0.05 to 0.1 Sodium gm.) repeated every three or four hours. Great care should be mtrate exercised not to produce too great depression and if the hemor- 310 HEMOPTYSIS Stimulants Ligation of extremities Opiates rhage is severe and the pulse low and feeble when the patient is first seen, it is evident that remedies like aconite and sodium are contra-indicated. In the latter cases heart stimulants like strychnine, brandy, camphor, coffee, ether may be required to save the patient's life. Of other general measures that should be employed in pul- monary hemorrhage, ligation of the extremities with a bandage or a piece of rubber tubing is a useful procedure. The bandages or rubber ligatures should be applied so tightly that the venous back flow is impeded, while the progress of the blood into the limbs through the afferent arteries is not interfered with. The ligatures should remain in place from a quarter of an hour to one hour. This plan of treatment is intended to reduce the volume of blood flowing through the bleeding area and hence to favor co- agulation. Of remedies that should be given in hemoptysis opiates occupy the first place. Opium or morphine may be given either by mouth or hypodermically (see above). If the insertion of the hypodermic needle does not excite the patient too much, the latter plan is by all means preferable. Occasionally the admin- Administration istration of opium or morphine by suppository or clysma becomes necessary (Dose and administration, see index). Opiates do not act as hemostatics but merely stop the cough and hence allay straining efforts ; they also counteract restlessness and excitement and hence prevent high arterial tension from this source. Theo- retically opiates are contra-indicated because they produce con- gestion in the peripheral vessels. Their exact mode of action upon the pulmonary vessels, however, is not altogether under- stood, and as we know empirically that they are highly effica- cious in hemoptysis their use can be warmly recommended. Of other hemostatic remedies ergot should, above all things, be eschewed for reasons that have been explained in full in the Sections on Epistaxis and Pulmonary Infarct (page 275). Hem- orrhage, in the minds of many practitioners, spells ergot as the remedy and however correct ergot treatment may be in hem- orrhage from the uterine cavity so incorrect it is in hemorrhages from most other portions of the body. Tannic acid has been used extensively. It is questionable whether it is very trustworthy as a hemostatic in hemoptysis. The best form in which to administer tannic acid, and the one in which the drug does the least injury to the stomach, is as the fluid extract of hamamelis, which should be given in thirty minim (2 cc.) doses, in water, every two or three hours. Lead acetate, which for a long time was very popular, is mentioned to be condemned. Lead acetate acts very well locally, Dangers of ergot Tannic acid Hamamelis Gelatin HEMOPTYSIS 311 but if given in doses large enough to reach the bleeding spot in Lead acetate a concentration that could promote arrest of hemorrhage, gen- eral lead-poisoning, nephritis or severe gastro-intestinal dis- turbances would assuredly develop. If given in smaller doses it would be ineffective as a hemostatic. Oil of turpentine given in five drop doses in milk or on bread and butter, every two or three hours, is a valuable remedy espe- Turpentine cially in slow, persistent bleeding from smaller vessels, and I have seen several cases of hemoptysis yield to this treatment when all other remedies seemed to have failed. The most reliable hemostatic we possess, however, is hydras- tis canadensis. It may be given as the fluid extract in doses of Hydrastis fifteen to sixty minims (1 to 4 cc), in milk, every hour for four or five doses ; as hydrastinine hypodermically in doses of one-half to two grains (0.03 to 0.1 gm.) ; as cotarnine (stypticine) in doses of one-third to one-half grain (0.02 to 0.03 gm.), in watery solu- tion, by mouth or hypodermically every hour for four or five Hydrastinine doses or until the desired hemostatic effect is produced. Cotarnine Gelatin has been used extensively in hemoptysis. In order to be efficacious it must be given in large doses. A very good method of administering it by mouth is to prepare a solution con- sisting of: i* Common salt, '1 Gelatin, 10 Water, 200 M. Sig. Of this mixture about one-third is given in one dose and two or three table- spoonfuls every hour thereafter. Sometimes the administration of gelatin hypodermically aids in arresting hemoptysis, but this plan can usually only be carried out in an hospital where a carefully sterilized gelatin solution is ready for immediate use. It is always a dangerous procedure to administer gelatin hypodermically or intravenously in pri- vate practice, because gelatin is made from the hoofs of animals and, unless very carefully sterilized by discontinued steriliza- tion on several successive days, may contain live spores of te- tanus. Leaving this danger aside, the injection of gelatin at best is not an indifferent procedure, for the patients often re- act with slight fever and much local pain. For the technique of administering gelatin subcutaneously see also the Section on Aneurism. After the hemoptysis has been stopped the patient should ment 312 PULMONARY TUBERCULOSIS Diet Causal treat- ment of slow hemoptysis remain in bed for some time. It is a good rule to keep the pa- tient perfectly quiet until the last traces of blood have disap- peared from the sputum. During this time he should be forbid- den to speak loudly, to call or to otherwise strain the voice and indulge in violent respiratory efforts. In order to prevent straining at stool it is always best to lock the bowels for several days by the administration of opiates. Later evacuation of the bowel contents should be made easy for several weeks after the hemorrhage by the administration of appropriate laxatives (see index) or the use of enemas. In the beginning the patient should be kept on a liquid diet consisting, during the first days only, of small doses of ice-cold milk given frequently, later gruels, a little fresh fruit and vege- tables, soft boiled eggs and, last of all, meat and meat products may be permitted. Tea, coffee, alcohol, very hot foods and car- bonated beverages should be denied as long as there is any oozing of blood. The causal treatment, finally, of slow hemoptysis occurring in the course of leukemia, the hemorrhagic diathesis and severe primary anemia is synonymous with the treatment of the under- lying disorder. The symptomatic treatment of this form of hemorrhage does not differ from that of any other variety of hemoptysis of a slow character. Hemoptysis in pneumonia rarely calls for special treatment. The treatment of the secondary anemia following severe hemorrhages or the continued loss of small quantities of blood through slow oozing from the respiratory tract has been fully described in the Section on Secondary Anemia. Spontaneous recovery Means of treatment PULMONARY TUBERCULOSIS. Pulmonary tuberculosis in most cases shows a spontaneous tendency toward cure or latency provided the proper conditions are created for recovery. The main object of treatment, if the diagnosis is made early enough, is to secure for the patient ideal surroundings adapted to the individual peculiarities of the case, to grant the patient the maximum of pure air under suitable climatic conditions, and to feed, rest and clothe him properly. Medicines play a subordinate role in the treatment of pulmonary tuberculosis. There is no specific remedy for the disease (tuber- culin, creosote, etc., see below) and drugs should be employed only to remedy especially distressing or dangerous symptoms and complications and, in the late stages, to render the patient comfortable. PULMONARY TUBERCULOSIS 313 Life in the open air when combined with proper feeding and Fresh air careful regulation of rest and exercise, when carried out in sur- Diet roundings and under conditions that favor a cheerful and hope- ful mood and, above all, when carefully supervised and controlled by a competent physician, is the best remedy for the cure of pul- monary tuberculosis. It is important to realize, however, that neither fresh air alone, nor over-feeding alone, nor rest alone, can cure tuberculosis of the lung. It is essential that the three elements be combined. A phthisical patient may live out doors for twenty-four hours during each day and still not improve unless his diet is properly regulated, and unless he avoids ex- ertion beyond his strength; or he may be over-fed and kept in bed and still succumb because the supply of fresh air is insuffi- cient and the surroundings remain gloomy and depressing. Why abundant fresh air aids so materially in the cure of Rationale of pulmonary tuberculosis is difficult to understand. Probably the ? es ? air t absence of turbercle bacilli and of pus germs and other bacteria that produce mixed infection is an important factor. The open air, moreover, contains a much smaller proportion of the noxious gases, notably C0 2 , of body emanations and chemical irritants that soon pollute the atmosphere of inclosed spaces. Finally, the ozone of out-of-doors, the radiation of the sunlight and, above all, the psychic stimulus of life near to Nature in open spaces, and the improvement of the appetite that results from an open- air existence must all be considered important elements. To secure an abundance of fresh air all the year round, in Advantages of good weather and in bad, in the heat of summer and the cold of Jreatmen? 1 winter, is a difficult problem. The best conditions are undoubt- edly obtained in a closed institution arranged especially for the care of tuberculous patients, and here assuredly the most brill- iant results are obtained. "Wherever feasible, therefore, the tuberculous patient should be advised to enter such an institu- tion. The choice of the location, i. e., whether at an altitude or at the level of the sea, whether moist or dry, whether hot or cold, in other words whether mountain, desert or sea-shore, must be made according to the general principles to be presently dis- cussed. If the circumstances of the patient do not enable him to Home treat- enter a private institution of this character, then he should be ment taught how to secure open-air treatment at home. Also in such cases the sacrifice, pecuniary and otherwise, incident to treatment in a closed institution, even if only for a short time, should wherever possible be urged. For the educational value of in- stitution life is of inestimable value to such patients, especially in the present state of deplorable ignorance and scepticism on 314 PULMONARY TUBERCULOSIS Technique of home treat- ment Room tem- perature Window tents Errors of Routine the part of the laity in regard to the curative value of such sim- ple measures as air, food and rest. A patient who has spent even a few weeks in a well-conducted institution soon becomes an ardent and enthusiastic convert to the open-air idea, for he has been convinced by the good results he has seen, by the tales of convalescents he has heard, and he has had the benefit of the precepts and the suasion of the medical corps in charge. On re- turning from the institution the patient is generally only too glad to co-operate in every way with the family physician at home. Above all, he has learned to help himself in solving the difficult problem of securing the proper arrangements at home necessary to continue the plan of treatment begun in the sani- tarium. Life in a tent placed in the back yard of a city home, or on a veranda with southern, southeastern or southwestern ex- posures, generally meets all the necessary requirements during the greater part of the year. During the rigid winter months tent life is usually unnecessarily uncomfortable and a room can be easily arranged in which the windows are kept wide open dur- ing the day and in which the patient properly clothed (see be- low) lives all the time. The room can be kept at a moderate tem- perature better than a tent. It is well to realize that air can be fresh and wholesome without being uncomfortable. During the night any one of the numerous window tents that are in the market, or that can be constructed by any carpenter, may be used to enable the patient to have at least his head out of doors while the body is warmly covered and comfortably tucked away in bed. Here the inventiveness and the ingenuity of the phy- cian, patient and friends must secure the proper conditions adaptable to the surroundings and circumstances peculiar to each individual case ; and it would be a futile and superfluous task in this volume to discuss all the mechanical devices and to enu- merate all the technical details that have been described to ren- der the carrying out of the fresh air treatment of consumption practicable. In recommending this mode of treatment for cases that are unable to avail themselves of the benefits of the sanitarium plan errors of routine are often committed. The physician who merely tells his patients to sleep out-doors or to keep the windows open all the year round, errs grievously if he contents himself with such general phrases; for it is very important to realize that many cases, especially in the beginning of the fresh air treat- ment, may become markedly aggravated unless the effect of the fresh air, especially during the cold and moist seasons of the year, is carefully controlled. PULMONARY TUBERCULOSIS 315 One will quite commonly find that, in the beginning, the Disagreeable , . „..; «, , n T !•(» symptoms in patients complain of irritation 01 the trachea and bronchi, 01 beginning dizziness, insomnia and a general feeling of discomfort. In some, fresn air P lan especially during foggy weather, the irritation about the respira- tory organs often becomes altogether unbearable, so that increased coughing and severe dyspnea supervene. To insist upon wide open windows or an out-door life under these conditions is cruel and wrong. Such patients should, by all means, be very grad- ually accustomed both to the increased amount of out-door air and to the greater moisture and lower temperature of the at- mosphere they are forced to breathe, and should not be allowed to ignore the disagreeable phenomena that make their appear- ance and to carry out the rigid fresh air plan despite of them. Again, most tuberculous cases are especially susceptible to drafts ; this is due to the fact that tuberculosis is often accompanied by anemia and profuse sweating. Such patients are very apt to catch cold in the beginning of the fresh air treatment and, in this way, to have their condition seriously aggravated. It often becomes necessary, therefore, as a preliminary to Hardening the the continuous fresh air treatment, to subject the patient to a preliminary 1 carefully regulated hardening process according to the principles that have been discussed in full in the Sections on Anemia and Acute Rhinitis (pages 79 and 266). For practical purposes the following method is very useful, not disagreeable, and, above all, never dangerous to the patients. The skin, in the beginning, is treated once or twice a day by dry rubbing under covers with a rough cloth or the hand. Later the surfaces of the body are treated with alcohol, then with alcohol and water and later with water that should be lukewarm at first and gradually used cooler and cooler until finally the patients can be sponged with water of room temperature. The sponging should be carried on under blankets, one extremity, the abdomen, back, chest, being treated at a time, and should be followed by a brisk alcohol rub. Still later the patient may be treated once a day by wet packs of room temperature, in such a way that the whole body is quickly wrap- ped in a linen cloth wrung out of cool water and covered with a woolen blanket. They are allowed to remain in this pack only from three to five minutes. The surface of the body is then rub- bed dry with a rough towel and treated with alcohol. In this way the superficial capillaries are educated to react more energetically to sudden temperature changes and the tendency to catching cold is materially reduced. At the same time the respiration, circulation and the general metabolism are greatly stimulated. While this hardening process is being carried out, it will 316 PULMONARY TUBERCULOSIS Intermittent fresh air plan Clothing Choice of climate When to send patients away from home usually be necessary to render the fresh air treatment inter- mittent, that is, to have the patients in the open only during certain hours of the day when the sun is shining and to have the windows open altogether only on days and nights during which the weather is not too cold or foggy, and only partially open on stormy days or nights with rain, snow, or violent winds. In such weather the patient should be carefully protected from the wind by a screen or some other protective device. The clothing of tuberculous patients undergoing the fresh air treatment should be regulated according to the temperature of the air. During warm weather flannel underwear that absorbs the moisture from the skin and allows its slow evaporation ; dur- ing cold weather wool garments should be worn. Silk or linen underwear should never be allowed, for they cling to the skin and in this way obliterate the layer of immovable air that should intervene between the body surfaces and the first garment (see page 267). A sufficient number of woolen blankets should be used to keep the patient comfortably warm ; on top of them furs may be placed, but furs should never be worn about the neck (see page 267). A cap made of wool may be used to protect the head and ears during the night, and hot water bags may be placed to the feet. It is a very important rule not to have the clothing about the chest too tight fitting in order that the respira- tion may not be impeded. Inasmuch as life in the open air is one of the most import- ant factors in the cure of tuberculosis, the choice of a climate for tuberculous patients becomes a matter of serious import. The ideal climate by all means is the one in which the patient can enjoy the maximum of out-door life with the least discomfort. Above all, the physician who sends his tuberculous patients away from home in order to give them the benefits of another climate should consider the circumstances and the accustomed mode of life of the patient at home, and should compare them with the environment the patient will be forced to live in at the resort to which he is sent. If the case is very far advanced, or if the patient is in very moderate circumstances, it is usually a cruel undertaking to send him away from home and friends, away from the physician in whom he has confidence, into strange surroundings, among strange neighbors and to a strange physi- cian. It is well to remember that climate alone can impossibly cure a case of tuberculosis unless the diet and the general mode of life are carefully regulated and unless the mood of the pa- tient can remain at least as cheerful as it was at home. It i& pitiable to see advanced cases of tuberculosis arriving at resorts for tuberculosis and eking out a miserable existence at a board- PULMONARY TUBERCULOSIS 317 ing house where they are shunned like lepers (provided they are admitted at all) : eating worse food than they received at home and living the lives of outcasts among unsympathetic strangers. Whoever has seen these poor sufferers sitting dejectedly on the curb in the broiling sun of a desert village, under-fed, over- exerted, helpless and thoroughly miserable, can hardly suppress a feeling of indignation at the almost criminal stupidity of those who are responsible for placing the unhappy exiles in such a position. It is a thousand times better that such cases should remain at home, even in a city and in a cold climate. Provided, on the other hand, the patient 's means permit him to secure the proper accommodations and diet and good medical supervision at the resort to which he is sent, then the climatic conditions that will most benefit the patient must be carefully considered. Two climates in particular enjoy deserved popu- larity in the treatment of tuberculosis, namely, mountain climate and Southern climates. Both have their advantages and their contra-indications. Some cases do best at moderate altitudes, others at the sea-shore or on an ocean steamer, some in the desert where the air is dry, others inland where the air is warm and moist. It would lead altogether too far to discuss in detail all the indications for the choice of climate as they arise in each individual case, especially as these indications vary with changes in the condition of the patient. The following general rules, however, may serve as a guide in the selection of a climate for tuberculous patients.* Best of all for cases of tuberculosis is mountain climate. Altitude Here we have low air pressure, comparatively low temperature, ^? un * am slight fluctuations in the daily temperature, dry air, an atmos- phere that is flooded with sunshine, that is pure and full of ozone and that contains no tubercle bacilli and few pus germs or other bacteria. The rarefied air exercises a beneficial in- fluence upon respiration and circulation, by forcing the patient to breathe more deeply it alters the composition of the blood, stimulates metabolism, promotes the action of the skin, increases the appetite, and usually induces sound sleep, often, however, only after a period of several days or a week of insomnia. There are, however, distinct contra-indications to choice of Contra-indi- a mountain climate in tuberculous patients. Cases in an advanced catioi i s . to . * mountain stage of anemia; cases suffering from continuous fever; cases climate with empyema, pleurisy or pneumothorax, or with laryngeal ulcerations; and patients with valvular heart lesions (see page 24) should be warned against life at an altitude. ♦See also Climate in Valvular Diseases of the Heart. 318 PULMONARY TUBERCULOSIS High altitude in winter and summer Moderate alti- tude in spring and autumn Low altitude Dry, warm climate Desert climate Low, moist climate Seashore and island climate Best The best time to send tuberculous cases to an altitude is in winter. While it is very cold in the mountains the air is dry and there is rarely much wind, hence the cold is not so percep- tible as in lower altitudes; the clear skies and abundant sun- shine and the absence of much fog or mist, moreover, render a sojourn in mountain resorts more pleasant and more beneficial than in warmer regions in the valleys or the plains. In the heat of midsummer too high altitudes are not useful for obvious reasons. During the Spring and Autumn it is best to send pa- tients to moderate altitudes rather than to high altitudes. This applies particularly to those who are sent to a resort for the first time in spring or autumn, for here sojourn at a moderate alti- tude, not to exceed 3,000 feet, for a time forms a beneficial transition to life at a higher altitude during the coming winter or summer months. Life at a low altitude or at sea level may be considered in- different as far as its effect upon the human organism is con- cerned. Here the temperature, the amount of sunshine and, above all, the amount of moisture in the air are the determin- ing factors. Broadly speaking a dry climate at sea level has a mildly stimulating effect, whereas a moist climate at sea level has a mildly sedative effect (see page 24). A dry warm climate at a low level is especially useful in tuberculosis if there is an abundant secretion from the bronchi ; such patients do especially well, as a rule, 'in a desert climate where there is also abundant sunshine and where the air is essentially free from pus germs. The latter element is very important, for most cases suffering from profuse expectoration are afflicted with a mixed infection. Life in the desert on ac- count of the absence of pus germs in the air often aids mate- rially in converting such a mixed infection into a simple tuber- culous infection. This is an exceedingly desirable effect. High mountain climate shares this advantage with the desert and mid- ocean. To the category of low, moist climates belong chiefly sea-shore and island climates. Here the air is pure, contains a large pro- portion of oxygen, considerable moisture and salt, and a small amount of carbon dioxide. The moisture of the air and the salt it contains exercise a mildly stimulating effect upon the bron- chial mucosa and the skin. The low pressure strengthens and retards the heart's action and induces deep, slow respirations. Appetite and sleep are usually improved in these climates. Very anemic patients, however, rarely do well at the sea-shore, for reasons that have been fully discussed in another section. Rest is an element that is of the greatest importance in PULMONARY TUBERCULOSIS 319 the treatment of tuberculosis. Consumptives, in the beginning, especially if they are suffering from a recent tuberculous infec- tion with high fever, immaterial whether they live out of doors or in, should be kept absolutely at rest and quiet, i. e. : they should remain all day and all night in a recumbent or a semi- recumbent position. This also applies with particular emphasis to cases of tuberculosis that have had one or more attacks of hemoptysis or are very anemic. As soon as some improvement has occurred and the tempera- Exercise ture is low or normal (the sputum free from blood and the anemia improved) the patient should be allowed to walk on the walking level for a little time once or twice a day, beginning with short walks of not more than ten or fifteen minutes; they may then gradually be allowed to increase the amount of exercise accord- ing to the reaction they show. Shortness of breath, palpitation, dizziness, sweating are all danger signals indicating that the amount of exertion is too great. A tuberculous patient should never be allowed to exercise to this point. Later, as the im- provement continues, very gradually controlled hill climbing may be permitted. In some resorts a regular Oertel-Terrain sys- Hill climbing tern (see page 23) is arranged and the amount of exercise care- fully regulated by this means. While walking the patient should breathe deeply and with great regularity, an object that is best accomplished by instructing him to take a deep breath through the nose with each step. In selecting the diet for a tuberculous patient an attempt Diet at over-nutrition should always be made. Mathematically ex- pressed, a sufferer from tuberculosis should receive instead of 0v er nutrition the ordinary thirty to thirty-five calories per kilo each twenty- four hours (see page 114) at least forty-five calories. In well managed institutions the regulation of the diet is carried out according to calorimetric methods. In private practice and in most resorts feeding, owing to the difficulty of carefully per- forming metabolic studies, is generally carried out according to empiric rules, some of them very crude, very one-sided and very wrong. The tastes and idiosyncrasies of the patient should always Tn e diet be very carefully considered and every endeavor should be ad- should be pal- vanced to render the diet palatable and agreeable. One of the Forced f ee dino- most serious obstacles encountered in the forced feeding of tuberculous cases is the lack of appetite and the aversion to food (see below) that so many of these patients develop after » time. To avoid this is a fine art which should be cultivated. The diet should not be too one-sided nor monotonous, but should incorporate the greatest variety of food, prepared in a tempting 320 PULMONARY TUBERCULOSIS Meat Fat Eggs Milk Fruits and vegetables Beverages Alcohol form, preference, of course, being given to those articles of diet that possess the greatest nutritive (caloric) values. The chief article of diet should, by all means, be meat, for it is a well known fact that carnivorous animals and peoples living on an abundant meat diet are much less susceptible to tuberculous infection than herbivorous animals and vegetarians. At the same time, abundant fat should be supplied in the form of cream, butter, bacon, olive oil in salad dressing or in mayon- naise, sardines, etc. In selecting meat those varieties contain- ing abundant fat should be given the choice; and the meats should be prepared with plenty of fat. Eggs are a very valuable article of food and a convenient vehicle for supplying abundant nitrogen. They are best eaten either boiled or poached or in soups, sauces or omelets, or as an addition to milk as egg-nog. There is no particular advantage, a popular prejudice to the contrary notwithstanding, in using them raw. In some institutions enormous quantities of raw eggs are administered as a routine, with the result usually of thoroughly disgusting the patients so that they cannot take eggs at all after a time, and without doing them any particular good that could not be obtained by having them prepared in a more tempting form; for no article of food can be made more palatable, and prepared in more different ways, than eggs. Milk is also a very useful article of diet and should be used liberally in the preparation of vegetables, sauces, gravies, etc. As a food between meals milk is also very useful, especially in the form of egg-nog or milk-cream mixture (two-thirds milk, one-third cream, one tablespoonful of lime water). Many people have a distinct aversion to milk and it is worse than useless to try to force them to drink it. Occasionally one can accustom patients to milk by serving it in small quantities and very cold, or with a little brandy. An attempt should always be made to do this. Some patients can drink milk without distaste but complain of a feeling of satiety even after taking small quan- tities, so they are utterably unable to swallow anything else with relish. In these cases, too, the administration of milk should be avoided or greatly curtailed, as otherwise over-nourishment of the patient becomes impossible. Fruits and vegetables of any kind are allowed, preference being given to vegetables containing large quantities of albu- men, as peas, rice, beans, etc. Plenty of milk, cream, butter, flour should be used in preparing all vegetable dishes. Of beverages, cocoa, chocolate, tea, coffee, bouillon, broths, meat extracts, buttermilk are all useful. Alcohol, too, is a food which should not be omitted from the bill of fare of tuberculous PULMONARY TUEERCULOSJS 321 m cases. It is best given in the form of dilute spirits or claret, or light wines diluted with water. Beer, owing to the percentage of carbohydrate it contains, is a particularly useful beverage and may be taken with impunity. It is especially useful in the evening on account of its slight soporific effect. Brandy or whisky as an addition to egg-nog is also useful. Strong alco- holic liquors, like straight whisky or brandy, should be avoided, especially in cases suffering from tachycardia or ulcerative pro- cesses in the larynx or digestive tract. That there are occa- sionally distinct contra-indications to the use of alcohol, espe- cially in sufferers from cardio-renal disease and arterio-sclerosis, need hardly be emphasized. Medicamentous Treatment. The treatment of tuberculosis Specific treat- with products made from the tubercle bacillus, i. e., tuberculin men and its various congeners, is still to be considered as in an ex- perimental stage. Clinicians who have worked for years with these products report results that are greatly at variance, some claiming good effects in all cases, others indifferent effects in most cases. In resorts in which the use of tuberculin and similar Tuberculin products is combined with rest, proper feeding and an out-door life the results seem to be fairly good, but here it is very diffi- cult to determine how much of the benefit is to be attributed to the "rest, the diet and the fresh air, and how much to the "spe- cific" remedy. From what experience I have had with this remedy in hos- pital practice and from what I can glean from the literature, I am inclined to think that tuberculin possesses some curative value if properly used ; but that this substance is also very dan- curative value gerous unless administered in very small doses and under very careful control.* Tuberculin should be used in small doses, so small that no reactive symptoms (i. e., fever, signs of local irrita- Dosage tion in the affected area, general lassitude, headache, pain in the joints, etc.) appear. The dose may be gradually increased until these symptoms appear and then it should be immediately reduced and the patient kept on a quantity slightly below that at which a reaction occurred. It is manifestly a difficult matter to determine the onset of a "reaction" in a febrile patient, so that this index is useful only in quiescent cases. Here a latent tuberculous process may be rekindled by the injudicious use Dangers of of tuberculin for therapeutic or for diagnostic purposes so that tuberculin at best the remedy is dangerous. Moreover, quiescent cases usu- ally get along very well with proper hygiene and without snecific medication with tuberculin, so that the remedy in those cases precisely in which it could be used with some probability of *The new method of determining the opsonic index has rendered the use of tuberculin much more safe and accurate. 322 PULMONARY TUBERCULOSIS Creosote and its derivatives Mode of action Effects Contr a-indi ca- tions to creo- sote success is not only dangerous in careless or unskilled hands but also superfluous. If used at all the initial doses should not exceed one-tenth mg., and in no case should the maximum dose exceed 0.01 to 0.02 gm. Personally, I have, however, abandoned the use of tuber- culin altogether. My main objection to its employment being the uncertain strength and unstable composition of practically all the tuberculins and, finally, the observation that the results obtained from proper hygiene, diet, fresh air and rest with tuber- culin are no better than those obtained by the same means with- out tuberculin. A remedy that has for many years enjoyed popularity in the treatment of tuberculosis is creosote and its derivatives, guaiacol, creosol and cresol. While this remedy can, in no sense, be considered a specific, it certainly does good in most cases of tuberculosis and its use is therefore to be recommended. Its exact mode of action is difficult to explain. It can hardly be said to possess specific anti-bacterial action against the tuber- culosis germ, for animals treated with creosote and subsequently tuberculized succumb to the infection as readily as animals that have not previously been treated with creosote. Again, the sputum of tuberculosis cases, that have received large doses of creosote for a long period of time, contains as many and as virulent tubercle bacilli as that of patients who have not re- ceived the benefits of creosote treatment. However obscure its pharmacological action may be, we know, clinically, that it increases the appetite, improves gastric and intestinal digestion and aids assimilation, hence improves the general nutrition and increases the strength of the patient ; that in most cases it relieves the cough, reduces the fever and stops the night sweats. The remedy is particularly useful in early stages, but it should also be given a fair trial in advanced cases. There are distinct contra-indications to its use. Some indi- viduals are altogether intolerant to the drug and react to the administration, even of small doses, by severe signs of intoxica- tion, notably violent gastro-enteritis with vomiting and purging, dizziness, fainting and profuse sweats. Upon the appearance of such symptoms the administration of the drug should, of course, not be insisted upon. In other cases the symptoms of creosote intoxication are less severe and manifest themselves by milder symptoms of gastric and intestinal irritation, such as burning in the epigastrium, belching, loss of appetite, slight colic and diar- rhea. In many cases as the patients become accustomed to the use of the drug these symptoms disappear, so that the administra- tion of small dosevS may for a few days be tentatively continued, PULMONARY TUBERCULOSIS 323 intermittently, in the hope that the patient will gradually tol- erate the remedy. The slight discomfort from the stomach aris- ing during this trial can well be borne in view of the benefits to be expected from creosote if it can be taken at all. Many preparations of creosote and its derivatives have been Dose and ad- recommended. If creosote itself is to be taken, it is best given minis *ration by mouth in gelatin capsule with a little cod liver oil, for in- stance : Creosotis 0.1 01. Jecoris aselli 0.3 M. One hundred such capsules. Sig. Five to ten capsules daily at meal time. Or the creosote may be given in wine, as follows : Creosotis, 13.5 Tinctura gentianae 30.0 Spiritus vini, 250.0 Sherry qs. ad. 1000.0 Two tablespoonf ids after each meal with a little water. — (Bouchardat and Gimbert.) Or it may be given in five to ten drop doses in a tablespoonful of cod liver oil several times a day; or by rectum in a milk or milk-egg enema, in such a way that thirty drops of creosote are dissolved in 300 cc. of warm milk to which are added one egg and a few drops of opium. Two preparations of creosote that, in my experience, are Creosotal better than creosote are creosotal and thiocol, the former being Thloco1 a yellowish liquid that is non-irritating and non-toxic (excepting to patients with an idiosyncrasy to creosote) even when given in large doses. It is given in drop doses in milk or water, be- ginning with twenty drops three times a day and increasing the D 0se and ad- dose to a tablespoonful three times a day during meals. The lat- ministration ter is a powder that can be given in doses of forty-five to sixty grains (3 to 4 gm.) a day in capsule or powder, best during meals, without producing any gastric or intestinal irritation. A very convenient method of administering creosotal is to give it in gelatin capsules, each containing twenty to thirty drops, four or five of these capsules being administered a day. Some pa- tients prefer to have the remedy administered in one dose a day per rectum, especially if they are taking other medicine 324 PULMONARY TUBERCULOSIS Guaiacc Remedies of historic in- terest Arsenic Dose and ad- ministration by mouth. Here a good plan is to mix 10 ce. of creosotal with yolk of egg, to stir this mixture into 300 cc. of warm milk, to add a few drops of tincture of opium and to inject this quantity into the rectum through a high rectal tube. Guaiacol is a useful derivative of creosote that is very popu- lar. It may be given as the carbonate, benzoate or salicylate of guaiacol in powder form, beginning with five grains (0.3 gm.) three times a day and increasing the dose until as much as fifteen to thirty grains (1 to 2 gm.) three times a day are being taken. These guaiacol preparations are decidedly more irritating when taken by mouth than either creosotal or thiocol. Innumerable other remedies have at different times been recommended as specifics in the treatment of tuberculosis, but none of these has vindicated its claim to usefulness in this disease. Among the remedies that possess the greatest historic interest and that created much sensation at the time when they were first recommended are cinnamic acid and its derivatives hetol and sodium cinnamate, copper and its salts, and nuclein. I have never been assured that these drugs are of any use what- ever in the treatment of tuberculosis. Arsenic is a remedy that possesses no specific power over the tuberculous process but may to advantage be used in tuber- culosis as a general tonic. It may be given in the form of Fowler's solution by mouth, beginning with three to five drops in plenty of water three times .a day and increasing the dose a drop per dose a day until fifteen to twenty drops, three times a day, are being taken. Then the amount should be gradually reduced until only three to five drops, three times a day, are again being administered; the same cycle should be repeated several times. The maximum dose must be determined some- what by the reaction of the patient to the remedy. If signs of arsenic intoxication, puffiness about the eyelids, epigastric dis- tress, colic, diarrhea, itching about the palms of the hands and soles of the feet appear, then the quantity should be reduced. Arsenic may also be given by mouth in the form of sodium ar- seniate in the dose of one-one-hundred-and-fiftieth to one-fiftieth of a grain, in capsule with sugar of milk, three times a day, for indefinite periods of time. Sodium cacodylate, hypodermically, is one of the best preparations if it is desired to administer large doses of arsenic without danger of intoxication. It is particu- larly useful, aside from its action as a general tonic, in aiding absorption of pleuritic exudates forming in the course of pul- monary phthisis. It is unnecessary to give more than one-fourth of a grain of sodium cacodylate in watery solution, hypoder- mically, once a day, although as much as one grain, several times PULMONARY TUBERCULOSIS 325 a day. may be given. The patients complain very shortly of a peculiar garlic odor of the breath and should be apprised of the probable occurrence of this phenomenon when cacodylate injections are made. For contra-indications to the use of ar- senic and details of administering the different preparations see also the Section on Anemia. In addition to these remedies various medicinal substances Codliver oil are given in tuberculosis more as foods and to replace tissue waste than as drug's. Among these codliver oil is the most pop- ular. It is questionable whether the iodine it contains, or the alkaloids it is said to incorporate, in any way determine its good effects in tuberculosis. It is more probable that the fat acts beneficially as a food (see page 114). Codliver oil, moreover, •is a very convenient vehicle for the administration of a number X)f remedies (see above) and as the laity have been educated to have much faith in codliver oil, its administration generally exercises a beneficial psychic effect that is by no means a neg- ligable quantity in the treatment of tuberculosis. The administration of different salts is always indicated in Salts tuberculosis, for in this disease the urinary and fecal excretion of mineral constituents especially of the calcium salts, chlorides and phosphates,* is exceedingly large. This loss should be re- calcium placed artificially, hence tuberculous patients should receive chlorides abundant table salt with their food and should receive phos- phosphates phates and calcium salts medicinally. The latter can conve- niently be administered in the form of calcium hypophosphite or as Syrup of Hypophosphites containing hypophosphite of calcium, potassium, sodium, free hypophosphoric acid, spirits of Hypopkos- lemon and sugar in the dost of one to two drachms (1 to 8 cc). Symptomatic Treatment of Special Symptoms. Provided the fever in tuberculosis does not yield to rest, proper feeding, plenty of fresh air and the use of creosote preparations, or if the patient reacts to even slight elevations of the temperature by especially disagreeable subjective sensations, such as profuse sweating, great prostration, chills, headache, nausea; or if, fin- ally, the fever remains persistently high so as to render it difficult to maintain the patient's general nutrition, because the con- sumption of his own tissues is so active, then the symptom fever must be specially treated. A very simple and generally efficient means of combating A , , . „ Alconol slight rises of temperature is the administration of alcohol, pre- ferably in the form of hot toddy, whenever the premonitory *See Croftan: The Urinary Calcium Excretion in Tuberculosis, Jour- nal of Tuberculosis, 1901. Fever 326 PUL.MONABY TUBERCULOSIS Antipyretics Hydrotherapy Night sweats Alcohol, alum, vinegar, sul- phuric acid washes signs (chilliness, hot flushes, etc., of a febrile attack occur), also in the form of light Burgundy or Moselle wine as a table bev- erage. Early cases of tuberculosis, in my experience, are not so apt to develop so much fever, and especially very high degrees of temperature, if they take some alcohol as when they do not. Sometimes it becomes necessary to combat the fever by the use of certain members of the antipyretic group, namely, acet- anilid, phenacetin, antipyrin, pyramidon or lactophenine. Acetanilid, phenacetin, antipyrin and pyramidon while effective in reducing the temperature are very liable to produce disagree- able sweating. Lactophenine does not seem to possess this prop- erty, hence it should be the remedy of choice (see index). Lactophenine and the other remedies enumerated above are best given in three to five grain doses about three or four hours be- fore the rise of temperature is expected, i. e., as a prophylactic. This method of administering antipyretics is much more elegant and more efficacious, and moreover requires much smaller doses, than if the drugs are given at the height of fever. Hydrotherapy is not so useful nor so safe in the reduction of tuberculous fever as in the reduction of fevers due to other infections. Only very mild hydrotherapeutic measures should be employed in any case. Best of all is sponging the different extremities, the abdomen, chest and back, singly, with water of room temperature, either exposing each part of the body for a short time and immediately drying and covering it, or spong- ing underneath the covers. Often it is best to merely rub the hands and feet, legs, arms and trunk with the hand that is re- peatedly dipped in cold water, taking each part of the body singly, rubbing dry promptly and following the wet rub by an alcohol rub and friction. Or a towel may be wrung out of cool water and placed on one extremity and the limb or arm rubbed or slapped through the wet towel. This practice is kept up for a minute or two, the wet towel removed, the limb quickly dried, rubbed with alcohol and dried again. Bath treatment or more active hydrotherapeutic means are generally objectionable in tuberculosis and should be avoided. Cleansing baths, so nec- essary in cases suffering from profuse night sweats, are always best given in bed with the patient lying down. Here lukewarm water should be used and the bath followed by a brisk alcohol rub and massage. The night sweats of tuberculosis often call for special treat- ment. Here the old fashioned remedy of washing the surfaces of the body with alcohol and water, or vinegar and water, or with a one to thirty solution of alum, or a one to two hundred solution of sulphuric acid, are all useful. PULMONARY TUBERCULOSIS 327 Of recent years formaldehyde, in 40 per cent, solution, mixed Formaldehyde with equal parts of alcohol, has been extensively employed. This preparation is remarkably efficacious in stopping the sweating in any part of the body and its effect usually lasts for several nights. Unfortunately the pungent and irritating odors of for- maldehyde are disagreeable and may become dangerous to the patient, hence in making these applications the windows should be wide open and the patient should breathe during the appli- cation through a cloth or a sponge saturated with turpentine. A useful dusting powder to control the night sweats of Tannoform phthisis is tannoform. This should be powdered over the whole body every night. Salicylic acid and talcum powder mixed Salicylic acid in the proportion of one to one hundred also forms a useful dust- ing powder. When this preparation is applied the patient should cover his mouth as the salicylic acid is exceedingly irritating to the throat and may produce violent coughing. For internal use alcohol in the form of brandy or whisky Alcohol in milk or water, given in the evening, is occasionally valuable in stopping profuse perspiration during the night. Atropine in large doses, that is, in one dose of one-fiftieth of a grain (0.0012 ro P me gm.), hypodermically, or in two or three one-one-hundred-and- twenlieth grain (0.0005 gm.) doses at one hour intervals, by mouth, before going to sleep is very useful. Some patients, however, cannot tolerate atropine without serious discomfort and complain of the dryness of the mouth and throat following- its administration. In such cases agaricin in one-twelfth to one Ao> . . grain (0.006 to 0.065 gm.) doses in pill form is an exceedingly useful remedy, or camphoric acid in fifteen to thirty grain (1 to Camphoric acir* 2 gm.) doses may be given in a powder or a capsule before the patient goes to sleep. The cough in pulmonary tuberculosis frequently calls for Cough special treatment. If it is due to local causes in the pharynx, Local treat- the larynx or trachea, then appropriate topical treatment, i. e., ment cauterization of ulcers or the application of lactic acid or in- sufflations of iodoform should be employed. The topical treat- ment of tuberculous lesions of the upper air passages should be left to the skilled specialist and the technique of this therapy need not, therefore, be described in this book. The internist, however, should always carefully examine the upper air pass- ages for ulcers or erosion, as otherwise cough medicines, opiates, etc., that may harm the patient, upset his digestion and derange his nerves may be given in vain when simple treatment of the local condition would promptly lead to the goal. Occasionally coughing can be symptomatically relieved by in- inhalations halations of steam through a steam inhaler, as described in the ;J28 PULMONARY TUBERCULOSIS Demulcent drinks Lozenges Education Section on Bronchitis. Here sodium chloride or sodium carbon- ate added to the water exercise a very beneficial effect. Or the patient may inhale the steam from a bowl of hot water through a paper cornucopia, or simply by covering his head and the dish with a towel, the water being medicated with a teaspoonful of tincture of benzoin, or twenty drops of opium tincture with five drops of belladonna tincture to the quart. Demulcent bever- ages and lozenges also frequently give relief, especially if the cough is due to local irritation in the upper air passages. A very useful demulcent beverage is the following: Narcotics Opium and its derivatives Expectorants Oleoresins Balsams ^ Sweet almond oil, Mucilage, Simple syrup, Water, 10 10 10 200 Lozenges medicated with eucalyptus, guaiacol, menthol, chlo- ride of ammonia, red gum are all useful. If these simple remedies fail to relieve the cough, then med- icines must be given internally. In the absence of much secre- tion, i. e., when the cough is irritative in character but non- productive then the education of the patient is frequently an important element in the treatment. Sufferers from any bron- chial or tracheal trouble are apt to cough much more frequently and more violently than is necessary. If they are told to sup- press or control the cough, when they feel a little tickling in the throat or in the chest, very much will be accomplished. Tuber- culous cases especially should be educated to cough as gently as possible as there is always danger of hemoptysis and spreading of the tuberculous process into remote regions of the lung by too violent coughing efforts. In the irritative form of cough without much expectoration that cannot be controlled by the will narcotics must generally be used, especially if the patient cannot sleep on account of the coughing, or if the coughing in- terferes with his eating, destroys his appetite or causes vomit- ing. Here the whole array of opiates, opium, heroin, codeine, morphine, dionin, may be employed, as described in full under Bronchitis. If, on the other hand, the secretion is very abundant, or if there are cavities filled with secretion, then opiates should be given very sparingly. Here the various expectorants that have been fully described in the Section on Bronchitis should be employed (see page 282). If the secretion is very purulent, then the balsams and oleoresins should be used as in any other form of putrid bronchitis. PULMONARY TUBERCULOSIS 329 Patients with large cavities who suffer particularly from severe coughing paroxysms at night should be instructed to at- tempt evacuation of the cavity by lying on the opposite side to it for a time before going to sleep. If this is done evacuation of Position of pa- the cavity is promoted and there is less tendency to a paroxysm tients Wlth of cough for some hours to come, i. e., until the cavity fills up again and its contents comes in contact with healthy bronchial mucosa near the orifice of the cavity. The treatment of tuber- culous cavities does not otherwise differ from that of bronchiec- tasis as fully described on page 283. The digestive disorders occurring in the course of tubercu- Digestive dis- losis are of great importance and should be carefully considered <> rders in the treatment because so much depends on the proper feed- ing of tuberculous subjects. If there are marked gastric dis- orders, then a careful study of the gastric function should be Gastric dis- made and the diet and medication arranged accordingly. In ur ances tuberculosis any variety of gastric disorder may occur from sim- ple nervous dyspepsia to different combinations of motor, sen- sory and secretory perversions, acute and chronic catarrhs, ulcer- ative processes with stenosis and dilatation or atony of the gas- intestinal dis- tric walls and amyloid degeneration of the gastric and intestinal ord ers mucosa. It will be seen, therefore, that the treatment of the stomach will : have to vary greatly in each case according to the exact character of the trouble that is found. Anorexia is a symptom that requires special discussion. ^ norexia It may occur in any of the above gastric disorders complicating tuberculosis, or it may occur without any marked stomach trou- ble. It is always a difficult condition to deal with. A tuberculous subject suffering from lack of appetite or selection of positive aversion to food should be allowed the widest choice diet in the selection of his diet, provided there are no distinct contra- indications, as revealed by the state of the gastric function to the use of certain articles of food that he may crave. Many cases of anorexia are produced by one-sided and forced feed- ing, so that here it is particularly important that the physician should not be a dogmatic doctrinaire. There are some cases in which the patient declares an aversion towards food of any kind and manifests an absolute unwillingness to eat. In such instances it may become necessaiy to insist upon forced feeding, Forced feeding the patient taking his food as he takes his medicine and, here, the diet may have to be one-sided but it should, above all things, be of the most nutritious kind. In extreme types of anorexia, especially in hysterical subjects, it may become necessary to ad- minister food by the stomach tube, the nasal catheter, or even by „ A . x t ... " Stomacn tuoe rectal injection (see index), in order to prevent the patient from Rectal feeding 330 PULMONARY TUBERCULOSIS Exclusive milk-cream feeding Raw beef Causal treat- ment of an- orexia Fever Coughing Pain on swal- lowing Stomachics and bitter tonics literally starving to death. Most of these cases soon elect to eat properly rather than be subjected several times a day to the ordeal of artificial feeding. In ordering an exclusive milk diet it is best to give a mixture of milk and cream, about two-thirds milk and one-third cream with a teaspoonful of brandy and a tablespoonful of lime water to each tumbler full. This mixture may be given every two or three hours during the day. If administered cold the pa- tients rarely object to this one-sided feeding. If raw meat is given, and this food seems to be of particular value in tubercu- losis, then at least 200 grammes of meat should be used in the twenty-four hours. The best method of preparing it is to scrape the raw beef, to grind the pulp in a mortar and then to press it through a sieve. It may be rendered palatable by mixing with mashed potatoes and seasoning with plenty of salt, or it may be mixed with one or two eggs and flavored with pepper and salt or with lemon juice. Every case of anorexia should be submitted to careful'study and the cause of the aversion to food discovered if possible. Sometimes the high fever itself disturbs the appetite of the pa- tient, then every effort should be made by the judicious em- ployment of antipyretics and of hydrotherapeutic means (see above) to keep the fever down. Often the administration of five grains of lactophenine, two or three hours before each meal time, will accomplish the desired result. In other cases the coughing interferes so much with eating that the patients prefer not to eat at all. Here a little codeine or dionin, or in extreme cases a hypodermic of one-fourth grain of morphine with one- two-hundredth of atropine may be given about an hour before each meal. In still other cases there is so much pain on swal- lowing that the patients refuse to eat for this reason. Cocaine employed locally on cotton pledgets, as a spray, or by insuffla- tion occasionally relieves the pain and enables the patient to swallow. In less severe cases cold must be applied to the throat, both externally by the application of ice cloths and internally by swallowing ice pills. In all these cases a liquid diet consist- ing o£ broths, predigested food and the milk-cream food described above, may be given. Very hot, highly seasoned liquids should, of course, be avoided. Cases suffering from tuberculous ulcera- tion of the larynx and the epiglottis can often swallow better ii' lying on their stomach and sucking the liquid food through a straw. Stomachics and. bitter tonics are of very little value in im- proving the anorexia in tuberculosis. Five to ten drops of the tincture of nux vomica, or a teaspoonful of the compound tine- PLEURITIS 331 tare of cardamoms or of gentian after meals can, however, do no harm. The treatment of the constipation that not infrequently de- Constipation velops in tuberculosis, especially if one-sided albuminous feed- ing is adopted and much opiate is given, will be found described elsewhere. Tuberculosis cases eating an abundant amount of fat food, however, rarely suffer from very obstinate constipation. Diarrhea, intestinal fermentation and meteorism must be Diarrhea treated as described in the appropriate chapters, The diarrhea of tuberculosis is a particularly obstinate symptom and dan- gerous, especially if it is due to ulcerative processes in the bowel or to amyloid degeneration of the intestinal mucosa. Insomnia, in tuberculosis, is, as a rule, due to the cough, the insomnia fever or to the pains, pleuritic or otherwise, about the chest, or to digestive disorders, flatulency, meteorism, etc. With the removal of these causes insomnia usually improves. If it does not, then the sleeplessness must be treated symptomatically with the aid of remedies described on pages 35 and 36. The treatment of the hemoptysis of pulmonary tuberculosis Hemoptysis has been discussed in full in the Section on Hemoptysis. III. DISEASES OF THE PLEURA. PLEURITIS. From a therapeutic standpoint the etiological and anatomic classification of the different forms of pleuritis is of very little value. It is clinically often a very difficult matter to differen- tiate between fibrinous, sero-fibrinous and fibrous pleurisy, for the reason that small amounts of fluid in so-called dry pleurisy frequently escape detection, and because many cases of fibrinous or fibrous pleurisy very gradually develop into exudative forms with liquid in the pleural cavity. The opinion is prevalent that most cases of simple primary ]y[ os t cases of pleurisy are tuberculous in character. Hence the causal treat- sim P le pleurisy tuberculous ment would be the same as that described in the Section on Pul- monary Tuberculosis. There remain a small minority of cases of pleurisy that are not tuberculous and that follow simple exposure to cold. Wheth- er or not this exposure acts by preparing a suitable nidus in the pleura for the invasion of micro-organisms, or w T hether germ infection has nothing to do with this variety, one cannot always determine; at all events the existence of an idiopathic pleuritis, lowing- expos- following exposure to cold, must be postulated that, for lack of ure to cold ^ ^ , ' , + . ("Rheumatic a better name, may be called rheumatic. pleurisy,") 332 PLEURITIS Salicylates in rheumatic pleurisy- Sodium sali- cylate Salol Aspirin Antipyrin Inefiicacy of salicylates in tuberculous form Treatment of acute pleurisy Position in bed Diaphoresis Dover's powder Whisky Hot air This rheumatic form of pleurisy in contradistinction to all other forms is amenable to causal treatment, for, here, the salicyl- ate preparations exercise a very apparent effect upon the course of the disease. In order to be useful salicylates must be given in large doses, either as sodium salicylate in fifteen to twenty grain (1 to 1.3 gm.) doses, four or five times a day, or as salol (phenyl salicylate) in the same doses, or, best of all, as aspirin (acetyl salicylate) in doses of thirty to forty-five grains (2 to 3 gm.) two or three times a day. Antipyrin, too, in doses of five to ten grains (0.3 to 0.6 gm.) given three or four times a day in combination with one of the above salicylates is of value in some cases. This salicylate treatment with or without antipyrin is with- out effect in the tuberculous variety of pleurisy and in those forms that are due to the invasion of the pleural cavity by other bacteria. If there is evidence, therefore, of a tuberculous focus or of bacterial infection anywhere in the body; if the onset of the disorder is not sudden and does not develop manifestly from exposure to cold and chilling of the body surfaces, then the above salicylate treatment is not to be employed. For no good can be accomplished by it and there is always danger of deranging the stomach and bowel and irritating the kidneys when large doses of salicylic acid or its derivatives are administered. A case of acute pleurisy upon the onset of the first symptoms of pain in the chest, dyspnea, cough and fever should be put to bed and should be kept there until the temperature is normal. The position that the patient occupies in bed should be largely left to himself, and it is wrong in these cases to be arbitrary in regard to this matter on theoretical grounds. Some patients prefer to lie on the unaffected side, especially in the beginning of the disorder, because it hurts them very much to lie on the sick side. Other patients prefer to rest on the affected side in order to aid in immobilizing the chest where it hurts and in- stinctively, possibly, by the pressure to reduce the local hyper- emia. When much exudate has been poured out the patients almost invariably prefer to lie on the affected side, in fact most of them cannot lie comfortably on the unaffected side. This is due to the fact, self -evidently, that they wish to give the healthy side of the chest the greatest freedom for expiratory excursions. In the beginning of an attack of pleurisy diaphoretic treat- ment is often useful. Medicinally this is best brought about by the administration of a ten grain Dover's powder given with a glass of hot lemonade to which a tablespoonful of whisky or brandy is added, preferably taken in the evening before going PLEURITIS 333 to sleep. In addition the patient may to advantage undergo a sweat in the hot air bath. The latter can be arranged as de- scribed in the Section on Cardiac Dropsy, page 42, by suspend- ing blankets over the patient supported by hoops or a wooden framework and conducting heat from an alcohol lamp, placed on the floor, through a funnel and rubber tube arrangement under- neath the blanket tent. Great care should, of course, be exercised that the end of the tube from which the hot air rises does not come into immediate contact with the patient 's person, as other- wise very disagreeable burns can be produced. If electricity is Electric light available in the house, then a chain of incandescent lamps can batl1 be suspended underneath the blanket tent, or inside of a wooden box constructed for the purpose, and degrees of temperature suf- ficiently high to cause profuse sweating generated in this way. The patient should remain in this hot atmosphere for an hour or two with cold cloths or an ice bag applied to the head. When the blanket tent is removed the patient's skin should be thor- oughly dried with a rough towel and rubbed down with alcohol. In cases of pleuritis without exudate immersion in a hot bath Hot bathing in is also a very useful procedure to bring about sweating. The y euri& y patient should be placed in a bath of from 98° to 100° F'heit and instructed to lie perfectly still in the water for fifteen min- utes. Here, too, an ice bag or cold cloths should be applied to the head in order to prevent reactive hyperemia of the brain. While in the bath the patient should be given plenty of water to drink. After leaving the bath the skin should be rubbed down thoroughly with a rough towel and alcohol. While these general measures are being employed every effort should be put forward to counteract the hyperemia in the pleura, and incidentally to stop the pain and the cough. This can be done by local applications to the chest, by strapping the affected side with adhesive plaster and by the administration of mor- phine. Counter-irritation by the application of five or ten leeches Counter-irrita- to the skin over the pleuritic area is a very useful means of pro- _ , cedure, especially in the beginning of the trouble. The technique wet cupping- of leeching has been described in full on page 37. Wet cups with or without scarification (see page 39) are also of some use as a local counter-irritant. In early stages of pleurisy dry cups should, however, never be used as otherwise ecchymosis of the underlying pleural membranes may be produced. One of the best and simplest counter-irritants is a large mus- Mustar ^ tard plaster. This is prepared by mixing equal parts of mus- plaster tard and wheat flour and moistening this mixture with warm 334 Cold and heat Ice bag Leiter coil Poultices Priessnitz compresses Chloroform Iodine Anodyne oint- ments dilute vinegar. This mass is smeared in a thin layer on a piece of linen lying on a thick sheet of paper and another piece of linen is placed over the mixture. This plaster is laid upon the chest with the paper to the outside and left in place until burn- ing sets in, it is then removed and the skin treated with olive oil. Heat and cold per se act as effective counter-irritants to the chest wall. Here the sensations of the patient must be our guide, some feeling very much more relieved by the application of cold to the pleuritic area, others by the application of heat. The ice bag or a Leiter coil (page 19) may serve the former purpose; poultices made of oatmeal, flaxseed or bread and medicated with a few drops of the tincture of opium or belladonna the latter. The best effects are produced, however, by cool Priesnitz compresses (see index) applied by wringing a linen cloth out of water of room temperature, applying it to the affected area and covering it with a piece of flannel ; this compress is left in place for three or four hours and then renewed. At the end of this time the linen will be found to be dry and the underlying skin hyperemic, showing that a counter-irritant effect has been pro- duced. Chloroform may also be used as a counter-irritant, but, on account of its blistering properties it is not so pleasant to bear. If it is used at all, pure chloroform should be rubbed into the skin over the affected area and the treated region covered with oiled silk. Iodine, too, may be used as a counter-irritant but is not so effective as the other measures enumerated above. If the pain is very severe certain anodyne ointments may be used. Two very useful ones are : V Menthol, Cocaine muriate, Vaseline, 2.5 1.0 60.0 And 3 Chloral hydrate, Camphor, Vaseline, 2.00 0.5 50.00 Cantharidal plaster In those cases in which the pleuritic process remains strictly circumscribed for several days, and very early in exudative forms of pleuritis, a cantharidal plaster applied once is of value. A PLEURITIS 335 piece of the plaster about six inches square is applied to the painful area and left in place six hours. The large blister that forms should be opened at once under careful aseptic precautions and with sterile instruments. If counter-irritation fails to bring about relief, then it may Strapping the become necessary to strap the chest with broad strips of adhesive chest plaster. The immobilization of the diseased side of the thorax that is brought about in this way is always grateful to the patient and often very effective in hastening recovery. To strap the chest one should proceed as follows : The patient is instructed to sit on the edge of the bed or to stand up with the affected side Technique away from the physician. The middle of a strip of adhesive plas- ter is pressed against the axillary region of the patient while the two ends are held by the physician. The patient now presses against the strip or is pulled away from the operator by an as- sistant and with the chest in an expiratory position the ends of the strip are tightly fastened to the middle of the chest and back. Two or three strips of this kind may be applied according to the extent of the pleuritic affection. If the pain is excruciating and the cough very severe, then Morphine for hypodermic injections of morphine, one-eighth to one-fourth C0U S n and P am grain, repeated if necessary, may have to be given. On account of the suggestive effect it is usually best to inject the mor- phine directly into the intercostal muscles over the painful area. In pleurisy, on account of the peculiar distribution and Pain referred termination of the intercostal nerves that are being irritated, r e ff ions° & it is well to remember that the pain is frequently referred to remote regions of the body, so that a patient with a mild pleurisy may complain of severe distress in the lumbar region or in the anterior abdominal region of either side, thus simulating gall- bladder or appendiceal affections, lumbago, renal colic, etc. These pains, too, can frequently be stopped by local counter-irritation over the affected area in the pleura and by the hypodermic use of morphine. If active treatment instituted early fails to prevent the forma- Diuresis and tion of an exudate, or if the patient is seen for the first time catharsis in exudative with fluid in the pleural cavity, then in addition to the measures pleurisy spoken of above diuresis and catharsis must be stimulated in the hope that depletion may aid in the absorption of the exuda- tive product. The stimulation of diuresis (see also Section on Cardiac Caffein Edema, page 42) is of questionable value unless it is combined Theobromin with the drink restriction to be discussed presently. Of the diuretics that can be employed the caffein group occupies the first 336 PLEURITIS Diuretin Digitalis Squills Sodium and potassium acetate Epsom, Glau- ber, Rochelle salts Compound in- fusion of senna Jalap Elaterium Drink re- striction Thoracentesis When to as- pirate place. Caffein citrate in doses of two to eight grains (0.1 to 0.5 gm.), or theobromin in eight grain doses (0.5 gm.), or, best of all, diuretin, the double salt of sodium theobromin and sodium salicylate, in doses of eight to ten grains (0.5 to 0.6" gm.) may all be given several times a day. Digitalis and squills, the former as the extract of digitalis in doses of one-sixth to one-third (0.01 to 0.02 gm), the latter in thirty to sixty minims (2 to 4 cc.) doses of the syrup of squills, are also useful and can profitably be given combined with one of the above mentioned caffein prepa- rations. The acetates of sodium and potassium in doses of 15 to 60 grains (1 to 4 gm.), taken with plenty of hot water several times a day are also very useful as diuretics. For the purpose of promoting catharsis salines given in con- centrated form, preferably in the morning on an empty stomach, are by all means the best remedy. A tablespoonful or two of Epsom salts, Glauber salts or Rochelle salts by drawing water into the intestine by osmosis (see Constipation) produce some concentration of the blood and the latter in its turn becom- ing more concentrated than the pleuritic exudate abstracts water from the pleural cavity. A useful preparation to produce watery stools is the Compound Infusion of Senna, containing as a very useful ingredient magnesium sulphate. The dose of the remedy is two fluid ounces once or twice a day. It is rarely necessary to stimulate very active catharsis by the use of jalap or elaterium. If these remedies are to be used, two to five grains (0.1 to 0.3 gm.) of the resin of jalap, or a quarter to one grain (0.016 to 0.06 gm.) of the trituration of elaterin, may be given. The good effects derived from diuresis and catharsis upon the absorption of the pleuritic exudate are often enforced by the use of a dry diet, i. e., a diet containing the minimum of liquids (see Cardiac Dropsy). Here the desire for water may be somewhat mitigated by allowing patients to eat ice pills, to chew gum or to suck peppermint or menthol lozenges. As a last resort in the treatment of pleurisy with effusion aspiration of the fluid by thoracentesis must be considered. It is often a difficult matter to decide just when to tap the chest. Axiomatically one may say that it is always better to aspirate too soon than too late, for if the pleuritic exudate is allow r ed to remain in the pleura too long the lung is very apt to lose its elasticity and its power of expansion, and interstitial pneumonia, carnification of the lung and bronchiectasy are quite liable to de- velop. Moreover, if the exudate is very large, so that it com- presses the lymph stomata in the pleura, absorption of the fluid is automatically prevented. PLEURITIS 337 The chief indications for thoracentesis are persistence of the Indications exudate at the expiration of three or four weeks and despite the for thora- employment of all the measures spoken of above ; then, bilateral exudative pleurisy developing rapidly and producing severe orthopnea; and, again, severe subjective symptoms due to dis- location of the heart with twisting or compression of the large vessels at the base of the heart, with pulmonary edema, cerebral anemia, peripheral cyanosis, stasis in the abdominal viscera and other remote symptoms that can be directly attributed to the presence of fluid in the pleural cavity. Finally, tapping of the chest may become necessary as a palliative measure in carcino- matous and sarcomatous processes involving the pleura. In the latter class of cases the fluid is usually hemorrhagic in charac- ter and almost invariably reappears after thoracentesis. Here, Thoracentesis therefore, one should be conservative in tapping the pleura, for in Hemorrhagic the repeated hemorrhages into the pleural cavity are without doubt weakening to the patient, so that the removal of the fluid, in this class of cases, should be undertaken only when the sub- jective symptoms become distressing or directly endanger life. The dangers incident to the operation of thoracentesis are often grossly exaggerated. It is true that accidents may hap- Dangers of pen after withdrawal of fluid from the chest under rigid asepsis, thoracentesis or if the fluid is too rapidly removed, especially if due care is not exercised in working, notably embolization of cerebral or pulmonary arteries, syncope from cerebral anemia, paralysis of the heart, pneumothorax, empyema, expectoration of albuminous sputum, etc. If the aspiration is carried out carefully and if emergency remedies are kept at hand to prevent all possible complications about the heart and circulation, then thoracentesis is fraught with very slight danger. One should have ready, therefore, for such emergencies, analeptics, i. e., a hypodermic Preparation foi syringe filled with a ten per cent, solution of camphor in ether thoracentesis and a hypodermic of one-thirtieth grain of strychnine sulphate, also some smelling salts and a small glass of brandy or whisky. Before performing thoracentesis it is always best to give the patient a quarter of a grain of morphine, hypodermically, Morphine be- to quiet him and to subdue his fear and excitement somewhat, fore thora- C6IltGSis so that he may co-operate with the operator to the best of his ability and also to prevent, as far as that is possible, the cough which so frequently follows withdrawal of pleuritic exudate. The little field of operation should be rendered thoroughly aseptic by scrubbing with soap and water and 1:2000 bichlo- Technique ride solution, alcohol and ether. A preliminary puncture should always be made with a hypodermic needle in order to ascertain 338 Asepsis IJhe place of puncture In the anterior axillary line At the outer angle of the scapula Danger of wounding the diaphragm Position of the patient Local anes- thesia Aspiration of the fluid with certainty that fluid is present about the spot where it is intended to insert the trocar, and also in order to insure the absence of a pleuritic adhesion at the point within the area of dullness that has been selected for the puncture. In selecting the place of puncture two regions are usually considered. Either a point in the fifth, sixth or seventh inter- space in the anterior axillary line, or a point posteriorly in the seventh or eighth interspace near the outer angle of the scapula. The former location is the better of the two, for while the bulk of the fluid usually accumulates posteriorly after the patient has been lying down for days, so that the insertion of the needle at the angle of the scapula is most apt to strike the fluid, still the posterior intercostal spaces are narrower and the muscles of the back are thicker than in the axillary line, so that the needle must be pushed in deeper and must ' overcome more re- sistence. The fluid, moreover, in the posterior part of the chest is apt to contain more abundant flakes of fibrin than in front, owing to the fact that the latter sink by gravity; consequently posteriorly there is always more risk of occlusion of the needle. The puncture should always be made as low down on the thorax as possible, care being taken, of course, not to wound the diaphragm. The exact location of the diaphragm is, there- fore, best determined first on the healthy side and its correspond- ing location on the sick side estimated therefrom. The patient should be instructed to sit up and to place the arm of the affected side on the opposite shoulder as this broad- ens the intercostal spaces. Then, as a rule, the needle is in- serted quickly into the fifth or sixth interspace, close to the upper margin of the rib to avoid injuring an intercostal artery. If necessary local anesthesia may be produced by an ether spray or a chloride of ethyl spray, and if it is desired to facili- tate the entrance of the needle still more and to reduce the pain to a minimum, a small incision through the outer integument in the anesthetized area may first be made. The entrance of the needle into the pleural cavity can readily be determined by a certain "give." The fluid is now withdrawn either with the aid of a Potain or Dieulafoy aspirator, although these complicated apparatuses are rarely necessary. The object of using them is to prevent the entrance of air into the pleural cavity. This accident can very readily be prevented in a simple manner by connecting the trocar with a small rubber tube about three or four feet long into the end of which a small funnel is inserted; close to the needle a clamp compresses the rubber tube. The funnel, tube PLEURITIS 339 and needle are filled with a four per cent, boric acid solution, the clamp closed, and, during the insertion of the needle, the funnel held high by an assistant. As soon as the needle enters the pleural cavity the clamp is removed and the funnel lowered into a vessel containing four per cent, boric acid solution. In this way the exudate is removed by direct drainage under slight negative pressure and there is practically no danger of air en- tering the pleural cavity. The rapidity of the out-flow can be governed by the clamp. After enough of the fluid has been withdrawn the skin is Dressing the squeezed tightly about the needle and the latter very rapidly ab- punc ure stracted. The little wound is quickly covered with a piece of court-plaster or with a small strip of iodoform gauze that is glued to the skin with collodion; usually no other dressing is required. The amount of fluid to be drained off varies according to Quantity of individual peculiarities of the case and the reaction of the pa- w ^thdr°awn tient. Upon the first appearance of syncope the needle should at once be withdrawn and the aspiration of fluid stopped. In very large exudates as much as a litre or a litre and a half of fluid may be slowly withdrawn with impunity. It will rarely be necessary, however, to take away more than 500 cc. After the thoracentesis has been performed the patient should After treat- remain in bed, hot applications or counter-irritation (see above) should be applied to the chest and diuresis and catharsis stimu- lated. At the same time in order to promote the expansion of the lung the patient should be instructed to take twenty or thirty deep, forced inspirations several times a day, raising the hands above the head with each expiratory effort or, better still, he should perform expiratory movements against pressure, either in a pneumatic cabinet or simply by slowly inflating a large rubber bag two or three times a day. If the contents of the pleura is purulent (empyema), or if Empyema and air enters the pleura (pneumothorax) through the chest wall pneumothorax after trauma or from perforation of a pulmonary or bronchiec- tatic cavity, or from the esophagus, stomach or colon as the result of ulcerative perforation, then the treatment becomes sur- gical. The only treatment of a purulent pleurisy is free incision Treatment of and drainage, if necessary with resection of portions of one or purulent more ribs. No case should be considered too desperate to at- p euri y tempt this operation, as remarkable improvement is generally seen in these cases when drainage is established and the pus is freely evacuated. As a precautionary measure thoracentesis may 340 PLEURITIS be attempted when the services of a competent surgeon cannot at once be secured, or if the patient is in so reduced a condition that the evacuation of some of the pus by means of a trocar is deemed a conservative preliminary measure instituted in order to give the patient more strength and resisting power to with- stand the shock of the later operation or, finally, if it is de- sired to withdraw large accumulations of pus gradually for fear of endangering the patient's life by suddenly changing the pressure equilibrium in the thorax. In all these instances thora- centesis must, however, always be considered merely as a pal- liative and not as a curative measure, notwithstanding the fact that very rarely an empyema gets well from simple aspiration of pus by tapping. The latter fortunate issue can never be counted upon. The after-treatment of empyema following evacuation of the pus does not differ materially from that employed after thora- centesis for simple pleurisy. Special attention should be direct- ed toward promoting free expansion of the lungs by forced ex- piration exercises against pressure (inflating a rubber bag, blow- ing bubbles through a water bottle, breathing in a pneumatic chamber, etc.), because in purulent pleurisy in particular there is a tendency to the formation of tough adhesions that seriously interfere with the expansion and aeration of the lung and hence prevent restitution to normal conditions. Treatment of In pneumothorax there is usually some fluid in the pleural pneumothorax cavity (rarely serous or sero-fibrinous, generally hemorrhagic or purulent) ; so that in many of these cases thoracentesis becomes necessary. If in simple pneumothorax the intra-thoracic pres- sure becomes very high so that the dislocation of the thoracic viscera, the excessive compression of the lung with great pain, distressing dyspnea, venous congestion about the head and the serious interference with the heart's action renders the condi- tion of the patient unbearable, then puncture of the chest wall may be performed for the purpose of allowing the escape of some of the air and rendering the pressure within the pleural sac equal to the atmospheric pressure. In valve pneumothorax this procedure may have to be repeated at frequent intervals. If the pneumothorax develops suddenly from the perforation with a sharp pain, profound dyspnea, a weak heart's action, liv- idity and symptoms of collapse, then a hypodermic injec- tion of one-fourth grain of morphine should be given at once, and repeated if necessary. The heart, at the same time, should be supported by analeptics (see page 32) ; hot poultices, a mus- tard plaster or one of the anodyne preparations enumerated PLEURITIS 341 above must be applied to the chest wall until the most violent symptoms have subsided. The subsequent treatment, until thoracentesis or thoracotomy are performed, does not differ ma- terially from that of any other form of pleurisy. CHAPTER VIII. DISEASES OF THE DIGESTIVE APPARATUS THE STOMACH. ACUTE GASTRITIS. Acute gastritis, whether due to over-eating or to the inges- tion of indigestible articles that irritate and overtax the stom- ach, or to alcohol, or to infectious agencies, calls for rest of the stomach and prompt evacuation of the offending material. As a rule these two postulates are promptly fulfilled by Nature, in- asmuch as the patient both manifests a violent aversion for food and promptly responds to the ingestion of food by nausea and Evacuation of vomiting, or vomits spontaneously. Many cases of acute gastritis * e stomacil recover within a few days if not interfered with, especially if Abstinence they receive neither food nor medicine. During the period of enforced or voluntary fasting most of To control the patients complain only of thirst, and this should be appeased thirst either by repeatedly washing out the mouth (a procedure that is especially agreeable to the patients on account of the bad taste and bad breath that usually accompanies acute gas- tritis) with some simple mouth wash (see page 260), or by swal- lowing ice pills or teaspoonful doses of ice water, ice cold lem- onade or orangeade, or very dilute hydrochloric acid. Small swallows of ice cold carbonated waters are particularly agree- able and soothing to the stomach, because the alkali of the water aids in dissolving the mucus and the carbonic acid exer- cises a slightly anesthetic effect upon the irritable mucous lining of the stomach. Should the stomach not spontaneously get rid of its con- tents by vomiting, then the evacuation of the stomach contents should be artificially promoted either by producing emesis or preferably by lavage. The ordinary emetics, as ipecac, tartar emetic, etc., should Emetics never be given by mouth on account of the irritating effect they Ipecac exercise upon the already hyperemic gastric mucosa; besides, ar ar eme 1C they take considerable time to produce their effect, and delay may be dangerous, especially in children. Sometimes such sim- ple measures as drinking lukewarm water, tickling the pharynx Lukewarm with the finger, are effective in producing vomiting, especially in water patients who vomit easily. Some people, however, vomit with great difficulty, or fail to vomit at all with the aid of these sim- ple measures, then the stomach contents is not completely evacu- 344 ACUTE GASTRITIS Apomorphine Lavage Apparatus to be used Introduction of the stomach tube Expression ated; under such circumstances apomorphine given hypoder- mically, in watery solution, in the dose of a twentieth to a tenth of a grain (3 to 6 mg.), repeated, if necessary, is a useful remedy. Best of all, however, is lavage of the stomach either with warm water or, better still, with a dilute soda solution con- taining one teaspoonful of soda to the quart of water; for the soda aids in dissolving the mucus that coats the inner gastric walls. Many kinds of apparatus have been devised for performing lavage of the stomach. It is unnecessary to employ the com- plicated systems of funnels, tubes, clamps and glass connections that have been described. The latter are chiefly useful in the treatment of chronic gastric disorders, and for use by the patient himself, or by the inventor of the device. For ordinary use at home a simple stomach tube and a glass funnel, or a stomach tube with an aspirating bulb, are the most convenient and the simplest to employ. If the funnel is used, the stomach contents is removed by siphonage ; if the bulb is used, by aspiration. The tube should be smooth and soft. Stiff tubes with longitudinal ridges should not be used. The introduction of the stomach tube should never be at- tended with much difficulty. Inasmuch as it is usually more diffi- cult for the physician and less agreeable to the patient to have the stomach tube passed in the recumbent than in the upright position, it is best, especially if lavage of the stomach is being performed for the first time, to have the patient sit up opposite to the physician with the head slightly bent forward. Before in- troducing the stomach tube the manipulation that it is intended to perform should be carefully explained to the patient and as- surance should be given that the tube will be promptly with- drawn if it does not slide down easily, or if it produces gagging or choking. In excitable or nervous subjects the physician should continuously speak to the patient, encourage him to breathe deeply and to keep his mouth open and to perform swallowing movements until the tube enters the stomach. The tube should be moistened with water (not with oil, vaseline or glycerin) and advanced to the pharyngeal wall; the patient should then be told to perform swallowing movements, with the head bent slightly forward and to continue swallowing while the physician pushes the tube down until it reaches the stomach. The patient may now attempt to express the stomach con- tents by retracting the abdominal muscles and straining; in this way a large proportion of the offending material may often be evacuated. If this manipulation does not bring out any of ACUTE GASTRITIS 345 the stomach contents, then a large funnel holding about 500 cc. should be inserted into the free end of the stomach tube and held about two feet above the patient's mouth and a dilute soda solution (see above) poured into it. As soon as most of the fluid has passed down, the funnel should be lowered below the level of the stomach and the contents removed in this way by siphonage. This manipulation should be repeated several times until the wash water comes out clear. If the patient shows con- syphonage siderable tolerance for the stomach tube, then it is well to have him lie down with the tube in place and to perform lavage again in the recumbent position. It will often be found that in this way considerable material will be removed from the stomach, Lavage in re- even if the wash water came out quite clear while the patient £JJJ£ en posl " was sitting up. In order to avoid retention of the wash water in the stomach it is best to catch the water returning from the stomach in a graduated vessel and to measure carefully the amount of water poured in and the amount recovered from the stomach. If the water is poured into the funnel too quickly a vortex is Accidents to be often formed and, in this way, considerable air is sucked into av01 e the stomach; when this occurs the funnel should be held in a slanting position at once, and the aspiration of air will stop. Quite frequently when the patient begins to perform vomiting movements the wash water pours out alongside the tube ; this is due either to pouring the water in too quickly or under too great pressure; the remedy, therefore, is to pour the water more slowly and to lower the funnel. If the tube has been pushed in a little too far so that it touches the sensitive mucosa at the fundus, then vomiting and retching may also occur; here withdrawal of the tube an inch or two will frequently stop the patient's distress and the pouring out of water through the mouth. The tube should be withdrawn with some water still in the Withdrawing funnel. It is always dangerous to let all the water run out of the funnel as, in this way, considerable air may be pumped into the stomach upon a second washing or in withdrawing the tube some of the mucosa may be pulled off. In removing the tube, therefore, it should be withdrawn with the water still flowing until its lowest point is well above the cardia. As soon as the tip of the tube is out of the stomach, the tube should be com- pressed below the funnel and drawn out quickly. Many of the accidents and disagreeable complications spoken Aspiration of above can be avoided by using an aspirating bulb instead of a funnel. The tube is inserted as described above, the aspir- 346 ACUTE GASTRITIS Laxatives Castor oil Calomel Diarrhea Constipation Bowel irriga- tion Pain Priessnitz compress ating bulb compressed and attached to the open end of the stom- ach tube and then allowed to expand, and in this simple way the stomach contents aspirated. In order to perform lavage with. the aspirating bulb the bulb is filled with water, the water pressed into the stomach and removed immediately by allowing the bulb to expand; the tube should be withdrawn with the bulb expanded. Evacuation of the stomach contents usually brings prompt relief. Often spoiled or fermenting food has passed on into the bowel before the stomach contents is evacuated, then empty- ing of the bowel may also become necessary. This is best brought about by the use of castor oil in tablespoonful doses; for the latter (aside from frequently producing nausea and thereby emesis) exercises a rapid purgative effect. Calomel r too, is a useful remedy in these cases, for it acts as a cholagogue, a rapid evacuant and an antiseptic. It should be given in doses- of two to three grains (0.13 to 0.2 gm.), or in several doses of a half grain (0.03 gm.) every hour for four or five doses, fol- lowed within a few hours after the administration of the last dose by a tablespoonful of castor oil or a saline laxative (see also page 414). This practice usually stops the diarrhea that is apt to super- vene if evacuation of the irritating bowel contents is not promptly brought about. It also successfully counteracts the obstinate constipation that sometimes complicates acute gas- tritis. It is always bad practice to attempt to check the diar- rhea by the use of opiates, tannic acid or other anti-diarrheie remedies before complete evacuation of the putrid bowel contents has been promoted. In addition to producing evacuation of the bowel by the ad- ministration of castor oil or calomel by mouth, bowel irrigation with oil or with glycerin in water or soapsuds in water is very useful. By cleansing the lower bowel the colicky pains are often relieved, for the latter are chiefly produced by the in- creased peristaltic movements of the small intestine and are rendered more severe if an obstacle to the evacuation of the bowel contents is offered by impaction of the colon with solid fecal material. The pain and the distress in the epigastric region usually disappear within a day or two if the above measures are adopted. If the pain persists or is very severe, a Priessnitz compress ap- plied to the epigastrium generally acts as an effective counter- irritant and analgesic. Such a compress is applied by laying ACUTE GASTRITIS 347 a linen cloth, wrung out of cool water, upon the epigastrium and covering it with a piece of flannel. This application should be repeated every two or three hours. Sometimes a hot water bag Heat over the stomach or a thermophore (see index) are grateful to the patient. In extreme cases with much pain and very persistent vomiting a hypodermic of an eighth of a grain of morphine with a two-hundredth of atropine, or opium with belladonna in suppository of the extract each y 2 gr., may have Morphine to be given; or if there is very much hyperesthesia of the gas- Belladonna trie mucosa, cocaine as described on page 19 may be adminis- Cocame tered. After a period of starvation lasting for twenty-four to forty- Diet eight hours some food should, by all means, be administered. The diet should at first be liquid and cold and should be given in small quantities, beginning with teaspoonful doses of cold milk or thin gruels made with water or milk, possibly with an egg stirred in. Later, as the patient recovers, easily digestible foods should be administered in gradually increasing quantities. THE DIGESTIBILITY OF FOODS This question of digestibilit}' is a difficult one. As a rule the criterion of digestibility is considered to be the length of time that an article of food remains in the stomach, and a num- ber of tables have been arranged by different clinicians, giving a scale of digestibility based on this standard. The following, by Pentzoldt, is one of the most reliable, and has the advantage, moreover, of giving the quantities of the different foods : The stomach normally empties itself of the following articles in the time named : SCALE OF DIGESTIBILITY. Within one or two hours. 100-200 cc. water, pure. 200 cc. water, carbonated. 200 cc. tea. 200 cc. coffee. 200 cc. cocoa. 200 cc. beer. 200 cc. light wine. 100-200 cc. milk, boiled. 200 cc. meat broth without additions. 100 gm. eggs. Within two or three hours. 200 cc. coffee with cream. 200 cc. cocoa with milk. 348 ACUTE GASTRITIS 200 cc. malaga wine. 300-500 water. 300-500 beer. 300-500 milk, boiled. 100 gm. eggs, raw, hard boiled, or as omelette. 100 gm. beef, raw sausage. 250 gm. calf's brains, boiled. 250 gm. sweetbreads, boiled. 72 gm. oysters, raw. 200 gm. carp, boiled. 200 gm. pike, boiled. 200 gm. codfish, boiled. 150 gm. cauliflower, boiled. 150 gm. cauliflower, salad. 150 gm. potaoes, boiled. 150 gm. mashed potatoes. 150 gm. stewed cherries. 150 gm. raw cherries. 70 gm. white bread, fresh and stale, dry or with tea. 70 gm. zwieback, fresh and stale, dry or with tea. Within three or four hours. 230 gm. young boiled chicken. 220-260 gm. squab, boiled. 195 gm. squab, roast. 230 gm. partridge, roast. 220-230 gm. young chicken, roast. 250 gm. beef, raw, boiled (lean). 250 gm. calf's feet, boiled. 160 gm. ham, raw and boiled. 100 gm. veal, warm and cold (lean). 100 gm. beefsteak, broiled, cold and warm. 100 gm. beefsteak, raw, scraped. 100 gm, roast beef. 72 gm. caviar, salt. 150 gm. brown bread. 150 gm. Graham bread. 150 gm. white bread. 100-150 gm. Albert biscuits. 150 gm. potatoes, vegetable. 150 gm. rice, boiled. 150 gm. carrots, boiled. 150 gm. spinach, boiled. 150 gm. cucumber salad. ACUTE GASTRITIS 349 150 gm. radishes, raw. 150 gm. apples. Within four or five hours. 210 gm. squab, broiled. 250 gm. fillet of beef, roast. 250 gm. beefsteak, broiled. 250 gm. beef tongue, smoked. 250 gm. rabbit, roast. 240 gm. partridge, roast. 250 gm. goose, roast. 280 gm. duck, roast. 200 gm. salt herring. 150 gm. lentil puree. 150 gm. string beans, boiled. The length of time during which an article of food remains Definition of in the stomach is not, however, the only measure of its digesti- 1 ^ estl lllt f bility, especially in pathological cases; for, broadly speaking, an article of food may be considered digestible, first, if it pro- duces no disagreeable subjective symptoms; second, if it does not over-tax either the motor or the secretory powers of the stomach. The element of idiosyncrasy also enters into the equa- tion here ; for an article may be very well digested in the stom- ach but not be well borne by the patient or, on the other hand, it may be well borne, i. e., cause no subjective symptoms of dis- tress and still may leave the stomach in a practically undigested form to undergo, finally, disassimilation in the intestine. In either case the article must, insofar as the stomach is concerned, be considered indigestible, for it fails to meet the prime require- ments of a digestible article, i. e., neither to over-tax the motor, the secretory or the sensory function of the diseased organ. In pathological cases where the perversions of these three func- tions are frequently associated this applies with particular force, as will be shown later when discussing chronic disorders of the stomach and the functional perversions of the organ. In this place, however, some general considerations in re- gard to the utility of different foods in stomach disorders, i. e., Dig-estibilitv their digestibility in a broader sense, may be inserted. of meats The digestibility of meats depends upon their origin, upon the amount of fat they contain and their mode of preparation. The most digestible varieties of meat are poultry, especially chicken and squab; less digestible are duck and goose. Yeal, if sufficiently aged (see below) and properly prepared, comes 350 ACUTE GASTRITIS The fat of meat Haw meat and cooked meat Methods of cooking" meat Smoked, cured corned meats Fresh and "hung" meat "Hig\h" meats next in the stage of digestibility, then fish with the exception of the fat varieties like trout, mackerel, pickerel and salmon; less digestible than the above are beef, pork and mutton. The more fat meat contains the less digestible it is; for fat is not at all digestible by the juices of the stomach and as it sur- rounds the muscle fibers it protects them from the action of the gastric juices, so that a large proportion of the albuminous con- stituents of fat meat pass from the stomach into the intestine practically undigested. Raw meat is more digestible than meat cooked in any way, especially if it is chopped or scraped, for in this manner the connective tissue fibers are torn and macerated and free access to the muscle tissue is given to the gastric juice. Rare meats are always more easily digested than meats that are well done. Boiled, stewed or roast meats are about equally digestible; their nutritive value, however, varies according to the method of cooking. If the meat is placed at once into boiling water, the albumens on the surface are promptly coagulated, so that the nutritive ingredients of the meat are retained. If it is intended to make stew, i. e., to extract the nutritive ingredients, then the meat should, of course, be placed into cold water which is gradually heated to the boiling point. The same principle obtains in roasting meat; it remains most nutritious if it is exposed at once to great heat, for in this way the coagulate that forms on the outside prevents the nutritive juices from running out into the pan. Smoked, cured and corned meats are less digestible than raw or cooked meats, because they contain creosote and similar products that are generated during the process of smoking and curing, and these creosote preparations materially interfere with digestion. The large amount of salt contained in salt meats and fish is also detrimental, so that the digestibility of the latter foods must be estimated as low. Meat in order to be digestible should not be too fresh, for, if eaten within a few hours after the animal is killed, i. e., while the muscle tissue is still in a state of rigor mortis, the coagulated myosin renders the meat fibers difficult of digestion. After hanging for a time lactic acid forms and softens the connective tissues while bacteria cause dissolution of the myosin coagulate. The meat should, of course, not hang too long nor in too warm a temperature, as otherwise putrefactive processes may set in with the formation of ptomaines. ''High" game and poultry, therefore, are very detrimental in any stomach disease. As poul- ACUTE GASTRITIS 351 try is eaten almost immediately after it is killed, i. e., before myosin coagulation occurs, both the above difficulties are usually obviated. Meat broths contain salts, extractives, kreatinin, gelatin, a Broths little albumen and peptones, hardly any fat, and water; their nutritive value, therefore, is very small. They act chiefly as stimulants to the flow of gastric juice and, through the extrac- tives they contain, as stimulants to the nervous system and the circulation. Unless contra-indicated by conditions of the stomach in which it is desired not to dilute the gastric juice or to over-tax the weak gastric musculature by the ingestion of much fluid, meat broths fulfill a useful purpose. So-called peptones and different predigested foods contain Albumoses and albumoses; the latter are more easily assimilable than native peptones albumen, and they can replace albumens to some extent. In- asmuch, therefore, as they are nutritious and non-irritating to the stomach wall they serve a useful purpose, especially in gas- tric catarrh. Their taste unfortunately is disagreeable to many people and occasionally they produce diarrhea. Gelatinous foods, in small quantities, are a very useful ad- Gelatin dition to the diet in the form of gelatin, aspic, meat jellies, calves' head, etc. ; they are non-irritating to the stomach, but also occasionally produce diarrhea. The digestibility of eggs depends exclusively upon their mode Eggs of preparation. Soft boiled eggs and eggs stirred in soups or poached very soft are the most digestible of all ; raw eggs, fried eggs and hard boiled eggs the least digestible. The white of egg is more digestible than the yolk on account of the fat that the latter contains. A very digestible and very nutritious prepa- ration is a watery solution of egg albumen with a little salt. Milk constitutes a very nourishing, digestible and non-irri- Milk tating food, so that it should occupy a large place in the dietary of stomach cases. Some people possess a distinct idiosyncrasy against milk, manifesting not only a thorough distaste for it in any form, but also an inability to properly digest it. The latter difficulty may occasionaly be overcome by the addition of lime water, soda, magnesia or brandy, all ingredients that are intended chiefly to change the character of the curds that form in the stomach. If milk cannot be taken, buttermilk, kephyr, kumyss or solutions of condensed milk serve an equally useful purpose. There is no difference in digestibility between raw or boiled milk. Inasmuch as milk, as shown in a previous section (see page Gruels 208) cannot fulfill the caloric requirements of an individual if 352 ACUTE GASTRITIS Vegetables Fruits Nut emulsions Bread stuffs given as the exclusive article of diet, it is best to add to it cer- tain cereals, as wheat, barley or oatmeal flour, rice, sago, tapioca, or one of the many dextrinized foods that are on the market. The addition of these various substances in no way renders the milk less digestible and materially adds to its nutritive value, so that the patient can subsist for a long time upon gruels made with milk in this way. Among vegetables, potatoes and other vegetables growing under ground and those growing in pods are most nutritious and most digestible, especially if served boiled in water or, best of all, mashed or as purees. Leafy vegetables are not very nutritious, contain abundant cellulose, which is not at all digestible, and frequently acids, which may be harmful in diseases of the stom- ach. Salads, therefore, prepared with oil, vinegar and spices are to be especially avoided in stomach diseases : for the character of the leaves from which the salads are made, the fat, the acid and the spices all render salad harmful. Very digestible and nutri- tious vegetables are cauliflower, asparagus (especially the heads), spinach and string beans. Fruits should be given sparingly in stomach diseases for they contain abundant cellulose, free acids and much sugar and are very commonly contaminated with bacteria. The least harmful fruits are apples and pears, better given stewed than raw. Grapes, too, are very useful. Berries on account of the seeds and acids they contain, cherries, plums and peaches on account of the acids and the abundant cellulose are not very good. Nuts are very indigestible. A useful preparation of nuts, however, is so-called nut-milk made from ground almonds or other nuts mixed with four or five parts of water and two or three parts of milk. Such nut emulsions are very soothing to the stomach and are also nourishing on account of the albumens, fats and sugar they contain. Of bread stuffs the best are toast, crackers and zwieback. Stale bread is always better digested than fresh bread, especially hot bread. The crust of bread is by far preferable to the soft portions ; for the former is better dextrinized and hence partially predigested and, moreover, requires more thorough mastication, hence preliminary dextrinization m the mouth, than the soft part of the bread. Breads made of coarse flours require a very active gastric juice and should never be given if the gastric function is weak; they have a distinct place, however, in the treatment of some gastro-intestinal diseases, especially where it is desired to stimulate peristalsis of the intestine. The so-called diabetic breads described on page 126 are digestible and nutri- ACUTE GASTRITIS 353 tious without being irritating to the stomach, hence they are very useful in stomach disorders. Sugar is introduced either in the form of cane sugar in Sugar ordinary table sugar and some vegetables; or as dextrose or levulose in grapes, honey and certain fruits; and as lactose in milk. Inasmuch as dextrose and levulose are absorbed directly and rapidly, whereas cane sugar must first be split (inverted) into dextrose and levulose before it can be absorbed, it is clear that the administration of the former sugars is more rational than that of cane sugar ; for the latter is forced to remain in the stomach and upper portion of the bowel longer than dextrose or levulose; hence fermentation is more apt to occur with gaseous distention of the stomach and bowel if cane sugar is given than if sugar is administered in the form of dextrose or levulose. It has been established, moreover, that cane sugar retards the digestion of the albumens and fats to some extent. In stomach diseases, therefore, cane sugar should be given sparingly and the demands of the patient for sweet foods should largely be satisfied by the administration of honey or dextrose. The digestibility of fats is approximately proportionate to Fats their melting point ; the lower the melting point the more digest- ible they are as a rule; thus vegetable oils and the milk fats, i. e., butter and cream and milk, are by far more digestible than animal fats. The digestibility of the latter, moreover, is im- paired by the fact that the fat is enclosed in a tough cell membrane. Of beverages, water in large quantities should always be Beverages avoided in stomach diseases, for it taxes the motor power of the stomach, retards digestion and dilutes the gastric juice. Suf- ferers from stomach disorders should, therefore, refrain from drinking much water immediately before, during or after meals. The use of coffee in stomach cases must be largely governed Coffee by the reaction of the patient. Tea and coffee, per sc, exercise Tea no effect upon gastric digestion, itself. In some persons they act upon the nervous apparatus, producing certain symptoms about the higher cerebral centers and also somewhat stimulating per- istalsis. The prejudice against coffee and tea in stomach dis- eases is largely exaggerated. If a choice is to be made between the two, tea, empirically, is probably less harmful than coffee. It is generally a superfluous restriction to forbid the use of small quantities of coffee, especially for breakfast, to people who have been used to this beverage all their lives. The use of small quantities of alcoholic beverages is generally Alcohol useful in stomach disorders. That alcohol in anv form should 354 CHRONIC GASTRITIS Brandy, liq- ueurs, Claret, Moselle Cider Beer Champagne Smoking be avoided in acute gastritis need hardly be emphasized, but in more chronic varieties of stomach disorders, especially in certain functional disturbances, small quantities of alcohol act as a stimulus to the motor power and the secretion of the stomach, increase the appetite and materially aid in the digestion of fats by promoting the evacuation of the latter from the stomach. It is true that alcohol precipitates pepsin, but this disadvantage is more than overbalanced by the advantages enumerated above. Most cases of chronic stomach trouble are benefited by the 'use of a little brandy, a liqueur or Sherry after meals or by drinking a glass or two of light Claret, Burgundy or Moselle wine during their meals. Cider on account of the large quantity of acid it contains is not so useful a beverage. Beer should be forbidden, for it con- tains abundant carbonic acid gas which distends the stomach, especially as it is always taken in relatively large quantities, hence violates the principle of restricting the liquid intake during and before meals. Beer, moreover, unless pasteurized, contains yeast cells which are very apt to set up fermentative processes in the stomach and bowel. Small quantities of cham- pagne are useful both on account of the alcohol and the carbon dioxide they contain. Large quantities should, however, never be given because of the danger of distending the stomach from the rapid evolution of gas. Smoking, finally, should never be permitted in acute gastric disorders. In other gastric troubles it should never be allowed when the stomach is empty, for it undoubtedly reduces the appetite. A cigar or two a day, however, especially in men who have been accustomed to the use of tobacco all their lives, in- dulged after meals can do no harm and it is a cruel and unnec- essary restriction to dogmatically forbid the use of tobacco in every case of stomach disorder. CHRONIC GASTRITIS. Causes Chronic gastritis may develop consecutively to a number of primary disorders about the heart, the liver, the kidneys and the lungs. In all these conditions disturbances of the circulation leading to venous stasis in the stomach or portal stasis are re- sponsible for the gastric catarrhal symptoms. In many meta- bolic disorders, in severe anemia and leukemia, chronic gastritis is an important phenomenon. Chronic gastric catarrh may also accompany certain organic diseases of the stomach like car- cinoma, ulcer, ectasy. CHRONIC GASTRITIS 355 Chronic gastritis does not invariably accompany these differ- ent diseases, hence the existence of special factors must be postu- lated in many cases that determine the development of catarrh. Chief among the latter are any of the agencies that have been en- umerated in the preceding section as producing acute gastritis, especially if these agencies remain operative for a long time. In- discretions in diet, that is, eating the wrong food or too much food, fast eating, failure to properly masticate the food, the abuse of alcohol, the excessive use of spices, of hot foods and of medi- cines, chiefly purgatives, can all cause chronic gastric catarrh. All these factors may also produce chronic gastritis without the presence of any of the general disorders mentioned above, either by causing acute gastritis, which is neglected, or which fre- quently recurs and finally becomes chronic, or by producing slow, gradual involvement of the gastric mucosa, so that chronic gastritis insidiously develops. In instituting causal and prophylactic treatment in chronic Causal and gastritis all these elements must be considered. Any circula- treatment 1C tory disorder that may be present must be corrected, if possible, by the use of all those measures that can counteract venous stasis in the general circulation and chiefly in the portal area. The renal, pulmonary, metabolic, hematic disorders that may be present must be carefully treated as described in other sections. In chronic gastric catarrh two elements predominate, there is first an excessive secretion of mucus and second, a perversion of the gastric secretion generally manifesting itself by a deficient outpouring of digestive ferments and of hydrochloric acid; (in rare cases, however, there may be hyperchlorhydria). The food introduced into the stomach owing to these abnormal conditions fails to undergo proper disassimilation and hence stagnates, especially as the chronic inflammation of the stomach wall often leads to weakening and atony of the gastric musculature ; conse- quently abnormal fermentation of the gastric contents com- monly occurs and the condition is further aggravated by the formation of irritating poisonous acids, ptomaines and gases. The indications for treatment are to remove the mucus; to General indi- correct the perversion of secretion ; to administer a diet that catl ° ns f J r r treatment spares the gastric function and that can be promptly propelled onward into the intestine; to remove the irritating products of fermentation ; and, last of all, to stop the fermentative processes, so far as that can be accomplished, by the use of appropriate measures. In order to remove the mucus, lavage is the sovereign remedy. Lavage In chronic gastritis the stomach should be washed persistently. 356 CHRONIC GASTRITIS Lavage in the morning Lavage in the afternoon Lavage in the evening Irrigation fluids Alkalies Salt Antiseptics Potassium per- manganate, salicylic acid, thymol, hydro- chloric acid In mild cases, lavage in the morning before breakfast is usually sufficient ; at this time any stagnating contents that may have re- mained in the stomach overnight has become decomposed and softened, so that it is easily removed with the stomach washings. At all events at this time any food material that may still be present in the stomach no longer possesses much nutritive value, so that it is best removed. It is, moreover, a precarious procedure to introduce fresh food into a stomach that contains ferment- ing and decomposed material from the previous day (see also page 388). In some cases of gastric catarrh in which the motor power of the stomach is sufficiently good to cause the evacuation of all the stomach contents during the night, it may be better to perform lavage six or seven hours after the main midday meal, especially as these patients suffer the greatest distress and discomfort at such time. In this way much of the mucus is removed and the stomach is relieved of labor that it is manifestly unable to per- form, for, normally, the stomach should be empty at this time. If the stomach contents is removed late in the afternoon, then the patient should receive a very light evening meal. In another variety of cases the patients complain of the greatest distress at night; this occurs particularly if the heaviest meal is eaten in the evening and the patients go to bed three or four hours after their dinner. Here distention of the stomach with gases, sour eructations, epigastric pain, awaken the patients in the night and seriously interfere with sleep and hence general nutrition. In such cases it is best to perform lavage of the stom- ach just before the patients retire for the night. In many cases, finally, it may be necessary to perform lavage both in the morning on rising and six hours after the main meal, or in the morning and on retiring. If there is only little mucus, simple water of body temperature may be used. In some cases, however, it is advantageous to use an alkaline or saline solution containing two teaspoonfuls of sodi- um carbonate to a litre, or five teaspoonfuls of lime water to a litre, or ten grammes of common salt to a litre, or a teaspoonful of a mixture of two parts of common salt and one part of sodium carbonate to the litre. The alkalines aid materially in dissolving the mucus and also in neutralizing the acids that are formed by fermentation. The addition of antiseptic remedies to the wash water can do no harm. Very useful solutions are potassium permanganate, 0.1 to 2000; salicylic acid, 1:1000; thymol, 1:2000; hydrochloric acid, five drops to 1000. Mineral waters CHRONIC GASTRITIS 357 The evacuation of the stomach mucus can be further aided by forcing the water into the stomach under considerable pressure, i. e., either by holding the funnel high above the mouth, or better still, by using the stomach tube and aspirating bulb and exercis- ing considerable pressure upon the bulb when the water is forced into the stomach. Lavage should be continued until the wash Technique of water comes out quite clear. In some cases it will be necessary lavage in to wash the stomach out with the patient sitting erect and also tritis 110 S&S lying down. In chronic gastritis, in which the patients soon be- come accustomed to the use of the stomach tube, there is no diffi- culty in keeping the tube in place while the patient changes his position. There are distinct contra-indications to the use of the stomach Contra-indica- tube, namely, advanced arterio-sclerosis, heart lesions in stages tions to us e of o -. , ,. it- • stomach tube oi pronounced decompensation, esophageal varices, aneurism, angina pectoris and great hyper-excitability or pronounced gen- eral debility of the patient. If any of the above named condi- tions exist, so that the use of lavage must be reluctantly aban- doned, then mineral waters must take the place of gastric lavage. Mineral waters may, of course, also be used in combination with lavage in any subject. They act very much like lavage, with the difference that the mucus and the fermenting material that they dissolve is washed into the intestine instead of being removed by the mouth. The use of mineral waters is, therefore, by no means so valuable nor are the results from their employ- ment to be compared with those obtained from washing out the stomach. If there is much motor insufficiency, the ingestion of abundant water is, moreover, distinctly contra-indicated. Much harm can be done from the routine use of so-called water cures. Part of the benefit accruing to stomach cases from the use of ;R esort treat- the various mineral waters must be attributed more to the life at ment the resorts in which these waters are taken than to any of the healing properties of the waters themselves; for sufferers from digestive disorders who go to a watering place lead a life of great regularity among pleasant surroundings, free from the worry and routine of their daily existence; they are careful in their diet and are, above all, under the supervision of physicians who are especially skilled in the treatment of this class of diseases. In many of the resorts routine regulations are given the pa- Dangers of tients in regard to their diet, and they are told, often on printed rou tine in re- slips, what to eat and what not to eat during their water cure. Broadly speaking these restrictions are all theoretically con- structed and no special dietetic restrictions need, as a rule, be observed when the different waters are taken that would not be 358 CHRONIC GASTRITIS Alkaline waters Saline waters Sulpho-saline waters Lime waters Carbonated waters Temperature of the waters observed if no water cure were being instituted. The chief dan- ger lies in the drinking of too much water and in drinking large quantities of water too rapidly, most patients imagining that if a little of the waters will do them good, a great deal must do them more good; and they are generally encouraged in this be- lief by the attendants and occasionally by the physicians in these resorts. The chemical ingredients of the different waters determine their use in different conditions. Alkaline waters aid in dissolv- ing the mucus, in combining the organic acids that are formed by fermentation in the stomach and by increasing intestinal peristalsis. They, as well as the alkaline saline waters, are espe- cially useful in atonic and secondary catarrh of the stomach. Alkaline waters alone have their particular field of application in chronic hyper-acidity with catarrh. Saline waters, which should never contain more than ten per cent, of sodium chlor- ide, stimulate the formation of hydrochloric acid and of the di- gestive ferments, and also excite the motor power of the stomach and to some extent the appetite. They are especially useful, therefore, in cases with hypo-secretion and slight motor insuf- ficiency. Waters containing Glauber salts, and sulphur waters, as well as the bitter waters, are useful, particularly when gastric catarrh is accompanied by obstinate constipation and abdominal ple- thora. As they are somewhat irritating to the stomach, their use is limited in gastric disorders. Lime waters act like the alkaline waters, i. e., they are useful on account of their antacid and mucus dissolving properties. The carbonic acid that many waters contain causes prompt belching of carbonic acid gas and this occasionally aids materi- ally in the expulsion of fermentative gases that are accumulat- ing in the stomach. The carbonic acid gas, moreover, acts as an anesthetic to the gastric mucosa in painful complications of the stomach, slightly stimulates the appetite and increases intestinal peristalsis. Carbonated waters should, of course, never be used in motor insufficiency and gastric atony, for here, precisely, dis- tention of the stomach is to be avoided. The same applies to cardiac or respiratory diseases in which the stomach function is perverted, for here, too, distention of the stomach and bowel, by interfering with the respiratory excursions of the diaphragm, and hence by imposing more labor upon the right heart, is to be avoided. The following rule may be formulated in regard to the tem- perature at which these different mineral waters should be taken : CHRONIC GASTRITIS 359 If there is some motor insufficiency with decreased secretion of gastric juice and a tendency to constipation, then the mineral wa- ters should be taken cold. If the gastric and intestinal mucosa is very irritable, and if there is a tendency to diarrhea, then warm or hot mineral waters are more grateful to the patient and probably more useful. No fixed directions can be given in regard to the diet in cases Diet of chronic gastritis. In each case repeated analyses of the stom- ach function should be made and the diet arranged according to the secretory and motor powers of the stomach, as described in subsequent sections. At the same time, in view of the fact that chronic gastritis is usually a disorder of long duration, every endeavor should be put forward to maintain full nutrition of the patient by supplying sufficient calories in the food. In most cases of chronic gastritis the presence of mucus (which covers the gastric walls and becomes intimately mixed with the food, thus preventing to some extent the outpouring of gastric juice and its mixture with the food) as well as the reduction of the hydro- chloric acid, will have to be considered. Hence the food should be finely divided, thoroughly masticated and insalivated in order to impose as little labor as possible upon the stomach digestion and to facilitate the prompt removal of the food onward into the intestine. The carbohydrates in the diet should preponderate, espe- Proportion of carbohydrates, cially if there is any motor insufficiency ; for they undergo diges- fats, proteid tion almost exclusively in the intestine. The same applies to fats and the latter should be supplied in the form of digestible varie- ties of fats, i. e., milk fat or vegetable oils. Enough proteid should be supplied in the form of digestible meats (see page 347) to meet the nitrogen requirements of the individual. In this way the gastric function will not be overtaxed and the stomach will be spared and enabled more readily to regain its normal tone than if it is continuously overloaded with food that it can only digest with difficultv or not at all. THE USE AND ABUSE OF HYDROCHLORIC ACID. The administration of hydrochloric acid as a routine measure Hydrochloric in gastric disorders is being abandoned since more careful chem- aci ical examinations of the stomach contents are being universally made and treatment is governed accordingly. It is self-evident that the administration of hydrochloric acid is, to say the least, superfluous, if not directly harmful in cases of dyspepsia in which the stomach contents or the vomit show a reaction for free Dangers of hydrochloric acid (congo paper or phloroglucin vanillin test). ™, tine use °* In cases in which free hydrochloric acid is absent and in which 360 CHRONIC GASTRITIS HC1 to replace the deficit of HC1 in the stomach Inadequacy of this treatment Disadvantages of giving much HC1 Effect of HC1 on flow of gas- tric HC1 the total acidity of the stomach contents is greatly reduced, hy- drochloric acid may, to advantage, be given, first, as an aid to the digestion of albumens in the stomach, i. e., in order to render peptic digestion possible; second, as an antizymotic, i. e., in order to stop abnormal fermentation in the stomach ; third, as a stom- achic, i. e., to stimulate the outpouring of gastric juice. The administration .of hydrochloric acid for the purpose of replacing the deficit of hydrochloric acid in the stomach is a sub- stitution therapy. The effect of this treatment is greatly over- estimated. The small doses of five or eight drops that are com- monly given after eating are practically useless and hydrochloric acid, in order to be effective at all, must be given in very much larger doses. It has been shown by direct experimentation that one cannot give enough hydrochloric acid with an albuminous diet to cause the appearance of free hydrochloric acid in the stomach contents, unless such enormous doses are given that the patient would be poisoned. One part of hydrochloric acid sat- urates eighteen parts of albumen, and as a hundred drops of dilute hydrochloric acid contain only 0.8 gm. of HC1, this amount would only be sufficient to neutralize fifteen grammes of albumen. In order to aid the peptic digestion of albumens, fifteen to twenty drops of dilute hydrochloric acid in about 100 cc. of water should be given immediately after eating, and the same dose repeated every hour thereafter for three or four doses; or the same dose may be given immediately after eating and every fifteen minutes thereafter for three or four doses. The introduc- tion of such large quantities of water is, however, not without detriment. Some patients react to the administration of so much hydrochloric acid by gastric distress and pain, and unless the remedy is taken through a glass tube the teeth may be injured; all these disadvantages render the administration of hydrochloric acid as a substitute for the gastric hydrochloric acid a rather hazardous and by no means always an effective procedure. Whereas, therefore, the administration of hydrochloric acid as a direct substitute for the deficient hydrochloric acid in the gastric contents is a procedure of doubtful efficacy, regarded from the purely chemical standpoint, we know, clinically, that the exhibition of much smaller doses than those required accord- ing to the above reasoning are occasionally useful in relieving dyspeptic symptoms. This may be due to the fact that hydro- chloric acid stimulates the flow of gastric juice. This point, how- ever, is still uncertain, for the cases in which an increased flow of gastric juice seemed to follow the administration of free hydrochloric acid are not without ambiguity. It is not impossi- CHRONIC GASTRITIS 361 ble that the administration of some hydrochloric acid after eating acts as a rest cure, so to say, to the hydrochloric acid glands of the stomach by relieving them of some of the labor necessary to ^^testinal manufacture hydrochloric acid, and hence enables them to more digestion readily regain their normal tone. Hydrochloric acid is also known to stimulate the pancreatic secretion and therefore it may aid intestinal digestion and, provided the motor power of the stom- ach is good, promote the vicarious disassimilation of the albumens in the bowel. If it is desired to utilize the stimulating effect of hydrochloric HC1 before acid upon the flow of gastric juice and upon the pancreatic secre- tion, the remedy should be given in doses of ten to twenty drops -diluted with about 100 cc. of water, a quarter to half an hour before eating. Administered in this way its full stomachic effect becomes promptly manifest. The administration of hydro- chloric acid in this manner is by far more rational and generally much more effective than the administration of larger doses dur- ing the meal or immediately afterwards. Hydrochloric acid administered in this way also stimulates the appetite. In some cases it appears moreover to increase peristalsis HC1 as an in- and to act, in a sense, as an intestinal antiseptic; so that it is septic antl " particularly useful in the treatment of the diarrhea and fermen- tative intestinal dyspepsia that so often complicates chronic gastritis. Aside from its action as a digestant and as a stomachic, H C1 as an an- hydrochloric acid is also administered for the purpose lzymo 1C of holding the pullulation of saccharophytes in the stom- ach in check. Fermentation due to various moulds, fungi and bacteria is particularly active in the stomach in cases in which the hydrochloric acid secretion is reduced and in which stagnation of stomach contents occurs. It is very •questionable whether the administration even of large doses of hydrochloric acid can stop fully developed fermentation in the stomach; as a prophylactic, however, given before meals, the administration of hydrochloric acid is exceedingly useful; for by this practice we are imitating Nature 's mode of preventing overgrowth of fermentative micro-organisms in the stomach. Here, too, then the administration of small doses of hydrochloric acid on an empty stomach is effective, whereas the administra- tion of large doses during or after meals is of very little value. DRUGS IN CHRONIC GASTRITIS. Alkalies are frequently administered in cases of hypochlor- Alkalies Tiydria or gastric anacidity on the supposition that they act as stimulants to the flow of hydrochloric acid, especially if given 362 CHRONIC GASTRITIS Alkalies be- fore and after meals Stomachics Bitters before meals. It has been claimed that a reactive outpouring of hydrochloric acid occurs upon their administration which is in- tended to neutralize the alkali placed into the stomach. Experi- mental and clinical evidence, however, demonstrates this suppo- sition to be wrong. It is true that in healthy subjects certain of the alkalies given on an empty stomach can cause some increased outpouring of gastric juice, but they share this property with any other drug that might be poured into an empty stomach and that irritates the gastric mucosa ; but they do not fulfill this pur- pose so well as the bitters or stomachics to be presently discussed. The administration of alkalies before meals is, of course, an exceedingly useful procedure in gastric hypersecretion and hyperchlorhydria on account of the antacid action they exercise (see page 397), and the same antacid properties render them useful when administered after meals, not only in the hyper- acidity that is due to an excessive outpouring of hydrochloric acid, but also in gastric acidity due to the formation of abnormal organic acids by fermentative micro-organisms. In the symptom- atic treatment of chronic gastric catarrh they have a place, there- fore, as neutralizers of organic acid and also of excessive hydro- chloric acid in those rare cases of chronic gastric catarrh that are accompanied by hyperchlorhydria. Furthermore, alkalies are useful in dissolving the mucus in chronic gastric catarrh. Much better, however, than the administration of alkalies by swallowing either for the purpose of neutralizing organic acids or dissolving mucus is their introduction into the stomach by means of the stomach tube when lavage is performed (see above). As the formation of organic acids and stagnation of stomach contents does not occur, however, in gastric catarrh if proper lavage is instituted, and as the administration of alkalies after meals would neutralize small amounts of hydrochloric acid that are usually formed in chronic gastric catarrh, their utility as a medicine in this disease is very limited. Their employment in hypersecretion and hyperchlorhydria complicating gastric catarrh will be discussed in the section on these disorders. Medicines belonging to the group of stomachics and simple bitters are very useful in chronic gastric catarrh. In most cases they increase the appetite, stimulate the flow of gastric juice and increase the motor power of the stomach. They are especially useful in cases of chronic gastritis accompanied by a reduction of hydrochloric acid, but they are distinctly contra-indicated in hyperchlorhydria of any kind. Whereas, from a pharmaco- logic standpoint two groups of remedies, viz. : stomachics and bitters, may, somewhat artificially, be distinguished, from a prac- tical, i. e., clinical standpoint, this differentiation is altogether CHRONIC GASTRITIS 363 superfluous. As a matter of fact, we know very little of the Mode of action exact mode of action of the stomachics and bitters, and the litera- ture is full of contradictory statements in regard to their efficacy. Some of the remedies of this group produce hyperemia of the gastric mucosa, others possibly exercise a directly stimu- lating effect upon the gastric glands. Inasmuch as all these remedies have a different composition and origin and are in no way related to one another chemically, but as they all have in common both their effect upon the appetite and digestion and their bitter taste, it seems reasonable to attribute their chief in- fluence to the latter property. It is quite probable, especially in the light of Pawlow's recent researches, that they act on the gastric digestion and upon the appetite through nervous reflexes emanating from the mouth, i. e., by their taste, producing, like many other substances with pungent odors or strong tastes, a reflex secretion of gastric juice. Besides, a certain psychic effect resulting from the popular prejudice in favor of bitter remedies as efficient stomachics cannot be excluded. The number of stomachics and bitters is very great, and it Gentian is a difficult matter to select from them. The most popular are Quassia the following: Gentian, given as the fluid extract in ten to Conduran p thirty minims (0.7 to 2 cc.) or as the compound tincture of gen- cinchona tian in the dose of one-half to four drachms (2 to 16 cc); quassia, as the tincture, fifteen to sixty minims (1 to 4 cc.) or the fluid extract, five to thirty minims (0.3 to 2 cc.) ; condurango, as the fluid extract, fifteen to twenty minims (1 to 1.3 cc.) or the wine of condurango, two to four drachms (8 to 16 cc). In place of these simple bitters preparations of mix vomica, one to five minims (0.06 to 0.3 cc.) of the tincture; cinchona, as the tincture, one to four drachms (4 to 15 cc.) or the fluid extract of cinchona in one drachm (4 cc) doses. Many drugs of the volatile oil series containing, in addition Cardamoms to the aromatic oils some bitter principle, are also used; for in- Cinnamon stance, the tinctures of cardamoms, cinnamon, anis, nutmeg", cara- , T ms Nutm.es? way, bitter almonds and many others in the form of spirits, caraway waters, tinctures, fluid extracts or infusions, and, besides, certain Bitter Almonds of the peppers and mustard. Peppers A very useful synthetic remedy that, in some instances, exer- Mustard cises a remarkably stimulating effect upon the appetite, is orexine. Orexine itself, if given in large doses, may cause a burn- Orexine ing sensation along the esophagus and in the stomach, and, in susceptible subjects, nausea and vomiting. Basic orexine is the best preparation, as it is only slightly irritating to the stomach Basic orexine and, in nearly all cases, produces an increased flow of gastric 364 CHRONIC GASTRITIS Digestive fer- ments Pepsin juice, aids digestion and stimulates the appetite. Basic orexine should be given in capsule containing five grains (0.3 gm.) in the middle of the afternoon with a full glass of water or milk ; or one can begin with a smaller dose of two grains (0.1 gm.) on the first day and increase it by a grain or two a day until a dose of five or six grains is reached. In either case the remedy should be taken only for four or five days; within this period good re- sults are usually obtained. After the fourth or fifth day the fur- ther administration of the remedy is generally superfluous, espe- cially as its effect wears off. It is often good practice to stop the administration of orexine for a week and then to resume the use of the medicine for four or five days again. THE USE OF DIGESTIVE FERMENTS. The administration of digestive ferments, pepsin, pancreatin, ptyalin, as well as of certain vegetable ferments with proteolytic or diastatic properties, is very popular. The utility of these products in dyspeptic disorders, is, however, highly problematic. Pepsin is indicated on theoretical grounds where the secre- tion of pepsin by the gastric glands is deficient. This is a very rare event ; for it will be found that even in those cases in which the hydrochloric acid secretion is very low, pepsin, or at least pepsinogen, is excreted and that the albumen digesting power of the gastric juice is small, not on account of the pepsin deficit, but for lack of hydrochloric acid. In an overwhelming ma- jority of these cases the addition of hydrochloric acid to the gastric juice will promptly restore its proteolytic power, so that stimulation of the flow of hydrochloric acid or the administration of large quantities (see above) of hydrochloric acid is all that is required. The administration of pepsin, itself, is indicated, therefore, only in those cases in which the gastric contents, ren- dered acid with hydrochloric acid, fails to digest proteids. To administer pepsin when free hydrochloric acid is present in the stomach contents is altogether futile, for it has been shown that, when free hydrochloric acid is present, pepsin is always secreted in abundant quantities. In rare cases of achylia gastrica, in nervous anacidity and apepsia, in atrophy of the gastric glands and occasionally in gastric carcinoma pepsin may be of some value. In certain advanced cases of chronic gastric catarrh, in which the pepsin secretion is reduced on account of functional weakness of the peptic glands, the administration of pepsin in combination with hydrochloric acid may also aid to some extent both by actually furnishing pepsin and by relieving the peptic glands of the labor of secreting pepsin, hence sparing them and enabling them better to regain their normal function. CHRONIC GASTRITIS 365 The popular wines and essences of pepsin are always weak Preparations and frequently possess no proteolytic power whatsoever ; in fact, p the alcohol they contain somewhat impairs the action of the pep- sin. These remedies, besides, if given in large quantities, may injure the stomach. The official pepsin of the U. S. P., made from the glandular layer of pig's stomach, should be capable of digesting not less than three thousand times its weight of coagu- lated egg albumen. It is dispensed in powder form or as fine scales, either in capsules containing five to ten grains (0.3 to 0.6 gm.), or in a 0.2 per cent, hydrochloric acid solution, immediately after or during meals. Papain (papayotin or papoid), a product made from carica Papain papaya, and bromelin made from pineapple and cradin from Broinelin ficus carica, all possess considerable proteolytic powers. The best of this group is papain, which does not digest pro- teids as energetically nor as rapidly as pepsin, but possesses this advantage over pepsin, that it digests albumen not only in an acid but also in a neutral or alkaline medium, so that it continues its effect after it has left the stomach. Pancreatin, a mixture of the enzymes of the pancreas, is ad- Pancreatin ministered in powder or capsule in the dose of two to five grains (0.1 to 0.3 gm.) only if the secretion of hydrochloric acid is reduced, or if hydrochloric acid is altogether absent from the stomach; for it does not act in an acid medium and is rapidly destroyed by the action of hydrochloric acid in the stomach. If some hydrochloric acid is present in the gastric juice, then this must be neutralized by administering sufficient soda with pan- creatin. In this way pancreatic digestion is, so to say, trans- ferred to the stomach. Inasmuch as the pancreatic secretion is rarely impaired in gastric disorders, it is much more rational to promote rapid propulsion of the stomach contents into the bowel, for there the food is at once exposed to the action of the normal pancreatic ferments. In cases of insufficiency of the pancreatic secretion in the bowel (a condition that it is almost impossible to diagnose), pancreatin might be given in gelatin capsules that withstand the hydrochloric acid of the stomach; or pancreon, a Pancreon tannic acid precipitate of pancreas, may be administered, for this remedy resists the action of the gastric juice for four or five hours. It may be given in doses of five grains (0.3 gm.) in watery solution, during meals, if hydrochloric acid is absent, half an hour before meals if hydrochloric acid is present in the stomach. It will be seen, therefore, that in chronic gastric catarrh the use of pancreas preparations is very limited. Pan- creas preparations as well as amylolytic, i. e., starch digesting fer- 366 GASTRIC ULCER Amylolytic ferments Ptyalin Diastase Taka-diastase Treatment of special symp- toms Nausea Vomiting Pain Belching Meteorism Constipation Diarrhea ments as, for instance, ptyalin made from salivary glands, malt diastase (malt extract, maltzyme, maltine, etc.) takadiastase (from aspergillus oryza) are indicated only in gastric hyper- acidity in combination with alkalies; hence they are practically never used in chronic gastric catarrh. With the introduction of systematic lavage, the judicious use of hydrochloric acid and stomachics, and the proper administra- tion of a carefully selected diet to fit the state of the gastric function as determined by analysis of the stomach contents, the use of medicines for the treatment of special symptoms like nau- sea, vomiting, gastric pain, belching, meteorism, diarrhea and constipation has become practically needless. If the decompos- ing and fermenting contents and the offending mucus are re- moved at frequent intervals by lavage with alkaline waters, the formation of gases and of irritating acids in the stomach and their propulsion into the bowel is to a large extent prevented. Hydrochloric acid, judiciously administered, also in a measure impedes the formation of toxic bodies and aids in the proper dis- assimilation of the food, hence increases the appetite and the gen- eral nutrition. No occasion, therefore, under this treatment is given for the development of nausea, vomiting, belching, meteor- ism or diarrhea. The constipation, if persistent, should be com- bated chiefly by the ingestion of abundant fresh fruits and vege- tables, by laxative mineral waters, occasionally by a little rhu- barb and by enemata, but not by strong vegetable or mineral purgatives, as the latter may seriously injure the irritated and inflamed gastric mucosa and hence impede the healing process. Severe and persistent gastric pain can, as a rule, be effectually stopped by the application of Priessnitz compresses or of hot water bags to the epigastrium, so that the use of narcotics will rarely become necessary. Hyperchlorhydria complicating chronic gastritis and producing pain (a rare event) should be combated according to the principles discussed in full in another section. General indi- cations GASTRIC ULCER. The healing of an ulcer of the stomach is, self evidently, accel- erated if the stomach walls are kept in a quiet, contracted condi- tion and if the surface of the ulcer is protected, so far as that is possible, from, mechanical, thermic and chemical iritation. An ulcer of the stomach differs in this respect in no way from an ulcer located in any other part of the body; for anywhere healing is promoted by quiet of the adjacent parts, the avoidance of stretching and the protection of the surfaces of the ulcer from extraneous irritants. GASTRIC ULCER 367 In gastric ulcer certain difficulties inherent in the character of the ulcer, the peculiar anatomy of the stomach and the nature of its functions, are encountered that render the carrying out of this plan very difficult. Complete rest of the stomach wall and avoidance of distention, as well as protection of the ulcer surfaces, can only be procured by withholding all food for a time, and later by carefully administering liquid, soft, bland foods of moderate temperature ; at the same time, the acidity of the stom- ach contents, which is usually increased in ulcer, must be re- duced by appropriate feeding and medication; and the healing of the ulcer, so far as that is possible, stimulated by direct medication. Above all things, during this time every effort must be advanced to maintain the patient 's general nutrition, as other- wise the organism becomes unfit to put forward its best efforts towards promoting regeneration and healing in the affected area. Inasmuch as ulcer of the stomach is presumably always pro- duced by some mechanical agency, trauma, thrombosis, etc., af- prophylactic fecting either a healthy subject or an individual suffering from treatment anemia, chlorosis or circulatory disorders in the stomach wall, causal treatment is manifestly impossible. This is due to the fact that the injury that directly produces the ulcer cannot be anticipated nor forestalled, so that prophylaxis in the broader sense is out of the question. We know, however, that the failure of gastric ulcer to heal as promptly as ulcers in other parts of the body, and its ten- impede healing dency to extend, must, in large part, be attributed to the hyper- and favor ex- chlorhydria that usually accompanies gastric ulcer; we know further that anemia and chlorosis not only predispose to gastric ulcer, but impede its healing ; hence in the presence of the gastric ulcer treatment should always be directed towards correcting gastric hyperacidity and any anemia or chlorosis that may exist, according to methods that are described in full in appropriate sections. Complete abstinence from food foi.' a period of time, fluctuat- Complete absti- ing from a few days to several weeks according to the peculiar nence from exigencies of the case, is always good practice. In most cases it is safe to resume the administration of some fo^d after the fifth day, for equally good results are generally obtained from this course, provided the feeding is carefulry instituced according to the principles to be presently discussed, as from total abstinence from food for a period of several weeks. The latter plan of treat- Feeding after ment, which is now very popular, is, therefore, as a rule, unneces- fifth day sarily severe, moreover very difficult to carry out on account of the unwillingness on the part of the patient to undergo such a 368 GASTRIC ULCER Disadvantages of rectal feed- ing Indications for rectal feeding Rest in bed Heat and cold to epigastrium Exercise during convalescence Thirst Rectal irriga- tion Rectal feeding trying ordeal ; above all, there is much difficulty in most cases to maintain adequate nutrition by rectal feeding (see below) alone. When one considers, furthermore, that rectal feeding undoubted- ly stimulates gastric secretion to some extent (one of the factors one is precisely trying to avoid by withholding food by mouth), this plan of treatment seems particularly useless in most cases. In patients suffering from severe gastric pain and vomiting, and notably from repeated hemorrhage from th* stomach, when- ever food is administered, the total abstinence plan with rectal feeding may, however, have to be reluctantly instituted for long periods of time, i. e., until all these symptoms disappear, or until, especially in cases of persistent hemorrhage, the proper time- arrives for surgical intervention (see below). A patient with gastric ulcer should always be kept in bed for a period of at least two weeks, or preferably longer, particu- larly if there is a tendency to hemorrhage or if symptoms of peri- toneal irritation or inflammation are present. In the latter event the application of an ice bag or of a Leiter coil to the epigastric region is a useful measure, otherwise Priessnitz compresses or hot poultices, or a hot water bag for several hours each day, are more grateful to the patient. While in bed all violent movements should be carefully avoided and the patient should not be al- lowed to get out of bed even for the purpose of emptying the bladder or rectum. During the third and fourtn weeks of treat- ment the patient may be permitted to sit up for a little while each day, and later take short walks about the room, and still later out-of-doors. For several weeks after the ulcer symptoms have disappeared, it is always a good plan to instruct the patient to lie down for an hour after each meal. During the period of total abstinence from food, the distress- ing sensation of thirst that so many complain of should be coun- teracted by frequently washing the mouth with cold water and allowing the patient to suck ice pills without swallowing the water. The demands of the organism for water should be ful- filled by rectal irrigation; i. e., from 250 to 500 cc. of normal salt solution containing eight to ten grammes of sodium chloride to the litre of water should be injected, lukewarm, into the rectum, several times a day. If it is desired to slightly stimulate the pa- tient, a little brandy or white wine may be added to this water enema, or a little bouillon may be used on account of its stimu- lating effect. In feeding a patient by the rectal route one should proceed as follows: Prior to the injection of the nutritive enema, the lower bowel should be carefully washed out with warm, soapy water. An hour later, or sooner if all the wash water has been GASTRIC ULCER 369 expelled, the nutritive clysma should be injected by means of a soft rubber catheter and an irrigating bag elevated about three feet above the patient. The tube should be introduced as far as possible into the colon. The patient should lie on the left side with the right leg drawn up and the hips elevated by a pillow or two. After the clysma has been injected the patient should re- main perfectly quiet, preferably in the same position, for about an hour. The temperature of the enema should approximate that of the body. If the patient is unable to hold the enema, or if the clysma produces too much irritation, an event that is especially apt to occur if peptones or albumoses are used, then ten to twenty drops of the tincture of opium may be added to the enema. The total amount of the clysma should not exceed 250 cc. Rectal feeding may. be instituted in this way two or three times a day. Many nutritive enemata of different composition have been Nutritive ene- described, for nearly every author who has written on this sub- mata ject has devised some new mixture. One of the best and simplest forms of nutritive enemata that answers all purposes if rectal feeding is to be instituted for a short time only, and this is usually the case, is the following : 250 cc. milk. 2 yolks of egg. 2 tablespoonfuls of claret. A pinch of salt. The addition of salt to nutritive enemata is very important, Addition of for it has been shown conclusively that the addition of sodium salt chloride greatly aids in the absorption of the nutrient bodies con- tained in the enema. The action of the salt is probably attribu- table to its power to stimulate antiperistalsis and hence to cause food injected into the rectum or colon to be carried into the small intestine, where absorption is much more active than in the lower bowel. Peptones and albumoses, i. e., predigested albumens, aside Peptones and from irritating the bowel in many cases are not absorbed more alb umoses rapidly than native albumen itself, hence theii addition to nu- tritive enemata, which is commonly recommerded, is usually superfluous. Nevertheless, the following clysma, recommended by Singer, is very popular and occasionally serves a useful pur- pose : 370 GASTRIC ULCER Ewald's nutri- tive enema "Egg enema Feeding after abstinence Milk Exclusive milk feeding 1 not practical Milk powder Condensed milk Buttermilk, kephyr, kumyss 125 ec. of milk. 125 cc. of claret. 2 yolks of eggs. A little salt. A dessertspoonful of Witte 's peptone. The different sugars are rapidly absorbed from the intestine, but, as they easily undergo decomposition and kad to fermenta- tive gas formation and distention of the bowel, their use cannot be particularly recommended. Of the various sugars that can be used dextrose is the most valuable, but its extensive employment is rendered impracticable by its cost. A simple nutritive enema recommended by Ewald and containing dextrose is made as fol- lows: Two or three eggs are mixed with a tablespoonful of cold water. A little flour is boiled in half a cup of a twenty per cent, dextrose solution and allowed to cool. To this solution a wine glass full of claret is added, the egg solution stirred in and the mixture filled up with water to 250 cc. When using eggs for a nutrient enema the bowels should be thoroughly cleansed about an hour or two later, as otherwise decomposition of the egg albumen in the rectum may occur and toxic putrefactive bodies that are highly irritating be formed. After four or five days of total abstinence from food with rectal feeding, milk should be carefully administered by mouth, at first in small doses of two or three tablespoonfuls, boiled and cold. After a hemorrhage it is best to give still smaller quantities of iced milk every two or three hours, or every hour. If the milk causes vomiting, and especially if large curds form, an event that is not uncommon if raw milk is administered but is not so apt to happen if the milk is boiled, the addition of a little lime water or of soda, or the administration of tablespoon- ful doses of ice cold milk at frequent intervals may stop these symptoms and enable the patient to take the milk by mouth. The latter mode of administration is also efficacious in subjects who manifest a severe dislike to milk. Exclusive milk feeding is never a feasible plan, for, in order to adequately nourish the patient with milk alone far too much liquid must be introduced, and if the patient is to be fed with small quantities of milk at a time the administration of milk would have to be practically continuous throughout the day; for this reason the addition of milk powder, 100 grammes to the litre of milk, or of one to two teaspoonfuls of condensed milk to the litre of milk, may be practised in order to increase the nutri- tive value of the milk. In order to afford variety, buttermilk, keph3 T r or kumyss may be tried, but it must be remembered that GASTRIC ULCER 371 all these milk products contain less fat and sugar than milk, and Gruels are hence less nourishing. Within the first ten days after total abstinence from food a little tapioca, rice, wheat, barley or oat- meal flour may be boiled in milk and these gruels given in place of milk alone. A very useful, nutritious and non-irritating addition to the bill of fare during this period is meat jelly prepared, according to Fleiner, by boiling chicken or beef with a calf's foot for several hours with the addition of a little salt. The soup, cooked in this way, is cleared by stirring in an egg and heating to a boil, the fluid is strained off and on cooling coagulates to a jelly. Of this meat jelly a dessertspoonful may be given every few hours. During this period, too, albumen water, made by dissolving white Albumen of egg in salt water, or an egg stirred up in a little bouillon, may water also be allowed. Twenty per cent, solutions of dextrose in milk Dextrose so- or water are also permissible. Such a sugar solution is quite lution nutritious and also possesses some antacid properties that are beneficial. On this simple diet, usually reinforced by one or two recta] Diet during feedings a day, the patient remains for the first ten days. Dur- second ten days ing the second ten days of the ulcer cure the amount of the gruels is gradually increased and some of the soft and digestible meats, like squab, chicken, calves' brains, scraped raw meat, also a little mashed potato, boiled rice, noodles or macaroni, tapioca, sago, a little boiled cauliflower or zwieback soaked in milk may be al- lowed. Later still, i. e., during the third and fourth week, a little Diet during roast beef, beef steak, poultry, some boiled fish, vegetable purees * hird . , and , made of green peas, beans, carrots, a little chopped spinach, as- paragus tips, some scrambled eggs or an omelet, may be per- mitted. As a more liberal diet is resumed, particular care should be Diet during exercised to exclude all mechanically irritating foods, as certain convalescence cereals and vegetables containing husks, stems, pips, skins or stalks, as well as berries, on account of their seeds, hard bread crusts, etc. Very hot or very cold foods and drinks, spices, con- diments, strong alcoholic beverages and coffee are best avoided. It is always safer to administer small meals at frequent intervals than two or three large meals a day, even for weeks after the ulcer has healed. A very useful measure, adopted almost as a routine in Euro- Carlsbad pean clinics, is the administration of one or two teaspoonfuls of salts Carlsbad salts dissolved in 250 cc. of water every morning on an empty stomach. The chief ingredients of Carlsbad salts are sodium chloride, sodium carbonate and sodium sulphate, and it 372 GASTRIC ULCER Reduction of hyperacidity Antacids is difficult to explain the beneficial action derived from the use of this mixture. It is probable that it acts in several ways, by dissolving the mucus, by neutralizing the excessive acidity and as a laxative. The reduction of hyperacidity, which is a very important element in the treatment of gastric ulcer, will be discussed in full in a separate section (page 393f ). In ulcer cases living on a diet consisting largely of milk and eggs, the hydrochloric acid of the gastric juice is partially neutralized by the latter, for the albu- men they contain possesses slight antacid properties. The addi- tion of an alkali, either a tablespoonful of lime water to each glass of milk, or soda or magnesia, enforces this effect. A very popular method of treating hyperacidity in gastric ulcer is by means of the following mixture : 3 Sodium carbonate, Burnt magnesia, of each, 100 parts Sugar of milk, 150 parts Carlsbad Salts Atropine Belladonna Silver nitrate This mixture is procured in bulk and the patient adds half a teaspoonful to each glass of milk. Carlsbad water or Carlsbad salts may also be used as an antacid addition to the milk, or Carlsbad salts may be taken immediately after each meal. If there is hyperacidity occurring not only after eating, but also hyper-secretion, so that acid gastric juice is present when the stomach is empty, then it may become necessary to administer alkalies between meals. In very excessive degrees of hyper- acidity that cannot be readily controlled by the administration of alkalies, the use of atropine or belladonna may be required. The former should be given hypodermically in the dose of one hundredth of a grain (0.6 mg.) once or twice a day, the latter as the extract of belladonna by mouth in capsule with an alkaline water in the dose of a quarter grain (0.01 gm.) three times a day. Another remedy used as an antacid and credited, moreover, with healing properties in gastric ulcer, is silver nitrate. This drug seems to be of particular value if much pain is complained of when the stomach is empty and also in gastric hyperesthesia with abnormal sensitiveness to the introduction of food. As silver nitrate neutralizes hydrochloric acid by precipitating the latter in the form of silver chloride, it is said to possess some antacid power, but, considering the small amounts of the drug that can be introduced, this effect is insignificant and the good sympto- GASTRIC ULCER 373 matic results obtained from the use of silver nitrate in gastric ulcer must be attributed in large part to some influence exercised by the drug upon the sensory apparatus of the stomach that is not altogether understood. Silver nitrate is best given in a solution of the strength of Dose and ad- one to one thousand in tablespoonful doses, three or four times a day on an empty stomach. If this concentration is well borne the strength of the solution may be gradually increased to one and one-half to one thousand, then to two to one thousand, and the patient kept on tablespoonful doses of the stronger solutions three times a day throughout the course of the disease, i. e., for a period of from four to six weeks. Slight nausea and diarrhea that occasionally make their appearance in the beginning of this treatment are generally negligible, as these symptoms usually disappear spontaneously within a few days, and without special interference. The bad taste that patients taking silver nitrate solutions sometimes complain of can best be counteracted by pep- permint or eucalyptus lozenges. As an anesthetic chloroform water can also be used in gas- Chloroform trie ulcer, either alone, in the dose of a tablespoonful every two water or three hours, or in combination with bismuth in the following formula : i* Chloroform 1 gm. Distilled water 150 gm. Bismuth subnitrate 3 gm. One to two teaspoonfuls every hour (Stepp). A number of indifferent powders like bismuth subnitrate or Indifferent carbonate, orthoform, talcum, chalk, etc., may be used to advan- P owders tage in gastric ulcer, more on account of their mechanical effect than because of any medicinal properties they possess. These sub- stances form a thin coating over the ulcer surface, thus protect- ing it from the irritating action of the food and the gastric juice ; at the same time they act as hemostatics by forming a powder cake over the bleeding area ; they also generally relieve the pain. Bismuth subnitrate should be given in large doses of two or Bismuth sub- three drachms (8 to 12 gm.) suspended in about 100 cc. cartonatT* of water, on an empty stomach. If the ulcer can be localized, the patient, after swallowing this mixture, should occupy such a position that the ulcer is in the most dependent part of the stom- ach; i. e., if the ulcer is situated at the lesser curvature or on the posterior wall of the stomach, the patient should occupy the dor- 374 GASTRIC ULCER Introduction of bismuth by tube Orthoform Talcum-Chalk Magnesia mix- ture sal position with his hips elevated; if at the pyloric part, he should lie on the right side ; if on the anterior wall, he should lie on his face or occupy the knee-chest position. The appropriate posture should be maintained for about fifteen minutes to one hour. If the exact localization of the ulcer is impossible, and this will be the rule, the patient should lie for fifteen minutes successively on his back, his stomach, his left and his right side; in other words, he should perform complete rotation of the body within the space of an hour. It is rarely necessary to introduce the remedy through a stom- ach tube; this procedure, in fact, is never without danger, espe- cially in recent ulcer, in ulcer near the cardia or in ulcer with a tendency to hemorrhages. If it is decided, however, to give the bismuth by tube, the stomach should first be thoroughly washed out with slightly alkaline, lukewarm water and after the last of the wash water, which should be perfectly clear, has been pumped or siphoned out, two or three drachms (8 to 12 gm.) of bismuth subnitrate or carbonate, suspended in a 100 cc. of lukewarm water should be poured into the fun- nel and washed down with a small quantity of water. The stom- ach tube should be left in place for five to ten minutes, in order to give the bismuth time to settle, then the water may be siphoned off and the tube withdrawn ; or the tube may be introduced a sec- ond time very carefully and the water drawn off in this way. The former procedure, however, is by far the more practical one of the two. Best of all and least disagreeable to the patient, is swallowing the bismuth mixture without the aid of the stomach tube. The bismuth treatment should be given from the beginning, at first every day, then every second day and later every third day. The effects from this therapy are generally very favorable and untoward symptoms on the part of the stomach, or poisoning from the absorption of bismuth (stomatitis, etc.), even when the drug is given in much larger doses than those indicated above, are never witnessed. Orthoform, as such, or in the form of its muriate, is as use- ful as bismuth subnitrate or carbonate; it should be given in doses of sixty to ninety grains (4 to 6 gm.) suspended in a 100 cc. of water in the same way as bismuth. Bismuth salts and orthoform, especially if they are to be used in such large quantities, are quite expensive, and in private prac- tice the following mixture, recommended by Pariser, may be ad- vantageously used instead: GASTRIC ULCER 375 Talcum 60 parts Chalk 60 parts Magnesia usta 15 parts Of this preparation five drachms are mixed with water and administered in the same way as bismuth. The slight antacid and laxative properties of the magnesia, and the fact that the ingredients of this mixture do not blacken the stools, and hence do not conceal small hemorrhages like bismuth, render this mode of treatment quite useful. Olive oil, too, may be used for its mechanical effect, especially Olive oil in cases of gastric ulcer with pyloric spasm due to intragastric irritation, with resulting dilatation of the stomach, stagnation of the stomach contents, and, consequently, irritation of the ulcer surface. Fifty cubic centimeters of olive oil may be introduced three times a day, or a hundred and fifty cubic centimeters taken on an empty stomach in the morning. The oil may either be swal- lowed or administered through the stomach tube. If the rest treatment, described above, the careful regulation of the diet after a period of total abstinence from food, antacid medication with alkalies or Carlsbad water and atropine, the silver nitrate, or the bismuth or orthoform treatment are insti- tuted, other measures intended to relieve special symptoms, nota- bly pain and vomiting, rarely become necessary. Narcotics should be used very sparingly and only in severe Narcotics cardialgia and gastric pain that does not yield to hot applica- tions to the epigastrium, antacid medication and the proper diet or total abstinence. The fact must never be forgotten that opium and morphine, aside from causing constipation, which is detrimental, increase gastric secretion, and hence favor precisely the outpouring of hydrochloric acid which is in most instances producing the pain in gastric ulcer. Narcotics, therefore, while they deaden the sensibility of the gastric nerves, favor the cause that irritates them. In most instances one must experiment with the use of hot or Hot and cold cold applications, some patients experiencing greater relief from 1 a 10ns the application of heat in the form of a hot water bag, poultices or the thermophore (see index), others being relieved by cold applied in the form of the ice bag, the Leiter coil or Priessnitz compresses. Hematemesis always calls for active treatment. Broadly Hematemesis speaking a recent hemorrhage or a tendency to recurrent hemor- rhages precludes the application of heat to the epigastrium; here 376 GASTRIC ULCER Hemostatic drugs Adrenalin chloride Opium Morphine cold applied to this region is always safer. Total abstinence from solid food should be insisted upon until all traces of blood, as determined by daily chemical tests, disappear from the stools. During this time the nutrition of the patient should be main- tained chiefly by rectal feeding. The patient should remain completely at rest in bed. Some patients do very well if they swallow teaspoonful doses of ice cold water at frequent intervals. If possible one should get along without the use of hemostatic remedies, and an opportunity for spontaneous cessation of the hemorrhage should be given; i. e., an expectant plan, as far as hemostatic drugs are concerned, should be followed for twenty- four hours, and the patient, during this time, treated by rest, cold applications and abstinence from food. If it becomes neces- sary to employ an hemostatic, the best remedy of all is probably adrenalin chloride, administered in the dose of ten to twenty drops of a one to one thousand solution, repeated at intervals of half an hour to an hour until the bleeding stops. At the same time excessive vomiting should be controlled by the use of opium or morphine given hypodermically or by suppository. Subcu- taneously, ergotine may be given in the following injection : Ergotine 3 Ergotine Glycerine Water 2.5 gm. 5.0 cc. 5.0 cc (Eiegel) Hydrastis Lead acetate Bismuth Gelatin Other remedies that are occasionally useful are the fluid ex- tract of hydrastis, given in fifteen to sixty minim (1 to 4 cc.) doses, by mouth, or hydrastinine hydrochloride, in the dose of one-half to two grains (0.03 to 0.1 gm.) by mouth or hypodermi- cally. Lead acetate, in the dose of one grain (0.06 gm.) every two hours, or large doses of bismuth, may also prove useful. Gelatin sometimes stops hemorrhage; it is conveniently ad- ministered in the following combination: 3 Gelatin 15.0 gm. Sodium chloride 1.2 gm. Water 200.00 cc. Of this mixture 100 cc. are to be given at once and the balance within two or three hours. The use of gelatin must be considered an extreme measure that will rarely have to be GASTRIC ULCER 377 resorted to; in very profuse hemorrhages, however, it occasion- ally proves efficacious as an emergency measure. The after treatment of hemorrhage from gastric ulcer with Af ter treat- . merit loss of much blood is the same as that described at length in the sections on Hemoptysis and Secondary Anemia. During the hemorrhage and for some days afterwards, the bowels should be kept locked by the use of opium suppositories. After the bleeding has stopped, soft evacuations of the bowel contents should be promoted by the use of frequent enemata of soapsuds and water, glycerine, or oil, in order to avoid straining efforts at stool. Ulcers of the stomach that persist or show a tendency to re- indications for currence despite the adoption of all the measures outlined above, surgical treat- and in which there is much vomiting and pain, or occasionally a slight hemorrhage, with resulting mal-nutrition of the patient, may call for surgical intervention. Simple, uncomplicated ul- cers, however, rarely fail to yield to proper medical treatment carried out for a sufficiently long time, so that surgery has its chief field of usefulness in the treatment of the sequelae and complications of gastric ulcer rather than in the treatment of the ulcer itself. Repeated, severe hemorrhage may call for a laparotomy, liga- Repeated hem- tion of the bleeding arteries or excision of the ulcer area. A sin- orrhages gle severe hemorrhage rarely calls for surgical intervention, as statistics show that cases recover from such a hemorrhage with- out an operation as well as with an operation; in fact, the mor- tality is slightly higher if a laparotomy is performed in such cases than if it is not performed. Perforation of an ulcer with invasion of the peritoneum by s ure> i ca i treat- stomach contents; cicatricial contractures about the pylorus or ment of per- cardia causing stenosis; scar tissue forming in other regions of sion^and^ther the stomach, causing hour-glass contraction or diverticulum sequelae of formation ; perigastric adhesions producing dangerous traction or pressure symptoms on adjacent organs; perigastric abscess, are all sequelae and complications of gastric ulcer that, being mechan- ical in character, call for mechanical, i. e., surgical, relief. Whether the ulcer is to be excised (and it is well to remem- Excision of ber that recent ulcers are not always easy to find, and that ulcers ulcer or gastro- may be multiple and hence cannot all be excised) or whether a gastroenterostomy is to be performed must depend upon the pe- culiarities discovered when the abdomen is opened. It is, as a rule, impossible to predict before the laparotomy just what oper- ation shall be made. A discussion of the different operative pro- cedures that can be adopted lies without the frame of this book. 378 CARCINOMA OF THE STOMACH Surgery the only means of cure Resection of pylorus Gastroenter- ostomy CARCINOMA OF THE STOMACH. The main duty of the internist in the treatment of gastric carcinoma is to make the diagnosis as early as possible and then to order surgical intervention. In the case of this disease sur- gery is not a last resort, as in so many other disorders, to be tried only after the skill of the internist has been exhausted, but a first resort to be adopted as soon as the diagnosis is positively made, and the only resort that can bring about a cure of this affliction. It is by all means a safe and conservative plan, and one that would save many lives if adopted more frequently, to perform an exploratory laparotomy in every case of organic stenosis of the pylorus ; for no material harm is done in the hands of a skillful surgeon if the stricture after laparotomy should be found to be due to the presence of benign tissue; while if it should be found to be due to carcinomatous tissue, early resec- tion may be life-saving. It is unfortunale, however, that car- cinoma producing stenosis symptoms about I he pylorus is usually already far advanced. Resection of the cancer in most cases, therefore, is merely a palliative measure capable, often, of prolonging the patients'" existence, but rarely of curing them. At best even complete re- section of a gastric carcinoma leaves the patient with a stomach whose secretory and motor functions, owing to the atrophy of the gastric mucosa that almost invariably accompanies gastric car- cinoma, remain permanently impaired. Resection of the carcinoma is the operation of choice if the tumor is located in the pyloric region, if it is freely movable,, i. e., not adherent to adjacent parts, if no metastases are pres- ent and if the general condition of the patient is good. These indications, one must confess, are more or less theoretically con- structed, especially in regard to the absence of metastases, for it is self-evident that small metastatic growths in the liver or the mesentery may very well escape detection. If metastases are found, if the tumor is adherent or if it cannot be completely resected, if serious symptoms of stenosis about the pylorus with stagnation of gastric contents are pres- ent, then gastroenterostomy becomes a useful palliative opera- tion that often restores the patient to a condition of fair health and better nutrition for many months or even years, despite the presence of a carcinoma of the stomach. By producing an artificial passage from the stomach to the intestine, and thereby facilitating the passage of the food from the stomach into the bowel, stagnation of the gastric contents is prevented, digestion CARCINOMA OF THE STOMACH 379 diverted altogether into the intestine and there vicariously car- ried on with more or less completeness, despite the atrophy of the gastric mucosa. At the same time the irritation of thp gas- tric carcinoma by food and by irritating decomposition products that arise from food stagnation is prevented and hence its growth retarded. In carcinoma involving the cardiac end of the stomach, pro- Gastrostomy vided dilatation of the cardia with bougies is not successful (and this measure only answers the purpose of keeping the cardia open temporarily) and in diffuse carcinomata of the stomach, the radical operation of gastrostomy must be thought of; for while the results of total extirpation of the stomach are not good and many early deaths have been reported from this operation, never- theless, this procedure may constitute a palliative measure in extreme cases that may enable the patient to live in comparative comfort for several months afterwards. If it has been determined that resection of the carcinoma is Conditions un- impossible; if the motor power of the stomach is so good that t( frnal treat^" gastroenterostomy appears a superfluous inroad ; if the case is ment is indi- n ...,-, cated seen too late xor a gastrostomy operation, m an advanced stage of cachexia or with metastases in various organs; if recurrences of gastric carcinoma appear after an operation and it does not seem feasible to operate a second time ; or, finally, if a patient afflicted with cancer of the stomach refuses an operation, then a num- ber of dietetic and medicinal means of treatment must be re- sorted to, all intended to maintain the general nutrition of the patient and to relieve a variety of distressing symptoms that may arise in the course of the disease. The regulation of the diet in gastric carcinoma is one of the Diet most important tasks of treatment. No set rules can be formu- lated as in the case of ulcer, and the selection of the diet must be governed chiefly by the state of the motor function and the pep- tic power of the stomach, as determined by frequent analyses of the stomach contents, as well as by the appetite, the particular likes and dislikes of the patient and his general state of nutri- tion. In most cases a fairly liberal diet is indicated. Every Liberal diet attempt should be made to allow the patient to enjoy his meals He should not, on the one hand, be forced to eat foods that he dislikes or that he knows do not agree with him even though such foods may be theoretically indicated, nor should he, on the other hand, be forbidden to eat articles that he craves and that he knows agree with him, unless they are absolutely harmful. To the latter class of foods belong all articles that undergo Harmful foods rapid fermentation; they are bad because in most cases of car- 380 CARCINOMA OF THE STOMACH No fermenting- foods No indigestible particles No large meals Aversion for meat Vegetable al- bumens Eggs Milk Gruels Bread Vegetables Fruits Tats Beverages Amount of liquid cinoma of the stomach there is, early in the disease, a deficiency or a lack of (anti- fermentative) hydrochloric acid and reduced motor power ; or if these conditions are not present in the begin- ning they are very apt to supervene sooner or later. In the second place, all articles of food that contain undigestible and mechanically irritating husks, stems, pips, seeds, tendons, car- tilage, skin and connective tissue must be considered detrimental to cases of carcinoma of the stomach. In the same sense large meals should always be forbidden, because they overtax the failing motor and peptic powers of the stomach; consequently small meals at frequent intervals should be advised. Most cases of carcinoma of the stomach instinctively have an aversion for meat; this is presumably a reflection in the appe- tite of the hydrochloric acid deficit. Meats should, therefore, be given sparingly and their administration never forced. Only soft and easily digestible varieties, like chicken, squab, calves' brains, sweet-breads, a little raw, scraped beef or rare steak or chop, fish, meat jelly should be given. If meat is altogether distasteful, or if it is not well borne, albumen must be supplied by milk and vegetable albumens (neutrose, tropon) and eggs, the latter soft boiled, scrambled, poached or as omelet, not hard boiled or fried. Milk may be served as described under Ulcer, or it may be rendered more nutritious by strengthening it with condensed milk or milk pow- der ; or it can be given in the form of gruels made of wheat, rice, oatmeal, barley, flour, or of arrow-root, sago, tapioca. Bread should be given in the form of old bread, toast, zwieback or crackers, never as hot bread. Of vegetables and fruits, cauli- flower, asparagus tips, fruit sauces, stewed fruits are permis- sible. Fats should be supplied not as animal fat but as vege- table or milk fat in the form of olive oil or mayonnaise on salad dressings, butter, cream or cocoa. There is a popular prejudice against the administration of fat in cases of carcinoma of the stomach, but it will usually be found that these patients can tol- erate considerable quantities of fat without digestive disturb- ances. The amount of liquid that should be introduced depends upon the motor power of the stomach. If there is much stenosis with gastric dilatation and stagnation of stomach contents, then the amount of liquids should be restricted and whatever beverages are administered should be given in small quantities. In extreme cases the ingestion of fluid by mouth should be restricted to the minimum compatible Avith comfort, and the water demands of the organism supplied by rectal irrigation as described elsewhere. CARCINOMA OF THE STOMACH 381 In many cases dilute alcoholic liquors can du no harm. In Dilute alco- pronounced motor insufficiency, however, they are detrimental, hollc ll( l uors because the alcohol attracts water into the stomach. The administration of hydrochloric acid and digestive fer- Hydrochloric ments to replace e the deficient hydrochloric acid and pepsin in a ^ e ferments 5 " the stomach is of doubtful utility. As discussed in full in the Section on Gastritis, hydrochloric acid unless given in very large quantities does not aid materially in the digestion of albumen. If it is used at all, therefore, it should be given in ten to twenty drop doses in a 100 cc. of water, immediately after eating, and in the same dose three or four times afterwards at hour in- tervals. The advantages that might possibly accrue from the administration of the hydrochloric acid would, in cases of gas- tric carcinoma with motor insufficiency, be more than neutral- ized by the ingestion of abundant quantities of water that must be given with such large quantities of hydrochloric acid. Small quantities of hydrochloric acid are of very little value as a digestant unless we agree to attribute certain stomachic proper- ties to the remedy administered in this way. If given as a stomachic, the drug is more useful when administered on an empty stomach half an hour or an hour before eating. If the motor power of the stomach is good, the administration of hydro- chloric acid, and particularly of the ferments, is altogether super- fluous, as the digestion of the albumens can be fully carried out vicariously in the intestine. If on the other hand there is much stagnation of stomach contents on account of motor in- sufficiency, then the small quantities of pepsin or pancreatin or papaya preparation, that might be added to the fermenting gas- tric contents, will not be efficacious. If it is desired to administer a stomachic, any one of the rem- Stomachics edies discussed on page 362 may be given either alone or in com- bination with small doses of hydrochloric acid before each meal. The best stomachic of all, however, is removal of the stagnating stomach contents by lavage. The indication for lav- Lava §' e age is impaired motility of the stomach; so that in any case of carcinoma of the stomach, in which food is found after the nor- mal period of digestion is over, methodic lavage should be in- stituted; in other words, if six or seven hours after a test din- ner, or two hours after a test breakfast, coarse particles of food are found in the stomach contents, or, above all, if the stomach Lavage super- after a late supper preceded bv lavage, contains food particles fluous if motor ' . power of stom- on the next morning, then washing out the stomach contents is ach good indicated. Unless the motor power of the stomach is impaired, however, lavage of the stomach is altogether superfluous, even 382 CARCINOMA OF THE STOMACH Time of per- forming- lavage in impaired motor power Lavage with medicated irri- gations Symptomatic treatment Vomiting if it is found by analysis of the stomach contents that the pep- tic power of the organ is greatly reduced. In severe degrees of motor insufficiency, i. e., in those cases in which undigested food particles are found in the stomach in the morning, lavage should be performed early in the day and before the first meal is taken. If the patient cannot sleep on ac- count of the gastric distention, belching, pain or vomiting, that result from stagnation of the stomach contents, then lavage should again be performed immediately before retiring. In the milder forms of motor insufficiency, lavage is best done before the evening meal, for, in this way, the residue remaining in the stomach from the midday meal, and possibly from the morning meal, is removed and the supper goes into a clean and empty stomach, so that the evening meal can either be properly digested or can be propelled into the bowel in time without producing nocturnal distress. Lavage of the stomach in carcinoma should be continued for a long time, best of all, throughout the course of the disease or until a gastro-enterostomy is performed or possibly until ulcera- tion of a pyloric carcinoma occurs whereby a free passage from the stomach into the bowel may become re-established. Lavage performed before breakfast or before supper may be combined with the injection of stomachics into the stomach; or the wash water may be medicated with antiseptics like salicylic acid, boric acid, etc. (see page 356). The addition of these rem- edies to the wash water is, however, rarely necessary and, in most cases, altogether superfluous. In most cases of carcinoma of the stomach, if the proper diet is administered and lavage of the stomach is methodically insti- tuted special medicamentous treatment for the relief of symp- toms is, as a rule, not required. Vomiting of large quantities of stagnating food material is effectually prevented by lavage, especially if the wash water is medicated with antifermentative remedies (see page 356). If the vomiting is due to gastric hyperesthesia, cocaine adminis- tered as described on page 19, or chloroform water in teaspoon- ful doses frequently repeated, may be used. Narcotics are rarely indicated, and if they are given at all they should be adminis- tered by rectum in suppository or enema, or hypodermically. The one serious objection to the use of opiates is their tendency to produce constipation. If the vomiting is persistent and does not yield to lavage and to a simple diet and the above named measures, then the stomach may have to be put at rest for a Cakcinoma of the stomach 383 number of days by total abstinence from food, and nutrition maintained by rectal feeding. Bleeding from the stomach is rarely severe in gastric car- Hematemesis cinoma ; it should be treated by administering a bland, non-irri- tating diet and by employing all those measures and remedies that have been described at length in the Section on Ulcer, on page 376. The best remedy of all to stop oozing in ulcerating gastric carcinoma is adrenalin chloride administered in ten to twenty drop doses of a 1 :1000 solution, at one hour or two hour intervals. In severe cases that are particularly intractable, or in cases of ulceration by carcinoma, in which the ulcer erodes a large blood vessel, total abstinence from food must be insisted upon and the patient fed by rectum. Opiates are occasionally indicated, especially if there is much stenosis about the pylorus with violent peristaltic movements on the part of the stomach; for opium possesses the power of reducing or stopping this per- istalsis ; its administration, therefore, in these cases aids in estab- lishing quiet and contraction of the walls of the stomach. Ex- ternally cold should be applied to the epigastrium either in the form of an ice poultice, an ice bag or repeated cold cloths. Hot applications are contra-indicated if there is much gastric hem- orrhage. The pain in carcinoma is usually relieved by the application Pain of heat to the epigastrium either in the form of hot poultices, hot cloths, a Leiter coil through which hot water flows, a ther- mophore (see index) or Priessnitz compresses. If the pain appears only when the stomach is full, lavage, i. e., removal of the irritating stomach contents, brings about relief. Sympto- matically the pain may be treated by the administration of co- caine (see page 19), by chloroform given in three to five drop doses on ice, and if there are signs of peritonitic irritation, by opium with atropine, administered hypbdermically, by clysma or in suppository. The constipation in gastric carcinoma is best treated by Constipation enemas of soap and water, glycerin and water, or oil. Laxatives are rarely necessary ; if any are employed, simple vegetable rem- edies like rhubarb or cascara may be given in the form of tln j compound rhubarb pill containing rhubarb, aloes and myrrh and peppermint oil in the dose of four to eight grains, or as the fluid extract of cascara in half to one teaspoonful doses in water. Mercurial purges, drastics or salines should not be administered. Diarrhea in carcinoma of the stomach is usually due to the Diarrhea entrance of fermenting and decomposing stomach contents into the intestine. This fermentative form of diarrhea can gener- 384 MOTOR INSUFFICIENCY OF THE STOMACH ally be prevented by methodic lavage instituted to remove the stomach contents before it undergoes decomposition and enters the intestine. If this measure is not carried out, then the intes- tinal antiseptics that are discussed in full in the Section on Intestinal Catarrh are of use. Very severe diarrheas, finally, may have to be combated by the use of opiates. Definition Motor insufii- ciency Gastric ectasy and dilatation Megalogastria Gastric atony Atonic and hypertonic gastrectasy MOTOR INSUFFICIENCY OF THE STOMACH. (GASTRIC DILATATION, GASTRIC ECTASY, GASTRIC ATONY.) The term motor insufficiency is employed to indicate that the stomach cannot get rid of food within the normal time limit. This condition may be due to a reduction of the normal propul- sive power of the stomach wall, or to the presence of an obstacle at the pyloric orifice, or it may be due to an abnormally large amount of work imposed upon an otherwise normal gastric musculature. Motor insufficiency,^then, primarily designates a perversion of function which may or may not be accompanied by changes in the size of the organ ; for there may be motor in- sufficiency when the stomach is still normal in size but the- pylorus is stenosed, or even when, as in some forms of gastric carcinoma and in cirrhosis of the stomach wall, the stomach is. abnormally small. The terms gastric dilatation and gastric ectasy should be reserved for those cases of enlarged stomach in which there is motor insufficiency. Simple enlargement of the stomach with- out impairment of its motor power is designated as megalo- gastria. Gastric atony means muscular weakness of the gastric walls. Wherever there is atony there is also muscular insufficiency and, as a rule, but not invariably, gastric dilatation (gastric ectasy). Gastric ectasy with atony of the stomach wall is called atonic ectasy. There is also a form of hypertonic ectasy in which the stomach is large and in which there is motor insufficiency, but in which the muscularis is hypertrophic and not atonic. This form of hypertonic ectasy occurs particularly in cases of steno- sis about the pylorus in which the muscles of the stomach wall are submitted to persistent overwork. Sooner or later this form, too, develops into atonic gastric ectasy, especially if the obstacle about the pylorus is not removed. It will be seen, therefore, that gastric atony and gastric dilatation are closely related and that the latter may develop from the former. They have this in common that both are accompanied by motor insufficiency. MOTOR INSUFFICIENCY OF THE STOMACH 385 For ordinary clinical purposes, the finer anatomic differen- tiation between motor insufficiency with ectasy or atony is super- Clinical dif- fluous and the following practical method of differentiation eren ia lon suffices for therapeutic purposes : The stomach is atonic if it requires an abnormally long time to expel the food, but, nevertheless succeeds in getting rid of all or nearly all of its contents during this abnormally long period. As a result little occasion is given for stagnation of the stomach contents and for its fermentative decomposition. A simple atonic stomach should always be empty in the morning. In atony the stomach is only slightly enlarged if at all and its lower boundary should not extend further than the umbilicus when it is filled (e. g., with a 1,000 cc. of water). The stomach is dilated (gastric ectasy) if it always contains food particles in the morning and if its lower boundary extends below the umbili- cus; here stagnation of stomach contents and fermentative de- composition are the rule. Inasmuch as gastric ectasy frequently results from and fol- lows atony, it is clear that intermediary stages between simple atony and atony with dilatation must needs be encountered. Gastric atony is often congenital. In most cases, however, Congenital, ac- quired atony it is acquired and constitutes a part phenomenon of general muscular asthenia; thus gastric atony is encountered in many chronic cachectic states, after severe infectious diseases, in many disorders of the liver, the heart and the kidneys, occasionally in chlorosis and anemia, after mental or bodily exertion and sexual excesses, after poisoning with alcohol and tobacco and in a variety of functional and organic diseases of the central nervous system. Dilatation of the stomach, on the other hand, may, as men- Causes of dila- tioned aboye, develop from simple atony of the stomach superin- tatlon duced by any of the above causes, especially in cases that despite the weakness of the stomach walls, persist in over-eating and over-drinking. In most instances, however, gastric ectasy is due to the presence of some mechanical obstacle to the passage of food in the pylorus or upper duodenum, as for instance, car- cinoma, cicatricial constriction following ulcer or erosion, pyloric spasm with or without hypertrophy of the pyloric musculature from different causes (see page 408), constriction or obturation of the pylorus by adhesions in the neighborhood or from com- pression from without by tumors, gall stones, etc. It will be seen from all that has been said that the causal Causal treat- treatment of motor insufficiency of the stomach with or with- ment out gastric atony or dilatation must take all these manifold fac- tors into careful consideration. In many instances the primary 386 MOTOR INSUFFICIENCY OF THE STOMACH Diet General con- siderations Diet with nor- mal or in- creased H CI Diet with Re- duced H CI No large meals cause cannot be removed or can be made to disappear only very slowly. In other cases the primary cause may be removed, but the motor insufficiency, i. e., the weak condition of the muscles of the stomach and enlargement of the organ persist. In all these cases active treatment directed towards -improving the motor power of the stomach; towards preventing further dila- tation and stagnation of the stomach contents ; above all, towards maintaining the patient's general nutrition, despite the exist- ence of gastric ectasy, must be energetically instituted. The diet in all these cases should be of such a character, first, that it imposes the minimum of labor on the stomach whose motor power is impaired; second, that it can be propelled easily and rapidly into the intestine; third, that it contains none of the articles that can undergo ready gaseous or acid decomposi- tion in the stomach when they stagnate there ; fourth, that it is sufficiently nutritious to sustain the patient. In selecting the proper diet the state of the gastric secretion must be taken into consideration in addition to the degree of motor insufficiency. The composition of the food will, therefore, have to vary accord- ing to the presence or absence of sufficient or over-abundant hydrochloric acid and peptic ferments. If the secretion of hydrochloric acid is normal or increased, then there is no objection to the use of meats and other albu- minous foods, inasmuch as these are promptly digested in the stomach; at the same time, especially in hyperchlorhydria, the ingestion of amylaceous foods should be reduced ; for the diges- tion of the latter is always impeded in hyperchlorhydria, so that they are apt to undergo abnormal decomposition when they re- main in the stomach in an undigested state for an abnormally long time. If the secretion of gastric juice is reduced no meats at all should be given, but eggs, milk and mnshy, amylaceous foods, i. e., gruels, made of milk with wheat flour, rice, barley, tapioca or sago, milk toast, vegetable purees, fruit sauces, butter, cream and olive oil may be administered. Large meals should always be avoided and all of the articles enumerated above should be given in small quantities at frequent intervals. The amount of food and its consistency depend in one important group of cases upon the degree of stenosis at the pylorus, and one may say axiomatically that the greater the obstacle to the passage of food through the pylorus the smaller should be the quantity of food that is administered at a time and the softer its consistency. From a practical standpoint it is best to experiment some- what in each case, i. e., to determine at frequep* intervals by MOTOR INSUFFICIENCY OF THE STOMACH 387 actual removal of the stomach contents after a mixed meal, which foods of the different kinds are retained and which are evacu- ated from the stomach within the normal time limits. In com- bination with such a motility test a study of the state of the Motility test gastric secretion may advantageously be made and the selection for Ceding* of the diet somewhat regulated accordingly. All articles of food that are coarse in texture, that contain N <> coarse indigestible parts like tendons, skin, connective tissue, in the case of meats ; stems, husks, skins, pips, seeds, in the case of vege- tables and fruits, should be altogether forbidden. Carbonated beverages that distend the stomach are alwavs bad. Alcoholic Carbonated and ■ • i o -. t o alcoholic li- liquors, solutions of albumoses and peptones, very salt foods, very quors to be sweet foods and sugar solutions are forbidden, because they all av0lded draw water into the stomach and hence over-burden the organ. The total liquid intake should be somewhat reduced. A dry Hquid^iSake diet is not, however, advantageous, the claims of certain clini- cians to the contrary notwithstanding, for the propulsion of semi-liquid and mushy foods is always easier in motor insuf- ficiency than the propulsion of a dry stomach contents. There is, therefore, no objection to the introduction of small quanti- ties of fluid with the meals nor to the administration of a liquid diet administered in reasonably small quantities, provided the liquids administered are nutritious, i. e., consist of milk, albumen solutions, strong soups, for the latter are propelled from the stomach as easily as mushy foods and more easily than solid foods of equal nutritive value. Too great restriction of the liquid intake may lead to a dehydration of the tissues manifesting itself by a strong sensation of thirst and theoretically, at least, in se- p^ger of . . tetany vere degrees of motor insufficiency by tetany. Excessive dehydration resulting from great liquid restriction that may be necessary in some cases must be forestalled there- fore by the administration of fluids by rectum, as described else- where, and this procedure is always indicated when the total Administration liquid intake is reduced below 1,000 cc. in the twenty-four rectum S y hours. In very advanced stages of gastric ectasy with serious stenosis, the ingestion of liquids may have to be reduced even below this minimum and in such cases rectal administration of liquids will have to be instituted several times a day. Occasionally total abstinence from food for a few days Occasional to- greatly aids in restoring some tone to the stomach; for when stinence the gastric walls are spared all labor one may assume that the mucularis recuperates under this rest treatment. In such cases the patient may be fed for a number of days to great advantages by rectum alone. Rectal feeding, too, has a place in many cases Rec t al feeding to supplement the insufficient food administration by mouth. 388 MOTOR INSUFFICIENCY OF THE STOMACH Rest after meals Position to be occupied when lying down Lavage Time for per- forming lavage In cases of gastric ectasy that are being prepared for operation, rectal feeding too may be instituted for several days preceding the operation. Rest after meals is a very essential element of the treatment. If the patient lies down after each feeding a larger proportion of blood determines towards the digestive tract than if the pa- tient moves about; for, in the latter case much of the blood is drawn to the periphery, so that digestion may be somewhat im- peded thereby. At the same time the erect position, especially when combined with active exercise, determines dragging and distention of the stomach when it is full of food and heavy, and, in this way, favors the further development of atony and dilata- tion. It is best to advise such patients to lie down for half an hour or an hour after each meal, preferably on the right side, as this facilitates the movements of the food toward the bowel. If there is an ulcer at the pylorus and much dilatation of the stomach, the latter position may, however, be hard to maintain on account of the pain and distress produced by the pressure of the food on the ulcerated area. In such cases the dorsal po- sition is preferable. The evening meal should never be eaten too near bedtime, as digestion is less active during sleep and hence food may remain abnormally long in the stomach during the night. Lavage of the stomach should be instituted in all cases of motor insufficiency according to the principles enunciated in a preceding section (see page 355). In simple atony without ectasy and with mild degrees of motor insufficiency, lavage may occa- sionally be dispensed with. In gastric ectasy due either to atony or stenosis, lavage, however, is of the greatest value. By instituting methodic lavage an attempt is made to re-establish physiological conditions ; this applies in particular to those cases of motor insufficiency in which food is still present in the stomach in the morning; for normally the stomach should always be empty at this time and it should enjoy several hours of rest dur- ing the night. In order to promote this object the evening meal should be taken, as stated above, several hours before retiring, preceded by a lavage ; for, in this way any residue that may have accumulated from breakfast or dinner will be removed and the supper, which should be light, is introduced into a clean stomach containing n<5 fermenting food particles. Such a supper should be digested within three or four hours. If it is found that the stomach contains food particles in the morning, even when this plan is adopted, or if the patient suffers much distress at night from distention of the stomach with gases, then it may be nec- essary to perform lavage before going to bed. In still other cases MOTOR INSUFFICIENCY OF THE STOMACH 389 in which only very little residue is found in the morning, the stomach may be washed out before breakfast and again before supper. In most cases the afternoon lavage, six or seven hours after the heaviest meal, is sufficient. Lavage of the stomach should be very thorough and should be Medicated performed both with the patient sitting up and lying down. ava S e Washing the stomach with anti-fermentative solutions like a three per cent, boric acid solution; two pro mille salicylic acid solution; two per cent, resorcin solution; two pro mille hydro- chloric acid, and other drugs, is occasionally useful. The objec- tion advanced against frequent lavage, viz : that nutritious ma- terial is thereby removed from the stomach, is more than over- balanced by the advantages accruing to gastric digestion from the removal of stagnating particles and the introduction of new pabulum into a clean, empty stomach. In combination with the morning lavage, douching of the Douching stomach may be instituted. This consists in forcing through a stomach tube containing numerous small openings, water, of eighty to ninety degrees Fahrenheit, under considerable pres- sure. Water injected into the stomach in this way hardly reaches all parts thereof, but the temperature of the water seems to exercise a tonic effect upon the weakened gastric muscula- ture. This method of treatment is applicable chiefly to cases of gastric atony without much dilatation; but in gastric ectasy the injection of much water into the stomach under pressure is not good. The addition of medicaments to the douche water is hardly necessary. Stomachics added to the douche (see page Addition of 362) if the secretion of gastric juice is reduced and the appetite drugs ,to is impaired, can do no harm. If the hydrochloric acid is low sodium chloride in the proportion of ten grammes to the litre may be used. If there is hyperchlorhydria, a silver nitrate solu- tion of the strength of 1 :1000 is useful. In order to lend support to the stomach, especially in cases in which the abdominal parieties are relaxed, and in general gastro- and entero-ptosis combined with gastric ectasy, band- aging the abdomen is of some value. Abdominal supporters and Bandaging th» bandages hold up the abdominal contents and thereby support abdomen the stomach; dragging and tugging on ligaments is prevented and consequently various reflex irritations that may react un- favorably upon the tone of the stomach walls eliminated. An abdominal supporter in order to do any good at all should fit correctly. Some cases of gastric dilatation cannot bear abdom- inal binders on account of the pressure they exercise upon the stomach, especially when it is full or distended with gas. 390 MOTOR INSUFFICIENCY OF THE STOMACH Electricity Technique of electro-thera- peutics Massage of the stomach To stimulate the tone of the atonic gastric musculature, elec- tricity applied in different ways has been used. Personally,. I have abandoned its employment, as its administration, espe- cially by the intra-gastric method, is rather complicated and usually disagreeable, and because nothing can be accomplished by the means of electric treatment that cannot be brought about equally well or better by other simpler means. In advanced stenosis of the pylorus, moreover, in which the gastric wall is not atonic, it is not good practice to over-stimulate the gastric musculature; for the latter is already working to the limits of its powers, as manifested often by the appearance of visible per- istaltic waves in the region of the stomach. Either the faradic or galvanic current may be used. Static electricity is rarely employed. The faradic or galvanic cur- rent may be applied either by the percutaneous (extra-gastric) method or by the intra-gastric method. If the motor power of the stomach is to be stimulated a faradic current applied per- cutaneously is the best. It should be applied by means of two large sponge electrodes, one of which is laid directly over the stomach, the other one about an inch removed from the right edge of the first electrode along the right side of the body. The current should be strong enough to produce muscular twitchings of the abdominal muscles but only very slight pain. The faradic current should not be applied in this way for longer than ten minutes. For the relief of sensory symptoms the galvanic cur- rent applied by the intra-gastric method is the most effective. A great variety of gastric electrodes have been described. The simplest one is a spiral wire with a knob at the end which can be pushed through an ordinary stomach tube. Before applying galvanic electricity by the intra-gastric method, the stomach should be filled about one-half with water in order to prevent burning of its walls by direct contact with the electrode. The anode should be connected with the intra-gastric electrode, the cathode with a large plate electrode which should be applied over the sternum or to the back. A weak current should be used and the treatment should not last longer than ten minutes. If the intra- ventricular treatments cannot be carried out, then either the galvanic or faradic current may be utilized for the relief of sensory symptoms by applying one large electrode connected with the anode over the epigastrium, another one connected with the cathode over the back or sternum. In skillful hands massage of the stomach is of some use ; this measure, however, is, as a rule, superfluous. It is expected to fulfill two objects, namely, to strengthen the musculature of the MOTOR INSUFFICIENCY OF THE STOMACH 391 stomach and to propel the gastric contents onward; the former object, owing to the inaccessibility of the stomach is probably very difficult to attain and therefore the value of massage in this direction is highly problematical. The latter effect is, at best, merely palliative and is, self-evidently, altogether fictitious and, at best, transitory, unless carried out immediately after each meal. There are, moreover, definite contra-indications to the use of gastric massage, notably the presence of an ulcer, the occurrence of a recent hemorrhage and perigastric adhesions. Of general hydr other apeutic measures the Scottish douche, Hydrotherapy- i. e., the application of a strong stream of water, the temperature of which is changed every twenty or thirty seconds from hot to cold, is the most useful. Fan douches, too, are of some value. Priessnitz compresses in many cases exercise a soothing effect and slightly stimulate contractions of the gastric muscles. Of drugs that are used to improve the tone of the gastric Medicamentous muscles, tincture of mix vomica or strychnia are the most popu- rea men lar. Tincture or extract of mix vomica should be given by mouth before meals or in the morning on an empty stomach with the n ux vomica stomach douche (see page 363). Strychnine is best given hypo- dermically. Constipation and vomiting should be treated by the use of enemata, mild vegetable laxatives like rhubarb and cascara, and by abdominal massage (see index) ; mineral waters are, of course, to be eschewed. Vomiting generally yields to the proper regulation of the Constipation diet and to lavage. Priessnitz compresses or hot poultices to Vomiting the epigastrium are frequently of value and if the vomiting is due to hyperesthesia of the gastric mucosa, cocaine (see page 19 ) or narcotics administered in suppositories or hypodermically may be used. A useful procedure finally, especially in pyloric spasm with resulting stenosis and motor insufficiency, is the so-called oil cure. It consists in the administration of 50 cc. of oil three times a day, half an hour before eating, or of 150 cc. of olive Oil cure oil on an empty stomach in the morning, either swallowed or administered through a stomach tube. This latter treatment fre- quently stops the spasmodic closure of the pylorus, facilitates the passage of the gastric contents into the bowel, exercises a slight laxative action which effectually counteracts any tendency to constipation and, at the same time, aids in nourishing the patient. Surgical treatment often becomes necessary in advanced de- Surgical treat- grees of motor insufficiency. It may consist either in removal of ment 392 MOTOR INSUFFICIENCY OF THE STOMACH Indications for surgery Surgical methods the obstruction at the pylorus, in drainage of the stomach by gastroenterostomy, in mechanical reduction in the size of the stomach or in producing mechanical changes in the size or the position of the stomach. The indications for surgical intervention are the following: First, the discovery of some mechanical obstruction to the passage of the food from the stomach into the intestine, especially if this obstruction remains persistent for a long period of time or if it increases, or if it is due to a malignant growth. Second, if the motor insufficiency, atony and ectasy grow worse instead of better, despite the treatment outlined above. Third, if despite all treatment and the apparently success- cul relief of symptoms, including the motor insufficiency, the nutrition of the patient becomes impaired and weight is lost. Fourth, if the patient does well under continuous treatment, but grows worse as soon as persistent treatment is stopped. In such cases, especially if the physician is convinced that the pa- tient could not improve unless treatment were continuously car- ried out, an operation may become necessary. The methods of removing pyloric obstruction by resection, pyloroplasty, etc., need not be discussed in this volume. The indications for resection of the pylorus in carcinoma have been formulated on page 378. In many cases, especially those in which the motor insufficiency and dilatation are far advanced, gastro- enterostomy is, by all means, the best operation; for in some cases even the re-establishment of a patency of pylorus would not restore the motor tone to the stomach. Sewing tucks into the stomach is a useful procedure only in mild degrees of atony in which the stomach muscles still retain some contracting and pro- pelling power. Gastroplication, shortening of the gastric- hepatic omentum, or of the gastric-hepatic and gastric- splenic ligaments, or fixing the stomach in a position where drainage through the pylorus becomes better, either by stitching or by making a sling of the lesser omentum sewed to the pancreas for the stomach to rest on, are methods of surgical treatment that have all been tried. All of the latter are applicable only to cases of motor insufficiency with dilatation due to atony, not to dilatation due to stenosis about the pylorus. It is altogether too early to pass definite judgment on the efficacy of these different, rather complicated, surgical procedures. GASTRIC HYPERSECRETION AND HYPERCHLORHYDRIA 393 ■GASTRIC HYPERSECRETION AND HYPERCHLOR- HYDRIA. These two conditions may be discussed together although Definition they occasionally produce somewhat different symptoms and may call for somewhat different treatment. In hypersecretion the gastric glands secrete gastric juice in excess when they are stim- ulated by the food, but they may also do this when they are not stimulated by the food, i. e., when the stomach is empty; con- sequently in this condition the stomach contains abundant gas- tric juice nearly all the time. Hypersecretion obviously is always accompanied by hyperchlorhydria, but the latter condition may -also occur as an independent affection without hypersecretion, And manifest itself by an excessive out-pouring of hydrochloric acid only when the stomach contains food. The two conditions, it will be seen, are closely related, the difference between them being more of degree than of kind. Hypersecretion may be con- sidered as a continuous form of hyperchlorhydria occurring without the stimulus of food; hyperchlorhydria as a periodic form of hypersecretion and one that requires the stimulus of food to be produced. Hypersecretion and hyperchlorhydria may be a part phenom- c auses -enon of a general neurosis; they may follow mental, emotional over-strain or psychic shock; they may occur in the course of chlorosis; they may result from abnormal irritation of the gas- tric mucosa, if dietetic indiscretions, especially accompanied by the abuse of alcohol, tobacco, very hot foods, spiced foods, are committed; or they may be seen in anatomic lesions of the stomach or may finally constitute a reflex phenomenon emanating from remote organs of the body. The causal treatment, therefore, of hypersecretion and hyper- Causal treat- chlorhydria must take all these elements into consideration. If m e n t the patient is a neuropath, then the neurasthenic or hysterical •condition should be treated as described in the Section on Gas- tric Neuroses. All emotional or mental over-strain should be avoided, any condition of anemia or chlorosis corrected, bad habits of eating improved and all factors that may become operative to irritate the gastric mucosa and the secretory nerves of the stomach, either directly or by reflex irritation, sought for and, if discovered, re- moved. Inasmuch as the out-pouring of excessive gastric juice with an The diet abnormal amount of hydrochloric acid is in most cases due to the stimulating effect of food which in these patients produces a 394 GASTRIC HYPERSECRETION AND HYPERCHLORHYDRIA Articles to be avoided Abundant al- bumen Meats Selection of meats in pres- ence or absence of motor in- sufficiency Starchy foods quantitatively abnormal secretory reaction, the selection of the proper diet is of paramount importance. The diet, while ade- quately nourishing the patient, should be mechanically non- irritating, i. e., it should contain no coarse and indigestible par- ticles like skin, tendons, cartilages, husks, seeds, pips, etc. It should contain no spices or condiments (mustard, pepper, paprica, cloves, etc.) ; nor any fruits or vegetables incorporating irritating oils (onions, radishes, horse-radish, etc.) ; nor should very acid foods, very hot foods, nor strong alcoholic drinks be administered. The diet should contain abundant albuminous pabulum; for the latter, owing to its power to combine with hydrochloric acid, acts as an antacid and thereby gives symptomatic relief. The va- rious albuminous foods differ in their power to bind hydro- chloric acid. Best of all among the meats are beef, mutton and raw ham (Fleischer), but other forms of meat or fish or poultry are suitable food for these cases, provided they are not served in the form of cured, spiced or corned meats ; for meats prepared in this way, on account of the spices, salts and extractives they con- tain, directly stimulate the flow of hydrochloric acid. The selection of the meats must also be governed somewhat by the presence or absence of motor insufficiency, atony, or dila- tation of the stomach. If the stomach does not empty itself with- in a normal time (and in hyperchlorhydria it usually empties itself more rapidly than normal, especially if an albuminous diet is administered), then all coarse varieties of meats should be avoided (see page 387). If there is no motor insufficiency, then coarse meats are particularly useful, as they require much hydro- chloric acid for their digestion and hence possess relatively great hydrochloric acid binding properties. In hypersecretion or hyperchlorhydria associated with motor insufficiency or ectasy, finely divided meat, i. e., scraped or hashed meat, milk in small quantities and given at frequent intervals, and eggs are the best albuminous foods. Milk, gruels and soups made with flour of rice, wheat, barley, or with arrow- root, tapioca, sago, eggs ; or milk rendered more nutritious by the addition of condensed milk or milk powder (see index) are all useful additions to the meat diet. Starchy foods are digested with difficulty in the stomach in hyperchlorhydria and hypersecretion. This is due to the fact that in hypersecretion, free hydrochloric acid is either present, when the food enters the stomach or appears there earlier than normal in simple hyperchlorhydria, so that it interferes with the amylolytic digestion of the starches in the stomach by inhibiting GASTRIC HYPERSECRETION AND HYPERCHLORHYDRIA 395 the action of the saliva that is swallowed. Starchy foods, there- fore, unless promptly evacuated into the bowel, undergo abnor- mal fermentation and lead to the formation of irritating organic acids in the stomach; moreover their digestion in the bowel is interfered with as they enter the intestine in an hyperacid me- dium that must first be neutralized and rendered alkaline by the intestinal juices before the latter can digest starchy pabulum; for this reason amylaceous foods should never be given on an empty stomach in the disease under discussion and should always be given in relatively small quantities together with, or better still, after an abundant proteid diet. The assimilation of starchy foods is greatly facilitated by Dextrinized administering them in a dextrinized, i. e., partially predigested, cart> oliydrates form, as malted foods, toasts, zwieback or as dextrose. The lat- ter, especially as it is readily absorbed from the gastro-intestinal tract, does not stimulate the hydrochloric acid secretion as much as other carbohydrate foods, so that the carbohydrate require- Dextrose solu- ment of the organism can very well and safely be satisfied by the administration of dextrose in ten to twenty per cent, watery solution, given at frequent intervals. In atony or ectasy of the stomach with stagnation of stomach contents, dextrose solution, however, should not be given, especially as it possesses the power to some degree of drawing water into the stomach, an event that, as stated in a previous section, is to be especially avoided. Cane Cane sugar sugar is by far less useful than dextrose, for the former must first be inverted into dextrose and levulose before it can be assim- ilated, and this process occurs with great difficulty in an acid medium, or in a medium that is only slightly alkaline. The mode of preparing amylaceous foods is important; the Preparation of carbohydrates are best administered in the form of vegetable starch y foods purees, mashed or baked potato, fruit sauces or in the form of different flours, with milk, as gruels or mushes as described above. Raw, stringy, coarse or acid vegetables or fruits, fresh or coarse breads, cereals containing husks should be carefully avoided. Fats never do any harm in hyperchlorhydria and hyperse- Fats cretion if given in a digestible form (see page 353) ; butter, cream, vegetable oils are all useful foods, whereas the animal fats, being less digestible, should be given very sparingly. Cer- tain theoretical objections have been formulated against the administration of fats. The claim in particular has been ad- vanced that they, too, require an alkaline medium for their diges- tion in the intestine and that in hyperchlorhydria and hyperse- cretion such a medium is not created as soon as it normally should be. These objections are overthrown by practical experi- ,m GASTRIC HYPERSECRETION AND HYPERCHLORHYDRIA Beverages Alkaline min- eral waters Alcoholic li- quors, tea, cof- fee Smoking Small meals at frequent in- tervals Stomach should never be empty Night feeding Lavage Douching ence. The high caloric value of the fat, the empiric fact that they are well digested in the intestine and that they are well borne, despite the existence of hyperchlorhydria, especially if they are administered together with abundant proteid, renders them very useful additions to the diet in nearly all cases. If there is combined with hyperchlorhydria or hypersecretion an advanced degree of motor insufficiency, especially if gastrectasy is present, then they should, of course, be given sparingly. Fluids, provided there is no gastric atony or ectasy, may be given abundantly. They act very well symptomatically by dilut- ing the hyperacid gastric juice without interfering with the digestion of the albumens. Alkaline mineral water, especially the carbonated varieties, are especially useful as table bever- ages; for they combine antacid properties with slightly anes- thetic powers (C0 2 ) and are consequently particularly useful when hyperchlorhydria is associated, as it so often is, with gastric hyperesthesia. That carbonated beverages should not be used in gastric atony or gastrectasy need hardly again be empha- sized. Alcoholic liquors, tea and, above all, coffee, should be forbid- den, for they all somewhat irritate the stomach and stimulate the flow of gastric juice. Smoking, too, is best forbidden altogether. Small meals containing abundant proteids, given at frequent intervals are better than large meals given at longer intervals. If small meals are administered over-secretion of gastric juice may often be avoided. It is a very good rule, however, never to let the stomach, in these cases, become altogether empty at any time during the day. The patient may have a breakfast, dinner and supper of moderate volume at the regular times, but should, in addition to these three main meals, drink a glass of milk or eat a soft boiled egg or two with a cracker or a piece of toast in the middle of the forenoon, in the middle of the after- noon and on retiring. If patients suffering from advanced de- grees of hypersecretion or hyperchlorhydria complain of much pain or distress during the night, on account of the presence of free hydrochloric acid in the stomach, then a glass of milk taken in the middle of the night is often of the greatest value in re- lieving this very disagreeable symptom. Lavage of the stomach is of relatively small value in hyper- secretion and hyperchlorhydria unless there is some motor in- sufficiency. In cases that suffer from nocturnal distress, as described above, washing out the stomach with a dilute alkaline solution just before retiring is, however, often of value. Douching the stomach (see index), after a cleansing lavage in the morning, with a 1:1000 silver nitrate solution or a two GASTRIC HYPERSECRETION AND HYPERCHLORHYDRIA 397 per cent, boric acid solution is also often of some value. 100-200 Silver nitrate cubic centimeters of the silver nitrate or boric acid solution are Boric acid left in the stomach for two to five minutes and then washed out with water. The silver nitrate, in particular, seems in some cases to reduce the secretion of gastric juice for the rest of the day; at the same time it acts somewhat as an anesthetic to the irritable gastric mucosa, so that the silver nitrate treatment is of especial value in hyperesthesia of the stomach. Of other remedies that can suppress the secretion of gastric Remedies to juice, belladonna and atropine are the most important. The excretion former given as the extract in combination with an alkali is Belladonna often of signal value. The following prescription is useful: Atropine Extract of Belladonna, 0.03 gm. Burnt magnesia, 0.5 gm. M. Fifteen such powders. Sig. One three times a day after eating. (Ortner.) Atropine is best given hypodermically in doses of from one hundredth to a fiftieth of a grain, once a day, in the morning. Alkalies are, as a rule, indispensable in the treatment of A-lkalies hyperchlorhydria and hypersecretion. The chief object of ad- ministering them is to neutralize the excessive hydrochloric acid that is poured into the stomach. In order to be effective they must be given in large doses after meals, at the period when digestion is at its height. In hypersecretion it may be necessary to give them also when the stomach is empty, i. e., before eating or in the middle of the night in order to neutralize the acid that is present at that time. Sodium bicarbonate is the most popular Sodium bicar- alkaline remedy, but it should be used with some care as it is slightly irritating to the mucosa. The copious development of carbon dioxide is generally distressing to the patient on account of the gastric distention and belching it produces and may even be dangerous in ulcer. The sodium chloride that is formed, moreover, somewhat stimulates the secretion of hydrochloric acid. It will be seen, therefore, that the popularity of sodium carbon- ate is not deserved. Far better as antacids are magnesia usta or magnesium Magnesia usta carbonate. Magnesia usta is probably the best remedy of all, carbonate for it is non-irritating to the stomach, it is capable of binding nearly four times as much hydrochloric acid as an equal bulk of sodium carbonate, and the magnesium chloride that is formed does not stimulate the hydrochloric acid secretion in the stomach. 398 GASTRIC HYPOSECRETION AND ACHYLIA GASTRICA Sodium bibo- rate Calcium car- bonate Alkaline and alkaline-saline waters Benefits of re- sort treatment Magnesia usta, moreover, possesses the power of binding any C0 2 that may be formed from fermentation in the stomach, and, finally, magnesia salts possess slightly laxative properties that are useful in order to counteract any tendency to constipation. The following mixture of sodium carbonate and magnesia especially is very useful and answers all purposes in practice: Sodium carbonate, Burnt magnesia, of each, 100 parts Sugar of milk, 150 parts This mixture should be procured in bulk by the patient and should be taken in half to one teaspoonful doses, in milk, at the height of digestion. Another good preparation is a compressed tablet containing equal parts of sodium carbonate and magnesium carbonate. The administration in a compressed tablet favors slow solution of the alkalies in the stomach and hence somewhat prolongs their effect. Moreover, this mixture leads to a very slow evolution of carbon dioxide. Other antacids that can be used are biborate of soda and calcium carbonate in the form of precipitated chalk, given in a third of a teaspoonful dose at the proper times. Carbonated alkaline waters (see above) and also saline waters are of considerable value in the treatment of hypersecretion and hyperchlorhydria. These waters are especially efficacious when taken at certain watering places or resorts ; but a great part of the good effect observed from their use must be attributed to the careful regime that the patients follow at these resorts, to the respite from every-day cares and worries, to the agreeable psychic stimulus and suggestive effect that is granted when they visit these watering places. The successful management of their cases, moreover, by resort physicians, who have much experience with this particular class of invalids plays an important role. The different waters administered at home are certainly less effective than when they are taken at watering places. Causes GASTRIC HYPOSECRETION AND ACHYLIA GASTRICA. The reduction or the complete suppression of the gastric juice may be a part phenomenon of a general neurasthenia or hysteria, or a symptom of various organic diseases of the stomach (carcin- oma, chronic gastritis, atrophy, amyloid degeneration), or it may attain the dignity of an independent neurosis. Simple hypo- acidity or anacidity are probably never seen. In most cases the GASTRIC HYPOSECRETION AND ACHYLIA GASTRICA 399 secretion of the gastric enzymes, too, is reduced, so that it is more proper to speak of hypochylia and achylia. The most important element in the treatment of hypochylia Diet and achylia gastrica is the selection of the proper diet. The regulation of the food is dependent on the presence or absence of motor insufficiency. If the motor power of the stomach is good, then every effort should be put forward to maintain it so, and all coarse and indigestible foods, large meals, large quan- Presence or flbSGHCG of tities of liquid should be avoided as a prophylactic measure. mo tor insuf- The patient, therefore, should receive small meals at frequent ncienc Y intervals, consisting of easily digestible meats, abundant carbo- hydrate and considerable quantities of fat. If the motor power of the stomach is impaired, especially if there is in combination with hypochylia and achylia gastrica some gastric atony or gastric ectasy, then the motor insufficiency becomes the more im- portant element to be considered and it should be treated as de- scribed in a previous section. Provided the motor power of the stomach is good or only Tne motor power is srood slightly impaired, then meats should be allowed. In selecting the kind of meat, its digestibility should be considered above all things (see table on page 349), consequently broiled or stewed poultry, certain varieties of fish, raw, rare, scraped or hashed beef, mutton or ham, calves' brains, sweet-breads, all finely divided and carefully freed from skins, tendons, etc., and ad- ministered in small quantities, are permissible. If the motor power is seriously impaired, meats are best er^is^mpaired'" avoided altogether, or, if given at all, administered in very small quantities; for one must realize that in the condition under dis- cussion the digestion of albuminous pabulum in the stomach is very decidedly impaired or altogether inhibited; consequently serious harm can be done to the stomach unless the gastric con- tents can promptly be propelled into the bowel where the dis- assimilation of the albumens can be vicariously carried on by tryptic digestion. In certain cases in which the motor power is Pancreas not too seriously impaired, pancreas preparations can to advant- age be administered together with small quantities of meat ; for in this way intestinal digestion is begun in the stomach and the disassimilation of the albumens aided. If there is some hydro- chloric acid secretion, the pancreas preparations must, of course, be given with sufficient alkali to more than neutralize the gas- tric hydrochloric acid. What has been said of meats applies with equal force to other ^SS S , ^ llk > ^ vegetables albuminous foods, i. e., eggs, vegetables rich in albumen and Albumens milk. Eggs should be given in a semi-liquid form or finely divid- ed, i. e., either soft boiled, or poached or as scrambled eggs, or 400 GASTRIC HYPO-SECRETION AND ACHYLIA GASTRICA Carbohydrates Fruits and vegetables Fats Delicacies Alcoholic bev- erages Lavage Douching as chopped up hard boiled eggs. Vegetables should be given as purees. Milk must be given in small quantities only; for the ingestion of abundant fluid, as stated above, is to be avoided. In allowing milk the tolerance of the individual for this food must always be determined by experiment, for by some patients with hypochylia and achylia gastrica milk is not well borne. Inasmuch as the digestion of the carbohydrates is in no way impaired in hypochylia and achylia gastrica, they should con- stitute the major portion of the diet. The same rule in regard to the avoidance of coarse, bulky and indigestible ingredients applies to the administration of vegetables; i. e., vegetables and fruits should be given in finely divided form, preferably as purees or fruit sauces and in small quantities after a careful removal of all coarse and indigestible stems, husks, seeds, pips, etc. Many starchy vegetables like rice,, barley, sago, tapioca, arrow-root, wheat and oatmeal flour, etc., are best given with milk as gruels or mushes. Toast, bread, zwie- back and crackers are all useful and permitted. Fats, especially butter, cream, cocoa and vegetable oils are- allowed. Animal fats like bacon, lard and suet are less digestible than milk and vegetable fats and should consequently be given sparingly. Very large quantities of fat should never be given on. account of the possible formation of irritating decomposition products. Moreover, large quantities of fat rapidly produce a sense of satiety and hence often impair the appetite and prevent the patient, whose albumen ration is reduced, from ingesting sufficient nutriment to maintain adequate nutrition. In this class of cases many delicacies, spiced and salted foods,, meat extracts, albumose and peptone preparations have a place in the menu ; for all these preparations slightly irritate the gas- tric wall and stimulate the flow of gastric juice. For the same reason small quantities of alcoholic beverages, either brandy or whisky with water, a little champagne, a light Moselle, Bur- gundy or claret are useful. Lavage of the stomach is rarely necessary unless there is, at the same time, an advanced degree of motor insufficiency. If the motor power of the stomach is impaired, then the same in- dications for lavage exist as in any other form of motor insuf- ficiency. Douching the stomach with a 1 :100 salt solution is in some cases a very useful procedure if persistently carried out ; for the injection of salt into the stomach in this way seems to exercise a stimulating effect upon the secretion of hydrochloric acid. Douching with salt solution is best performed early in the morn- ing before breakfast or after a cleansing lavage. Many of the- GASTRIC NEUROSES 401 saline waters, taken in small quantities on an empty stomach, Saline waters answer the same purpose. The use of medicines to stimulate the flow of hydrochloric Drugs acid and of gastric enzymes is theoretically indicated, but prac- tically very problematical. The administration of small quanti- ties of sodium bicarbonate before meals is claimed to be an effi- Sodium bicar- cient means of stimulating a reactive flow of hydrochloric acid. me als This effect, however, is very doubtful (see page 362). Hydro- chloric acid given in small quantities, together with one of the Hydrochloric stomachics before meals, is fullv as useful (see page 361). The _, . . c Stomachics use of hydrochloric acid even in large quantities after meals, or the use of peptic enzymes, is of doubtful utility as a substitution therapy. If the motor power of the stomach is good the arti- Enzymes ficial ingestion of these gastric products is at least superfluous, because the intestine vicariously assumes peptic digestion ; in fact, in such cases the administration of large quantities of hydrochloric acid by reducing the alkalinity of the intestinal juices may somewhat retard tryptic digestion. If the motor power of the stomach is impaired, then lavage and other measures that have been discussed in the Section on Motor Insufficiency are far more effective than the use of hydrochloric acid and pepsin. In the purely neurotic form of hypochylia and achylia gas- Neurotic form trica, a variety of hydriatic measures, massage, electricity, the selection of a proper climate and resort and, to some extent, sug- gestive treatment are all useful. For all these methods, their exact indications and employment 1 refer to the next Section. II. GASTRIC NEUROSES. To the category of gastric neuroses in the broader sense be- long certain functional disturbances of the stomach that are pro- duced by lesions of the stomach itself, but in which a marked disproportion exists between the organic cause and the functional effect, indicating that some perversion must exist about the Definition and causes nervous apparatus governing the function that is perverted and stomach^e- causing it to react abnormally to a stimulus that, in a healthy sions subject, would produce a (quantitatively) different reaction. Gastric neuroses proper, however, occur without any anatomic changes about the stomach. In most cases they are of reflex origin and superinduced bv irritation of the gastric nerves from Without ana- ° tomic stomach some remote diseased organ. In this class of cases, as well as lesions in the first mentioned group, the stomach nerves must again be considered to be in an abnormal state of irritability. The two 402 GASTRIC NEUROSES Reflex causes Psychic causes Intoxications Neuropathic disposition Difliculty of rendering the diagnosis Motor secretory, sensory, neu- roses groups differ merely in this, that in the first reflex irritation emanates from some intra-gastric source, whereas in the second category the primary focus of reflex irritation lies outside of the stomach ; thus eye-strain, certain organic lesions of the brain, the cord, the meninges, disorders about the sexual sphere, intes- tinal parasites, violent pain anywhere in the body, as for instance renal or hepatic colic, angina pectoris, peritonitic pain from dif- ferent causes, etc., may all produce gastric neuroses. In a third group of cases psychic causes, mental and emo- tional disorders, sudden emotional shock, depression, anger, fear, mental over-work all react on the innervation of the stomach and produce a variety of functional disorders. Finally, various intoxications as from lead, alcohol, mor- phine, tobacco ; infectious toxemias, notably in tuberculosis and malaria; different forms of self -poisoning as uremia, acidosis, may all produce functional gastric disorders that have no ana- tomic substratum in the muscular, sensory or glandular appa- ratus of the stomach. All these factors, as already indicated above, cannot, how- ever, operate to produce gastric neuroses unless there exists as a basis a neuropathic disposition which may be either congenital or acquired. The diagnosis, therefore, of a gastric neurosis should never be made from negative evidence alone, i. e., on the ground that no anatomic gastric disorder is discoverable, but it should only be arrived at if to this negative evidence is added the positive discovery of general neuropathic stigmata in the afflicted subject. • It is clear, therefore, that the diagnosis of a gastric neuro- sis should always be made with the greatest conservatism. It is probably never altogether positive but generally tentative and preliminary; for, in many cases, one must realize that the discovery of an anatomic basis is impossible merely on account of the deficiency of our methods and on account of lack of skill or thoroughness on the part of the physician. To determine definitely that an individual is a neuropath is a very precarious undertaking. In all patients who are not frank neurasthenics or hysterics the dyspeptic symptoms of an incipient tuberculosis or chronic uremia or intestinal toxemia, gastric disorders occur- ring in the presence of adhesions about the stomach (and intes- tine) are consequently often grossly misinterpreted. Gastric neuroses pure and simple, I believe to be really quite rare, and the diagnosis gastric neurosis or nervous dyspepsia is often merely a cloak for ignorance or carelessness. Neurotic disorders of the stomach may affect either the motor, the secretory or the sensory apparatus of the organ, in- GASTRIC NEUROSES 403 eluding the sensation of appetite. For the sake of clearness neu- rotic disturbances affecting these different spheres may be dis- cussed separately. It is important to realize, however, that perversions of several functions are, as a rule, associated, that in most cases perversions of single functions alternate. This alternation of functional disorders about the motor, secretory and sensory apparatus of the stomach, as well as the fact that the subjective distress of the patient is, as a rule, out of pro- portion to the severity of the functional disorder that is ob- jectively determinable, may be considered to some extent char- acteristic of all gastric neuroses. Chief among the motor neuroses are spasm and insufficiency Motor neuroses of the cardia and of the pylorus, hypermotility and peristaltic unrest of the stomach, nervous vomiting, nervous belching and gastric atony ; among the secretory neuroses hypersecretion and hyperchlorhydria, hyposecretion and nervous achylia gastrica; Secretory neu- among the sensory neuroses, gastric hyperesthesia, gastralgia roses and, in a broader sense, nervous dyspepsia, so-called; in the Sensory neu- roses latter condition no motor or secretory perversions of the stomach are discoverable, but the patients complain merely of a great variety of disagreeable subjective sensations during and after eating. Perversions of the appetite, finally, manifesting Perversions of themselves as anorexia, akoria and bulimia may also be included the a PP etlte under the category of sensory neuroses. The treatment of all these forms of gastric neuroses con- Correction of sists primarily and chiefly in correcting the underlying neuro- neurotic taint pathic taint, that is, in restoring normal tone, normal equi- librium to the nervous system at large, in re-establishing cen- tral autonomy, if it is lost; and in addition any lesion that may be considered a cause for reflex irritation of the gastric nerves either in the stomach or in other organs (see above) must be sought for and, if possible, removed. The methods at our disposal for curing the neuropathic taint are largely psychical and physical. The element of suggestion, education and moral suasion enters largely into this treatment ; while rest, hydrotherapy, the selection of a proper climate and resort, massage and, to some extent, electricity are all important adjuvants to the treatment. Medicines play a very subordinate role. In addition certain special methods of treatment may have to be instituted that are intended to relieve certain symptoms. In order to avoid endless reiteration, the general treatment treating the of the neurotic individual that is indicated in all forms of gas- n f u . r , oti ^ in ~ dividual trie neuroses may be discussed first, and the special treatment 404 GASTRIC NEUROSES Institution and resort treat- ment Simple hydro- therapy at home Hot baths Wet, cool pack Priessnitz com- presses Half baths that is useful in the different gastric neuroses, later, under sepa- rate headings. Most cases of gastric neuroses do best, by far, when treated either in an institution or at a resort. In. the latter case the good effects result from a change of scene, from temporary free- dom from worry, excitement and business cares and the attend- ance of skillful medical men who are specialists in the treatment of these cases, because they see so many of them. The feeling, moreover, that something definite is being done exercises both a restful effect on irritable nerves and, at the same time, a strongly suggestive effect, the value of which, in these patients, cannot be overestimated. In most resorts, moreover, and this applies also to sanitaria, the various hydrotherapeutic and electric treatments, massage and proper dietetic measures can all be carried out much better than at home. If the patient cannot or will not enter a sanitarium or go to some resort where good institutional facilities are available, the following simple hydrotherapeutic measures, which can be pursued at home, may be of considerable benefit : Simplest of all is immersion in a bath of about -95° F. The patient should remain perfectly still in the water for about five minutes. The temperature of the water slightly below the body temperature exercises a distinctly soothing influence. After the bath the patient should be dried with a rough towel and the surfaces of the body rubbed with alcohol. The patient should then be put to bed between woolen blankets and should lie there for an hour or two. This treatment may be applied every day either early in the morning or late at night before retiring. Or the patient may be wrapped in a cloth wrung out of cool water of room temperature and the surfaces of the body ener- getically slapped and kneaded through the wet sheet. After the treatment the patient's body should again be rubbed dry with a rough towel, treated with alcohol, after which he is put to bed between woolen blankets as above. Or a large Priessnitz compress may be applied as follows: The patient is wrapped in a sheet wrung out of water of body temperature, the wet sheet is covered with a dry sheet and a flannel blanket. In this compress the patient remains for one or two hours by which time slow evaporation of water has occurred and the first sheet will usually be found to be perfectly dry. The patient is then given a massage with cocoa butter and again kept in bed for an hour or two between woolen blankets. A very useful measure, finally, are half baths. The patient should sit down in a bath tub containing water of 80° to 90°. GASTRIC NEUROSES 405 The water should reach to the umbilicus. An attendant pours water of the same temperature as the bath water over the back and shoulders of the patient; and at the same time he ener- getically rubs the back and arms, while the patient himself rubs his chest and sides. The temperature of the water that is poured over the patient may be gradually cooled off. This half bath may to advantage be followed by a spray douche, the tem- perature of which is gradually cooled. The patient is then rubbed dry with a rough towel^ and the surface of the body treated with alcohol and the patient put to bed between blank- ets as above. A very simple measure that the patient can carry out him- self is to fill two basins with water, the one with water of about 100°, the other with cold water. Into each basin a large sponge Spinal spong- is placed. The patient sits on the edge of the bath tub and in S alternately places the sponge filled with hot and cold water on the nape of the neck and squeezes it out so that the water runs down the back into the bath tub. Hot and cold water are, in this way, alternately applied about ten times. The patient then rubs his back thoroughly with a Turkish towel until a glow is felt. In institutions many other hydrotherapeutic means can be employed that require special facilities so that they need not be described in this place. Massage should be performed only by an expert and it is M assaee unnecessary to describe the technique in this volume. The effect of general massage is soothing to the whole nervous apparatus and when combined with rest is one of the most efficient means to quiet hyperirritable nerves, to correct irritable weakness of the nervous system at large or of certain nervous areas. The soothing effect of massage can be enforced bv general _ ,. .. & ^ J & Faradization faradization, by the faradic Bath or by combining massage with the full bath or half bath or the application of large Priessnitz compresses. The best time for administering massage, in most cases, is either early in the morning or in the evening before retiring. Many patients suffering from gastric neuroses of various Weir Mitchell organs do very well under a Weir Mitchell fattening cure. This cure consists largely in over-feeding the patient with a nutritious, assimilable diet administered at frequent intervals. In order to be properly carried out the patient should be sent to an in- stitution where he can be isolated and wmere, above all, he is removed from sympathetic friends and relatives; -where abso- lute rest can be enforced, and massage and hydrotherapeutic means can be scientifically administered. In addition, the sug- 406 GASTRIC NEUROSES Dangers of ex- clusive milk feeding Proper diet Heat to the epigastrium Constipation Diet schedule gestive effect of such a treatment should never be underesti- mated. The personality of the physician and of the attendants in an institution and, in many cases, firmness to the verge of severity, are very important elements in the treatment. An exclusive milk diet is not only unnecessary, but may even become harmful, because most cases soon acquire a violent dis- taste to this monotonous feeding; because the ingestion of such large quantities of liquid may be detrimental in certain forms of gastric neuroses; and because an exclusive milk diet gener- ally leads to very obstinate constipation. It is impossible to* designate a diet that applies to all cases. It is necessary, gen- erally, to individualize and to arrange a dietary somewhat ac- cording to the neurosis that the patient is suffering from.. Broadly speaking, fats and carbohydrates should predominate- and only enough albumen should be given to satisfy the nitro- gen requirements of the patient. The appearance of dyspeptic symptoms does not necessitate discontinuing the treatment, especially if they appear on the first day or two, for they usually disappear if the treatment is carried out for a few days consecutively. The application of heat to the epigastrium before each meal and during the meal, sometimes continuously, often prevents or stops disagreeable subjective symptoms about the stomach. The constipation, that not uncommonly supervenes, is best coun- teracted by increasing the ration of fruit sauces, fresh vege- tables and fats or by adding bran with some cereal, cream and sugar to the diet. In most cases it will be necessary in addition to give soap-suds enemata every few days, which may be medi- cated with a little glycerin or, if there is much flatulency, with a few drops of turpentine. A little rhubarb or cascara every day can do no harm. The administration of large doses of calomel, which for a long time constituted a popular routine measure in instituting a Weir Mitchell treatment is to be con- demned as unnecessary and, in some cases, directly harmful. The following dietetic schedule approximately illustrates the character of the diet that the patient should receive when under- going a Weir Mitchell fattening cure: First meal. 7 a. m. 250 cc. of milk-cream mixture* or of cocoa made with equal parts of milk and water, three crack- ers. Second meal. 9 a. m. A cup of beef, mutton or chicken broth, twenty-five grammes of scraped beef with butter and salt, two pieces of toast with plenty of butter. *Two-thirds milk; one-third cream; a teaspoonful of lime water. GASTRIC NEUROSES 407 Third meal, 11 a. m. 200 cc. of egg-nog, two pieces of zwie- back with butter. Fourth meal. 1 a. m. A cup of broth with rice or barley, 50 to 60 grammes of roast, stewed or boiled meat, poultry or fish, two baked or boiled potatoes or their equivalent in mashed potatoes, a dish of some stewed vegetable, a large saucer of apple sauce or preserves. Fifth meal. 3 p. m. A glass of egg-nog with two crackers. Sixth meal. 6. pm. Twenty to thirty grammes of cold meat or poultry, two slices of toast and butter. Seventh meal. 8 p. m. 200 cc. of milk-cream mixture, two crackers. Eighth meal. 10 p. m. A glass of egg-nog with two tea- spoonsful of brandy and two crackers. Many patients assert that they cannot take this quantity of food. If strenuous objections on the part of the patient are encountered, they may have to be fed by means of a nasal catheter. If artificial feeding of this kind must be resorted to for the first few days, then, of course, a liquid diet must be given. A little firmness on the part of the physician, however, will usually succeed in overcoming the objections of the patient. After two or three weeks of this treatment the patients usu- ally fare better if they are allowed a little exercise, and can go Exercise out into the fresh air for an hour or so once or twice a day. The duration of this Weir Mitchell fattening and rest cure should vary from three to six w T eeks according to the improvement man- ifested in the patient's condition. MOTOR NEUROSES. Hypermotility of the stomach and peristaltic unrest of Hypermotility purely nervous origin are rare. These motor manifestations J£y e g® r may be considered as a spasm of the whole gastric musculature. Aside from treatment directed against the underlying neuro- sis, all irritation of the gastric mucosa by coarse and indiges- tible foods, by very hot or very cold, spiced or alcoholic ar- ticles, should be carefully avoided. The diet should be bland and non-irritating and should not distend the stomach by its bulk or by the formation of gases. The use of sedatives or narcotics, bromides, opiates, belladonna, atropine or hyoscyamus will rarely become necessary. Spasm of the cardia is also rarely a primary neurosis, but Spasm of the generally accompanies various organic disorders of the esoph- cardia agus, the cardiac orifice or the cavity of the stomach. It may, therefore, be merely a symptom of a variety of causes that must be carefully sought for and removed as described in other sec- tions. It may, however, be a primary neurosis and if this is the case it is usually associated with hyperirritability of the esoph- 408 GASTRIC NEUROSES Spasm of the pylorus Nervous belch- ing agus. Here, again, therefore, the ingestion of food and drink that may irritate the esophageal museosa, either mechanically, chemically or thermically, must be avoided as a prophylactic measure. The insertion of sounds of gradually increasing cal- ibre and . leaving these sounds in place is the best method of treating cardiospasm, provided no organic lesion about the cardia of an ulcerative character contra-indicates the use of bougies. In extreme cases the above mentioned sedatives and narcotics administered hypodermically or in suppository, com- bined with complete abstinence from food for several days and rectal alimentation, may become necessary. Spasm of the pylorus is almost always due to some intra- gastric irritation. The neurotic character of pyloric spasm is problematical in any case. If no determinable cause like ulcer, hyperchlorhydria or some mechanical lesion about the pylorus is discoverable, and if symptoms of pyloric spasm (pain, in- creased gastric peristalsis, vomiting) appear when food that is irritating by its texture, temperature or mechanical constitu- tion enters the stomach, then the existence of an increased pyloric sphincter reflex, i. e., pyloric spasm of neurotic origin, may be suspected. In an overwhelming majority of cases, how- ever, some organic disorder or secretory perversion about the stomach will be found. The treatment consists in the removal of any mechanical or organic condition about the stomach that may be incriminated with causing the spasm, and in correcting the underlying neu- rosis, in the neurotic type. The treatment in all cases should concern itself with removing or counteracting any accompany- ing hyperchlorhydria. In extreme instances, again, sedatives and narcotics may have to be used. The bougie treatment of pyloric spasm has been variously attempted, but this mechanical means of treatment is manifestly a procedure accompanied by such immense technical difficulties and uncertainties that it is hardly to be considered practical. Nervous belching is in most cases an hysterical phenomenon due to the swallowing of air. The treatment is largely psychic, i. e., educational. Very often persistent attacks of nervous eruc- tation can be stopped, like hiccup, by suddenly frightening the patient. In other cases the patient should be ordered to breathe with the mouth open for half an hour two or three times a day. This exercises a pronounced psychic effect and, at the same time, prevents the patient from swallowing the air, at least during the periods of mouth-breathing, and hence prevents eructation. If there is much distention of the stomach with air (pneumatosis), passing the stomach tube brings prompt re- GASTRIC NEUROSES 409 lief. v If there is any doubt in regard to the character of the belching, a fermentation test with the stomach contents will quickly tell the tale. Aside from the suggestive treatment and general measures directed towards the neurasthenic and hysteric state, bromides, belladonna and atropine, and in some cases, especially in pro- nounced pneumatosis, the hypodermic use of morphine, may be- come necessary. Silver iodatus, in doses of a sixth of a grain (0.01) after eating, and strychnine in one-thirtieth to a six- tieth of a grain doses also after eating, are recommended. The diet should, of course, contain no carbonated beverages and the minimum of articles that can undergo gaseous fer- mentation in the stomach should be allowed; for the develop- ment of gas in the stomach by producing real eructations may by suggestion start an attack of nervous belching. Nervous vomiting, in a broad sense, includes vomiting orig- Nervous vom- inating from reflex irritation from the sexual sphere, from float- itin & ing kidney, from diseases of the brain and cord, from colic in the liver or the kidneys, from peritoneal irritation and from the pregnant uterus. Here the treatment of the underlying cause and the correction of a nervous predisposition, that must be assumed to exist in all cases becomes necessary. In every case of nervous vomiting, the gastric irritability should be re- duced. In severe cases the patient should remain in bed, should abstain altogether from food for a few days and should be allowed to swallow only teaspoonful doses of ice cold drinks like milk, tea, champagne, or ice pills. No definite dietetic regulations can be formulated in the neurotic type of vomiting. Of drugs morphine, codeine and belladonna hypodermically or in sup- pository are the best. Morphine may be given in doses of an eighth of a grain in combination with a two-hundredth of a grain of atropin hypodermically, once or twice a day; codeine or codeine phosphate in doses of half a grain (0.03) hypoder- mically, once or twice a day; or opium and belladonna in sup- positories containing half a grain (0.03 gm.) each of the extract of opium and the extract of belladonna and administered once or twice a day. Other remedies that are occasionally useful are chloroform given in the dose of three to five drops on sugar or in teaspoon- ful doses of ice cold chloroform water; menthol in ethereal solu- tion (1 to 10) in the dose of five to ten drops three times a day; chloral hydrate in a solution of one part to ten parts of water may be given in fifteen drop doses in a teaspoonful of ice water every two or three hours. Bromides and chloral nitrate, ten to twenty grains each, may be given by rectum. 410 GASTRIC NEUROSES Pyloric insuf- ficiency Regurgitation and rumina- tion (insuffi- ciency of the cardia) Neurotic atony Lavage is generally superfluous in these cases. Douching with silver nitrate in 1 :1000 solution, or simple irrigation of the stomach, is occasionally useful. In employing lavage or douch- ing the suggestive effect exercised by passing the stomach tube- is generally more helpful than the procedures themselves. Pyloric insufficiency is usually due to mechanical causes oper- ating either to interfere with the closure of the pyloric sphinc- ter (cicatrization, ulceration, etc.) or leading to abnormal stretching of the pyloric ring. Nervous cases of pyloric insuf- ficiency due to paralysis 'of the motor nerves supplying the sphincter are seen in hysteria and in certain diseases of the spinal cord. The neurotic form is exceedingly rare and should only be diagnosed if the organic form can be definitely excluded. In the organic variety the treatment is exclusively causal, in the nervous form, it is directed towards correcting the general neuropathic taint, and local treatment has no effect. Regurgitation and rumination (insufficiency of the cardia) should be treated chiefly by education and suggestion and by measures directed towards correcting the underlying neurosis. The patients should be told to chew their food thoroughly and to eat slowly. Inasmuch as the disease is frequently produced in friends or schoolmates of the patients by imitation, isolation of the patient in an institution, aside from facilitating the treat- ment of the patient himself, is often effective in preventing- the spread of the disease in persons closely associated with the sufferer. Gastric atony has already been discussed in a previous sec- tion (see index). The treatment of the neurotic variety dif- fers in no way from that produced by organic or mechanical causes. Neurotic secre- tory perver- SECRETORY NEUROSES. The secretory neuroses of the stomach that manifest them- selves as hypersecretion and hyperchlorhydria, as hypochlorhy- dria and achylia, have already been discussed in special sections,, so that it is needless to repeat here what has been said. If one is dealing with a purely neurotic form of secretory neurosis, then, in addition to the dietetic, mechanical and medicinal means- that have been recommended for the treatment of these condi- tions, recourse must be had to the use of the general hydro- therapeutic, and electrotherapeutic means and all the other meas- ures that are used in the treatment of neuropathic individuals. In the same sense organic lesions in and around the stomach or in remote organs that may by reflex irritation cause functional perversions of the gastric secretion, must be sought for and cor- rected, if possible. GASTRIC NEUROSES 411 SENSORY NEUROSES. Gastric hyperesthesia may occur as an independent affection, Gastric hyper- but it is usually found attended by secretory perversions of the stomach. It is indicated by a variety of abnormal sensations about the stomach, as fullness, tension or burning, or by severe paroxysms of pain, i. e. gastralgia proper. Gastralgia occurs in Gastralgia many organic diseases of the stomach and also in affections of organs adjacent to the stomach as, for instance, in the presence of adhesions, aneurism of the abdominal aorta, aortic insuffi- ciency, (see page 19), in neuroses of the solar plexus, especially in sexual disorders, in cord diseases (gastric crises of locomotor ataxia) and in a variety of intoxications and infections, in con- stitutional diseases (poisoning with tobacco or lead, in malaria, Addison's disease, the uratic diathesis, chlorosis, tuberculosis, etc.). Finally, paroxysms of gastralgia may be a part phenom- enon of neurasthenia or hysteria. Manifestations of gastric hyperesthesia or attacks of gas- Causal treat- tralgia occurring when the stomach is empty are best relieved by men the ingestion of food. If hyperesthesia or gastralgia are not due to remediable causes, or if the latter are not discoverable or, again, if these symptoms, occurring in a neurotic subject, do not yield to the general treatment of the underlying neurosis, then certain measures for the symptomatic relief of gastric pain must be employed. One of the most useful measures is the application of heat Symptomatic to the epigastrium, either by means of hot poultices made of treatment oatmeal, linseed, or bread, and medicated with a few drops of Heat to epi- opium or belladonna tincture; by the use of a Leiter coil (see 8&S rmm index) through which hot water is flowing, ur by means of a so-called Winternitz compress applied as follows: A wet wintemitz linen cloth is applied over the epigastrium; over it is placed compress a Leiter coil through which flows hot water and over this again another wet sheet ; the whole is covered with a flannel. By the use of this Winternitz compress a prolonged heat effect and considerable counter-irritation is produced. The thermophore, as described on page 39, is also useful for the application of con- tinuous heat to the epigastrium. Electrization Electrization of the stomach too is of some value in the of stomach treatment of hyperesthesia and gastralgia. Either the intra- ventricular or extra-ventricular method may be employed. In the former case the anode should be inserted into the stomach through a stomach tube, in the latter case the anode should be applied to the epigastric region by means of a large plate elec- trode. The cathode is connected with a large sponge electrode applied either to the sternum or between the shoulder blades. 412 GASTRIC NEUROSES Gastric douches Morphine Chloroform Cocaine Bromoform Antineuralgics Nervous dys- pepsia Alternation of diet Starvation plan A weak galvanic current is applied for not longer than ten min- utes (see also page 390). Douching the stomach with chloroform water or with silver nitrate solution 1 :1000, or simply with hot physiological salt solution, is a very useful measure, especially in cases that do not yield to the simple application of heat to the epigastrium. For internal use a variety of remedies can be employed. Morphine in the dose of one-eighth to one-fourth grain, or codeine phosphate in the dose of half a grain, may occasion- ally have to be given hypodermically, or a suppository contain- ing extract of opium and belladonna (see page 409), may be used. A few drops of chloroform on ice, or ice cold chloroform water in teaspoonf ul doses, sometimes afford relief. Cocaine is a useful remedy administered by pouring twenty drops of a five per cent, solution of cocaine in a third of a glass of water and administering a teaspoonf ul of this solution every fifteen minutes. Bromoform in two or three drop doses on ice, or in a teaspoonful of ice water, or in a 1 :1000 solution, a teaspoonful every two or three hours, may also be used. Finally, antineu- ralgic remedies as antipyrin, phenacetin in five to fifteen grain doses (0.3 to 1 gm.), lactophenin or exalgin in eight to fifteen grain doses (0.5 to 1 gm.), or pyramidon (especially in tabetic crises) in the dose of fifteen to thirty grains (1 to 2 gm.) ad- ministered with water two or three times in one or two hour intervals, may be employed. In the treatment of "nervous dyspepsia" suggestion and the appropriate hydrotherapeutic and electrotherapeutic measures, massage or a Weir Mitchell fattening rest cure, as described above, are usually sufficient to bring about a cure. Any reflex disorders should be removed (see page 402). The patients should be protected from care, worry and excitement and any 'psychic or emotional shock. No fixed rules in regard to the diet can be formulated. Some patients do exceedingly well on a Weir Mitchell fattening cure, others on a starvation plan, some thrive on an exclusively vegetable diet, others on milk feeding, still others, on a mixed general diet. Very often a change from one diet to another acts beneficially for a time ; and it is generally a good plan, partially, it must be confessed, on account of the suggestive effect produced, to alternate with the diet, feeding the patient for a time on vegetables exclusively, letting him hunger for a week, and giving him rectal feeding for another period, then allowing a general diet for a time or a milk diet, or insti- tuting a Weir Mitchell cure. A starvation plan with rectal feeding should always be given a trial. Within certain limitations the caprices of the patient ACUTE INTESTINAL CATARRH 413 should be considered and if a general diet is permitted, great care should be exercised to render the food palatable and tempt- ing to the patient. In no disease are the arbitrary methods of the doctrinaire more dangerous than in this disorder. Care should always be exercised not to administer any really indiges- tible foods that might produce genuine dyspepsia; for the lat- ter would produce a bad moral effect upon the patient who can- not distinguish between a real and a nervous dyspepsia. That every endeavor should be put forward in all these methods of feeding to maintain full nutrition, excepting possibly for short periods of time, need hardly be emphasized. Smoking is, as a rule, to be forbidden. Alcohol in the form Smoking of dilute whisky or brandy, Claret or Moselle as a table bever- Liquor age, may be used in moderate quantities. Rest after eating is also a useful measure for. reasons that Best after have been discussed above. Lavage and douching are rarely indicated in nervous dyspepsia and whatever good effects may be witnessed from the use of these measures must be attrib- uted largely to their suggestive influence. Medicines play a very subordinate role in the treatment of nervous dyspepsia. Stom- achics and hydrochloric acid given as discussed on page 359f, can do no harm. Any accompanying constipation or diarrhea should be combated chiefly by dietetic and mechanical means and bj^ medicines only in extreme cases. III. THE INTESTINE. ACUTE INTESTINAL CATARRH. Causal treat- Most cases of intestinal catarrh are due to irritation of the ment bowel wall by toxic or infectious agencies. The latter may be ingested with the food and irritate the bowel directly from within, or they may be borne to the intestinal wall through the blood. Causal treatment must attempt, therefore, above all things, to promptly rid the organism of these toxic bodies. In the case of the blood-borne toxins this is not always an easy task. In some instances, however, as in malarial toxemia where we possess specific antimalarial treatment (see page 546), this is Malarial di- possible. In catarrh of the bowel occurring in the course of arr kea other infections and intoxications and due to the circulation of xj rem i c di _ bacterial toxins or of metabolic poisons (e. g., uremic diarrhea) arrhea through the bowel wall with irritation of the bowel mucosa, very little can be done towards attacking the primary cause of the intestinal disorder. Acute intestinal catarrh due to the ingestion of toxic mate- rial is much more amenable to causal treatment. If the poison 414 ACUTE INTESTINAL CATARRH Eliminants Calomel Castor oil Bowel irriga- tion Mode of insert- ing? rectal tube is one that is foreign to normal food and if its character is known, the appropriate antidote should, self-evidently, be administered at once, and removal of the offending material promoted by lavage of the stomach and free evacuation of the bowel contents. In all forms of food poisoning, whether due to mechanical irritation of the bowel wall by coarse foods or compacted feces in chronic constipation, or to chemical irritation from poisons contained in spoiled foods or formed from the gastro-enteric contents by abnormal bacteria vegetating in the bowel, prompt emptying of the intestine and evacuation of the noxious agency is the first rule. The two principal eliminants that should be employed in these cases are calomel and castor oil. Drastic purgatives and salines should not be used in acute catarrh of the bowel, as they irritate the inflamed mucosa still more. Calomel is best given in one large dose of three to five grains (0.2 to 0.3 gm.). Smaller doses are more apt to irritate the bowel wall without exercising so pronounced a purgative effect. Castor oil should be given in the dose of half an ounce to an ounce (one to two teaspoonfuls to an infant or a little child) either in gelatin capsules or in a small glass of beer or in beef tea; or the oil may be mixed with peppermint water, or with milk flavored with peppermint oil and rapidly gulped down; or it may be poured into a wine glass and an equal quantity of sherry or port wine superimposed and the whole taken in one swallow. In order to mitigate the severe griping and colic that frequently follows the use of castor oil, a few drops of tincture of opium, or a drop of cinnamon oil, may to advantage be added to the dose. Removal of the offending material from the bowel should also always be promoted by irrigation of the large intestine. The rectal catheter used for colonic flushings should be about thirty to forty centimeters long and should have a lumen of about one centimeter. Before inserting it all the air should be driven out of the tube by filling it with water from the funnel or irri- gating bag it is connected with. The tube should always be well lubricated with oil or with vaseline and should be inserted gently and carefully with a slow rotary movement until fifteen to thirty centimeters have entered the bowel. If the tube catches it should not be pushed in forcibly, but slowly withdrawn a little and reinserted. The patient should be placed either on the left side with the right leg drawn up and the hips elevated by one or two pillows, or in the knee-chest position, or in the dor- sal position with raised hips. As soon as the tube is in place the irrigating fluid is allowed to flow in very slowly and under low ACUTE INTESTINAL CATARRH 415 pressure, i. e., from a height not to exceed two feet. Fully ten to fifteen minutes should be consumed in injecting two liters; in this way retention of the irrigating fluid is made much easier and less pain and discomfort are produced. If the water stops flowing altogether, this may be due to the impaction of a fecal plug in the opening of the tube or to knuckling of the catheter; in either case the tube should be withdrawn a few inches. If the flow does not start again, then the catheter must be entirely withdrawn, cleansed and reinserted. For the purpose of colonic flushing, pure water, normal salt irrigating solution 6 to 8 to 1000, soapy water or water medicated with fluids a tablespoonful of glycerin to the quart, or with certain laxa- tive, disinfectant or astringent remedies (see page 420), may be used. In some cases in which there is much impaction of hard fecal material in the lower bowel, a preliminary injection of six to eight ounces of olive oil may be practised in order to pro- mote softening of the contents of the large intestine. After removal of the poisonous and irritating bowel con- R es t f the tents by calomel or castor oil and by rectal irrigation, the next bowel most important rule is to place the bowel wall at rest, to spare the intestinal mucosa in order to allow the undisturbed re-estab- lishment of normal conditions. In order to do this, the following dietetic rules should be ob- Diet .-served : During the first twenty-four hours complete absti- nence from food is the best plan, and this treatment can usually Abstinence he carried out without difficulty because the patients sponta- neously refuse to eat. The severe thirst that suffererers from Thirst acute intestinal catarrh usually experience during the first twenty-four hours can be relieved by small swallows of sterile wa- ter or tea, or b}^ allowing the patient to dissolve pieces of ice in the mouth. Chewing gum is also an efficient means to relieve the sensation of thirst. Inasmuch as sufficient liquid to satisfy the Water by- water requirements of the organism cannot and should not be rec um supplied in this way, irrigation of the colon with normal salt solution may aid in supplying this deficit. In very mild cases a little gruel or soup made of oatmeal, rice Gruels or barley flour, sago, arrow-root or tapioca and water, carefully strained and flavored with a little salt or a little meat extract, may be allowed on the first day, in tablespoonful doses. In all •cases this diet is permissible on the second day. In addition, Albumen water the patients may receive a little albumen water or egg-nog made of the whites alone ; a little Claret or brandy diluted with boiled water, or weak tea should constitute the chief beverages on the second day. Milk is well borne by some subjects and not at all by others. Milk It should never be given raw in cases of acute intestinal catarrh, 416 ACUTE INTESTINAL CATARRH Diet after the third day- Food to be avoided Drugs Intestinal anti- septics Calomel Dilute H CI Resorcin Menthol Creosote Salicylic acid Salol Beta-naphthol Benzo-naphthol Danger of met- allic anti- septics but only boiled or carefully sterilized, never cold and never too- hot, but only lukewarm in small quantities at a time and best with a tablespoonful of lime water or a teaspoonful or two of brandy to the tumblerful. If milk increases the diarrhea, then buttermilk or kumyss or kephyr, administered in tablespoon doses, may be tried. The nourishing character of these milk preparations renders them very useful provided they can be borne. On the third day it is permissible to add a little toast, zwie- back or crackers to the above dietary. In addition, meat broths with an egg, or some cocoa may be given. This simple, semi- liquid diet should be continued until the diarrheic discharges have stopped; then a little raw, scraped meat or broiled beef or mutton may be given, also squab or some white meat of chicken, meat jelly, gelatinous food, a little rice or tapioca, some vegetable purees and mashed potatoes. All fried foods, foods prepared with much fat, fresh fruit,, acid or spiced foods, very hot or very cold foods should be avoid- ed for some days after the diarrhea has stopped. Special medicines are rarely required in the treatment of acute intestinal catarrh. Certain of the group of intestinal antiseptics may ' be employed to hold the development of the bacterial flora in the intestine in check. The use of some of the intestinal antiseptics, sodium glycocholate, organic perox- ides and sulpho-carbolates has already been fully discussed in the Section on Bright 's Disease, page 207. Other intestinal an- tiseptics that can be used are calomel in very small doses, i. e. 7 a twentieth to a tenth of a grain, two or three times a day. In this dose calomel does not irritate the bowel wall nor does it purge, but merely inhibits bacterial life. Dilute hydrochloric acid in five to ten drop doses may be given for a similar purpose. The following remedies may all be tried: Resorcin in five per cent, solution, three to five teaspoonfuls a day; menthol, two grains (0.12 gm.) two or three times a day; creasote, one to three drops (0.06 to 0.18 gm.) in brandy or wine several times a day or in olive oil, in gelatin capsules or in solution with some simple syrup; salicylic acid, five to thirty grains (0.3 to 2 gm.) in cap- sule or in solution ; salol, in the same dose ; naphthaline, one to five grains (0.06 to 0.3 gm.) • beta-naphthol, three to ten grains (0.2 to 0.6 gm.) ; benzo-naphthol, five to ten grains (0.3 to 0.6 gm.). In acute intestinal catarrh particular care should be exer- cised to avoid the administration of intestinal antiseptics that are irritating to the bowel wall; thus most of the metallic salts with antiseptic properties, with the exception of calomel given as above, should be eschewed. A very useful preparation is ACUTE INTESTINAL CATARRH 417 ichthoform, a combination of formaldehyde and ichthyol, which ichthoform splits off formaldehyde in the intestine. It should be given in two to three grain doses, twice or three times a day. Many of the above intestinal antiseptics can to advantage be Administration given in keratinized pills or glutoid (Sahli) capsules, i. e., cap- Siig 6 ™* 1 ^ 1 * 6 ^ sules, made of gelatin hardened with formaldehyde or, also, capsules in pills coated with salol; in this way they pass through the stomach unchanged and exercise their full effect in the bowel. Astringent remedies are not often indicated in acute catarrh Astringents of the bowel. They should never be used during the first two or three days. If the diarrhea persists for many days unin- fluenced by other measures, then some of the astringent group of medicines may have to be employed. They will be discussed in full in the Section on Chronic Intestinal Catarrh. Narcotics are generally superfluous. If there is much pain Narcotics and if the diarrhea persists, despite the complete evaluation of the irritating bowel contents by calomel or castor oil and by in- testinal irrigation, then opium or morphine may have to be re- sorted to. Opiates stimulate the nerves that inhibit intestinal peristalsis, i. e., check the latter. They also render the sensory nerve endings in the bowel less sensitive to irritation by bowel poisons and thereby also aid in arresting peristalsis. The best mode of administering opiates is either in suppository with bella- donna (of each extract % grain), or in the dose of fifteen to twenty drops of the tincture of opium as an enema in starch water (two teaspoonfuls of starch flour in eight ounces of water). If there is much gastric or rectal irritation, so that the administration of opium by mouth or rectum is disagreeable then morphine in one-sixteenth or one-eighth grain doses may be given hypodermically. The constipation following the use of opiates, as well as the Constipation following' opi- constipation that generally follows the diarrhea in acute intes- ates or di- tinal catarrh, calls for no special treatment. It may be allowed arrhea to persist for several days after the diarrhea is checked and should then, if necessary, be relieved by enemas and by the proper diet (see Section on Constipation). Heat applied to the abdomen in the form of hot water bags, Heat poultices, hot compresses or dry, hot cloths is always grateful to those afflicted with acute intestinal catarrh and materially aids in reducing the colicky pain. If there is much flatulency, turpentine stupes (cloths wrung out of hot water medicated with stu P es two or three drops of oil of turpentine) or enemata medicated with two or three drops of turpentine or with carminative rem- edies are useful (see also Section on Meteorism) . If there is fever rest in bed should be enforced. Cases of Fever 418 CHRONIC INTESTINAL CATARRH Analeptics acute intestinal catarrh that manifestly follow exposure to cold, should be given a hot bath, wrapped in blankets and allowed to sweat. Drop doses of the tincture of aconite repeated four or five times, at hour intervals, or a ten grain Dover's powder, given in the beginning, often aid in shortening the attack. That the other measures described for the treatment of acute intes- tinal catarrh should be employed in addition, is self-evident. In cases that go into collapse analeptic remedies like cam- phor, ether or ammonia (see page 32) should be administered. Hot alcoholic drinks should be taken, hot water bags or bottles put to the feet and legs, the extremities rubbed with rough towels, and the patient wrapped in woolen blankets with an ice bag to the head. General indi- dications Diet General char- acter of diet Forbidden foods CHRONIC INTESTINAL CATARRH. In no case of chronic intestinal catarrh is it possible by any known means to directly influence the diseased condition of the intestinal mucosa. All one can do is to avoid further irritation of the inflamed area by the selection of the proper food and by the administration of drugs that prevent the formation of irri- tating products in the bowel and their stagnation in intimate contact with the catarrhal lining membrane of the intestine. At the same time general hygienic means may be employed in- tended to improve the general health and nutrition of the pa- tient and thus enable him to put forward the maximum effort towards restoration of tissue integrity. The diet, above all, in chronic intestinal catarrh, as in any other chronic disorder, should be nutritious enough to satisfy the daily caloric requirements of the individual. The ingestion of sufficient calories is often a difficult task owing to the ex- istence of diarrhea with loss of valuable pabulum in the stools, and also on account of the presence of chronic catarrhal changes in the intestinal mucosa which interfere with the proper intes- tinal digestion and hence render only part of the ingested food available for the nutrition of the patient. Generally speaking the diet, aside from being nutritious, should also be non-irritating to the bowel wall, i. e., it should con- tain no coarse or indigestible particles, no spices, condiments, no very acid, very sweet or very fat foods of any kind. Fruits and salads are forbidden. In selecting a general dietary from permitted articles, the individual likes and dislikes of the patient must be considered. In so prolonged a disorder as chronic intestinal catarrh it is worse than useless to force the patients to eat articles of food CHRONIC INTESTINAL CATARRH 419 that they thoroughly dislike. On the other hand to be too arbi- trary in absolutely forbidding small quantities of articles of food that theoretically might be harmful, but that the patients crave, is also bad practice. The stimulation of the appetite above all is an important element in aiding digestion and in maintaining the nutrition of the patient. The main index, however, that teaches whether or not an Analysis of article is well borne and properly digested is an analysis of the stools as index J for the dietary stools. A study of the feces after various "test meals" is of equal importance here as the analysis of the stomach contents in stomach disorders. Whenever an article, that, on theoretical grounds, is indicated and permissible, persistently reappears in the stools in a semi-digested or undigested form, then its fur- ther administration becomes worse than useless; for not only does it not contribute to the patient's support, but it positively aggravates the catarrhal condition of the intestinal mucosa by its action as a mechanical or chemical irritant throughout the length of the intestinal canal. The following articles, with the above reservations, are the useful and per- most useful in chronic intestinal catarrh: All meats of tender missible foods varieties, especially white meats, fish and poultry, always finely Meats divided and freed from skin and tendon; meat jellies (see page 536), gelatinous foods, meat broths; eggs should be given only Eggs soft boiled, scrambled and prepared with very little fat. Gruels Gruels made with water or milk and tapioca, sago, arrow-root, rice, barley flour, etc., are useful. Milk is usually well borne in Milk chronic intestinal catarrh even when administered in large quan- tities, provided it is altogether fresh, otherwise it may become troublesome. It is always safer to administer it boiled or care- fully sterilized than raw. The digestibility of milk, as repeat- edly stated, may be increased by the addition of lime water or of a little brandy. Kephyr, kumyss and buttermilk are also Buttermilk allowed. The lactic acid contained in these beverages acts, to Kephyr some extent, as an intestinal antiseptic and may be useful on Kumyss these grounds. Cereals and bread stuffs, noodles, macaroni and Cereals and other dishes made of flour are permissible, provided they are bread stuffs not prepared with too much fat. Of breads, sour and coarse kinds should never be given, but chiefly dried bread, toast, crack- ers, zwieback. The fat demand may be supplied by fresh butter and cream, and vegetable oils; meat fats, like lard, suet and bacon are not so well borne. Of beverages, boiled water, sterile milk, a little dilute Claret Beverages or Moselle wine or whisky and water, mineral waters that have been shaken in order to cause the evaporation of carbonic acid 420 CHRONIC INTESTINAL CATARRH Diet in consti- pation Diet in di- arrhea Small meals Drugs Tannic acid Tannigen Tannalbin Catechu Rhatany Colombo Kino Bismuth prep- arations gas, tea and cocoa are all allowable. Beer, champagne, strong alcoholic liquors and coffee are to be denied. In cases of chronic intestinal catarrh accompanied by very obstinate constipation, a little more of cereals and fats, of fresh vegetables, even of fruits, may have to be given. In cases, on the other hand, that suffer from diarrhea more meat and milk and less of the above articles should be administered. Small meals at frequent intervals are always better than large meals. The patients should be instructed to eat very slowly and to thoroughly masticate their food. If at all possible they should be instructed to lie down or to rest quietly for from half an hour to an hour after the main midday and evening meals. For the purpose of inhibiting abnormal fermentative pro- cesses in the bowel a variety of medicines are used ; chief among these are tannic acid preparations, especially in that large group of cases of chronic intestinal catarrh that suffer from persistent diarrhea. The members of the tannic acid group are credited with "astringent" properties. As a matter of fact they aid chiefly by stopping putrefaction of bowel contents. The best tan- nic acid preparations in chronic intestinal catarrh are tannigen and tannalbin ; for neither of these drugs is attacked by the gas- tric juice, so that the tannin they contain really exercises its full effect upon the bowel contents. Tannic acid, itself, and prepara- tions of catechu, rhatany, Colombo, kino, etc., that all contain some tannic acid, may all be used in the diarrhea of chronic in- testinal catarrh (usually in combination with opium) to check fermentation, but they are not without effect on the stomach,, and, besides, a large part of the tannin is absorbed in the stomach and hence does not become available for use in the bowel. Tan- nalbin, however, an albumin compound of tannin, containing about five per cent, of the latter and rendered resistent to peptic digestion by heating to 120° C, enters the bowel unchanged and is there split up by the alkaline intestinal juices. Tannigen (diacetyl tannic acid) possesses similar properties. Each of these remedies should be given in ten to thirty grain (0.6 to 2 gm.) doses several times a day, in powder form. Next in importance to tannic acid preparations in the treat- ment of diarrhea due to chronic intestinal catarrh are a variety of bismuth preparations. The exact mode of action of bismuth in these cases is not altogether understood. It is probable that it acts mechanically by forming a coating over the inflamed mucosa and thereby protects it against irritating bowel con- + ents. Bismuth, in order to be effective, should be given in large quantities, either as the subnitrate or as the subsalicj^late in doses of fifteen to thirty grains (1 to 2 gm.) in powder, three CHRONIC INTESTINAL. CATARRH 421 or four times a day. Both these bismuth preparations can, to advantage, be given together with a little extract of opium. Two other good preparations of bismuth are dermatol given in the Dermatol dose of one and a half to three grains ((0.1 to 0.2 gm.) and xeroform* in the dose of fifteen to sixty grains (1 to 4 gm.). Both Xeroform of these preparations are split up in the bowel into bismuth and tannic acid, in the case of dermatol; or an aromatic antiseptic radical in the case of xeroform, so that they combine the mechan- ical action of bismuth with the antiseptic action of the tannin and phenyl derivative they incorporate. The administration of other metallic salts, lead acetate, zinc Metallic salts suphate, alum, or silver nitrate is not so common nowadays as it used to be. These remedies are all quite irritating to the bowel wall and the stomach, and as it is most important to pre- vent injury to the gastric wall in chronic catarrh of the intes- tine, the use of all these drugs must be considered somewhat pre- carious. The advantages derived from their antiseptic action are more than overbalanced by their irritating effect. The least harmful of all this group of medicines is silver nitrate, which is promptly converted into silver chloride and silver proteid Silver nitrate compounds in the stomach, both substances that possess only slight irritating powers, but very powerful germicidal proper- ties. Silver nitrate should be given in dessertspoonful doses of a 1 :100 solution, three or four times a day. In addition to the administration of antiseptics and astrin- gents by mouth, free evacuation of the bowel should be promoted, especially in all cases of chronic intestinal catarrh accompanied by constipation ; an occasional dose of castor oil in combination Castor oil with an enema is, therefore, of benefit in these cases; or a va- riety of mineral waters may be employed. Just how mineral waters act in chronic intestinal catarrh is Mineral waters not understood. Empirically it is universally recognized that they favorably influence not only symptoms like constipation or diarrhea, but that they materially aid in restoring normal con- ditions about the bowel mucosa. That this good effect is not due alone to life at a resort where these waters are taken, or to rest and the proper regime that is carried out in these watering places, is shown by the benefits accruing to sufferers from chronic intestinal catarrh from the use of these waters at home. Alkaline and saline waters are the best, chief among them the waters of Carlsbad, Vichy, Marienbad. They should be taken Alkaline-saline hot, a tumblerful on rising, another one in the middle of the (Carlsbad, _ forenoon and a third in the middle of the after- * n bad) waters ♦To the same group of aromatic bismuth compounds belong eudoxin, orphol, dermol, bismuth sulpho-carbolate, -cresolate and -plienolate. 422 CHRONIC INTESTINAL CATARRH Sulpho-saline waters Colonic flush- ings Opium in the diarrhea of chronic intes- tinal catarrh Hydrotherapy noon. The water should always be taken slowly in small swallows. Some patients cannot tolerate these waters on an empty stomach and they fare better if they take their first glass after breakfast. Waters of this type are most effective in cases of chronic intestinal catarrh associated with diarrhea. If there is much constipation, or if constipation and diarrhea alternate, then the sulpho-saline waters, or waters containing Glauber salts,- are best. These should be taken cold and the quantity administered should be gauged by the action of the bowels. The proper quantity is enough to produce free daily evacuations. These waters, too, are best given after a meal and not on an empty stomach. In order to be effective these min- eral water "cures" should be kept up for long periods of time, i. e., their use should be continued at home and not only at the watering places for a few weeks once or twice a year. Colonic flushings and rectal irrigation are useful adjuvants to the treatment. In performing irrigation of the rectum and colon, either simple warm water or normal salt solution may be used. As a rule water of body temperature is the best. If, how- ever, there is very much pain or irritation about the lower bowel, then hot irrigations of 105° to 110° F. are more grateful to the patient. Of antiseptics and astringents that may be employed to medicate the irrigating water, tannin, 5:1000; silver nitrate 0.5:1000; salicylic acid, 1:1000; boric acid, 5:100; and creo- line, 1 :1000, may be mentioned. Injections of 500 to 1000 cc. of olive oil, warm, are also very useful. Opium preparations should be given with care in the diarrhea of chronic intestinal catarrh, and only as a last resort in order to secure symptomatic relief from pain and to stop persistent diarrhea that will not yield to any of the other measures spoken of above. The danger of opium treatment lies in this, that the drug by checking intestinal peristalsis favors stagnation of fer- menting bowel contents, and hence may increase the bowel irri- tation. In view of the slightly irritating effect that opium occa- sionally exercises upon the gastric mucosa the drug is best given in the form of suppositories or hypodermically, either alone or in combination with belladonna (see page 409), or in combination with some of the above mentioned astringent and antiseptic remedies. Hydrotherapeutic measures are of subordinate importance in the treatment of chronic intestinal catarrh. Priessnitz com- presses applied to the abdomen are, however, useful and generally agreeable to the patient. If there is much diarrhea with violent peristalsis and considerable irritation of the bowel and pain, a Winternitz compress (see page 411), or hot turpentine stupes are INTESTINAL STENOSIS AND OCCLUSION 423 very useful. Iu obstinate constipation on the other hand sitz baths, cold douches, Scottish douches, are often of great benefit. The latter measures with exact indications for their employ- ment and the technique of applying them will be found described in full in the Sections on Diarrhea and Constipation. A patient suffering from chronic intestinal catarrh, espe- cially with acute exacerbations, with persistent diarrhea, pain and tenesmus, should remain in bed until the attacks of diar- rhea are checked or greatly reduced. Cases of chronic intestinal catarrh with chronic constipation, on the other hand, should indulge in a mild amount of exercise. No fixed rules in regard to rest and exercise can be formulated but the peculiarities of each individual case must be studied and rules made accordingly. The clothing and footwear should be carefully selected to protect the patient from catching cold. In winter woolen under- wear and stockings and thick shoes should always be worn. An abdominal binder made of flannel or wool should be worn all the year round. During the warm weather a hardening process may be begun and carried on into the winter, as described in the Section on Rhinitis. Rest and ex- ercise Clothing and footwear INTESTINAL STENOSIS AND OCCLUSION Surgical vs. internal treat- ment Most cases of occlusion of the bowel, immaterial whether they develop independently and suddenly or whether they de- velop less acutely on the basis of chronic stenosis of the bowel that gradually progresses to complete obliteration of the bowel lumen, are amenable to surgical treatment alone. Not infre- quently, however, a case will be encountered in which a restora- tion to normal conditions is produced by internal treatment. Such cases, in the very nature of things, are rare and constitute probably not one-third of all intestinal occlusions that are seen. This happy outcome manifestly can only occur under certain definite anatomic conditions to be specified below, whereas, in the majority of cases, the obturation of the bowel is of such a mechanical character that it can only be relieved by radical, mechanical, i. e., surgical, means. It will be seen, therefore, that the indications for internal or indications for for surgical intervention are dependent altogether upon the na- ture of the occlusion ; and, as it is in most cases impossible to make an altogether positive diagnosis in this direction, internal treatment should only be employed tentatively and never for longer than forty-eight hours after the onset of the first symp- toms of bowel occlusion. If at the end of this time patency of the bowel lumen is not re-established, recourse should be had surgical or medical treat- ment 424 INTESTINAL STENOSIS AND OCCLUSION Fecal ob- struction Gall stone occlusion Occlusion from pressure from without Intussusception to surgery. The different internal measures, to be presently described, should, therefore, be tried quickly and in rapid suc- cession in the hope that one or the other of them may lead to the goal and obviate the necessity of a laparotomy. The following forms of bowel occlusion occasionally yield to internal treatment : Above all, fecal obstruction, i. e., occlusion of the bowel by a plug of fecal matter occurring either as the result of obstinate constipation and coprostasis, in an otherwise patent canal, or occurring on the basis of a chronic narrowing of the lumen of the bowel by cicatricial stenosis or neoplastic growth from with- in, or by compression of the bowel from without by some en- larged or dislocated organ, by peritoneal adhesions or thicken- ing of the bowel wall. In the latter category of cases removal of the fecal obturator which may be very small or may consist merely of some coarse or indigested food particle, is, however, more difficult than in simple fecal stasis. Occlusion of the bowel lumen by a large gall stone or some other foreign body is also amenable to internal treatment in a certain proportion of cases. Here, too, the presence or absence of chronic stenosis determines to a large extent the facility with which the obturator may be expected to pass on and out under appropriate medical treatment. The obstruction is (self -evidently) removed much more rapidly if the bowel lumen is normal throughout its course than if it is constricted or stenosed in some portion. Here the previous history of the case, the existence of stenosis symptoms prior to the occurrence of the occlusion, must, to a large degree, determine the treatment. Occlusion of the bowel by pressure from without, especially by compression of the bowel by large movable organs or tumors adjacent to the bowel, may yield to bandaging and manipula- tion and to placing the patient in certain positions in which the large abdominal mass that produces the compression is held away from the bowel. In this group such non-surgical treatment is, however, purely palliative and in most instances merely prelim- inary to an operation. Intussusception of the bowel also occasionally yields to in- ternal treatment (opium, atropine, lavage, irrigation, — see be- low) ; most cases, however, do not. An attempt to relieve the ob- struction by non-surgical means should, therefore, always be made in these cases, but one should never persist in this treat- ment for longer than forty-eight hours at the utmost. Upon the appearance of collapse symptoms, or evidence of an impaired heart's action (see below), recourse should at once be had to surgical mean* INTESTINAL STENOSIS AND OCCLUSION 425 The same rules, provided the diagnosis can be made at all, volvulus kinks apply to volvulus and slight kinks of the bowel, although here the probability of restoring bowel patency by internal treatment is even smaller than in the case of intussusception. All the other forms of bowel occlusion, namely, firm strangu- strangulation lations, either internal or external, severe kinking or knotting Knotting of the bowel, double axial rotation, are surgical altogether from Axial rotation their onset and to waste time with internal measures in the • treatment of these forms of ileus is bad practice. Even in the first named group of cases that may be said to indications for occupy a position on the borderland between surgery and medi- instituting pre- •cine, a variety of elements about the general condition of the cal treatment patient must determine the advisibility of trying non-surgical means first, or of having recourse at once to operative interfer- •ence. The considerations that should govern us in instituting preliminary internal treatment are the following: The method of treating any cases of internal occlusion by medical means, i. e., of adopting an expectant plan, is justified by the fact that about one-third of the cases recover without an operation. Of this group by far the greatest number, it is true, are due to fecal obstruction. Some clinicians claim, furthermore, that to wait is always good practice, because repeated examinations of the patient will enable the physician to make a better diagno- sis, to localize the seat of the obstruction and hence formulate more clean cut indications for surgical intervention. As a mat- ter of fact I have never found this to be the case; for if the Junior or swelling in the abdomen cannot be found on first ex- amination, it is usually still more difficult to find it later in the course of the disease, on account of the meteorism and the muscular rigidity that generally develop within twenty-four hours and renders the palpation of the abdomen much more •difficult than in the beginning, even if an anesthetic is given. As against the expectant plan surgeons advance the just Arguments argument based on conservative statistics that the mortality a & ains t the ex- .... . . pectant plan from an operation in this disorder increases in proportion to the length of time that is permitted to elapse between the onset of occlusion symptoms and the operation. They argue, further- more, with some justice, that internal treatment, especially the use of opium and the reduction of the intra-abdominal pressure by lavage or colonic irrigation, produces a sense of euthanasia, relieves the patient's distress and hence engenders a false sens* 7 of security in the patient, the friends and the physician; fur thermore, raises false hopes that are apt to be shattered; and above all, favors loss of valuable time during which the intra- 426 INTESTINAL STENOSIS AND OCCLUSION Critique of above argu- ments The heart's action abdominal conditions are really being aggravated and the chances of recovery from surgical intervention are being re- duced. All these arguments, pro and con, would, it appears, speak directly for surgery in every case of bowel obstruction. Un- fortunately, however, operative interference, even in the most skillful hands, is always dangerous in this disease, probably less safe than laparotomy performed for almost any other acute intra-abdominal disorder. This is due to the peculiar condi- tions created by intestinal occlusion, the necessity in most cases of exploring large areas of the abdomen and of submitting many feet of the intestine to manual examination; the existence of meteorism with bowel distention, possibly paralysis of the bowel wall and, above all, in many cases, ulceration and great fria- bility of the intestine. In most cases, in fact, the operation will have to partake of the character of an exploratory laparotomy and often the surgeon will have to content himself with estab- lishing an artificial anus or performing a simple enterotomy, re- serving the radical operation for a second occasion, provided the patient should be so fortunate as to survive the shock of the first emergency inroad. Cases in which the exact location of the occlusion and its precise character are known before the oper- ation, or in which the occluded area is quickly found after laparotomy, are unfortunately relatively rare and even in these the success of the operation is of necessity doubtful, as every- thing depends upon the mechanical conditions discovered and the possibility of relieving them promptly by surgery. Surgery is, therefore, by no means the panacea for occlusion of the bowel that one might imagine it to be. There are cases in which it is our only means of succor, but there are also many cases in which surgery, as well as medicine, is helpless, and there are still other cases, constituting, as stated above, about one- third, in which the patients get well without an operation. A conservative expectant plan with the adoption of all the non- surgical means we know of is, therefore, justified in the large class of cases delineated above, provided, of course, the patient is carefully watched during this time and everything is held in readiness for the operation should the necessity for it suddenly arise. So long as the heart's action is good, i. e., while the arterial tension is normal or slightly elevated, the pulse full, strong and of moderate rapidity ; so long as no symptoms of acute strangu- lation or collapse (cold sweats, cyanosis, cold extremities, etc.) appear, it is generally safe to rapidly try all the non-surgical means. As soon as the heart begins to fail, the pulse becomes INTESTINAL STENOSIS AND OCCLUSION 427 small, rapid and thready, the blood pressure low; if collapse occurs or signs of peritonitis or perforation develop, then no time should be lost in placing the patient on the operating table. The existence of collapse symptoms, appearing even one or Collapse two days after the onset of occlusion, or collapse occurring from the initial shock of the occlusion, cannot be considered a contra- indication to surgical intervention; for without the operation these patients will surely die and with the aid of surgery they have at least a chance of recovery. Peritonitis or perforation do not prohibit a laparotomy; for in the light of modern surgical experience an occasional case of localized, even of mildly dif- fused peritonitis, unless too horribly septic, recovers after lapa- rotomy. The internist has a number of means at his disposal for over- The means of coming intestinal obstruction, chief among them lavage of the the mtermst stomach, irrigation of the lower bowel, inflation of the rectum and colon with water or carbonic acid gas, the use of laxatives in some cases, of opium in others, massage, counter-irritation by means of heat or cold. The employment of mercury that was The use of formerly so popular in ileus is being discarded nowadays as ]^te CUry useless and occasionally harmful. For the application of all these measures distinct indications and contra-indications exist in the different forms of intestinal occlusion that may now be discussed. Lavage of the stomach and removal of the stomach contents, Lavage which is generally abundant and frequently contains fecal ma- terial, acts favorably in three ways, viz : First, lavage reduces the intra-abdominal pressure and hence greatly relieves the most distressing symptoms, especially vom- iting and flatulency; at the same time it decreases the violence of peristaltic movements and favors the straightening of kinked or twisted bowel loops. Second, lavage causes removal of a mass of toxic material accumulating in the stomach that may do serious harm by pro- ducing general symptoms of toxemia, especially about the heart and nervous system, if allowed to remain behind or if only in- completely evacuated by spontaneous vomiting. Third, lavage in many cases, materially aids in the evacuation of the bowel contents above the constricted area ; for as soon as the stomach is thoroughly emptied by lavage, regurgitation of bowel contents into the stomach occurs, so that within a few hours the stomach will generally be found full again. In some cases during the performance of lavage new masses of fecal mat- ter will suddenly appear in the stomach even after the wash 428 INTESTINAL STENOSIS AND OCCLUSION Time of per- forming lavage Contra-indica- tion Bowel irriga- tion Contra-indica- tions waters were already clear, showing how rapidly bowel contents in this condition can regurgitate into the stomach. It is obvious, therefore, that in cases of bowel occlusion lavage of the stomach should be performed repeatedly and at short intervals. It is always good treatment to wash out the stomach at two or three hour intervals until nothing more of fecal material can be pumped out. It is unnecessary to wait for fecal vomiting before performing lavage, as removal of the stomach contents, even if it is not contaminated with bowel eon- tents, is good practice on account of the reduction of the intra- abdominal pressure and the removal of toxic stagnating mate- rial that is thereby brought about. Moreover, the stomach may contain abundant fecal material and still no fecal vomiting occur. The one contra-indication to gastric lavage is severe collapse. In cases that are distinctly surgical m character and in which an operation has been decided upon, gastric lavage is also of signal benefit ; for it is manifestly easier to manipulate the bowel after laparotomy if the stomach is small and empty than if it is large, heavy and distended, and occupies a large space in the abdomen; besides the danger of vomiting under an anesthetic and the occurrence of pneumonia from aspiration of foul vom- ited material is greatly reduced if lavage of the stomach is per- formed as a preliminary to the operation. Bowel irrigation is always of value in intestinal occlusion. In ileus, due to fecal obturation, it is, of course, the sovereign remedy. It is generally of use in impaction of a gall stone or of some other foreign body. In occlusion of the colon it is self- evidently of value, immaterial whether the occlusion is due to the impaction of a fecal plug in a chronically stenosed, con- stricted area of the colon, or whether the ileus is due to invagin- ation with the abdominal mesentery. In most cases irriga- tion of the lower bowel acts mechanically by softening and re- moving the fecal plug or loosening the impacted foreign body. In invagination the use of an eight to ten per cent, salt solution (see below) by producing anti-peristaltic waves may even act directly curatively ; for • as soon as the anti-peristaltic waves reach the invaginated area the obstruction may disappear. In kinks or twists of the sigmoid flexure irrigation helps both by removing heavy, dragging fecal masses and by producing stretch- ing and straightening of the affected bowel section ; and, even in ileus in the small intestine, the peristaltic and anti-peristaltic waves that are stimulated may be of signal benefit in promoting restoration of bowel patency. There are distinct contra-indications to the use of rectal or colonic irrigation, namely, ulceration or great friability of the INTESTINAL STENOSIS AND OCCLUSION 429 bowel wall that may be suspected and feared in a variety of dis- orders that produce intestinal occlusion. It is also clear that rectal irrigation should not be repeated if, in a given case, the first enema does not promptly return, or if the patient is alto- gether unable to retain the injected fluid. In some cases irriga- tion of the bowel becomes impossible on account of the presence of large, hard masses of impacted feces in the rectum or lower bowel. Here an attempt should always be made to soften the latter by the injection of small quantities of oil or, if neces- sary, to remove them mechanically with a blunt spoon or some other instrument. The technique of rectal irrigations and of colonic flushings Solutions to be has already been described (see page 422). The best irrigation em P lo y ed fluid in ileus is a ten per cent, solution of sodium chloride in water. Salt solutions of this concentration produce anti-per- istaltic waves so that the water is often carried up as far as the lower portion of the ileum. One other great advantage of these strong salt enemata is that only small quantities, i. e., from 300 strong salt to 400 cc. need be injected in order to produce the same effect, enemata or even a greater one, than would ordinarily be produced by the introduction of several litres of any other injection fluid. By using these strong salt enemata, therefore, the increase of the intra-abdominal tension and excessive stretching or disten- tion of the bowel is avoided. The addition of a few ounces of infusion of senna, or of some other laxative infusion to the salt clysma, can do no harm, but is, as a rule, superfluous. The use of cold enemata or of ice water given for the pur- Cold enemata pose of stimulating peristalsis is always dangerous, especially in cases threatened with collapse or actually in collapse. This meas- ure is unnecessarily severe and in view of the diagnostic uncertainties obtaining in each case of bowel occlusion, and the inability to predict in advance whether or not stimulation of peristalsis is desirable (see below), it is sometimes decidedly pre- carious. Small clysmata of warm water or of physiological salt solution are much better. They should be injected very slowly in order to avoid over-distention of the bowel. Rectal irrigation should be performed at intervals of three or four hours until the bowel passage is cleared or the time for operation has arrived. Injections of one-half to one litre of lukewarm olive oil can Oil injections always be given with safety as a preliminary measure. They are very useful to soften and dissolve hardened fecal masses or to loosen a fecal plug and to render the way open for the passage of after-coming bowel movements. Inflation of the lower bowel with air or carbonic acid gas Air inflation possesses no particular advantages, so far as its mechanical effect 430 INTESTINAL STENOSIS AND OCCLUSION Technique of inflation Opium Objections to opium Bationale of opium is concerned, over the injections of water, oil or salt solutions; as the latter, aside from distending the bowel, aid in cleaning out the intestine, they are by all means preferable. Following a series of fluid injections an air or carbonic acid gas inflation may, however, be practised to advantage, especially as this method of distending and stretching the lower bowel is often better borne and less distressing to the patient than distention with the heavier fluid irrigations. Inflation, too, is particularly useful in invagination and in kinks or partial rotation of the sigmoid flexure. The same contra-indications to the use of air and gas in- flation exist as in the case of water injections, namely, friabil- ity of the bowel wall and ulceration, provided the existence of these conditions can be determined, or is even strongly suspected. To perform inflation of the rectum and colon with air a rec- tal tube is joined by a T tube with an air bulb. The free limb of the T tube is connected with a piece of rubber tubing held shut with a clamp. When it is desired to allow the escape of air from the rectum, this clamp is opened. To inflate the rectum with carbonic acid gas the rectal tube may be connected with an ordinary siphon and carbonated water injected into the bowel, or a watery solution of bicarbonate of soda is injected first and a solution of tartaric acid immediately afterwards. Of the former, twenty grammes, of the latter, fifteen grammes are com- monly used. A violent controversy has been going on for many years between physicians and surgeons in regard to the administra- tion of opium in occlusion of the bowel. Internists generally advise its use in all cases as a routine measure in the beginning of the disease. Surgeons, on the other hand, condemn its em- ployment, claiming as stated above, that it produces merely a sense of euphoria, lulls the medical attendant into a sense of false security, permits aggravation of the bowel condition and favors waste of valuable time before the operation is finally per- formed. Inasmuch, however, as opium certainly relieves the suffering of the patients and in some cases, by reducing peristaltic move- ments, directly aids in restoring normal conditions, its use during the first twenty-four hours is indicated and can be advised. If, at the end of this time, the bowel lumen is not open, the sur- geon in any doubtful case comes into his right anyhow, and so much at least has been gained by the administration of opium that the patients remained relatively comfortable during the time that internal treatment was administered. That severe collapse symptoms from reflex irritation emanating from the bowel and peritoneum are often prevented and that the section INTESTINAL STENOSIS AND OCCLUSION 431 of bowel immediately above the obstruction is not so unduly stretched and injured by continuous packing of bowel contents into this area, when opium has been given to allay the violent peristaltic movements of the bowel, must be conceded. Even in those cases, finally, that are surgical from their onset, opium can do no harm. On the contrary it usually does good by pre- venting collapse, by quieting the general sensibilities and ner- vousness of the patient and also by reducing the violence of per- istalsis. The surgeon's plea against opium, provided the drug is given only during the first twenty-four or forty-eight hours, cannot, therefore, be considered valid. To summarize, opium is permissible in all cases of intestinal occlusion. In cases that are clearly surgical from their onset (and to know this is one of the most difficult and uncertain tasks of diagnosis) the drug can do no harm when given as a prelim- inary to the operation. In cases in which the diagnosis is alto- gether doubtful opium should be given for twenty-four to forty- eight hours, first, for the purpose of relieving the patient's anxiety and restlessness, and to allay the vomiting and mitigate the terrific pain; second, for counteracting the sudden, early collapse from reflex irritation emanating from the sensory nerves of the intestinal peritoneum ; third, for reducing the over- violent intestinal peristalsis and hence preventing to some extent, dam- aging paralysis, ulceration or perforation in the bowel area sit- uated immediately above the obstruction. In certain forms of intestinal occlusion, finally, chiefly invagination, volvulus or slight degrees of kinking or twisting of the bowel, the arrest of peristalsis that is brought about by opium, combined with other measures (lavage, irrigation, etc.), may even aid in restoring normal conditions. In order to be effective large doses of the drug should be Dose and ad- given early in the disease. As the absorptive powers of the stomach are usually greatly reduced or inhibited in occlusion of the bowel and as opium, moreover, is a distinct irritant to the gastric mucosa and may precipitate vomiting, it is best ad- ministered not by mouth but in suppository or hypodermically. The exact dosage depends somewhat on the reaction of the in- dividual to the opiate. The proper dose in any case is enough to produce the desired effect. It is best given in amounts of half a grain (0.03 gm.) of the extract, every one or two hours, in suppository or in the form of a watery solution of the ex- tract of the strength of 1 :10. Of the latter, an amount corre- sponding to about a third of a grain (0.02 gm.) should be in- jected every two hours until the desired effect is produced; or morphine should be injected in the dose of an eighth to a fourth 432 INTESTINAL STENOSIS AND OCCLUSION Opium in collapse Atropine of a grain, every two or three hours, until the patient is clearly under the influence of the drug. If the rule is observed not to rely upon opium for longer than forty-eight hours in cases in which the bowel lumen is not reopened by that time, no harm can be done and the. most se- rious objection against its use, namely, production of a false sense of security, is rendered invalid. After forty-eight hours have elapsed the administration of opium is unnecessary unless the drug is given for purposes of euthanasia in cases in which an operation cannot be performed. Above all things, it is im- portant to remember that the relative comfort of the patient when under the influence of opium should never constitute a contra-indication to an operation. The only criterion that should guide the internist in advising an operation is whether or not the bowel is open at the expiration of forty-eight hours; for^ while some cases have been known to live for many days with complete occlusion of the bowel, this event is exceptional. Whereas opium may be considered an efficient remedy to prevent the occurrence of collapse early in occlusion of the bowel, it should be given with great care in collapse occurring later, i. e., after the expiration of twenty-four or forty-eight hours, an accident that is especially liable to happen in cases that have not had the benefit of opium treatment from the beginning. To give large doses of opium suddenly in these instances is a precarious matter; for the weak heart, the peripheral cyanosis^ the cold extremities, the rapid, thready pulse constitute direct contra-indications to the use of the drug. If, in such patients,, it becomes necessary on account of the great pain to give opium or morphine, then these drugs should, by all means, be adminis- tered in combination with some analeptic like ether, camphor or ammonia to support the heart. Atropine should be given with the same reservations as opium. No time should be wasted with atropine treatment in clearly operative cases, nor should its use ever be continued for more than two days. Any patient with occlusion of the bowel who is treated with atropine should be carefully watched and if resolution does not promptly occur, recourse should be had to an operation. It is known empirically that atropine is occa- sionally highly effective in causing reopening of the bowel lu- men. All the favorable cases, however, were presumably due to fecal obstruction or occlusion of the bowel by a large gall stone or other foreign body, or cases of "dynamic" ileus. In view of the difficulty of diagnosing the precise character of the occlu- sion, it is clear that too much reliance should never be placed upon atropine, especially as its mode of action in these cases is. INTESTINAL STENOSIS AND OCCLUSION 433 very obscure. It is doubtful how the remedy acts, whether it reduces secretion in the bowel above the obstruction and hence prevents distention of this intestinal area with fluid, or whether it aids by contracting the blood vessels in the occluded area and hence reduces the thickness of the bowel wall. Atropine should be given, hypodermically, in large doses of a sixtieth to a thir- tieth of a grain (0.001 to 0.002 gm.), three or four times in the course of thirty-six to forty-eight hours. If the bowel passage is not opened after the third injection, then it is useless to con- tinue the exhibition of atropine any further. It will be seen, therefore, that the use of atropine in ileus in- variably partakes of the character of a therapeutic experiment that, in rare cases, produces brilliant results, but unfortunately, in the majority, produces no results whatever. As no harm can ever accrue to the patient from the use of atropine, especially if lavage, irrigation, etc., are performed at the same time, and pro- vided valuable time is not wasted thereby in clearly surgical cases, the administration of three or four doses of the drug can be recommended in most cases. This applies even to cases of ileus that develop on the basis of a chronically stenosed bowel; for here the removal of the fecal plug, or the foreign body, which may have produced the complete occlusion has occasionally been facilitated by atropine. In cases, finally, that are clearly due to fecal obstruction or to impaction of a gall stone in an other- wise normal intestine it is especially useful. Laxatives are distinctly contra-indicated in all forms of acute Laxatives intestinal obstruction, with the possible exception of fecal occlu- sion of the bowel. If the latter diagnosis can be positively made, and this will be an exceptionally rare event, laxatives may be safely given. Even in this group of cases, however, they should be given early in the disease as otherwise paralysis of the bowel wall above the fecal plug may have supervened. In this case removal of the fecal ping by the use of laxatives would not materially relieve the situation ; for the mass of after-coming bowel contents would be packed forcibly into the paralyzed area which, being unable to propel this mass onward, would in its turn become obstructed by a new and more bulky fecal plug. Besides, in fecal obstruction of somewhat longer stand- ing, especially when it develops upon the basis of a chronic progressive stenosis of the bowel, there is always danger of ulceration and increased friability of the intestinal wall above the obstructed area, so that in these cases the administration of laxatives favors rupture or perforation. Several cases are on record in which this accident occurred after the administration of laxatives. 434 INTESTINAL STENOSIS AND OCCLUSION In cases of ileus, finally, in which the character of the occlu- sion is doubtful laxatives should, by all means, be withheld; for if the bowel occlusion is not due to fecal obstruction they may do serious harm even if given early. In nearly all cases of ileus laxatives increase the distress of the patient, especially the vomiting and the pain. Often- times, in fact, fecal vomiting only occurs after the administra- tion of purgative drugs. On account of the increased pain and peristalsis that may be produced by these remedies, collapse, too, may be precipitated by their use. Finally, purgatives may do decided harm in ileus due to knuckling of the bowel, strangu- lation, axial rotation or intussusception. This can sometimes be positively determined, in cases that present favorable conditions for examination, by palpation of the abdomen ; for upon the ad- ministration of laxatives the abdominal tumor will be felt to grow harder and larger. In occlusion due to a foreign body or to a gall stone impaction, purgatives do very little good; for the bowel wall is already putting forward its maximum effort to propel the obstacle onward, and to over-stimulate peristaltic movements that are already abnormally exaggerated can only do harm. It will be seen, therefore, that laxatives are preferably alto- gether avoided in any form of ileus unless the case is one of very recent fecal obstruction occurring in an individual whose bowel movements, up to the time the ileus occurred, were normal in calibre. Late in fecal obstruction, or in any other form of sud- den occlusion of the bowel, laxatives are best avoided. In view of the great difficulty of making a positive diagnosis of fecal obstruction in any case the administration of laxatives in general is to be condemned. Massage of the bowel performed by an expert masseur, pre- ferably under an anesthetic, sometimes aids, when used in com- bination with other measures, in relieving occlusion of the bowel due to a fecal plug or an impacted gall stone or foreign body. Massage may be performed either by directly kneading and pushing the obturation onward, or by stimulating the bowel wall, around and immediately above the occluded area, to increased contractions. Here, again, this method of treatment is dan- gerous in cases of fecal occlusion or foreign body obturation that are not quite recent, on account of possibly causing rupture of the friable intestine or of producing perforation of a stercoral ulcer that may have formed in the area of coprostasis. In all the other forms of intestinal occlusion massage must be considered altogether dangerous, especially on account of the friability of the intestinal wall, and the danger of ulceration INTESTINAL STENOSIS AND OCCLUSION 435 or gangrene about the occluded area. In fecal obstruction of the colon, however, massage of the large intestine, preceded by an oil injection to soften the fecal plug, is of considerable value, but, even in this variety of cases, one can get along very well without massage. Consequently this method of treatment, which was formerly very popular, must be considered to have an ex- ceedingly limited field of application. Electric treatment is, in most cases, a waste of time. The Electricity only condition in which it might do some good would be in bowel paralysis following the removal of the obturator. This sequel of ileus may be treated by applying two electrodes to the abdominal surfaces and passing a strong faradic current through them, or by applying one pole to the abdomen and in- serting the other one in the rectum and using a galvanic cur- rent. Either form of current should be used in the same man- ner and same strength as described in Stomach Diseases, on page 390. Hot or cold applications to the abdomen in the form of hot Hot and cold water bags, stupes, compresses, a thermophore or a Leiter coil applications charged with hot or cold water are useful as counter-irritants, chiefly to aid in controlling the pain. If peritonitic symptoms appear, cold is more useful than heat, otherwise the sensations of the sufferer alone must be considered and heat or cold ap- plied according to the likes and dislikes and the general reaction of the patient. In cases of very extreme meteorism in which surgical relief Meteorism cannot be promptly obtained, or in which the patient or rela- tives refuse an operation, puncture of the intestine with a fine needle trocar not larger in calibre than the needle of a hypo- dermic syringe, may be performed in order to promote the escape of gases. In this way the intra-abdominal pressure may be materially reduced and some symptomatic relief obtained. In Puncture of addition, the reduction of the pressure occasionally aids in re- the howel lieving certain forms of intestinal obstruction. Here the same effect is produced as by the relief of abdominal pressure by stomach lavage (see page 427). Paracentesis of the bowel must, however, always be considered a very precarious procedure and one that should never be resorted to in any case in which a laparotomy can be performed, or in which there is any possible way to obtain relief of the meteorism by other means. The chief danger from puncture of the bowel is evidently the development of peritonitis, especially in cases in which the bowel is paralyzed or gangrenous. Under these conditions the puncture opening may not close promptly or completely and bowel contents ooze into the peritoneal cavity. Inasmuch as over-distention of the 436 INTESTINAL STENOSIS AND OCCLUSION Diet Thirst Hypodermo- clysis Rectal feeding bowel from excessive meteorism frequently leads to paralysis or even gangrene, it will be seen how dangerous this operation is. In fact, the interference with the normal blood supply in the bowel, that commonly results from the over-stretching of the bowel wall, renders it possible for gangrene to develop secondarily about the trocar opening, so that perforation or rupture of the bowel and peritonitis may follow some time after the puncture has been performed. The operation, moreover, is not always easy to perform and it may occasionally be necessary to insert the needle several times before a loop of bowel is actually punc- tured; or the bowel may be punctured but no gas escape, so that a second or a third insertion of the needle may become necessary. Under these conditions, the dangers resulting from the puncture are, of course, still more increased. Very little need be said in regard to the diet in cases of acute intestinal occlusion. Complete abstinence from solid or liquid food is absolutely necessary. The introduction of any food by mouth can only increase the accumulation of material be- hind the obstacle. In ileus, the administration of food or drink is a useless procedure inasmuch as the power of the stom- ach or intestine to absorb any of the gastric or intestinal contents is practically inhibited. Moreover, vomiting, which may be aggravated by the introduction of food, would promptly expel everything that might be introduced into the stomach. There is rarely any difficulty in maintaing total abstinence from food, as the patients themselves never manifest a desire to eat anything. Most of them, however, suffer from excessive thirst. This symptom is usually materially allayed by the use of opium, as described above. If the thirst is very distressing, it may be somewhat relieved by allowing the patient to suck a little ice, or to allow ice pills moistened with a few drops of brandy to dissolve in the mouth. They should always be instructed not to swallow the water. Washing out the mouth at frequent intervals with plain water or soda solution is usually very grateful to the sufferers. The administration of water by hypodermoclysis in the form of normal salt solution, or in the same form by rectal irrigation, is a useful means of supplying to some extent the water demands of the organism. Rectal feeding, however, is rarely indicated, especially if an operation is performed within forty-eight hours after the onset of the trouble in all cases that do not yield to other means by that time. INTESTINAL ULCER 437 In chronic stenosis of the bowel in which the time for opera- Diet in chronic tion has not yet arrived, or in which the conditions producing stenosis the stenosis are unalterable, or in which the patient refuses an operation, the diet should, as a prophylactic means, be arranged in such a way as to prevent a sudden occlusion of the stenosed area. In order to fulfill this purpose a diet that leaves the smallest possible residue in the bowel and that contains no coarse particles that might form a plug in the stenotic area, is advis- able. The food, therefore, should consist largely of milk, eggs, broths, strained gruels, vegetable purees, butter, cream, scraped or hashed meats, carefully freed from skin and tendons. Raw fruit and vegetables containing seeds, stems, pips, kernels, skins, etc., cereals containing husks, pips, seeds, stems, skins, coarse breads and similar foods should be absolutely forbidden. The patient should be instructed to most carefully masticate his food and to eat small meals at a time. Any tendency to constipation should be overcome by giving constipation fruit sauces and abundant fat with the diet and by instructing the patient to drink olive oil once or twice a day. At the same time the lower bowel should be kept thoroughly cleaned out by means of enemata (see page 450), and, with great care, mild vegetable laxatives like cascara, rhubarb, senna, etc., or gently- acting laxative waters, or an occasional dose of castor oil may be administered. In cases, however, in which the stenosis has advanced to such a point that the peristaltic action of the intes- tine is greatly increased, as manifested by the appearance of visible and palpable peristaltic waves on the abdomen, laxatives of any kind are, to say the least, superfluous. For, in these cases, the bowel wall is manifestly already putting forward its maximum effort to overcome the obstruction. Here, in fact, much more can be gained from the administration of opium, for reasons that have been discussed in full above, than from the administration of laxatives. In sudden intestinal occlusion occurring on the basis of a chronic stenosis of the bowel, the same rules of treatment obtain as in any other form of acute ileus, only that here the indica- tions for surgical intervention are more exact and positive, be- cause generally abundant time has been given to determine the nature of the lesion and its precise location in the abdomen. INTESTINAL ULCER. The treatment of ulcer of the bowel is largely limited to the symptomatic relief of the diarrhea, the pain and the hemor- rhages. 438 INTESTINAL ULCER Causal treat- ment Rest in bed Diet Hot and cold applications Internal rem- edies Bismuth The causal treatment of ulceration of the bowel occurring in the course of different infectious diseases, as tuberculosis, ty- phoid, dysentery, erysipelas, variola, sepsis, etc., is synonymous with the treatment of the underlying disorder. The same ap- plies to the causal treatment of intestinal ulcers occurring in the course of leukemia, gout, the hemorrhagic diathesis, or in uremia. Syphilitic ulcers of the bowel are self -evidently amenable to anti- luetic treatment. Stercoral ulcers occurring as the result of chronic constipation or in stenosis of the bowel, if they are at all discovered before perforation occurs, should be treated by correction of the underlying constipation, or mechanically, i. e., by surgical correction of the stenosis of the bowel lumen. The radical removal of an ulcerous area by excision may be included under the possible methods of causal treatment. A patient, with an intestinal ulcer producing much diarrhea, or causing much pain and showing a tendency to hemorrhage, should remain in bed. The diet, broadly speaking, should be ar- ranged according to the same principles that obtain in chronic catarrh with diarrhea, i. e., it should be free from mechanical, chemical or thermical irritants, should be easily digestible and, at the same time, sufficiently nutritious to maintain the physical equilibrium of the patient. The ideal, therefore, is a nutritious liquid or semi-liquid diet consisting largely of milk, broths, milk dishes, strained gruels, etc., given in small quantities and at frequent intervals. Heat or cold applied to the abdomen in most cases materially aid in relieving the severe distress of the patient and in reducing violent peristaltic movements of the bowel; they, therefore, act curatively, in a sense, by allowing the bowel to remain at rest and by checking the diarrhea. If there is evidence of periton- ize irritation, cold applications to the painful area, provided it can be definitely localized, are the best, otherwise, heat, either dry or moist, is more pleasant to the patient and probably more efficacious. The patient should be instructed to keep the ice bag or the hot water bag, or the Leiter coil, or the compress contin- uously in place. Very little can be expected from internal remedies given for the purpose of healing an intestinal ulcer. The most popular preparations and the ones that are almost universally employed for this purpose are bismuth salts and tannin derivatives. If bis- muth is given, it should be administered in large quanties, prefer- ably in pills coated with salol ; for the latter resist the acid gas- tric juice and are not dissolved until they reach the alkaline medium of the intestine. It is questionable whether even large doses of bismuth can really form a coating over one or multiple INTESTINAL ULCER 439 ulcers when distributed throughout the length of the small intes- tine. Bismuth may be given in the form of the subnitrate or the subgallate, or as dermatol in doses of fifteen to twenty grains (1 to 1.3 gm.), several times a day. Together with the bismuth a quarter or an eighth grain of opium can, to advantage, be administered ; for both the bismuth Opium and the opium possess hemostatic and anti-diarrheic properties and the latter, moreover, acts as an anodyne in painful ulcers. If opium is to be administered alone, it is better given in suppos- itory or clysma, or hypodermically, than by mouth, especially if larger quantities are to be administered. The best tannin preparations are tannalbin or tannigen (see Tann albin page 420), given either alone or with opium. The antiseptic anm & ei1 properties of the tannin preparations combined with the anti- diarrheic and anodyne properties of opium make this a useful combination. Ulcers of the colon and rectum are amenable to local treat- Ulcers of ment. Here astringent and disinfectant irrigations may be em- rectum^ ployed. The safest disinfectant solutions are thymol, 1:100; salicylic acid or boric acid, 1 :500. Bichloride of mercury injec- tions or solutions of carbolic acid should never be employed in Astringents- i A - * n -, t , . , „ and disinfect^ ulceration ot the lower bowel, as there is always danger from ants this practice of producing general carbolic acid or mercurial poisoning. The most useful astringent solutions are silver nitrate, 1 :100 ; or tannic acid in the same strength. Silver nitrate injec- tions or instillations frequently produce violent tenesmus. If these painful sensations persist for some time, or become unbear- able to the sufferer, then an injection of a salt solution will cause precipitation of the silver nitrate as silver chloride and stop the irritation. In case of intestinal hemorrhage, complete rest in bed and intestinal total abstinence from food should be insisted upon. Even after ner *orrhage the hemorrhage has stopped the diet should be liquid, exclusively, for several days or longer, i. e., until even chemical traces of blood have disappeared from the stools. The application of the ice bag to the abdomen is useless unless there is evidence of peri- tonitic irritation. The best remedy is opium given in supposi- tory or by mouth; it acts chiefly by arresting peristalsis and Opium hence placing the bowel at rest and favoring clotting and arrest of the hemorrhage. Ergot, given as the fluid extract in the dose Erg-ot of one to two drachms (4 to 8 cc), or as the dry extract in the dose of three to fifteen grains (0.2 to 1 gm.), by mouth, or as the Injectio Ergotina Hypodermica, three to ten drops, is, in my ex- perience, ri very doubtful value. Much better is hydrastis, Hydrastis 440 INTESTINAL ULCER Hamamelis Adrenalin chloride Calcium chloride Gelatin Bismuth Lead acetate Perchloride of iron Hemorrhages from colon or rectum Collapse and secondary hem- orrhage given as the fluid extract in doses of fifteen to sixty minims (1 to 4 cc), or as hydrastinine hydrochlorate, in doses of one- half to two grains (0.03 to 0.1 gm.), or as stypticine, in the dose of one-third to one-half grain (0.2 to 0.3) several times a day. Hamamelis, in the form of the fluid extract, in thirty minim (2 cc.) doses, repeated several times, is also a useful remedy. Very good results are often obtained from the use of adrenalin chloride, given in ten to fifteen drop doses of a 1 :1000 solution, several times at two or three hour intervals. Calcium chloride, in thirty grain doses (2 gm.) in watery solution, repeated sev- eral times, is also a method of treatment that is worthy of a trial. The latter remedy, of course, is given with the object merely of promoting coagulation. Gelatin solutions are also occasionally of use ; they should be administered as described in the Section on Ilemoptysis (page 311). Bismuth and lead acetate and, above all, the perchloride of iron, three preparations that are very popular, are, in my experience, utterly devoid of value in arresting intestinal hem- orrhages. It is possible that the perchloride may be effective indirectly in large hemorrhages by causing the formation of a clot that acts as a tampon in the intestine. In hemorrhages occurring from ulcers of the colon or the rectum, irrigations with hot water are usually effective. Ice water injections are, as a rule, dangerous because they produce active peristalsis, which prevents clotting of blood and may lead to further hemorrhage. In very extreme cases, however, that resist all other treatment, ice water applied directly to the bleed- ing spot, provided it can be seen through the rectoscope or sig- moidoscope, may be tried as an emergency measure. The addi- tion of tannin, silver nitrate or alum to the hot water can do no harm ; better still are calcium chloride solutions, employed in the strength of 4:1000, for the latter salt in many cases aids in the local coagulation of the blood. Adrenalin solu- tions; solutions of the fluid extract of hamamelis; or a solution of" gelatin 10 :200, all administered in small quantities by rec- tum, are also often efficacious in arresting hemorrhage of the large intestine. The treatment of collapse symptoms occurring upon the onset or during the course of an intestinal hemorrhage, and the treatment of the secondary anemia that generally follows severe intestinal bleeding, has already been discussed in full in different sections of this book (see index). MEMBRANOUS ENTERITIS AND MUCOUS COLIC 441 MEMBRANOUS ENTERITIS AND MUCOUS COLIC. The excretion of large quantities of mucus may accompany Definition any form of intestinal catarrh; it may also occur without enter- itis. Inasmuch as most cases of intestinal catarrh run their course without the expulsion of abundant mucus, one must postulate, in that variety in which mucous stools occur, the exist- ence of some specific element that determines the excretion of mucus. The exact character of this element is uncertain, but, in all probability it is a general neuropathic disposition that upon the incidence of certain determining factors like intestinal catarrh in enteritis membranacea, or chronic constipation in sim- ple mucous colitis (colica mucosa), leads to over activit}' of the secretory glands of the bowel. As a matter of fact, a nervous disposition and general neu- Neurotic ele- rotic manifestations will be found in nearly all cases suffering from either of the two diseases under discussion. Causal treat- ment in any case must, therefore, attack the underlying neuras- Causal treat- ment thenia or hysteria. In cases suffering from true enteritis, the intestinal catarrh must be treated, whereas in cases of mucous colitis, it is, of course, useless to treat a hypothetical catarrhal condition that does not really exist. As a prophylactic measure and as an important symptomatic treatment during the attacks, the evacuation of the mucus must be accelerated by artificial means; for in this way the attacks of colic are mitigated and abbreviated, or altogether aborted. The treatment of the underlying neurasthenia or hysteria Treatment of must be carried out according to the principles that have been •described at length in the Section on Gastric Neuroses. A rest cure with isolation, or a Weir Mitchell treatment; various hydrotherapeutic or electrotherapeutic measures; the removal of reflex irritation emanating from any organ of the body; -change of scene ; a pause in the daily routine ; respite from worry and mental overwork; avoidance of all psychic or emotional shocks ; in fact, all the psychic and physical means that are often so effective in re-establishing nervous equilibrium, must be em- ployed. The results from this treatment, the exact arrangement of which must needs vary according to the peculiarities of each individual case, the surroundings, the state of life of the patient, are generally very satisfactory, although, as a rule, not per- manent. The most effective means of producing evacuation of the To produce mucus is by irrigation of the bowel with warm water or with a evac "^ atlon °* the mucus normal salt solution containing from 6 to 8 grammes of sodium 442 MEMBRANOUS ENTERITIS AND MUCOUS COLIC Oil injections Combined oil and water in- jections The pain Opium Hot applica- tions Hot bath Laxatives chloride to the litre, or sodium bicarbonate solution containing- five parts to the litre. Better than water irrigations are injections of warm olive oil r especially during the attack; fully 500 cc. should be injected in the manner described on page 451. In cases with much pain,, five to ten drops of the tincture of opium may be added to the latter injection. The oil should always be injected slowly, ten to fifteen minutes being consumed in carrying out the treatment. The oil probably acts by dissolving the fecal masses clinging to the bowel and, in this way, aids in loosening the mucus; if it remains in the bowel long enough (and several days usually elapse before all the oil is evacuated) it is decomposed into oleic acid wh?ch stimulates peristalsis. Consequently oil injections constitute a very effective means to prevent stagnation of bowel contents in the colon and rectum. For the purpose of combating the chronic constipation, smaller quantities of oil, about 50 to 100 cc. may be injected, daily, for a time, between the attacks, and in a sense as a prophylactic measure. Oil given in this way can to advantage be combined with a water irrigation in such manner that a hundred cc. of oil are emulsified by beating with the yolk of an egg, and this emulsion mixed with half a glass of water and injected by means of a small syringe high into the colon through a rectal catheter; an hour later the bowel is irrigated with a litre of lukewarm water. The best time for performing this treatment is after breakfast. The pain during the attack can be controlled by the addition of opium to the oil injection or, if necessary, by the administra- tion of small quantities of opium by mouth in the form of five drops of the tincture or as an eighth of a grain of the extract with a two hundredth grain of atropine. Opium, belladonna or atropine given thus are also the best remedies for the relief of chronic spastic constipation (see page 446) ; and inasmuch as the constipation in mucous colitis, as in most other neurotic disorders, is generally of the spastic variety, it will be seen that opium is a very useful remedy in this disease. It acts pre- sumably by deadening the irritability of the sensory nerves of the bowel and hence preventing the reflex spasticity of the intes- tinal muscularis. During the atack the pain can also be controlled to some extent by the application, externally, of hot cloths or turpentine stupes, hot poultices or a Leiter coil charged with hot water. Immersion of the patient in a warm full bath or a sitz bath is- also an exceedingly useful measure to reduce the severity of the pain and to abort the attacks. Laxative remedies are very rarely MEMBRANOUS ENTERITIS AND MUCOUS COLIC 443 indicated in this disease. In the spastic type of constipation they do very little good and in the atonic type (see page 452) they are generally superfluous; for constipation of the latter variety can usually be corrected by dietetic and mechanical means alone. An occasional dose of castor oil or of calomel, or here and there one of the mild vegetable purgatives like cascara, rhubarb or senna, may become necessary in order to promote the evacuation of large accumulations of feces. All of these elements of the treatment, as well as the advisability of "educating" the bowel by insisting on an attempt at stool at a certain time of the day, suppressing the stool during others (a method of treatment that better than anything else aids in restoring the normal autom- atism of defecation) will be found described in the Section on Constipation. The diet, in cases of mucous colitis, should contain an abund- Diet ance of coarse, indigestible particles, i. e., plenty of fresh fruit and fresh vegetables, coarse bread and cereals containing cellu- Coarse, bulky lose, in other words, foods containing husks, pips, seeds, stems, foods skins, kernels, etc. The addition of two or three tablespoonfuls of bran to one of the breakfast foods is a very practical means of fulfilling this postulate. In addition plenty of fat in the form of cream, butter, olive p a t s oil on salad dressing, or in mayonnaise, bacon, sardines, meat fat, should be given; or the patient may be ordered to take two or three tablespoonfuls of pure olive oil once or twice a day. Occasionally the sudden transition from a bland mixed diet Sudden change to a diet containing abundant cellulose and indigestible particles of diet and much fat, aids materially in preventing attacks of mucous colitis and even in curing the disease. A diet, such as the one described, is of necessity bulky and fatty, at the same time flurry and aerated on account of the formation of C0 2 and CH 4 from the fermentation of the fruit acids and the cellulose that are ingested. That meats, eggs and all other foods that leave a small residue, should be correspondingly reduced and only given in such quantities as are necessary to adequately nourish the patient and supply his demands for albumen, need hardly be emphasized. In cases suffering from entero- and gastro-ptosis, the wearing Abdominal of an abdominal binder or bandages to support the abdominal bmders walls, or a fattening cure may materially aid. 444 CHRONIC CONSTIPATION Physiological constipation Alimentary- constipation Constipating effect of meat, eggs, milk Laxative effect of fruits and vegetables CHRONIC CONSTIPATION. There are several types of constipation and each requires special treatment. Before undertaking to manage a case of constipation a variety of factors must, therefore, be determined and, on the basis of this preliminary study, the plan of treat- ment arranged. In the first place it is important to recognize that many peo- ple evacuate the bowel contents only once in two or three days, or even at longer intervals, throughout their life time with no discomfort or any detriment from this habit. This condition of constipation must, therefore, be considered physiologic and if no morbid cause can be discovered and no untoward symptoms make their appearance, that are attributable to the infrequent bowel evacuations, then this form of constipation is negligible and no special treatment is called for. It must be remembered that the peculiar mechanism that at regular intervals, in most people once in twenty-four hours, propels the contents of the colon and sigmoid into the ampulla of the rectum and thereby produces the peculiar sensation that leads to the act of defecation (in pathological cases, tenesmus) is altogether auto- matic and that this automatism may very w^ell vary in different subjects. Here habit, or what may be called "education," plays an important role; or there may be a congenital element that determines less frequent relief of the automatic mechanism that in most people occurs once a day. There is a second form of constipation that is, in a sense, also physiologic and that may be called alimentary constipation. Here daily evacuation of the bowels occurs, but the stools are small and very solid. This form is readily corrected by the administration of the proper diet containing abundant vegetable, fat and carbohydrate material and relatively little albuminous food. For meat, eggs, and milk, the chief representatives of the albuminous foods, are so thoroughly disassimilated in the stomach and the bowel that they leave a very small residue; moreover, they incorporate only a small proportion of indigesti- ble material and hence produce a small amount of feces ; finally, very few chemical bodies are contained in albuminous food and few are formed in the bowel from their disassimilation that can stimulate peristalsis. Vegetables and fruits, on the other hand, contain abundant indigestible cellulose material, skins, pips, seeds, husks, stems, etc., that leave a large and bulky residue and also mechanically CHRONIC CONSTIPATION 445 irritate the bowel waJl to increased peristaltic action. In addi- tion, the organic acids and other salts that most fruits and vegetables contain, furnish material lor the development of C0 2 in the bowel by the action of intestinal bacteria and this gas, aside from rendering the stools fluffy, accelerates the peristaltic movements of the bowel. The sugar, finally, contained in fruits and vegetables, or Laxative action formed from the starches contained in these products, is also starches' 3 ^ promptly decomposed into C0 2 and CH 4 , and these gases again render the stools voluminous and stimulate peristalsis. Sugar, moreover, on account of its hygroscopic properties, prevents the absorption of water from the bowel and hence aids in main- taining a liquid or pultaceous character of the stools. Fats act as laxatives both by lubricating the wall of the Laxative action intestine, hence rendering the propulsion of the bowel contents ats easier and, by favoring the formation of various acid bodies, soaps and glycerin, in the bowel, all of which possess laxative and peristalsis stimulating properties. A diet, therefore, like that described above, usually produces copious stools in alimentary constipation and no further treat- ment of this condition is, as a rule, required. There are, however, some forms of constipation in which Varieties of such a diet does not produce the desired effect. There are, to constipation in . P . which the begin with, varieties of constipation that are due to anatomic above diet is lesions in or about the bowel causing mechanical stenosis, con- co^tra-indi- striction, compression or knuckling of the intestine, in which a bulky diet that stimulates peristalsis not only is of no value, but may be decidedly detrimental. To the same category belong cases of venous engorgement of the bowel wall, occurring in heart disease, and portal stasis, in which over-loading the bowel and irritating its mucosa is decidedly dangerous, as already mentioned in another section. In many gastric disorders, or in chronic intestinal catarrh accompanied by constipation, such a diet again is distinctly contra-indicated. In all these forms of chronic constipation the underlying anatomic cause must, there- fore, be carefully sought for and a diet arranged according to the nature of the primary lesion that produces the constipation. The principles that should govern this selection I have described in other places. In this variety of constipation the evacuation of bowel contents must, in many instances, be promoted artificially by means to be presently discussed. All the types of constipation mentioned in the preceding paragraphs, must be considered either as physiological or as sec- ondary to different disorders. In addition many cases of pri- 446 CHRONIC CONSTIPATION Primary habit- ual constipa- tion Atonic and spastic consti- pation Spastic consti- pation Causal treat- ment Symptomatic treatment Opium and bel- ladonna Atonic con- stipation Uses and abuses of veg- etable-fat diet mary, habitual constipation occur and they form the proper sub- ject of this section. Here it is important to determine whether one is dealing simply with insufficiency of the intestinal musculature (usually associated with secretory anomalies) or with spasticity of the bowel muscles. The spastic form of constipation usually develops on the basis of various functional disorders of the nervous system, notably neurasthenia and hysteria, also in certain organic disor- ders of the cerebro-spinal axis and, finally, in certain forms of intoxication, chiefly by lead. Causal treatment of this form of constipation must be directed primarily against the organic le- sions of the brain or cord, that are frequently of syphilitic origin and hence may call for antiluetic medication, or against the poison that produces the bowel spasticity. In the purely neurotic form the same general hygienic, hydrotherapeutic, electrothera- peutic and psychic measures that have been described at length in the section on the Gastric Neuroses, can be applied, and the results obtained from this therapy are generally satisfactory. If it is impossible to remove the primary cause, symptomatic treatment must be attempted. Here the sovereign remedies are opium and belladonna, both drugs that reduce the sensibility of the gastric mucosa and, in this way, reduce the reflex spasticity of the bowel wall. Paradoxical as it may sound, therefore, opi- um, which, as presently will be shown, is one of the chief reme- dies in the treatment of diarrhea, becomes in this class of cases the most important means of relieving constipation. Laxative remedies, massage, irrigation of the bowel, all measures that are exceedingly useful in the atonic form of constipation to be pres- ently discussed, are directly harmful in this variety. Whereas spastic constipation is a comparatively rare disor- der, the atonic variety, which is characterized by weakness of the bowel musculature, is very frequent and probably constitutes the majority of the cases of habitual constipation that are en- countered in practice. In atonic constipation, as in the alimentary variety, the ad- ministration of a vegetarian fat diet generally produces relief. This regime should, however, be instituted with some care and conservatism ; for, in rare instances, it will be found that the re- lief obtained from the institution of such a diet is not permanent, and that after a few free defecations, the bowels become consti- pated again. This phenomenon must generally be attributed to habituation of the bowel wall to the mechanical and chemical irritation of such a diet, so that the atonic musculature of the bowel after a short time refuses to respond to the stimulus that, CHRONIC CONSTIPATION 447 in the beginning, incited it to increased contractions and forcible propulsion onward of the voluminous contents. If this sequence of events occurs, then it is wrong to persist in the use of the veg- etable-fat diet; for the latter will stagnate in the bowel and in- jure the atonic bowel wall both by its bulk and by the irritation that emanates from acid and gaseous fermentative decomposition products that form from the stagnating material. In such a case the evacuation of the bowel contents must, in the beginning, often be promoted by other than dietetic means. If it is found, however, that, in favorable cases, the diet de- Additions to scribed above continues to produce copious daily stools, then above diet there may be added to this diet salt foods of different kinds, i. e., salt meat, salt fish; for the sodium chloride that these articles Salt foods contain draws water into the bowel, or at least, like sugar, pre- vents the absorption of a certain proportion of the water from the bowel. This self-evidently promotes the liquefaction of the bowel contents. In order to further render the stools soft and pultaceous abundant liquid should, by all means, be ingested. •Cold, plain water or, better still, cold aerated, i. e., carbonated, Abundant beverages are very useful and a glass of cold soda water or of wa er plain water, taken on an empty stomach, is, in many instances, an efficient means to stimulate defecation. Beer, kephyr, sour Beverages con- milk and similar beverages containing yeast cells, are also par- taming- yeast ticularly useful ; for they aid in the formation of carbon dioxide in the bowel from the starchy or sweet pabulum that, as stated above, should be administered in abundant quantities. Fruits Juicy fruits containing abundant water, especially, therefore, melons, juicy pears, apples, peaches, plums, are also valuable in this condition and constitute a very convenient means of introducing large quantities of liquid together with sugar and fruit acids and a certain amount of indigestible cellulose residue. Coffee, in most Coffee and tea cases of this kind, acts as a laxative. Tea, on the other hand, Claret and claret, on account of the tannic acid they contain, as well as chocolate and cocoa, are less useful, in fact, have a tendency to constipate. Milk, in the majority of people, produces a con- Milk stipating effect. In others, again, it produces diarrhea. Gruels, Gruels if the coarse particles are strained off, also constipate and should hence be avoided. It is necessary, therefore, as will be seen, to experiment a little in each case with different articles of food and drink, finally selecting a permanent dietary for these cases from the articles that are known to produce the desired laxative effect in each par- ticular individual. It may be added in parenthesis that smoking Smoking a cigarette after breakfast often aids in stimulating peristalsis and procuring a good bowel movement. 448 CHRONIC CONSTIPATION Education Massage Self-massage Hydrotherapy Cold sitz baths An important element in the cure of atonic constipation is the education of the patient. An attempt at stool should be made at some regular time, preferably a little while after breakfast, and if the attempt is abortive for a few days, or if no desire for stool is experienced at this time, the effort should, nevertheless, be persisted in. On the other hand, the desire for stool at other times of the day should be suppressed; for, in this way a suffi- cient amount of fecal residue is allowed to accumulate for expul- sion at the proper time. Massage of the bowel and abdomen is a very important aid to the treatment. The main objects of massage are to stimulate the peristalsis of the bowel, especially of the large intestine, and to mechanically propel the bowel contents onward by forcibly kneading and compressing the colon. In order to be effective this massage treatment should, for a few weeks in the beginning, be carried on daily. It is best conducted in an institution in combination with proper hydrotherapeutic means and then, for many months afterwards, two or three times a week at home. In- asmuch as general abdominal massage, in order to be effective, should only be performed by a specially trained expert, and as the technique of massage cannot be learned from a verbal de- scription, it need not be outlined in this volume. A very simple means of self -massage, that I have found high- ly effective, is to roll a large wooden ball, of about five or six inches in diameter, over the abdomen for five or ten minutes every morning. The patient should lie on his back with the knees drawn up and should breathe with his mouth open in order to relax the abdominal muscles as much as possible. The ball is then placed in the right ileo-cecal region and under slight pres- sure gradually rolled around the abdomen following the course of the colon to the left inguinal region, and then back again to the right inguinal region. Of hydrotherapeutic measures, aside from those employed for the cure of the general neurasthenic or hysteric condition that so frequently underlies the atonic as well as the spastic form of constipation, the following measures are of particular use in overcoming constipation due to atony or abdominal congestion. Sitz baths are probably the best measures of all. If they are given cold, their first effect is to drive the blood away from the abdomen to the upper extremities. Very soon a reactive back flow of blood into the abdominal vessels occurs with a resulting hyperemia of the bowel wall. This back flow becomes sensible to the patient by a feeling of warmth. The reactive hyperemia produced in this way is beneficial, inasmuch as it improves the nutrition of the bowel musculature and hence aids in overcoming CHRONIC CONSTIPATION 449 muscular atony. A cold sitz bath should last not longer than five to six minutes. If the patient leaves the cold water at the expiration of this time, the hyperemic effect is prolonged, where- as, if the patient remains in the water longer, a secondary condi- tion of anemia occurs. This secondary anemia can be utilized to advantage in catarrh- al disease of the bowel in which it is desired precisely to reduce the hyperemia of the intestinal wall. Here, cold sitz baths carried out for fifteen to twenty minutes are more useful than short ones and exercise a good effect upon the constipation that not infre- quently accompanies chronic intestinal catarrh. The effect of cold sitz baths can be enforced by having the patient vigorously rub the abdomen, legs and back while immersed in the water." The best time for giving the sitz bath treatment is late in the Hot sitz baths afternoon about an hour before the evening meal. Hot sitz baths lasting five to fifteen minutes are also useful inasmuch as the> stimulate the whole digestive tract. Their mode of action is not so clearly understood as that of the cold baths, and the latter are by far more efficacious in overcoming atonic constipation. Douching of the abdomen is also useful. The douches should Douching the be cool and the water should be directed with considerable force abdomen against the abdominal parietes. Cool douches are very stimulat- ing and cause contractions both of the external abdominal mus- cles and of the muscularis of the intestine ; they combine a ther- mic and a mechanical effect. In strong individuals Scottish douches are of particular value; they consist in directing an al- Scottish ternating stream of hot and cold water against the abdominal douc kes wall. The hot stream, combined with the mechanical effect of a strong jet of water, causes dilatation of the superficial vessels and the cold stream, following immediately afterwards, produces a rapid contraction. This change in the calibre of the superficial vessels is reflected in the vessels of the internal organs (see also Ether sprav page 448). A similar effect can often be exercised by directing a spray of ether against the sides or the front of the abdomen. Large, cool Priessnitz compresses, especially applied during Priessnitz com- the night, are also of great value in overcoming atonic con- Passes stipation. They are applied by wringing a linen sheet out of cold water, placing it all around the abdomen and covering it with a flannel bandage. The water gradually evaporates through the pores of the flannel and in the morning the compress will be found dry and the skin underneath slightly hyperemic. In win- ter it is safer to rub the abdomen with alcohol and a dry towel before going out, if the Priessnitz compress has been applied during the night. 450 CHRONIC CONSTIPATION Exercises Swedish move- ments Electricity- Irrigation Medicated ene- mata Salt Glauber salt Soap Vinegar Castor oil and egg Passive and active exercises are also useful and any of the simpler free-hand exercises that stimulate contractions and stretching of the abdominal muscles and compress the liver and hence determine a flow of blood to the abdominal viscera, are useful. In institutions, Swedish movements answer the same purpose. Outdoor sports of all kinds are also very helpful; for the increased respiration and deep breathing stimulated thereby favor wide excursions of the diaphragm and hence, in a sense, constitute a massage of the whole abdominal contents. Electricity is of some value in atonic constipation. The most convenient way of giving electrical treatment is to perform far- adization of the abdominal parietes by the aid of two large sponge electrodes that are placed a short distance apart upon different parts of the abdominal surfaces. As it is not desired by this faradization to produce long tetanic contractions of the colonic musculature, the electrodes should be constantly moved about, chiefly along the course of the colon, and not kept for any length of time in any one place. It is probable that faradization of the abdomen acts favorably in constipation more by causing vigorous contractions of the abdominal muscles than by its effect upon the bowel musculature itself. The galvanic current can be applied by the intra-rectal method. Here the same general rules apply as in the galvanic treatment of motor insufficiency of the stomach. A large sponge electrode should be placed upon the abdomen somewhere along the course of the colon, a little water is injected into the rectum and a rectal electrode inserted through a rectal tube and connected with the anode. Here weak currents applied only for three to five minutes are perfectly safe and answer all purposes. To mechanically clean out the colon and to stimulate peris- talsis of the lower bowel, irrigations are exceedingly useful; the colder their temperature, the more do they stimulate peristalsis. Ice water, however, is rarely used and in some cases hardly safe. Small quantities of cool water or of physiological salt solution injected into the colon with a high rectal tube answer all pur- poses. If it is desired merely to cleanse out the contents of the ampulla of the rectum, then lukewarm water is better than cold water. In order to increase the stimulating effect of cool irrigations injected into the higher portions of the large intestine, certain chemical irritants can be added to the irrigating fluid, for in- stance, common salt or Glauber salt in the strength of two table- spoonfuls to the pint ; or soapy water may be used, or a mixture of equal parts of vinegar and water. A very useful irrigating mixture is a tablespoonful of castor oil beaten with the yolk of CHRONIC CONSTIPATION 451 one egg and mixed with a glass of cold water. This can be in- jected through a high rectal tube into the colon and exercises a very prompt evacuating effect. Glycerin, on account of its hygroscopic properties, i. e., its power to draw water into the intestine, may be injected directly into the bowel by instillation. If pure glycerin irritates too much it should be given in watery solution in the dose of about two tablespoonfuls to the quart, and this mixture injected through an ordinary fountain syringe; or glycerin supposito- ries may be used. Soft stools are usually produced in a short time by the use of glycerin. Finally, olive oil or sweet oil in the dose of 150 to 500 cc. may be injected through a high rectal tube, five to ten minutes ii injections being consumed in the process. Oil acts by loosening the pieces of feces that are firmly attached to the colon wall, it allays local irritation and hence spasmodic contractions of the bowel muscu- lature, it prevents water absorption and hence keeps the stools pultaceous, and it, finally, leads to the formation of oleic acid, which actively stimulates the peristaltic action of the colonic musculature. Even if a free evacuation of the bowels occurs after an oil injection, a certain quantity of the oil is usually re- tained, unless the oil injection is followed by a copious soap and water enema. Hence, if no water injection is given, then smaller quantities of oil may be injected on subsequent days. If pure oil is not retained well, then it may be beaten up with a yolk of egg and water, as described above, and five to ten drops of the tinc- ture of opium added to the mixture. This irrigating emulsion is almost invariably retained without difficulty. The chief advantage of using these small amounts of irrigat- ing fluid for the purpose of stimulating local peristalsis and me- chanically softening the stools, is that the stomach is not irritated by the ingestion of laxative purgatives or drastic remedies. Large quantities of irrigating fluid are not so safe on account Sma11 a ^ d lar S e of the inevitable stretching and relaxation of the atonic bowel that they produce. This detrimental effect of large enemata can to some extent be counteracted by using irrigations of low tem- perature, for the cool water causes contraction of the bowel mus- culature and hence neutralizes, to some extent, the mechanical stretching of the bowel wall. If it becomes necessary to flush out the whole colon, it is best to do this by means of a back flow 2atheter or by repeated small injections. The best time for irri- gating the bowel in chronic constipation, especially if irriga- tions are ordered for daily use or several times a week, is imme- diately after breakfast. The irrigations should, by all means, always be given at the same time of the day. 452 CHRONIC CONSTIPATION Choice of lax- ative Alternation The different groups of pur- gatives Mode of action The haphazard and indiscreet administration of laxatives that is so commonly employed in cases of chronic constipation is, in most cases, directly harmful to the patient and, at best, be- stows only temporary relief. Far from curing constipation, it usually aggravates the conditions that it is intended to correct and makes the patient a slave to the use of this class of drugs. In the spastic form of constipation, as already mentioned above, laxatives are rarely needed; in fact, they are usually harmful, and opium and belladonna are the proper remedies. In the atonic form laxatives should also be given with great care and in small doses. If they are given in doses large enough to produce a diarrheic stool, then a condition of constipation, as is well known, usually follows for several days thereafter, which will generally, in its turn, have to be relieved again by large doses of a purgative. After all the dietetic and mechanical means that have been described above fail, then it may become necessary, in rare cases, to resort for a time at least to the use of certain laxative drugs. It is impossible to predict in any one case which of the many lax- atives that can be employed will be effective, and it is necessary to experiment a little in each individual. Even if one drug is found to be effective for a while, then it is always a good plan to alternate from time to time with some other remedy in order to prevent habituation to any one laxative. That the smallest pos- sible dose to produce the desired effect should be administered in these cases need hardly be mentioned. For continued use in chronic constipation, either alone or, far better, in combination with dietetic and physical measures, I have selected a few reme- dies out of the immense number of laxatives that are contained in the Materia Medica. These are probably the least harmful and the most efficacious in relatively small doses. It is impossible to enumerate and describe the dose and administration of all the laxatives that are known. For this information I refer to text books on pharmacology. The vegetable purgatives, i. e., the purgative oils (castor oil, croton oil), anthracene purgatives (rhubarb, senna, aloes, fran- gulus, cascara and others) and the preparations of the jalapin and colocynthin group (colocynth, podophyllum, jalap, elaterin, leptandra and others), all act by irritating the bowel mucosa, thereby stimulating peristaltic movements of the intestine and hastening the propulsion onward of the bowel contents. In this way less time is given for the absorption of water from the small intestine, and the stools, consequently, reach the colon in a liquid or pultaceous form and are promptly evacuated. It is possible that these remedies, also, at the same time, cause an increased CHRONIC CONSTIPATION 453 outpouring of watery secretions into the bowel. The character of the stool deposited after the administration of these remedies will, of course, largely depend upon the dose. Small doses pro- duce one or two soft movements, very large doses produce pro- Nomenclature fuse, frequent watery evacuations. It is unnecessary, however, and de nitlon to retain the old classification into aperient, laxative, purgative,- hydragogue cathartic and drastic remedies, the violence of their action depending largely upon the dose, not the character of the drugs. Saline cathartics do not irritate the intestine unless given in Saline cathar- very large quantities. They act chiefly by retarding the absorp- 1CS tion of water from the bowel and, to some extent, by increasing intestinal peristalsis, more on account of their bulk, however, than because of any irritating action that they exercise upon the intestinal mucosa. In addition, they act as concentrated solu- tions of salts tl^at are only slightly diffusible through the bowel wall into the blood, and hence, according to the laws of osmosis, draw water into the bowel. The mercurial purgatives, chiefly insoluble preparations like Mercurial pur- calomel (blue pill and gray powder), do not affect the stomach, gatives but irritate the bowel, owing to their long sojourn there, which leads to their partial conversion into irritating soluble salts of mercury. In order to produce a mildly laxative effect, cascara, rhu- indications for barb, aloes, podophyllin or an alkaline saline are the best reme- J^e use of dif " dies for continued use. If large, hard fecal masses have accumu- lated in the bowel, these milder remedies are very apt to produce griping, so that castor oil, calomel, jalap and colocynth are bet- ter. If the patient is in an unconscious state or in a condition of mania, so that no medicine can be swallowed, one or two drops of croton oil placed on the back of the tongue are more effective. In lead colic, too, w r ith obstinate constipation, croton oil, adminis- tered as above, is especially useful. Combinations of the vege- table purgatives with salines or with bitter tonics are justly pop- ular. Cascara is best given as the fluid extract, in doses of one-half Cascara to one teaspoonful ; or as the wane of cascara, in doses of one to two tablespoonf uls ; or as the dry extract, in doses of two to eight grains (0.1 to 0.5 gm.). It produces a mild laxative effect usually within twelve to eighteen hours after its administration. It is, therefore, eminently useful in habitual constipation that does not yield to other means, if given every night before re- tiring. Rhubarb and senna are both old established remedies of tried „, , , Rhubarb and effect. The chief drawback to the use ^f ^hiibarb is its tendency senna 454 CHRONIC CONSTIPATION Aloes Podophyllum Jalap Elaterium to produce constipation after the evacuation of the bowel con- tents has been brought about. It is best, therefore, dispensed in combination with a saline cathartic as, for instance, in the com- pound rhubarb powder, twenty to sixty grains (1.3 to 4 gm.) ; or as the Compound Infusion of Senna (black draught), two to four ounces (60 to 120 cc.) ; or as the Compound Mixture of Senna, one-half to two fluid ounces (15 to 60 cc.) ; the Mistura Rhei et Sodas, two to three ounces (60 to 100 cc.) ; or the Syrups of Rhu- barb or Senna, in doses of one to three drachms (4 to 12 cc). Senna is more active than rhubarb bulk for bulk. The former remedy, however, as well as aloes, to be presently discussed, should be given with considerable care in inflammatory disorders of the intestine, in renal inflammation and in pregnancy. Aloes may be given alone in the form of the extract, two to seven grains (0.1 to 0.6 gm.) ; or in combination with rhubarb, cascara or senna in pill form; or as the Pil. Aloes, one to five pills at a dose; or as the Compound Laxative Pill containing aloes, strychnine, belladonna and ipecac; also as aloes contained in the Compound Extract of Colocynth, the Compound Rhubarb Pill and the Compound Tincture of Benzoin. Any of these preparations are useful. Podophyllum is especially valuable for continued use in hab- itual constipation. It is best given in combination with bella- donna as the latter neutralizes, to some extent, the irritation and the colic sometimes produced by podophyllum. The effect of small doses of podophyllum does not become apparent for about twelve hours after its administration, so that it is best given in the evening before retiring. Convenient pharmaceutical prepa- rations of podophyllum are the Pill of Podophyllum, Bella- donna and Capsicum (U. S. P.), and the resin of podophyllum, one-quarter to one grain (15 to 60 mg.) in pill form. Podo- phyllum is a remedy of varying strength and not always reliable. Jalap, too, is best given in pill as the resin of jalap, in doses of two to five grains (0.1 to 0.3 gm.) ; or as the Compound Jalap Powder, in doses of fifteen to sixty grains (1 to 4 gm.). Elaterium may be given as the triturate or the compound powder ; the former containing one part of elaterin to nine parts of sugar of milk and employed in doses of one-quarter to one grain (15 to 60 mg.) ; the latter containing thirty-nine parts of sugar of milk and given in doses of one to four grains (0.06 to 0.25 gm.). Neither of the last remedies should be administered continu- ously in habitual constipation. They are useful particularly if it is desired to produce a rapid evacuation of accumulated feces. CHRONIC CONSTIPATION 455 Sulphur alone, or in combination with rhubarb, magnesia, Sulphur or milk sugar, produces a soft, well formed stool. An equal mix- ture of precipitated sulphur, powdered rhubarb, sugar of milk and magnesia, taken in the dose of a teaspoonful with a glass of water every morning and evening, is one of the simplest, least harmful and most efficacious remedies for continued use in cases of chronic constipation that do not yield to the proper diet and to physical means, or that are due to anatomic conditions that demand the use of laxative remedies. A large number of saline laxatives may be employed in the Saline laxatives treatment of chronic constipation. It is a very difficult matter to choose among them. The chief members of this group that are employed in medicine are the sulphate of soda (Glauber salt) and the sulphate of magnesia (Epsom salt), both given in doses of thirty grains to one ounce (2 to 30 gm.) in solution, preferably in milk. It is important that they should not be £ A ven in a greater concentration than about ten per cent. Phos- phate of soda is given in doses of fifteen grains to one ounce (1 to 30 gm.), in the same way as the sulphates of soda and mag- nesia. The double tartrates of potassium and sodium (Rochelle salts), and the citrates of potassium and magnesium, are both given in doses of fifteen to forty-five grains (1 to 3 gm.) in so- lution. The oxide and carbonate of magnesia, in doses of five to sixty grains (0.3 to 4 gm.) are useful administered in a pow- der sweetened with sugar of milk or in one of the combinations enumerated above. Besides, a number of effervescent laxative salts are given. Effervescent The best known of these is the Seidlitz powder. This is made salts up in two papers, a blue one and a white one, the former con- taining three parts of Rochelle salt and one part of sodium car- bonate, in all one hundred and sixty grains (10.4 gm.) ; the lat- ter containing thirty-eight grains (2.25 gm.) of tartaric acid. The powders are dissolved separately in water and the two solu- tions poured together and the whole rapidly swallowed. The liquor of magnesia citrate is a solution of magnesium citrate with an excess of citric acid and potassium bicarbonate bottled tightly; upon opening the bottle effervescence occurs. The dose of this solution is five to twelve ounces (150 to 400 cc). A great many natural mineral waters containing laxative Laxative min- salts are used. The best of these are Hunyadi Janos or Apenta eral waters water or Carlsbad water. The action of these waters is due chiefly to the sodium or magnesium sulphate they contain. In addition they contain a number of inert and less active saline constituents. 456 Hypodermic purgation Introduction of purgatives by- rectum The attempt has been made repeatedly to induce purgation by the administration of remedies hypodermically. The best remedy for this use is apocodeine, which should be given in doses of one-twentieth to one-tenth grain (3 to 6 mg.) } dissolved in a little water. Besides, aloin, cathartinic acid and citrullin have been used, but their administration is very painful and their ef- fect is inconstant. Magnesium sulphate injected in small doses hypodermically is the latest hypodermic purgative to be intro- duced. Finally, the administration of purgative remedies may be attempted by the rectal route. Colocynth in the dose of 0.1 to 0.03 gm. ; aloin, 0.4 to 0.5 gm. ; and cathartinic acid, 0.6 gm. dis- solved in a little glycerin cause prompt purgation. It is prob- able that these remedies after they have been absorbed from the rectum are carried to the intestinal mucosa through the blood, and act in this way rather than locally. Diarrhea in in- testinal atony, stenosis and catarrh Daxative diet as a prophy- lactic Diarrhea gastrica DIABRHEA. Diarrhea, in most cases, is a symptom only of a variety of primary conditions, the treatment of which has already been discussed. Thus diarrhea from irritation of the bowel wall by stagnating and decomposing or poisonous (ptomains) bowel contents is a common phenomenon in bowel stenosis, in copro- stasis and in acute or chronic catarrh of the bowel. Here treat- ment must, in all cases, be chiefly directed towards promoting prompt evacuation of the offending bowel contents by the ad- ministration of castor oil, calomel or the use of bowel irrigation as already fully described in the sections on these different dis- orders. Besides, of course, the underlying disorder must be at- tacked and, if possible, corrected. In diarrhea occurring in fecal stasis due to stenosis or intes- tinal atony, it is important, contradictory as it may seem, to give a slightly laxative diet (see page 444) rather than one that pos- sesses constipating properties; for, in this way only can the ac- cumulation of fecal matter that directly produces the diarrhea, effectually be forestalled. An important form of diarrhea (diarrhea gastrica) occa- sionally owes its origin to disorders of the stomach, chiefly achylia gastrica and motor insufficiency of the stomach or hy- peracidity. This variety is closely related to the one mentioned above, inasmuch as the food fails to undergo proper disassimila- tion in the stomach, and enters the bowel in an insufficiently digested or partially decomposed condition, and hence throws an abnormal amount of labor on the tryptic functions of the in- DIARRHEA 457 testine, while, at the same time, irritating and overloading the canal. This overtaxation and irritation may become so great as to produce true catarrli of the bowel with diarrhea, but even before this time the intestine periodically gets rid of the abnor- mal material which it cannot properly assimilate by diarrheic movements. Many of these cases do not apparently suffer from the stomach at all, especially if the motor power of this organ is unimpaired. At the same time, the primary disorder prob- ably lies in the stomach alone and the treatment of the under- lying gastric disorder by proper dietetic and medicinal means, lavage, etc., generally leads to a cure of the diarrhea. From this it will be seen how important it is in every case of chronic diarrhea of doubtful origin to carefully determine the state of the gastric functions and to arrange treatment accordingly. Dyspeptic (or better dystryptic) diarrhea must be included Diarrhea dys- in a similar category. Here the bowel irritation, the increased P e P tlca peristalsis, the very rapid propulsion of the contents of the small intestine into the colon and its prompt evacuation in the stools must be attributed to the ingestion of food that is irritat- ing or poisonous. In this variety, too, the stomach is usually, though not always, affected at the same time. Here, again, the chief indication for treatment lies in aiding Nature in its en- deavor to rid the bowel of the irritating material; and the prompt administration of a dose of castor oil or of some other effective, but not too irritating, laxative remedy (see index) combined with cleansing of the lower bowel by irrigation, is the proper preliminary treatment. The fact that copious and frequent diar- rheic stools may have occurred is no contra-indication to the use of such remedies; for much offending material will usually still be evacuated by their administration and the course of the dis- ease materially shortened thereby. To give constipating medi- cines in such cases is a gross error (see also the section on Acute Catarrh of the Bowel). A little opium and hot applications to the abdomen may in persistent cases be required as a sympto- matic means to stop very severe abdominal pain. To the rarer forms of diarrhea of intra-intestinal origin, be- Diarrhea due long, finally, those varieties that are produced by entozoa. That the removal of parasites is a sine qua non of successful treatment need hardly be mentioned. On the borderland between diarrhea produced by the action of irritants affecting the bowel from within its lumen and reach- ing the bowel through the blood, is the diarrhea seen in a va- riety of infectious diseases accompanied by catarrh and ulcera- Diarrhea in tion of the intestine. In some of them, notably in typhoid, small- e a S es 10U * 1S " pox, sepsis, erysipelas, varioloid, diphtheria, dysentery, anthrax 458 Diarrhea due to blood-borne poisons Specific treat- ment Diet Diarrhea in uremia and tuberculosis, it is often difficult to decide whether the diar- rhea is due to local irritation in the bowel and the presence- of ulcers or to the action of blood-borne poisons. The fact that in typhoid, for instance, profuse diarrhea often occurs long be- fore ulcers are present, that, in cholera, no anatomic changes of the bowel are generally found despite the most profuse diarrhea, that in sepsis, malaria, influenza, pneumonia, similar relations are frequently encountered, renders it very probable that the diarrheic discharges in all these forms are in great part produced by the circulation of specific toxins through the bowel wall and the irritation of the intestinal mucosa from this source. The treatment of this variety of diarrhea is essen- tially synonymous with the treatment of the underlying infection and, in most cases, correspondingly successful or unsuccessful. If specific remedies are available the diarrhea can usually promptly be checked by their use ; thus the diarrhea of malaria and diphtheria promptly ceases, as a rule, unless complicated, by food poisoning (diarrhea dyspeptica), upon the administration of quinine or the injection of diphtheria antitoxin. The clean- ing out of a septic focus, the healing of the ulcers in typhoid pro- duces the same result without further interference directed to- wards checking the diarrhea. The diet, in the latter form of diarrhea, need not be modified materially on account of the ex- istence of profuse bowel discharges. Whatever food is proper,, in consideration of the primary disease, should be continued, every effort being put forward to maintain the nutrition of the- patient. Fat or coarse irritating foods should be avoided. That nourishing semi-liquid and easily digestible foods should be given the preference is self-evident. The ordinary fever diet de- scribed in the Section on Infectious Diseases of itself answers- all these requirements. To the class of blood-borne diarrheas, finally, belongs the diarrhea of uremia. This is probably caused by the circulation of ammonium carbonate which has failed to undergo proper conversion into urea. Here, too, appropriate causal treatment directed towards restoring the function of the liver (see page 488f ) and promoting the renal elimination is the most important element. This diarrhea must be looked upon as a conservative process of disintoxication that it is dangerous to check by consti- pating remedies ; for, if this is done, the vicarious elimination of circulating urinary end products and of intermediary products of perverted metabolism that the kidneys fail to eliminate prop- erly is interfered with and the patient is often seriously injured; thereby. DIARRHEA 459 The diarrhea occurring in the course of heart disease, espe- Diarrhea in cially in the stage of failing compensation, or in portal stasis, is heart disease due to the venous engorgement or edema of the bowel wall. Here appropriate cardio-tonic medication and the use of those means that can correct venous congestion and stasis in the portal circulation is the most important element of the treatment. In none of the forms enumerated, it will be seen, is the use Remedies of constipating remedies, as a rule, indicated. Occasionally opi- ates, as already mentioned, have to be administered for the sake opiates of producing symptomatic relief. Opiates allay the pain and by reducing the violence of peristaltic movements check the fre- quency of the bowel discharges, place the bowel wall at rest and, in most cases, materially aid in enabling the irritated, usually hyperemic, intestinal wall to regain its normal state. In the dys- peptic variety of diarrhea, in diarrhea due to coprostasis and in nervous diarrhea, to be presently discussed, opium should, how- When pium ever, never be given. Its chief sphere of usefulness lies in the should not be treatment of catarrhal and infectious types of diarrhea in which the evacuation of the irritating bowel contents does not bring relief and in which the patients suffer severe pain, and the nu- trition is seriously interfered with. Here opium, morphine or codeine may be given ; opium, in the form of the extract or the tincture, is generally more effective than its alkaloids; for the resins contained in preparations of the crude drug favor the slower liberation and absorption of the active principles of opium and hence grant a more prolonged effect in the bowel. Other anti-diarrheic remedies like bismuth, tannin prepara- Bismuth tions, lead acetate, silver nitrate, etc., are indicated only in defi- Tannin nite anatomic lesions of the bowel, and their use has been dis- Lead acetate cussed in full in the part on Acute Intestinal Catarrh (see pages ver m ra e 413-418). Heat, finally, applied to the abdomen, either in the form of Heat moist stupes, poultices or cataplasms, or in the form of dry, hot cloths, a Leiter coil or a thermophore, or in the form of a Priess- nitz or a Winternitz compress (see page 411) is always grateful, and distinctly reduces the irritability of the intestine. By re- lieving the pain it materially allays the subjective distress of the patient and, at the same time, in most cases reduces the num- ber of diarrheic discharges. In the symptomatic treatment of diarrhea, therefore, immaterial what its cause, it is an invalu- able adjuvant. There remains for discussion an interesting form of diarrhea Nervous di- that must be regarded as a neurosis of the intestine, namely, so- arrhea called nervous diarrhea. It may occur acutely in predisposed 460 Treatment of the neurotic individual Diet Alcohol Smoking Hest after meals Arsenic Placebo neurotic or even in otherwise normal subjects following severe psychic or emotional shock, or it may be a chronic recurring condition accompanying a variety of organic diseases of the nerv- ous system, viz. : Exophthalmic goitre, migraine and the func- tional neuroses, hysteria and neurasthenia. In most of the cases neurotic manifestations about the vaso-motor sphere, as sudden pallor or flushing of the face and neck, or hot flushes, vertigo, stupor, palpitation, dyspnea, various psychoses appear together with the attack of diarrhea. Nervous symptoms do not, how- ever, invariably accompany this form of diarrhea. If it occurs in subjects who present no neurotic manifestations, the diagnosis can only be made by exclusion ; from the absence, namely, of any digestive disorder, from the character of the stools and the pecu- liar, often highly bizarre factors that determine the attacks. The treatment of nervous diarrhea in a neurotic subject con- sists primarily in the use of the general measures applicable to the treatment of any neurosis. Here change of scene, a pause in the daily routine, life in a resort, a rest cure, suggestive treatment and all those hydrotherapeutic and electrotherapeutic measures that have been described in full in the section on Gas- tric Neuroses, are applicable. In addition any possible reflex cause, chiefly about the sexual sphere (in some women nervous diarrhea occurs chiefly during the menstrual period) and in other regions of the body must be sought for and relieved. No special dietetic rules can be formulated for the treatment of this form of diarrhea. It will often be found that any change of diet is effective for a time. It is probable that here the change of regime, possibly following a change of doctors, exercises a strong suggestive effect. Alcohol should be used with great moderation. It is a pe- culiar fact, however, .that in some forms of nervous diarrhea that occur immediately after eating, a small glass of brandy or liqueur is often efficacious in warding off the attack and also in preventing the occurrence of some of the other nervous symp- toms described above that frequently accompany the diarrhea. Smoking is best prohibited. Sufferers of this kind should be advised to lie down for half an hour or an hour after each meal, with hot applications to the abdomen. Of remedies arsenic is the most popular one, but I have never been convinced that it exercises any effect upon the frequency of the attacks. A strong suggestive effect is as fre- quently exercised by a change of medicine as by a change of diet and in some of the cases the administration of a bitter tonic, or of any placebo, is, in my experience, fully as efficacious as the ad- ministration of any of the remedies that are credited with heal- FLATULENCY (METEORISM) 461 ing powers in this disease. In very extreme eases opium may be Opium given in order to check the violence of the peristaltic movements, but it should be used with great care in chronic cases because, especially in these neurotic subjects, the danger of creating an opium habit must always be feared. Bismuth I have found to be altogether without effect. To the same category probably belongs the peculiar form of Diarrhea fol- diarrhea that suddenly follows any exposure to cold or any chill- J^ur? toxoid ing of the body surfaces, especially when a draft strikes the neck, the feet or the region between the shoulder blades. This variety must be looked upon as due to a vaso-motor neurosis and be- longs to the same class as vaso-motor coryza. The morning diarrhea, coming- on suddenly with one or several profuse watery discharges about four or five o'clock in the morning before the patient gets up or immediately when the patient gets out of bed or puts his feet to the floor, must be looked upon as a nervous form of diarrhea, possibly of a vaso-motor origin and produced by the change in the temperature of the room in the early morn- ing hours or the chilling of the body surfaces when the patient leaves the warm bed. Patients suffering from this form of diarrhea should avoid any sudden exposure to cold, should, for instance, never step on a cold floor when getting out of bed, should always wear a flannel binder and appropriate clothing and footwear, as described in the section on Rhinitis; they can, also to advantage, undergo a hardening process, as described in the section on Vaso-Motor Coryza. FLATULENCY (METEORISM). The causes that can produce this very distressing symptom are manifold, and in undertaking to relieve the suffering or dis- comfort that accrues from the abnormal accumulation of gas in the bowel, the exact cause must be looked for and, if possible, re- moved. When this cannot be done, or in cases in which the deter- mining factor is chronic and irremediable in character, certain measures must be adopted that afford at least symptomatic re- lief. In habitual sufferers from flatulency, finally, certain pro- phylactic treatment can often be instituted. In cases of stenosis of the bowel, in which the normal pas- sage of gas through the intestine is mechanically interfered with; to decreased in cases of acute diffuse peritonitis, typhoid fever, pneumonia expulsion of and certain other infectious diseases in which there is toxic par- alysis of the bowel wall ; after abdominal operations, in which the manipulation of the intestine or the shock must be incrimi- nated with producing intestinal paresis; in general intestinal gas 462 FLATULENCY (METEORISM) Meteorism due to increased formation of gas Meteorism due to peculiarities of bacterial flora The diet Laxatives and carminatives atony in which there is not paralysis, but merely weakness of the intestinal musculature; and, finally, in certain circulatory dis- turbances leading to venous stasis and edema of the intestinal wall, less gas than normally is expelled from the bowel so that it accumulates and produces meteorism. In other cases, again, the bowel lumen may be open, there may be no muscular insufficiency and a normal or even an in- creased amount of gas may be expelled from the bowel, and, nev- ertheless, meteorism develop. In such cases flatulency is attrib- utable to the formation of abnormally large amounts of gas in the bowel. Here evidently one must assume that the intestine has been invaded by an exceptionally profuse or especially active flora of bacteria or of hyphomycetes capable of producing fer- mentation. To this group also belong many of the cases of flatu- lency that are seen in catarrhal disorders of the stomach and in- testine for here the proper disassimilation of the food does not take place while, at the same time, the absence of the normal secretions renders the bowel a suitable nidus for various fermen- tative bacteria. In treating meteorism, therefore, aside from attacking the primary cause that creates stenosis, atony or paresis of the bowel, the diet must, in every case, be regulated in such a way that espe- cially fermentable pabulum and articles of food undergoing fer- mentation when eaten, i. e., containing abundant yeast cells, are excluded. Thus, vegetables containing much cellulose, like cab- bage, peas, turnips, beans, potatoes; fresh bread, cakes, sweets of any kind; and of beverages, fresh fermenting liquors and drinks containing an abundance of C0 2 , like beer, kephyr, champagne, aerated mineral waters, should be excluded. As milk in some subjects undergoes rapid fermentation in the bowel, it should be stopped if symptoms of flatulency appear after its administration. That the diet should, in addition, be regulated in such a way as to take into consideration the exist- ence of a stenosis or any of the primary diseases that may cause intestinal atony, paresis or congestion of the bowel need hardly be emphasized. Provided there are no distinct contra-indications to their ad- ministration (see page 452), laxatives and carminatives are the best remedies for causing expulsion of gas that has accumulated in the bowel. Laxative remedies, by promoting vigorous peris- talsis, obviously aid in the propulsion of gas through the bowel, and in addition promptly remove any fermenting material that may be stagnating in the intestine. The different laxatives that can be employed have been fully discussed in the section on Con- stipation. FLATULENCY .(METEORISM) 463 The so-called carminatives comprise a large group of vola- Action of car- tile oils and of essences, spirits, waters, tinctures, extracts and minatives infusions containing the latter. They are useful only in mild ■cases of flatulency and are best given in combination with some laxative by mouth. Their action is probably that of mild laxa- tives and antizymotics. Besides, by mildly irritating the mucous lining of the stomach and bowel they produce a pleasant sensa- tion of warmth and comfort that often obscures the distress ex- perienced from flatulency, consequently their administration •causes considerable subjective relief; possible, too, that their strong (and usually agreeable) smell and taste stimulates the gastro-intestinal secretions and the appetite by a nervous reflex route and hence aids digestion like the bitter tonics (see page 362). Following the administration of carminatives, eructation of gas and propulsion of gas into and from the bowel is generally produced, and this result would indicate that they actually in- crease the movements of the stomach and intestinal peristalsis. Whether they aid in promoting the absorption of intestinal gases into the blood is questionable. At all events, we know, clinically, that they produce marked subjective relief in most cases of flatu- lency and hence their administration can be recommended. The most common carminatives employed are preparations of Different car- cloves, anise seed, caraway seed, peppermint, cinnamon, sassa- amative rem " fras, thyme, asafetida, lemon and orange peel, fennel, carda- moms, nutmeg, ginger and many others; or the oils themselves may be given, singly or combined, or in various combinations with bitter tonics and stomachics according to the requirements of each case. Teas prepared from the herbs and seeds containing these oils are also a very convenient household method of admin- istering carminatives. In addition to laxatives and carminatives, certain remedies Remedies may be administered in flatulency on account of their power to given to bind absorb and combine intestinal gases. The chief representative of this group is powdered charcoal. On account of its porosity charcoal it possesses the power of accumulating gas in its interstices. When swallowed it usually holds abundant oxygen. This is lib- erated in the intestine, hastening the oxydization of decomposing material, while the gases of fermentation are in their turn ab- sorbed. It majr be administered as animal charcoal (carbo ani- B }smuth sub- ,. . * nitrate mahs) or as vegetable charcoal (carbo ligni) in powder form or in the form of compressed tablets, in doses varying from sixty to one hundred and twenty grains (4 to 8 gm.) alone or in com- bination with bismuth subnitrate or magnesium oxide. The lat- ter remedies are also credited with virtues similar to those pos- sessed by charcoal. They bind a certain amount of H 2 S and Magnesia usta 464 INTESTINAL PARASITES Physostigmine Colonic irriga- tion Rectal tube Massage of the abdomen Hot applica- tions and lini- ments Puncture of the bowel C0 2 chemically with the formation of sulphids and carbonates of bismuth and magnesium. Physostigmine (eserine) salicylate, in the dose of a one hun- dred and twentieth to a sixtieth of a grain (0.0008 to 0.016 gm.) in pill form, or hypodermically, given two or three times a day, has been recommended by von Noorden for meteorism due to in- testinal atony or paresis. The drug in such small doses can do no harm and its administration is worthy of a trial. Irrigation of the colon with cool enemata by stimulating per- istalsis often aids in the expulsion of gas from the lower bowel. The addition of a tablespoonful or two of some carminative wa- ter, or of a few drops of oil of turpentine, to the enema is often helpful; or a long rectal tube may be introduced into the colon and kept in place for some time; in this way much gas some- times escapes. Aspirating the gas from the lower bowel with an aspirating syringe is usually superfluous. Gentle massage of the abdomen performed for the purpose of stimulating peristalsis, especially in the colon, may be practised to advantage, provided no contra-indications to manipulation of the abdomen, as stenosis, ulceration, intestinal paralysis, exist. Hot applications are best of all to relieve distress Turpen- tine stupes may be applied and sometimes aid in producing re- lief. Various liniments (see page 334) applied to the abdomen are also occasionally effective in relieving the subjective distress of the patient until the expulsion of gas can be promoted. In extreme cases, and as a precarious emergency measure,, puncture of the distended coils of the intestine with a needle tro- car (see page 435) may be attempted in order to allow the escape of some of the gas from the bowel. Contra-indica- tions to tape- worm cure Preliminary treatment INTESTINAL PABASITES. Tape-worm. — Tcenia solium, Tcenia mediQcanellata, both- riocephalus latus). In the presence of gastro-intestinal ca- tarrh, great debility, pronounced anemia, chronic alcoholism, serious cardiac or renal lesions, a tape-worm cure should always be instituted with great care. During pregnancy, the puerperium, lactation and during the menstrual period, a tape-worm cure is. best not instituted. Very little children (status tliymicus!) and very old people seem to stand badly the rigorous treatment nec- essary in order to expel a tape-worm. In instituting a tape-worm cure the patient 's intestine should be thoroughly emptied as a preliminary measure. This is accom- plished by practically starving the patient for twenty-four hours, allowing only a little milk, coffee, some soup and plenty INTESTINAL PARASITES 465 of water on the day before. The main object of this preliminary starvation is to deprive the tape-worm of the protection from the remedy he obtains if mnch fecal matter is present in the bowel. This object is further accomplished by administering a brisk purge, either castor oil or calomel, on the evening before the administration of the anthelmintic, followed in the morning by one or two rectal injections, provided profuse evacuations of the bowel have not been produced. Four remedies in particular are efficacious in promoting ex- Aspidium pulsion of the tapeworm, viz. : Male fern (aspidium felix mas) ; Granatum pomegranate (granatum) and pelleticrinc, a mixture of several e letierme of the alkaloids of pomegranate; pumpkin seed (pepo); cusso (bray era anthelmintica) . These remedies are all given on an empty stomach in the fol- lowing dosages : Male fern, as the oleo resin, in the dose of one-half to two Male fern fluid drachms (2 to 8 cc), or as the liquid extract, in the dose of forty-five to ninety drops, preferably in a gelatine capsule. One hour after the drug is swallowed a purge is given, either the compound infusion of senna, in doses of four ounces, or two or three grains of calomel, followed within an hour by a table- spoonful of magnesia sulphate in a glass of water. Castor oil is not so useful, as poisoning from aspidium seems to occur more commonly if castor oil is given than if one of the other purga- tives is administered. If within two or three hours after the administration of the purge the desired effect is not produced, a large colonic irrigation of normal salt solution should be em- ployed ; this will usually bring the worm away. If only links are secured, but no head or heads, a second or a third irrigation should be practised. If this first attempt to expel the tape-worm is not successful, at least a week or two should be allowed to elapse before a second tape-worm cure is undertaken. Some patients become very much nauseated or even vomit after they have taken the medicine. This effect can often be prevented by having them lie down and chew small pieces of lemon or orange peel or take peppermint drops, or swallow small ice pills, or teaspoonful doses of ice tea or ice coffee. Pomegranate is best given as pelletierine in doses of two to Pomegranate four grains (0.12 to 0.25 gm.) in capsule or pill; or one to two ounces (32 to 64 cc.) of the decoction (decoct, granatce cortex) in 250 cc. of water, taken in two portions, one hour apart, may be given ; as the latter preparation is very disagreeable and bitter to the taste, it is best administered together with some flavor- ing syrup. 466 INTESTINAL PARASSiTES Pumpkin seed Cusso After treatment Hound worm Santonin Santonin poisoning Xanthopsia Spigelia Oil of cheno- podium Pumpkin seed is given in the dose of two to three ounces (64- 96 gm.) of the powder suspended in an emulsion or made into a paste with sugar, molasses or honey. Cusso is administered by suspending half an ounce (15 gm.) of the powdered flowers in water. It is not so efficacious as the other preparations. The after treatment by purging and irrigating is the same, immaterial which of the vermifuges is employed. Round Worm. — (Ascaris lumbricoides.) Here, too, as in the case of the tape-worm, a preliminary starvation and purgatiors treatment should be instituted. The most trustworthy remedy to promote the expulsion of round worm is santonin. This medicine is best administered in the form of troches (Troch. Santonin U. S. P.), in the dose of one lozenge for a child, two for an adult, each lozenge containing half a grain of santonin ; or the remedy may be given in solution in castor oil, but less of the remedy seems to be absorbed from the stomach if given in this menstruum than if given in tablet form. Three or four hours afterwards an active purge should be used to carry off the parasites. In some persons toxic symptoms appear, namely, muscular twitchings about the head, rolling of the eyes, grinding of the teeth, even epileptiform convulsions, mental confusion, nausea, vomiting and xanthopsia (yellow vision). The last named symp- tom occurs in most people after the administration of santonin. It need cause no alarm for it usually passes off quickly without any further treatment. It is best, however, to call the attention of the patient to the possible occurrence of this phenomenon. The appearance of the other signs mentioned above, which indicate intoxication of the central nervous system, calls for prompt evac- uation of the gastro-intestinal contents by emetics and purges. The spasms, if they are severe, may be controlled by chloroform or ether inhalations. Spigelia is another useful remedy to expel round worms. It should be given as the fluid extract, in doses of a teaspoonful (4 cc.) to a child, two teaspoonfuls (8 cc.) to an adult, fol- lowed by full doses of the infusion of senna, castor oil, or mag- nesium sulphate; or it may be administered in the form of the fluid extract of spigelia and senna, in three doses, of one tea- spoonful each, given two hours apart to a child, in three doses of two teaspoonfuls given at the same interval to an adult. Still another remedy that is occasionally efficacious and that may be mentioned for the sake of completeness, is the oil of chenopodium. It should be given in doses C"f five to ten drops INTESTINAL PARASITES 467 (0.3 to 0.6 gm.) in an emulsion or on sugar followed by a purga- tive. Thread Worms. — (Oxyuris vermicular is.) This parasite Thread worms finds its chief habitat in the large intestine, especially in the rectum, although, as a rule, the worms are also found in the small intestine. The parasite must, therefore, be attacked both by mouth and by rectum. Sufferers from thread worms should, Santonin therefore, receive santonin or spigelia, given in the same manner pi8>e ia and dose as described above in the treatment of round worm, followed by a purge. In this way the parasites contained in the small intestine are destroyed or propelled into the large intestine where they can be attacked by the rectal route. The chief attention, however, should be directed towards rid- ding the lower bowel of the parasites by large medicated injec- tions. The best medicine of all is the infusion of quassia made by Infusion of Quftssis -adding one or two ounces (32 to 64 gm.) of quassia chips to a pint (500 cc.) of water and injecting the whole quantity, under -considerable pressure, after a preliminary cleansing of the bowel with a copious warm soap and water enema. An attempt should be made to hold this injection for about five minutes. In very little children a cotton plug may be pressed against the anus in order to aid the child in retaining the medicine. Generally these injections must be repeated a number of times and on successive nos i s un- ready indicated, to recover under expectant treatment. Of those de** internal that do not improve a certain number will die with as well as treatment*^ without an operation, and a certain proportion will recover after a laparotomy who would not have recovered without it. 484 CHRONIC PERITONITIS AND TUBERCULOSIS OF PERITONEUM Contra-indica- Unless the patient, therefore, is in an advanced stage of gen- tions to sur- , , , ™ £ * . „ , gical inter- era l tuberculosis or suffers irom so serious a type of pulmonary vention or intestinal tuberculosis that it in itself renders the prognosis hopeless, the surgical treatment of chronic tuberculous perito- nitis should be given a trial in every case of the disease that does not yield to medical treatment. CHAPTER IX. DISEASES OF THE LIVER AND BILE PASSAGES CATARRHAL JAUNDICE. The treatment of catarrhal jaundice, especially in the begin- Treatment of ning of the disease, is essentially the same as the treatment of ^ al ca t a rrh the gastro-intestinal catarrh that produces the disorder. As the treatment of this catarrh has been discussed in full in previous sections, it need not be repeated here. As a rule the icterus does not develop until several days after the onset of the gastro-intestinal disorders (although in excep- tional cases it occasionally precedes them), so that, as a rule, cleaning out the stomach by lavage or by the use of an emetic is superfluous and the chief attention should be given to ridding the bowel of any irritating or poisonous material it may still incorporate. For this purpose a brisk purge, best of all, three Purgation by to five- grains (0.2 to 0.3 gm.) of calomel, or castor oil, followed 1^1°* salines " by a large dose of sodium phosphate or of magnesium sulphate colonic flush- and a colonic flushing, should be given at once upon the appear- ing ance of icteric symptoms. Such remedies as podophyllin, rhu- barb, jalap, convolvulin, scammony, gamboge and cathartic acid Purgatives not should not be used as purgatives in this condition, because they to be em P lo y ed seem to be practically inactive if bile is absent from the bowel. As soon as evidence of acute gastro-intestinal dyspepsia is Diet in the present, the patient should either refrain from food altogether or e § ,innm §' should be allowed to take only a little milk, some thin soup or strained gruel and water. During this period and until the Rest in bed tongue is clear, the fever normal and the epigastric or abdominal discomfort is gone, the patient is best kept in bed. With the disappearance or the mitigation of dyspeptic symp- Regime after toms, the diet should be made more liberal and the patient al- o^dvsnetrt^c 6 lowed to get up a little each day. Some patients, in fact, are symptoms able without discomfort to attend to their daily work without displaying any other signs of illness than the yellow discolora- tion of the skin or sclera. Others, again, feel so ill throughout the course of the disease that they are forced to remain in bed for long periods of time. This occurs particularly in patients who develop, consecutively to the catarrhal swelling of the bile ducts, a condition of hepatic insufficiency (see page 488) with symptoms of profound self-intoxication. 486 CATARRHAL JAUNDICE Exclusion of fats Albuminous foods and car- bohydrates General char- acter of the diet Predigested foods Alkaline and alkaline-saline mineral waters Abundant water drinking During the whole period of bile duct occlusion or obstruc- tion the diet should be carefully regulated to take into considera- tion the absence of a normal amount of bile from the small intes- tine. Fats should be excluded from the diet, because their emul- sification and saponification, hence their absorption, is always- seriously interfered with, so that they travel through the intes- tine in an undigested form, undergo abnormal decomposition by intestinal bacteria, with the formation of poisonous and irritat- ing products and hence increase the catarrhal irritation that originally caused the trouble. Inasmuch, moreover, as in many cases of catarrhal icterus the pancreatic duct is in all probability also stenosed or occluded by catarrhal swelling (as manifested by the appearance of abundant undigested meat fibers, fat and starchy granules in the stools and sometimes glycosuria) fat is especially contra-indicated. The chief food, therefore, in catarrhal jaundice should be al- buminous material to which may be added easily digestible car- bohydrates, preferably dextrinized starchy foods and sugars. All food should be administered in an easily digestible form (see page 347), in the beginning, chiefly as liquid and semi-liquid arti- cles, namely broths, thin gruels, milk, buttermilk, meat jellies, gelatinous foods, very soft boiled or poached eggs; later finely chopped raw or rare beef, mutton, poultry, fish, a little zwieback, toast or crackers soaked in milk, gruels made of milk and rice or barley, arrowroot, tapioca, sago, etc. All foods containing coarse and indigestible particles, like skins and tendons, husks, seeds,, stems, pips, should be withheld for a long time. Alcoholic bever- ages are to be altogether forbidden. In case the pancreatic duct is occluded, too (see above), the digestion of albumens also suffers. In such cases the patients usually display a strong aversion for meat, and it should not be forced upon them. Here albumoses and peptones, various pre- digested foods, peptonized milk, etc., as well as certain of the easily digested vegetable albumens, can be utilized to advantage. Alkaline and alkaline-saline waters play an important part in the treatment of catarrhal jaundice. Their exact mode of ac- tion is not quite clear. It has been claimed that the alkalies they contain are excreted through the bile ducts and exercise a bene- ficial effect on the congested mucous lining of the bile channel. It is more probable that they favorably influence the catarrh in the small intestine and reduce the swelling around the bile duct orifice and hence aid in restoring patency of its lumen. The large amount of water that is ingested and absorbed might even be imagined to dilute the bile and hence render its outflow CATARRHAL JAUNDICE 487 through the narrowed bile ducts easier. Whereas this effect of abundant water drinking is somewhat problematical, the limita- tion of water drinking certainly leads to thickening of the bile, an event that is to be energetically counteracted. Mineral waters at all events aid in dissolving some of the mucus accumulated in the bile ducts and hence act beneficially. Whatever the exact action of alkaline or alkaline-saline mineral waters, or of plain water, may be, clinically it may be considered established that the abundant ingestion of such waters, especially when they are taken warm and at frequent intervals, materially aids in restor- ing normal conditions in catarrhal jaundice. Intestinal irrigation with large quantities of water also exer- Intestinal irri- cises a useful effect, so that frequent enemata should be ordered § ' a 10ns in combination with copious water drinking. The injection daily by clysma of one or two quarts of cold water is a very popular and a very useful measure. The increased peristalsis of the in- testine combined presumably with increased contractions of the gall-duct musculature that is stimulated by such injections, aids in the expulsion of mucus and bile from the bile passages; more- over, the circulation in the whole portal system, and hence in the liver, is accelerated by such injections, while nervous reflex stimuli must also be imagined to travel to the liver from the lower bowel. All these factors aid in causing a decrease in the swelling of the bile-duct lining, in expelling the mucus and in re-establishing the flow of bile. Finally, the mechanical distention of the colon which is brought about by the injection of large quantities of water may exercise some traction on the region about the bile-duct orifices, and hence, too, stimulate contractions of the latter. Whereas all these explanations of the exact action of large, cool colonic flushings are more or less Irypothetical, clinical ex- perience, as in the case of copious water drinking, shows them to be actually useful. In order to stimulate the flow of bile towards the intestine cholagogues various cholagogue remedies were formerly employed. As a mat- ter of fact, however, only two drugs can be definitely credited with the power to stimulate an increased flow of bile, viz., prep- arations of salicylic acid and of bile acids. All the other so-called Salicylates cholagogue remedies act merely as purges and the appearance of Bile acids bile in the stools after their administration must be attributed to the abnormally rapid propulsion of the contents of the small intestine into the lower bowel, rather than to any stimulation of the bile flow. This subject will be referred to again in the Sec- tion on Cholelithiasis. In catarrhal icterus the use of cholagogue remedies is not indicated ; for the slight increase of the pressure 488 CHRONIC INFLAMMATION OF THE LIVER Bile Salol Itching Bathing and sponging Menthol within the bile-ducts that may be brought about by a stimula- tion of the flow of bile can hardly be considered effective in any way in overcoming the resistance offered to the outflow of bile by the catarrhal swelling of the bile-duct mucosa. Moreover, as soon as the back pressure within the bile-ducts reaches a certain, not very high, point, the manufacture of bile by the hepatic cells is automatically inhibited. Before this occurs stimulation of the bile flow will probably lead rather to increased diapedesis of bile constituents from the bile channels into the blood channels, which is detrimental, than to an exit of the bile into the bowel through " the stenosed bile-ducts. Bile and bile acids, however, serve a useful purpose in ca- tarrhal jaundice as well as in certain other forms of obstructive icterus, because by their administration a certain amount of bile is supplied to the small intestine and thereby intestinal digestion is aided, while at the same time a mild intestinal antisepsis is produced. Salol, too, answers the latter purpose. Both bile and bile acid and salicylic acid preparations, however, should be given in small doses only. Of symptoms complicating catarrhal icterus, intense itching often calls for relief. Here a variety of measures must often be tried before an efficient remedy is discovered, and it will gen- erally be found that the remedies that are helpful at first soon lose their power to relieve, so that frequent changes or alternation are generally required. Lukewarm baths, cold sponging, alcohol rubs, inunction of the skin with cocoa butter or lanolin all occa- sionally relieve. One of the best remedies is menthol applied in alcoholic solution in the strength of one to five, or in the form of a dusting powder in the proportion of one part of menthol to five parts of talcum, or as an ointment consisting of menthol, one part; sweet oil, two parts; lanolin, twenty-five parts. CHRONIC INFLAMMATION OF THE LIVER. (atrophic, hypertrophic cirrhosis, cardiac, biliary cirrhosis, syphilitic hepatitis, hepatic insufficiency.) Hepatic insufficiency is an important symptom complicating a great variety of hepatic disorders and leading in its ultimate ♦Quoted in part from my article on Hepatic Insufficiency, Medical Record. 1906. CHRONIC INFLAMMATION OF THE LIVER 489 consequences to complications about remote organs of the body. Its general pathogenetic significance and the means at our dis- posal for correcting hepatic insufficiency may therefore be treated of in this place, especially as a connected discussion of hepatic insufficiency will obviate the necessity of reviewing separately the treatment of the different organic lesions of the liver that pro- duce this symptom. Whenever an organ fails to perform its functions properly Hepatic msuf- we say that it is insufficient. This term may denote both quali- tative and quantitative variations from the normal. The more complicated and the more active the functions of an organ the more liable it is to insufficiency. The liver, therefore, possessing as it does the most manifold functions of any organ of the body, is particularly subject to functional derangements. Its exposed situation, moreover, and the peculiar arrangement of the four systems of capillaries that form an intricate labyrinth around and through each hepatic cell render the latter especially liable to injury by circulating toxins. These poisons reach the liver cells continuously from the general circulation in the hepatic artery, through the lymphatic circulation (especially from the peritoneum), the portal circulation and the bile channels. One may differentiate for clinical purposes between median- Causes ical, parasitic, and toxic causes of hepatic insufficiency, remem- bering always that the three may be and usually are, correlated and intimately connected. Chief among the mechanical causes are all sclerotic changes Mechanical causing overgrowth or contraction of interstitial liver tissues and causes thereby producing mechanical compression of liver cells or of their afferent blood-vessels. Then there is mechanical stenosis, occlusion or obliteration of large blood-vessels by embolism, thrombosis, or pressure from without, causing similar nutritional Cirrhosis changes, and, later, necrosis of large areas of liver cells. Again, Thrombosis the bile-ducts of the liver may become similarly narrowed or oc- cluded by biliary concretions or by the invasion of these chan- nels from without by parasites, in either instance producing stag- Bile duct oc nation of bile and mechanical compression of liver cells or of ary^cirrhosisS the blood-vessels that nourish them. Finally, certain heart lesions Heart lesions must be included among the mechanical causes, for, by producing (cardiac cirr- stasis of venous blood in the capillaries of the liver, they, too, exercise mechanical compression upon the hepatic cells and cause derangement of their function. As has been intimated, the parasitic causes of hepatic insuf- parasitic ficiency occupy an intermediary position between mechanical causes and toxic causes, for any micro-organism that invades the liver 490 CHRONIC INFLAMMATION OF THE LIVER Toxic causes General symp- tomatology channels or the liver tissues proper may act either as a foreign body by mechanically destroying liver cells by pressure or by occluding the blood- vessels or bile channels, or it may lead to the formation of chemical poisons that intoxicate the liver cells. The toxins, finally, that "-an produce hepatic insufficiency are so manifold that it would be useless to attempt to enumerate them in this place. It is sufficient to say that all the poisons gen- erated in the bowel, the spleen, or the pancreas must travel first to the liver before they can reach the general circulation beyond ; that all the manifold array of metabolic poisons that can be formed in the system at large always comes into particularly in- timate contact with the liver cells owing to the intricate inter- lacing of the capillaries of the hepatic artery and the hepatic lymph-channels in the liver. Finally, the liver, possessing as it does a most active metabolism of its own, continually manu- factures toxic intermediary bodies within its substance ; and this is particularly the case if its function is in any way deranged. The changes that the liver may undergo as a result of all these causes may vary from mild transitory functional derange- ments to destructive histological lesions of the hepatic cells. The symptoms of hepatic insufficiency are, therefore, very numerous. This is self-evident when we consider the many functions of the liver, any one of which may become qualitatively or quantitatively perverted. Our knowledge of the finer mechanism of the inter- mediary metabolism going on within the liver is, however, still so woefully incomplete that it is unfortunately well-nigh im- possible to interpret slight derangements of many of these func- tions correctly. For this reason we are as yet unable to recog- nize as early as we might wish the first manifestations of hepatic insufficiency, as we can, for instance, recognize early functional changes of the kidneys in the urine, or mild derangements of the stomach function in the gastric contents long before ana- tomical lesions supervene. From the standpoint of prophylaxis and therapy this is particularly deplorable. In order to understand the symptomatology of hepatic in- sufficiency and to treat it properly it is necessary to have a clear understanding of liver physiology, because it is manifestly im- possible to understand the pathology of any group of functions unless we understand their physiology; to appreciate or correct the abnormal until we understand the normal. The normal function of the liver may be summarized under the following five heads: (1) formation of urea; (2) conversion of sugar into glycogen and the storage of the latter; (3) forma- tion of bile; (4) elaboration both by anabolism and catabolism CHRONIC INFLAMMATION OF THE LIVER 491 of circulating radicals of the fats and albumen ; (5) general dis- intoxication of circulating poisons and the formation of anti- toxic bodies. Perversion of these five mentioned functions must lead to the following results: (1) A diminution of the circulating urea and a flooding Decreased urea of the blood-stream with bodies that have failed to undergo con- version into urea in the liver, notably ammonia salts and ami do- acids, with the appearance of corresponding urinary symptoms — i. e., a decrease of the urinary urea and a corresponding increase of the urinary ammonia and amido-acids. At the same time, as urea is the most potent physiologic diuretic, a decrease in the amount of urine. (2) Owing to the inability of the liver to convert sugar into Interference glycogen and to store the latter, a flooding of the blood-stream / glycogen with an excess - of sugar that is derived from the ingested sugar or starches, with resulting hyperglycemia and glycosuria. This condition may be obscured if the patient does not happen to have eaten much starch or sweet foods, but it should readily appear even in mild degrees of hepatic insufficiency, as an alimentary glycosuria, if the patient is given appreciable quantities of starch or sugar in the food. (3) The inability of the liver to form bile leads to numerous Decreased bilo serious consequences that have already been indicated above. Chief among these is stasis of bile within the biliary channels and as a result diapedesis of poisonous bile constituents from the bile- capillaries into the blood-capillaries, in other words, icterus. In this connection a very important subject should be mentioned, viz., that jaundice occurs only in relatively mild degrees of hepatic insufficiency, whereas in very severe degrees jaundice cholemia cannot possibly occur, for the reason that the liver cells no longer form bile. Here the intoxication is especially severe because the products that should normally be disintoxicated by the liver and excreted into the bile pass through the liver cells unchanged and are returned to the circulation in a highly toxic form. This con- dition has been called by the French grande insuffisance hepa- tique. Another result of failure of the liver cells to produce a normal amount and the normal kind of bile is interference with the function of the upper portion of the intestinal tract. The withdrawal of the bile or the entrance of abnormal bile into the bowel allows intestinal fermentation to go on unchecked, fenders the normal emulsiflcation of fats impossible, and produces nu- merous other results that have been enumerated above. At all events the withdrawal of normal bile from the bowel in itself 492 CHRONIC INFLAMMATION OF THE LIVER Metabolic de- rangements Reduced disin- toxicating power Uremia General indica- tions for treatment Causal treat- ment causes an increased now of toxic bodies to pour into the liver through the portal vein and the intestinal lymphatics and hence promotes the causes that produce hepatic insufficiency. The de- rangement of the bile-forming function therefore produces a vicious circle that is highly dangerous. In the urine this condition usually becomes manifest by an increase of the aromatic sulphates, notably indican, and the ap- pearance of urobilin, bile pigments, and bile acids. (4) Failure of the liver to properly perform its share in the metabolism of the albumen and fats causes fragments of the lat- ter to be returned to the circulation, either unchanged or dis- assimilated into abnormal products. This, too, produces a gen- eral intoxication and may, in its ultimate consequences, lead to a syndrome that is not distinguishable from uremia, and that is, moreover, in all probability uremia (see page 237). Here the urine contains abundant ammonia salts, relatively small quan- tities of urea and usually an abnormal amount of fatty acids, possibly of leucin and tyrosin. (5) The loss or reduction of the normal disintoxicating power of the liver finally is the most serious result of hepatic insuffi- ciency and usually constitutes a terminal stage of the affection. Here the portals are thrown wide open to the invasion of the body with poisons of a thousand kinds that are formed in the bowel and in the tissues at large. That the organism cannot long withstand this toxic flood is self-evident. In such cases the toxicity of the urine will be found to be enormously increased, while, at the same time, the kidneys invariably became affected, for upon them is now thrown the task of ridding the body of cir- culating poisons, a function that normally they share with the liver. When renal insufficiency complicates hepatic insufficiency a severe toxemia must develop in very short order, and again a fulminating syndrone is presented that closely'simulates uremia. The treatment of hepatic insufficiency may be considered under two headings: (1) The suppression of its causes. (2) The symptomatic treatment of its manifestations. Causal treatment is in most instances synonymous with pro- phylaxis. Three factors, as I have mentioned above, chiefly deter- mine insufficiency of the liver cells, i. e., infection, intoxication, mechanical causes. The latter, unless we are dealing with some lesion that me- chanically compresses the common duct and that can be removed surgically, is not amenable to treatment, so that in this instance we are limited to symptomatic therapy. There is an exception to this rule, that is, syphilis. Here we may be dealing with a CHRONIC INFLAMMATION OF THE LIVER 493 gumma located in such a way that it produces compression of a Antiluetic large bile duct or of an important blood-vessel, or there may be g^^^tfc "* a syphilitic interstitial hepatitis. In both of these instances anti- Hepatitis syphilitic treatment may remove the cause, mechanical though it be. To an extent this also applies to what may be called me- chanical hepatic insufficiency due to venous stasis in the liver following heart lesions. Here cardio-tonic treatment may cause the symptoms of hepatic insufficiency to disappear. In the case of the intoxicating factors the source of poison is in the overwhelming majority of cases the gastro-intestinal Intestinal anti- tract. Here causal treatment should be carried out according to se P sls the following principles : To regulate the diet in such a way as to limit the ingestion of substances that are in themselves poison- ous or that undergo changes in the bowel that lead to the forma- tion of poisonous bodies; to reduce to the lowest possible min- imum intestinal putrefaction; to prevent as far as possible the absorption of whatever poisonous bodies may have gained en- trance to the bowel or may have been formed there; to promote the destruction of the latter in case they enter the circulation, and, above all, to hasten the rapid elimination of circulating toxins. The latter indication prevails with equal force in the case of poisons that are not formed within the bowel, but that are generated within the tissues of the body (endogenous poisons), as in infectious diseases and in a variety of metabolic disorders. Under the head of causal treatment all those measures might stimulation of also be included that we know are capable of stimulating the hepatic cells hepatic cells to renewed activity when their energies begin to flag, but this treatment must be carried out with conservatism, as I will have occasion to show further on. Symptomatic treatment includes the treatment of the protean Symptomatic array of sequelae of hepatic insufficiency. As derangement of treatment the liver function in its ultimate consequences may lead to the greatest variety of psychic, nervous, cardio-vascular, renal and metabolic disorders, symptomatic treatment of hepatic insuffi- ciency, as stated above, in the broader sense covers a large field of therapy. Probably the most important dietetic rule in the treatment Dietetic treat- of hepatic insufficiency is a negative one, i. e., that all alcoholic ment beverages should be rigidly excluded from the diet. We do not realize sufficiently that pure alcohol is the least toxic of the alco- hols that are used in the food of man; the higher alcohols and certain aldehydes and essential oils that are found in cheap liquors and that bestow the aroma or bouquet upon the various wines, liqueurs, and cordials, are much more poisonous even in 494 CHRONIC INFLAMMATION OF THE LIVER Spices and condiments Reduction of fats Meat and eggs Carbohydrates Vegetables Milk General ar- rangement of the diet the small quantities in which they are used ; thus, e. g., absinthe contains some eleven different principles, all of which are poi- sonous. Alcohol itself, therefore, unless taken in enormous quan- tities, is not so terribly dangerous ; but no one drinks pure dilute alcohol, but rather alcoholic beverages of various kinds, and as the latter are poisonous on account of the impurities they con- tain, it should be a cardinal rule in the treatment of hepatic in- sufficiency to exclude them rigidly from the diet. On the same grounds spices and condiments should always be excluded because they contain essences and alkaloids that are toxic to the liver. A second cardinal rule is to limit the ingestion of fats, for they are very poorly digested owing to the deficiency of bile acids from the bowel ; it is clear that in this case, as stated above, they are not properly saponified and emulsified, undergo rapid decom- position in the bowel, and in this way lead to the formation of acid and acrid products that are highly irritating to the liver and the bowel. It has been shown that in cases of hepatic insuffi- ciency the urinary toxicity increases greatly when much fat is given. "While it is not necessary, therefore, to exclude the fats altogether from the diet, they should be reduced to a minimum. Meat and eggs should also be reduced, for they furnish the bulk of the most toxic intestinal products whenever intestinal putrefaction goes on unchecked, and this we know to be the case when the bile is deficient or its composition is changed. There remain, therefore, as chief articles of food, vegetables and carbohydrates; the latter, in particular, are not toxic nor do they lead to the formation of toxic bodies in the bowel; and besides, sugar, as we know, stimulates the liver functions to ac- tivity. Of course, care should always be exercised not to admin- ister a diet containing too large a proportion of carbohydrate food, for otherwise fermentative dyspepsia, constipation, and a variety of digestive disorders may supervene. One should simply in- crease the amount of carbohydrate food to replace the deficit of fat. Milk can always be given with impunity. An exclusive milk diet, however, is for many reasons objectionable. (See page 208.) To summarize, the patient should be placed upon a bland mixed diet, containing no alcoholic beverages, a minimum of fat, a small amount of albuminous food, and plenty of fresh fruits, vegetables, milk, cereals, starches, and, with care, sweets. That the details of this diet should be regulated in such a way as to consider the individual idiosyncrasies and tastes, and above all complications in other organs, notably the kidneys, need hardly b° emphasized. CHRONIC INFLAMMATION OF THE LIVER 495 In view of the fact that the chief source of the poisons that intoxicate the liver and produce hepatic insufficiency is the in- testinal tract, it is of paramount importance to attempt intestinal antisepsis (see index) in every case of hepatic insufficiency that comes under observation. That the absorption of bowel poisons after they have once Evacuants formed can be restricted by the use of evacuants is clear. A saline laxative given at frequent intervals, combined possibly with enemas to clean out the lower bowel, is a useful measure. Purgatives or drastics that can irritate the liver should be used cautiously. All attempts that have so far been made to promote the de- struction of poisons after they have once been absorbed have been Oxidizing- abortive. A. Kobin, as is well known, introduced a so-called reatni8n oxidizing treatment and advised the inhalation of oxygen, the use of iron and manganese preparations. I have never seen any tangible good results follow this treatment. Cold hydrothera- Cold hydro- peutic measures, thanks to the leucocytosis, the increased meta- era Py bolism, and the better circulation of lymph they produce, are of much use. The elimination of absorbed poisons by the various emuncto- ries of the body is always indicated. Here elimination by ca- tharsis (see above) and diaphoresis, preferably brought about Diaphoresis by hydriatic measures, has a useful place. To attempt elimina- and catharsis tion by forced diuresis is, however, dangerous, as the toxins that are forced through the kidneys are bound to irritate them, and injury to the kidneys should of all things be avoided. The last and most important task is to attempt to restore the To restore function of the destroyed hepatic cells. Here the same principles * unc t 1 . on °* must obtain as in the treatment of any organ that has become fatigued. In very mild cases slight stimulation may at once restore normal tone; in more chronic conditions, however, rest is the prime requisite, for when the affected organ is spared nature soon re-establishes functional equilibrium. "We follow this plan exclusively in diseases of the stomach by withdrawing food for a while or by reducing the daily ration. We do it in dis- eases of the nervous system when we give a rest cure. We do it Rest in diseases of the heart when we put the patient on a mild, non- irritating diet with an ice bag over the heart. We are beginning to apply the same plan in diseases of the kidneys, and it cer- tainly has a grateful field of application in the case of the liver. Following a period of rest, what might be termed gentle ex- Exercise ercise of the organ may be instituted either by throwing upon the liver tasks that it should normally be able to fulfill, or by 496 CHRONIC INFLAMMATION OF THE LIVER Danger of ac- tive stimula- tion of the liver Hydrotherapy Cholagogues Alkalies Antipyrin Urea Organotherapy Liver extracts gently stimulating it with remedies or physical measures that we know can produce this purpose. Active stimulation with powerful remedies should be reserved as an emergency measure- in extreme cases, for nothing will so rapidly produce complete functional inadequacy of an organ that is functionally impaired as over-stimulation in the beginning. For the purpose of stimulating the function of the liver we- can have recourse in the first place to certain hydrotherapeutie measures. It has been established by careful studies that general hot baths or the brief application of cold locally over the liver,, preferably in the form of a stream of cold water directed for a minute or two against the hepatic region, will energetically stim- ulate the flow of bile. The same result can be obtained by the application of a so-called Priessnitz compress over the liver region. A towel is wrung out of cold water and laid over the liver and covered with a flannel. Many remedies are said to stimulate the formation of bile. Unfortunately, most so-called cholagogues do not possess this- power at all, but simply irritate the stomach, the intestine, and the liver. Best of all are the salicylic preparations and the bile- acids. (See page 488.) Preference should be given to the lat- ter remedy because the salicylates are somewhat irritating to the kidneys. The stimulation of the glycogenic function of the liver can be brought about by an active alkali therapy. Antipyrin/ too, possesses this power. Best of all, however, are the starchy and sweet foods, and these are already properly included in the diet. We know of no remedy that can stimulate the urea-forming function of the liver. The administration of abundant al- buminous food constitutes a physiological stimulant to this func- tion, and, if sufficient care is exercised that the bowel is kept aseptic, there is no reason why enough of albumen should not be given for this purpose, only however in mild stages of the dis- ease. Some writers have advised the use of urea, itself, claiming that a certain amount of urea is necessary, especially in order to promote diuresis, and that where its formation is deficient it should be supplied. This plan does not appeal to me, and, de- spite the various favorable reports on this therapy I have never been able to convince myself of its value. Liver extracts given in the form of powdered calf's liver or pork liver, suspended in milk or water, by enemata, or even sub- cutaneously, is worthy of trial. Symptomatically I have seen some good results from the ingestion of liver extract in cases; of cirrhosis of the liver with hepatic insufficiency, especially in CHOLELITHIASIS, CHOLANGITIS AND CHOLECYSTITIS 497 the direction of an increased urea excretion, an increased toler- ance for carbohydrates, and an apparent improvement in some of the nervous manifestations. That the administration of liver extract stimulates the regeneration of liver cells, as is claimed by some clinicians (Gilbert andCarnot) ; that it produces a vicarious hypertrophy of those portions of the liver that are not affected is hard to prove. Finally, something* may be said in regard to the danger of Dangers of op- operative interference in cases of hepatic insufficiency. There f erence an a " is in most of these cases a tendency to hemorrhage due, possibly, chloroform to the circulation in excess of bile acids; for the latter have a distinct hemolytic power and interfere with the coagubility of the blood. Besides, the administration of chloroform is a very dangerous procedure in any case, even of mild hepatic insuffi- ciency, for, in predisposed subjects who, we must assume, possess an idiosyncrasy against chloroform, a condition may develop which closely simulates acute yellow atrophy of the liver, both clinically and anatomically. I think it is just as important for this reason that surgeons should, as far as possible, examine the functional state of the liver before an operation as they do, or should, study the condition of the kidneys. If any of the evi- dences of hepatic insufficiency that have been enumerated above should be present, then chloroform at all events should not be administered as an anesthetic, and the possibility of profuse capillary hemorrhages be remembered. If it were not for this difficulty of operating upon cases of hepatic insufficiency the so- called Talma operation, which consists in producing an artificial Talma opera- collateral path for the flow of blood from the portal circulation tlon into the systemic circulation, either by epipoplexy or by curet- ting the parietal peritoneum and the omentum, would be more useful than it really is. Treatment of the dyspeptic symptoms, the ascites, the hem- symptomatic orrhages, the cardio-vascular changes, the nervous manifesta- treatment tions, the nephritic lesions, and the icterus that accompany or fol- low chronic inflammations of the liver need not be discussed again in this place, the different measures to be employed having been fully presented in appropriate sections. CHOLELITHIASIS, CHOLANGITIS AND CHOLECYS- TITIS. In simple uncomplicated cholelithiasis, i. e., in a subject show- Prophylactic ing a tendency to recurrent attacks of gall stone colic, prophy- treatment lactic treatment directed towards promoting an active flow of 498 CHOLELITHIASIS, CHOLANGITIS AND CHOLECYSTITIS Stimulation of the bile flow Diet Albumens Carbohydrates Pats Alcohol Small meals at frequent inter- vals Abundant water drinking Mineral waters bile, and towards hindering catarrhal inflammation of the gall- ducts and the gall-bladder, can be instituted. Every endeavor should be put forward to promote a steady flow of bile towards the intestine ; for, in this way stasis of bile constituents is prevented. This is an important element in prophylaxis, inasmuch as stagnating bile forms a suitable nidus for the development of bacteria. Besides the invasion of the bile ducts and gall-bladder by bacteria from the intestine is ren- dered quite difficult if the bowel passages are constantly drained by an active stream of bile flowing towards the intestine. In order to stimulate the current of bile the diet should be mixed. It should contain an abundant quantity of albumen and relatively small quantities of carbohydrates and fats. Al- bumens more than starchy, sweet and fat foods lead to the for- mation of abundant bile acids and the latter render the bile more fluid, more abundant and also impart to it certain antiseptic properties. Carbohydrate foods, on account of their tendency to produce congestion of the liver and intestinal fermentation, when given in abundant quantities, should be somewhat reduced in quantity. Fats are apt to irritate the bowel and to produce in- testinal dyspepsia, hence they should be very much reduced or altogether excluded from the diet, especially as their presence in the bowel would be particularly detrimental should an attack of gall stone colic with gall-duct occlusion suddenly supervene. Alcoholic beverages, spices, condiments and all irritating or coarse foods that can determine catarrhal conditions of the upper digestive tract should be avoided. A steady flow of bile, moreover, is stimulated by the admin- istration of meals at frequent intervals. Consequently in addition to the three regular main meals a day a patient with cholelithi- asis should be instructed to take a glass of milk or an egg-nog with a few crackers, or a piece of toast, in the middle of the fore- noon and the middle of the afternoon. The administration of a similar meal in the middle of the night is rarely necessary. Plenty of water, especially some of the alkaline or alkaline- saline mineral waters, should be taken; the latter in particular aid in dissolving the mucus in the bile passages and hence in maintaining the bile ducts open. It is questionable whether alkaline waters exercise any determinable effect upon the alka- linity of the bile and hence, as some clinicians claim, aid in keep- ing the ingredients that precipitate in the form of concretions in solution. So much is certain that they exercise no solvent action upon gall stones after the latter have once formed. The chola- gogue action of mineral waters is also in doubt and the dilution of the bile that is postulated from the administration of abundant CHOLELITHIASIS, CHOLANGITIS AND CHOLECYSTITIS 499 liquids is problematical. Too great restriction of the intake, how- ler, assuredly leads to greater viscidity of the bile, hence favors sluggishness of the bile stream and stagnation. The chief action of alkaline mineral waters is presumably exercised in preventing ^astro-intestinal catarrh, hence abnormal fermentation, the devel- opment of bacteria and catarrhal swelling about the orifices of the gall-ducts. The laxative properties, finally, of certain min- eral waters stimulate intestinal peristalsis and indirectly also peristalsis in the bile ducts; in this way, then, they also aid in the expulsion of the bile. The great benefits accruing from the use of certain mineral Eesort treat- waters taken in resorts must be attributed only in part to the m e n t abundant ingestion of the liquid and the incorporation of the alkaline and saline principles they contain. The life in a resort, itself, the respite from the daily routine, the out-door existence, the careful regulation of the general regime and of the exercise, the scientific employment of hydr other apeutic measures and the management of the case by skilled specialists are all elements that contribute towards the good results obtained from the resort treatment of cholelithiasis. The regulation of exercise and abdominal massage are all _ . , ° ° Exercise and useful adjuvants to the treatment, chiefly on account of their massage power to stimulate the flow of bile. Violent exercise should never be permitted to patients showing a tendency to gall stone colic ; for sudden movements of the body are very apt to cause im- paction of a gall stone and to precipitate an attack of colic. Vio- lent exercise is altogether contra-indicated in cases of cholelithi- asis complicated with cholecystitis and cholangitis, or in patients with chronic icterus due to impaction of a gall stone ; for in these cases there is always danger of perforation and resulting peri- tonitis. The clothing should be loose and all pressure by the cloth- ing on the liver region avoided. In women tight skirt bands and ° ins corsets should be forbidden and the clothing suspended from the shoulders. In men the wearing of belts is to be forbidden. It is usually a good plan to order these patients to loosen the cloth- ing about the waist after meals. The use of cholagogues is indicated as a prophylactic measure in cases of cholelithiasis. As stated above in the Section on ° a ^°^ ues Catarrhal Jaundice, only two remedies can directly be credited ' with bile-stimulatiniz' properties, namely, the bile acids and the salicylates. In addition to their cholagogue powers, these two remedies als^ possess antiseptic properties that are especially use- ful in cholelithiasis; for both these remedies after absorption 500 CHOLELITHIASIS, CHOLANGITIS AND CHOLECYSTITIS Sodium glyco- cholate Salicylic acid Expulsion of gall stones Olive oil Enteroliths after oil from the bowel are re-excreted in part via the gall-ducts, hence they promote an increased outpouring of bile that has been ren- dered, to some degree at least, antiseptic. The best way to administer bile acids is in the form of sodium glycocholate in doses of one-half to two grains (0.03 to 0.13 gm.). Salicylic acid is better than the salicylates and a pill containing a grain each of sodium glycocholate and of salicylic acid, given three or four times a day, must be considered an efficient means to stimulate the flow of bile. All the other rem- edies that have been recommended at different times as chola- gogues act presumably chiefly as laxatives. They may exercise some effect upon the flow of bile by increasing intestinal peri- stalsis and indirectly the peristalsis of the gall-ducts. They are vastly inferior, however, in efficacy to the two above-mentioned remedies (see also Section on Catarrhal Jaundice). All the measures enumerated not only aid in preventing the formation of gall stones, but also assist in the expulsion of gall stones that may be present in the bile ducts. In addition certain other remedies may be used for the latter purpose, namely, olive oil and glycerin. The former is warmly recommended by some clinicians and condemned as utterly useless by others. Personally, I have never been convinced that the use of olive oil materially influences the course of a case of cholelithiasis, prevents the formation of gall stones, or aids in their expulsion. It is very questionable, in fact, whether the oil after absorption really enters the bile ducts and is re-excreted with the bile. Whatever good effects may oc- casionally be observed from the use of olive oil must be attributed in great part, at least, to its slightly nauseating and laxative properties whereby it stimulates peristalsis and contraction of the bile ducts. After the administration of olive oil small masses of saponified oleic acid are frequently deposited with the feces, and it is quite probable that these enteroliths have occasionally been taken for expelled gall stones. Olive oil may either be given in one or two tablespoonful doses in the evening before retiring, or, better still, in fifteen drop doses before breakfast on an empty stomach, every day or every other day. A convenient formula for the administration of olive oil is the following, recommended by Rosenberg: * R Olive oil Brandy Menthol The yolk of one egg 200.0 20.0 0.2 CHOLELITHIASIS, CHOLANGITIS AND CHOLECYSTITIS 501 This mass is thoroughly mixed and taken in two doses an hour apart. The disagreeable fatty taste of the oil can be removed by eating little pieces of orange or lemon peel, or taking a teaspoon- f ul of orange or lemon syrup. Glycerin, which is sometimes a very effective remedy in renal Glycerin lithiasis (see page 231), is hot so useful in cholelithiasis. It should be given in the dose of about half a teaspoonful in some mineral water once a day. Glycerin, too, probably acts on ac- count of its laxative properties. The attempt to promote solution of gall stones in the biliary The solution of passages by the administration of any medicine by mouth must 8& be considered altogether futile. Various drugs, like olive oil, ether, turpentine, chloroform, sodium oleate (eunatrol), and many others that are credited with this power are, I think, alto- gether inert in this direction. If large masses of gall stones are present and if their re- Surgical re- moval becomes desirable (see below), then surgical means should SJInes be promptly adopted and no time wasted with medicinal meas- ures. In view of the tendency nowadays to operate somewhat pro- Warning miscuously in every case of gall stone disease, a certain warning miscuous sur- may be uttered. There are distinct indications for surgical in- gical treatment tervention which will be presently discussed. The appearance disease of gall stone symptoms, or even of signs of gall-bladder or bile channel infection, must not, however, be considered the signal for an operation in every case. A large proportion of patients suffering from chronic cholelithiasis recover without surgery, and it is well worth while in each case to give the patients the full benefit of medical treatment. Surgery at best can only remove gall stones or promote drain- Limitations of age of the gall ducts or gall bladder, but it cannot affect the sur £ er y morbid processes that originally led to the formation of gall stones or infection of the bile passages. The treatment of the case, moreover, is by no means completed after the gall stones have been removed, or the gall-bladder or the gall passages have been drained; and a patient once afflicted with gall stones, even after he has been operated upon, should remain under careful supervision until the hepatic disorder and the catarrhal condi- tion of the bile passages are completely cured. This aim can only be accomplished by medical means, namely, by careful reg- ulation of the patient's diet and general mode of life, by the ad- ministration of proper remedies and the institution of the other measures that have just been enumerated. Under the following conditions surgical intervention, how- Indications for ever, becomes necessary and constitutes the only effective means tervention 1 " of treating these cases, namely: 502 CHOLELITHIASIS, CHOLANGITIS AND CHOLECYSTITIS Recurrent at- tacks of colic Suppurative cholangitis and cholecystitis Complete gall duct occlusion Peritonitic signs Adhesions First. In frequently recurring attacks of gall stone colic that do not yield to internal treatment, that reduce the patient's health and impair his working capacity, especially if the pres- ence of many gall stones in the gall bladder can be determined. While one can never predict that an attack of gall stone colie may not be the last one, it is, nevertheless, important to remem- ber that each attack injures the bile passages and may lead to ulceration or the formation of dangerous strictures or adhesions or stenosis (or acute, hemorrhagic pancreatitis). Repeated at- tacks, therefore, in which any evidence of such complications ap- pears, must be considered fit for surgical intervention. Second. If suppurative cholangitis or cholecystitis compli- cates the disease. Here spontaneous recovery may occur (see below), but free drainage and irrigation and removal of the gall stones that keep up the irritation of the gall-bladder and bile passages, is usually the quickest and most certain means of pro- ducing a cure. Third. In complete common duct occlusion which persists and leads to the development of profound icterus. This condi- tion should never be allowed to persist for longer than two months at most. If, during this time, serious impairment of the patient's health occurs, an operation should be performed much sooner. It is usually dangerous to wait too long in this condi- tion, because in chronic icterus of this kind a tendency to hem- orrhage develops which may render an operation especially dan- gerous. Fourth. Peritonitic symptoms developing as the result of perforation or rupture of the gall-bladder or its ducts, occurring either during an attack of gall stone colic or developing slowly in the course of chronic stenosis or ulceration of the gall-bladder or the bile duct. Fifth. Adhesions forming around the gall-bladder and pro- ducing mechanical dislocation or stenosis of adjacent organs, es- pecially the stomach, the duodenum and the colon, and causing a variety of distressing symptoms, chiefly pain, gastro-intestinal disorders, and biliary colic. While it is true that adhesions are apt to form again even after an operation, a skillful operator can usually manage the field of operation in such a way that the new adhesions form in a more favorable locality. Treatment of the acute at- tack TREATMENT OF THE ACUTE ATTACK. In treating an acute attack of gall stone colic the following- indications must be met : — First, to stop the excruciating pain. CHOLELITHIASIS, CHOLANGITIS AND CHOLECYSTITIS 503 Second, to facilitate the passage of the stone and prevent its permanent impaction. Both of these indications are best met by opiates; for the Opiates latter not only promptly stop the pain, but also cause the relaxa- tion of the muscularis lining the gall-ducts and hence facilitate the passage of the stone. One must imagine that spastic reflex contractions of certain portions of the bile duct are stimulated by the stone and that, in this way, the concretion is held tightly in one place. If opium or morphine are given, this tonic con- traction stops and new peristaltic movements are gradually re- sumed until the stone is either expelled or is again arrested by spastic contractions of some part of the bile passages farther down; as soon as this occurs an opiate should again be admin- istered. The best way to administer opiates is, therefore, to give a Dose and ad- hypodermic injection of a quarter of a grain (0.005 gm.) of mor- ministration phine as soon as the patient is seen and to repeat the dose once or twice according to the requirements of the case; or a hypo- dermic of morphine may be given at first and later, when attacks of colic return, ten to twenty drops of the tincture of opium by mouth, to be repeated at intervals of one or two hours. Belladonna and atropine also relieve the muscle spasm and Belladonna and can be used instead of, or together with, opium or morphine. atro P me Belladonna is best given either as the extract of the leaves in powder form in the dose of y± to V2 grain (0.015 to 0.03 gm.) ; or in the dose of five to fifteen minims (0.3 to 1 cc.) of the tinc- ture of belladonna leaves repeated several times; or as atropine sulphate, in the dose of one-hundredth to one two-hundredth of a grain (% to 1 mg\), either alone or in combination with a quar- ter of a grain (0.015 gm.) of morphine. Other remedies employed for the purpose of stopping the Antipyrin and pain in cholelithiasis are antipyrin and other members of the otlier anal- g GSXCS group of coal tar analgesics, sodium salicylate and many more, god-rim sa i- No remedy, however, is as efficacious as opium or belladonna, icylate If the pain is very severe and does not yield promptly to the ad- ministration of morphine, then a few drops of chloroform on ice, or a teaspoonful of chloroform water, repeated at frequent inter- Chloroform vals, or even a few whiffs of chloroform, may have to be given. Chloral is not as valuable as chloroform and is, in most cases, Chloral a dangerous remedy to be employed. Heat or cold may be applied locally. Heat is usually much Hot and cold more effective in alleviating the pain, especially when applied a PP llcatio,x « continuously by means of hot poultices, a Leiter coil charged with hot water or a thermophore (see index). Immersion of Hot batn ; 504 CHOLELITHIASIS. CHOLANGITIS AND CHOLECYSTITIS Cold applica- tions Laxatives Enemata Collapse Analeptics Alcoholic drinks Cholangitis and cholecys- titis Cholagogue- antiseptic treatment the patient in a hot bath is also a very effective means, in most cases, of cutting the attack short. If heat is not well borne, and this is most apt to be the case, especially in the presence of complicating cholecystitis and cholangitis, cold may be used instead. As pressure upon the gall-bladder region is rarely well tolerated, it is best to suspend the ice bag over the patient and to have it barely in contact with the gall-bladder region, or to use a Leiter coil charged with ice cold water applied to the same place. Free evacuation of the bowels by the use of laxatives and enemata should always be promoted when an attack of gall stone colic occurs. If castor oil or sodium phosphate are vomited, then high rectal injections of cool water may be administered both for the purpose of cleaning out the lower bowel and for the pur- pose of stimulating intestinal peristalsis (see the Section on Ca- tarrhal Icterus, page 487). Enemata of olive oil are also useful. If very reduced and weak patients should develop symptoms of collapse or shock from the severe pain, analeptics (see page 32) may have to be administered, especially if the pain is not promptly controlled by the use of morphine. A little champagne, hot alcoholic drinks, camphor, ether, ammonia, or adrenalin chlo- ride administered by mouth or hypodermically are all of use. CHOLANGITIS AND CHOLECYSTITIS. In infections of the bile ducts and gall-bladder (cholangitis and cholecystitis), an attempt should always be made to control the infection by medical means ; for this purpose hot or cold ap- plications to the gall-bladder region should be made and con- tinued for several days. The choice of heat or cold will have to be made according to the subjective sensations of the patients. The bowels should be thoroughly cleaned out and kept clean by the administration of laxatives and enemata. Here a chola- gogue-antiseptic treatment with the salicylic acid and bile acid combination described above, to which may be added half a grain of menthol as an antiseptic and anesthetic, is useful. The follow- ing combination is also very popular for continued use : 3 Sodium benzoate 0.5 Sodium salicylate 1.0 In pill or capsule, to be given three or four times a day. (ChaufPard.) I consider the salicylic acid and bile acid pill, however, to be more efficacious. CHOLELITHIASIS, CHOLANGITIS AND CHOLECYSTITIS 505 The diet during this treatment should be bland and non- Diet irritating. During the first week of the bile passage infection, milk alone is best given, during the second week soups or thin gruels may be added to the milk, and during the third week and later a little meat and a gradual resumption of a general mixed diet may be allowed. If all these measures fail within a few months to relieve the inflammation, or sooner if the patient suffers from recurrent at- Surgical tacks of pain with or without icterus, and develops signs of gen- eral septic toxemia, loses much strength, becomes emaciated and anemic, recourse must be had to surgery. Opening of the gall- bladder, free drainage and irrigation usually produce prompt relief and, in most cases, constitute the only means of effecting a permanent cure of this obstinate and dangerous condition. treatment CHAPTER X. INFECTIOUS DISEASES INTRODUCTORY. Acute infectious diseases are in a sense self -limiting and dis- General indict play a tendency towards spontaneous recovery. The chief duty tl0n s for treat- of the physician, therefore, must be to imitate the methods put forward by Nature towards restoring normal conditions, wher- ever that is possible. Wherever, in the obscurity of our present knowledge, that is impossible, he should concern himself with creating ideal conditions about the patient in order to enable him to exercise his best efforts towards combating the infection. Here and there, besides, it may become necessary to strengthen, reinforce and stimulate reactive processes when they begin to flag; to hold them in check when they threaten to exceed safe bounds. Finally, various disorders about the different organs and functions of the body produced by the infection call for reg- ulation and symptomatic treatment. The specific (diphtheria), or antiseptic (syphilis, malaria, Specific anti- rheumatic fever), and specific prophylactic (small pox, tetanus, septic prophy- hydrophobia, tuberculosis [ ?] ) treatment of the disease is pos- ment sible only in a few infections. In all the others we are limited Expectant- in our endeavors and can only treat the patient by an expectant- symptomatic symptomatic plan. Provided the broad principles of hygiene and of the general management of the patient afflicted with an acute infectious dis- ease are understood and carefully applied, the basal treat- ment of most infectious diseases, for which we possess no specific remedy, is very much alike. In order to avoid unneces- sary repetition a few general remarks in regard to the rationale of fever treatment, and in regard to the principles that should underly the arrangement of the fever diet may be discussed in this place. THE TREATMENT OF FEVER. The treatment of the fever is an important element in all Treatment of acute infectious diseases. It is essential to realize that the fever fever, provided it is not too high nor too persistent, does not se- riously damage the organism. In fact, the febrile reaction must be considered one of Nature's most effective means of combating Fever a salu- the infection. Interference on the part of the physician is re- tar y reaction quired, therefore, only if the febrile reaction exceeds safe bounds. The old idea that the fever must at all costs be kept down was 508 INFECTIOUS DISEASES The normal au- tomatic fever mechanism The initial chill Radiation of heat via the pulmonary and the cutaneous route Fresh, cool air and hydro- therapy Antipyretics based on the erroneous idea that the parenchymatous changes seen in many organs during the course of acute infectious dis- eases were produced by the high temperature. Nowadays, we have learned to recognize that these lesions are caused by the ac- tion of circulating bacterial toxins. Upon the onset of •an infectious fever the high temperature is produced not only by an increased manufacture of heat but also by a decreased radiation of heat. The loss of heat is in- hibited chiefly by contraction of the cutaneous vessels, so that early in most infectious diseases the skin becomes cool and the patient suffers a chill. Sometimes this reaction presumably suf- fices to abort the infection. If this preliminary condition were to continue throughout the course of the disease the patient's temperature would rise to unsafe limits ; consequently, the radia- tion of heat is automatically resumed very soon after the initial chill chiefly by two paths, namely, by the pulmonary and the cutaneous route. This adjustment must be considered as a self-regulating mechanism. Inasmuch as the increased produc- tion of C0 2 which accompanies the initial febrile rise stimulates the respiration, more rapid breathing occurs, more water is ex- haled and considerable heat is lost in this way (each gramme of water evaporated in the expired air causing a loss of about 575 calories). The loss of heat through the skin is promoted by sweating and the evaporation of surface water. (Sweating dur- ing the crisis serves a different purpose ; it must be considered as an endeavor on the part of the organism to rapidly get rid of the surplus water which was retained in the blood and tissue juices during the fever in order to maintain proper osmotic equivalents). In cases suffering from excessively high degrees of fever these methods that Nature spontaneously puts forward must be imi- tated. The pulmonary radiation of heat must be encouraged by supplying plenty of cool, fresh air (see Section on Pneumonia). The cutaneous radiation must be aided chiefly by hydriatic means (see Section on Typhoid). In addition certain remedies can be employed for their anti- pyretic effect. Here what may be called "central" as against "peripheral" regulation of the temperature is attempted, inas- much as most antipyretic drugs act on the central nervous ele- ments and paralyze the heat centers. In the latter case, there- fore, the manufacture of heat is reduced, whereas by the former method the radiation of heat is increased. In nearly all cases of acute infectious diseases one can get INFECTIOUS DISEASES 509 along very well without antipyretic drugs, and they should be General indica- given very sparingly and with great care only in extreme cases c^ntra^ndica- in which high degrees of temperature cannot be reduced by the tions for the pulmonary or the cutaneous route. Antipyretics should, more- retic arugs Py " over, only be given intermittently and always in combination with heart tonics. Their use is rarely called for early in the disease arid they are useful chiefly when the tone of the heart and of the vaso-motor centers has begun to flag, when the self- controlling mechanism fails and calls for regulation by artificial means. It will generally be found that antipyretics exercise a much more profound and rapid effect precisely during these later atonic stages than during early sthenic periods of the infection. To enumerate all the antipyretic drugs that can be employed The chief anti- (and to this class, broadly speaking, belong remedies that act Pv retics directly on the fever-producing toxins like quinine and salicy- lates, drugs that paralyze the muscles (curare), drugs that par- alyze the peripheral capillaries and hence promote increased radiation) is unnecessary. The chief antipyretics to be employed are quinine, salicylic acid, antipyrin and its congeners, and alco- Quinine hoi. The dose and administration of these drugs and of certain Salicylic acid other antipyretics will be discussed below in their appropriate its conveners places. Alcohol THE FEVER DIET. The most important element in the feeding of febrile cases is to maintain the albumen content of the organism. The amount of albumen consumed by a fever patient and the degree of gen- eral emaciation that supervenes depend somewhat on the char- acter of the poison and the complications that arise. To main- tain complete nitrogen equilibrium is usually a very difficult task. The attempt, however, should always be made to introduce small quantities of albumen daily in some form, together with plenty of carbohydrate and some fat. Both fats and carbohydrates pro- tect the albumens of the body; the latter much more than the former, however, inasmuch as 100 fat calories can replace only 5.4 albumen calories, while a hundred carbohydrate calories can replace 15.4 albumen calories. The demand for food is decreased in febrile cases and its as- caloric re- similation interfered with; at the same time the individual is quirements of n o ii ii ii- febrile organ- quiescent and performing no labor, so that the total caloric re- ism quirement, despite the increased metabolism, is lower than one might expect and can consequently be supplied much more readily than if the individual required a normal amount of caloric values to maintain nutrition. In a subject weighing about 510 INFECTIOUS DISEASES Milk 8ug"ar solu- tions Gruels Gel;: .inous foods Fats Water seventy kilos the following ration theoretically calculated is usu- ally sufficient : 50 gm. of proteid = 205 calories 50 gm. of fat = 495 calories 500 gm. of carbohydrate =2050 calories 2720 calories or about 30 calories per kilo.* In practice the following general rules of feeding sufficiently approximate the above requirements. Albumen should be sup- plied in the form of one or two eggs in some shape daily, or in the form of milk ; the latter being the most valuable fever food of all, inasmuch as 1000 cc. of milk incorporate 35 grammes of pro- teid, 35 grammes of fat and 45 grammes of sugar, representing a total caloric value of 650 calories. The addition of abundant carbohydrate to milk, in the form of sugar solutions or gruels made of milk and flour, barley, arrowroot, sago and tapioca, usually suffices to bring the daily ration up to the required ca- loric value. Proteids may also be supplied in the form of gela- tins, meat jellies, etc., and other liquid and semi-liquid meat products, the preparation of which is described in the Section on Typhoid Feoer. The fats should be given in small quantities and supplied only in the form of cream, or as a little butter added to gruels, or in the small quantities of meat fat that re- main in the meat preparations that can be administered. Alco- hol in small quantities, aside from its antipyretic properties, con- stitutes a useful food in fever cases, especially as it possesses very marked albumen sparing properties. "Water should always be given in abundant quantities in fever cases, not only in order to quench the thirst and to dilute the toxins, but to relieve the organism of the necessity of manufac- turing water from its own tissues, thereby splitting up complex molecules and flooding the blood and tissue juices with waste products. A febrile patient should be offered a drink every fif- teen to thirty minutes during the day, alternating the beverage, i. e., offering milk, soups, lemonade, a little wine, coffee, tea and water. The following fever diet, which is employed as a routine in the Charite Hospital in Berlin, may serve as a prototype of an average fever diet: — For breakfast 500 cc. of milk sweetened with plenty of sugar and flavored with a little coffee. For dinner 250 cc. of meat broth. ♦See also chapter on Diseases of Me tabolism. PNEUMONIA 511 In the middle of the afternoon 500 cc. of milk, with sugar and coffee as above. For supper 250 cc. of gruel made of milk* and flour. Distributed over these four meals 80 grammes of rolls, toast or zwieback. The following dietary constitutes a daily ration which about meets all requirements: 1000 cc. of milk = 650 calories 2 eggs = 150 calories 400 cc. barley gruel = 200 calories 100 g. zwieback or toast = 350 calories 100 g. cane or milk sugar = 410 calories 200 cc. of Tokay or port wine = 300 calories Total =2070 calories In. arranging a dietary, finally, the state of the digestive state of the function must be carefully included in the calculation. Both digestive func- the fever and the toxemia affect the digestive organs in the sense that the amount of saliva and its amylolytic power are reduced, that the motor and secretory powers of the stomach and bowel .are impaired and the flood of bile is decreased. These perversions of the digestive function are reflected in the loss of appetite. In cases of fever in which there is a com- plete distaste or aversion for food, rectal feeding (see index) Rectal feeding may therefore have to be resorted to. An important element, finally, in maintaining the proper nu- trition of fever patients is to perform a careful toilet of the To11 ®* °* tlie mouth, as described in the Section on Stomatitis. In the following pages those infectious diseases that are amenable to specific treatment have been discussed in full, where- as of the large group of infections that must be treated by the expectant-symptomatic plan, only the most important and the most common members have been specially noted. In order to avoid useless repetition in this volume the treatment of the com- plications occurring in different organs has only been touched upon, for full symptomatic treatment of the different organ lesions has been already described in the preceding chapters. PNEUMONIA. (By Dr. E. F. Wells, Chicago.) Pneumonia is a widely prevalent and very dangerous dis- ease ; in temperate regions it is responsible for more deaths than any other malady; its prevalence and dangers, measured by any 512 PNEUMONIA Materiel morbi Prophylaxis rule which you may choose to apply, are increasing with each passing year; it§ treatment is the greatest and most pressing medical problem of the day. "What can we do to lessen its prev- alence and reduce its mortality? These are the questions, shorn of all minor and collateral issues, which are presented for our careful consideration. Pneumonia is caused by the pneumococcus. This bacterium, in one or another of its varieties, you may find in the upper re- spiratory passages in a large proportion — probably one-half — of all healthy persons. It is disseminated through the air which has become pneumococcus-laden by the spray produced in coughing and sneezing, and from dried and pulverized sputum of infect- ed, but not necessarily pneumonic, individuals. If such air is inhaled by a healthy person the germs may find permanent lodgment in his nose and throat. In this locality the pneumococcus is probably an innocent parasite, but if it finds its way into the pulmonary alveoli pneumonia results. The entrance of this organ- ism into the air cells may be invited by any condition which ren- ders paretic the laryngeal and bronchial reflexes. It is found in the circulating blood, early — I have recovered it within an hour of the initial chill — in a very large proportion, if not all, of the cases. Intercurrent or independent pneumococcal in- flammation, with sanguineous infection of other organs and tis- sues, as, e. g., endocardium, articulations, peritoneum, etc., may occasionally occur. The various strains of the pneumococcus vary in virulency, and those which are most virile obtain the widest distribution and create the greatest havoc. With the basic etiological facts fully appreciated we are prepared for an intelligent consideration of the prophylaxis of this malady. This I believe to be the most important and most hopeful section of the whole pneumonia question, which is com- mended to the earnest attention of the profession. In the case of each individual under professional care the tonsillar surface secretions should be examined for the pneumo- coccus. If a Gram positive encapsulated diplococcus (or strep- tococcus) • is obtained it may be considered, for this purpose only, sufficient evidence of the presence of the pneumococcus Such examinations should be repeated at intervals, in order to have fair knowledge whether the patient is, or is not, affected. Keep a record of, and report to him, your findings. With the throat free from pneumococci the individual is practically ex- empt from pneumonia. For the medical practitioner I recommend the following 1 gm. 2 gm. 200 ec 0.5 cc 10.0 cc 10.0 cc 4.0 cc 60.0 cc PNEUMONIA 513 technique: Rub a sterile cotton swab over both tonsils; make Technique of one- 544 Intubation Tracheotomy half grain (0.003 to 0.3 gm.), hypodermically ; by hot, wet packs; by the steam tent (see index) or by hot air, are considered efficacious in relieving the dyspnea and in promoting loosening of the membrane. In nearly all cases the administration of antitoxin acts with particular efficacy in promoting shedding of the membrane. The expulsion of the membrane may further be facilitated by the use of emetics, apomorphine, ipecac, tartar emetic (see page 281). If despite the administration of antitoxin and the employ- ment of steam inhalations, sweating and emetics the membrane continues to form or is not loosened and expeiled, then intubation or even tracheotomy may have to be performed. Fortunately the necessity for this operation is becoming less and less. The description of the methods of intubating or tracheotomy does not lie within the scope of this book. Quinine a specific Mode of action Mode of ad- ministration Preparations of quinine to "bo given by mouth Cuinine hydro- chlorid sulphate MALARIA. The employment of quinine as a specific renders the treat- ment of malaria exact and simple. Quinine and its salts are protoplasmic poisons. They act more strongly, possibly specific- ally, upon lower forms of life than on the more highly organized cells of the human body ; hence quinine in doses that do no harm to the protoplasm proper of the host possesses the power of de- stroying unicellular organisms like malaria parasites that in- vade it. Quinine preparations may be given by mouth, by rectum, hy- podermically and intravenously. In the great majority of cases the administration by mouth is effective. If much gas- tric irritation develops from the administration of quinine by mouth, or if it is desired to obtain a somewhat more rapid effect, the administration by rectum in clysma or suppository may be adopted. If a still more rapid effect is desired the drug may be given hypodermically ; and in pernicious forms of malaria when the patient is in danger of his life and an immediate re- sult is desired, quinine may be injected into the veins. Numerous preparations of quinine have been used. For ad- ministration by mouth the hydrochlorid of quinine is the best. Quinine sulphate is also very useful. The quinine hydrochlorid, however, contains percentically more quinine than the sulphate, it is also more rapidly absorbed, so that twice to three times as much of the sulphate must be given as of the chlorid in order to obtain the same effect. In very nervous subjects and in individuals in whom the administration of quinine exercises an irritating effect upon the MALAEIA 545 nervous system the valerianate or bromid of quinine may be Quinine vale- given in place of the chlorid or sulphate. It will rarely be nee-, ^^id essary to use these compounds, however, for if it is desired to secure a valerianate or bromid effect it is always simpler and safer to give the two drugs separately. This is especially true as quinine in order to be effective must be given in large doses, as will be presently shown, and because this task is rendered difficult if the drug is given in chemical combination with sub- stances that cannot safely be administered in large quantities. A very useful preparation of quinine is euquinine. This Euquinine remedy is particularly useful for administration to children, as it does not possess the bitter taste nor most of the toxic prop- erties of quinine Irydrochlorid or sulphate, while it is quite as effective as any of the latter preparations. In giving euquinine instead of quinine salts about one-and-a-half parts of euquinine should be allowed in place of one part of quinine. Quinine hydrochlorid or sulphate are best administered in Administration capsule or pill form. It is true that in solution the absorption goiutkm 1 * of quinine is very much more rapid, but the bitter taste of such solutions, that is only poorly disguised by the administration of the drug in syrups or in watery solution flavored by various volatile oils or in coffee, is a serious deterrent to its employment in liquid form. For hypodermic use the acid hydrochlorid of quinine Hypodermic (quinine bimuriate) is the best; it should be administered in method ten to twenty grain doses dissolved in about 2 to 3 cc. of water. The neutral chlorid of quinine is not very soluble in pure water. If the solution is prepared with hot water, however, and if a little urea is added, the solubility of the quinine chlorid is in- creased and the injection is not quite so irritating. For rectal use a little opium should be added to the quinine Rectal method solution as quinine salts are somewhat irritating to the rectal mucosa. The solution may either be made with water or with mucilage and one of the following two formulae can be utilized for preparing the clysma : Quinine hydrochlorid, 2.0 gm. Or Tincture of opium, 10 drops. Water, 100.0 cc. Quinine hydrochlorid, 2.5 gm. Tincture of opium, 10 drops. Mucilage, 40.0 cc. 546 Intravenous method Time to ad- minister qui- nine For intravenous injections an acid solution of quinine can- not be used. The solution should be neutral. The best prepa- ration is the following, recommended by Bacelli: The simple intermittent type of malaria ? Quinine hydrochloride Sodium chloride, Distilled water, 1.0 gm. 0.075 gm. 10.0 cc. This solution is to be heated to body temperature and trans- fused directly into the veins of the fore-arm, as described in the Section on Pernicious Anemia, on page 75. The injection of such large quantities of quinine intravenously generally produces severe symptoms of intoxication, i. e., a bitter taste in the mouth, dizziness, tinnitus aurium, cold sweats, some precordial distress, palpitation and a feeling of oppression. These symp- toms usually disappear promptly in from fifteen minutes to half an hour and are usually negligible. If the pulse becomes very weak and slow a hypodermic injection of ether, or camphor and ether, may be given. The treatment of the malarial paroxysms with quinine varies somewhat according to the type of malaria. Inasmuch as very large doses of quinine are apt to produce a variety of disagree- able symptoms as indicated above, it is desirable to produce the desired effect with the smallest possible quantity of the drug. For this purpose, especially in the simple quotidian type of malaria, it is important to administer the quinine in one or two relatively small doses at exactly the right time rather than in- discriminately throughout the day. The rules that should be observed in the treatment of the simple intermittent form of malaria are the following : Provided the patient has been observed for several days and it is known that the type of malaria is of the quotidian variety, or if the blood examination reveals this to be the case, then the patient should receive fifteen grains of quinine, twice, six and five hours before the time when the attack is expected. This therapy some- times aborts the attack. In most cases, however, the administra- tion of quinine on the first day does not stop the attack. If administered at the same time and in the same way on the sec- ond day, the attack is, in the great majority of cases, aborted. It is best then to continue the administration of thirty grains of quinine for two or three days more in the same manner. This is particularly necessary if a blood examination is not made and the type of malaria positively established, for it is important to remember that a daily malarial paroxysm may be due to three MALARIA 547 colonies of quartana, so that here it would be necessary to ad- minister the dose of quinine for at least four or six days if the parasites are to be destroyed in the amebic stage. If the patient is seen for the first time, when the attack To abort an is just impending, and if the first attack occurring on the pre- attack * ceding day was exceedingly severe, so that it is desirable to prevent the occurrence of another attack, then fifteen to forty- five grains (1 to 3 gm.) should at once be administered hypo- dermically. If the patient is seen for the first time during an attack, it No quinine is altogether useless to give quinine in the simple intermittent durm £ attac form of malaria. If the patient is seen after the attack and if the seizure was Quinine treat- very severe, and especially if the exact type of the malaria is Stack not known, then fifteen to twenty grains (1 to 1% g m -) of quinine should be given at once and the same dose repeated on the next day about five or six hours before the time of the ex- pected paroxysm. In atypic intermittent types of malaria and in the sub- Atypic inter- continuous pernicious variety no definite rules can be formu- mittent *yP e lated in regard to the exact time for administering the quinine. A safe rule is to give from ten to fifteen grains (0.6 to 1 gm.) of the drug by mouth every four or five hours for several days. It will often be found that the type of the disease then changes to the simple intermittent variety which should be treated as indicated above. If one is dealing with the pernicious type of malaria with Pernicious severe apoplectic symptoms, or an overwhelming intoxication pro- type ducing coma and tetanic convulsions, then quinine in doses of fifteen to thirty grains should be given at once and preferably by the intravenous method, this dose to be repeated every ten or twelve hours on several successive days. There are some individuals unfortunately possessing a marked idiosyncrasy idiosyncrasy to quinine. They respond to the administra- a f ainst exposure to X-ray is always worthy of a trial (see page 93). " r:iy With the reduction of the splenic tumor the cachexia frequently improves rapidly, hence every effort should be put forward to accomplish this result. In order to prevent re-infection with malaria and, generally To prevent speaking, as a prophylactic measure to be adopted on entering J^nces* recur " malarial regions, the administration of five to ten grains of quinine, two or three times a day, is to be recommended. The role of the mosquito and the means that must be adopted Role of the to prevent infection from this source are discussed in full in mos( l ulto the Section on Yellow Fever. 550 ACUTE ARTICULAR RHEUMATISM Early adminis tration of salicylates Salicylic acid and its deriva- tives almost a specific Large doses necessary Proper dosage Choice of prep- aration Dosage in children Salicylic acid Sodium sali- cylate ACUTE ARTICULAR RHEUMATISM— (Rheumatic Fever). At the onset of the disease with high fever, pain in one or several joint, often sore throat (tonsillitis) and the malaise, an- orexia, furred tongue and other phenomena attributable to the high fever, the patients should be put to bed and the adminis- tration of salicylic acid or salicylate preparations begun at once. Salicylic acid and its derivatives must be considered almost a specific in most cases of the disease. Its exact mode of action is not known. It exercises an influence upon the nerve ends, chiefly in the joints, relieving the pain, and it may also prob- ably possess some specific antibacterial and antitoxic action. In order to be effective large doses of the salicylic prepara- tions must be given. It is futile to give five or ten grains, three times a day; in order to accomplish the desired result doses of from sixty to one hundred and twenty grains (4 to 8 gm.) should be administered in the course of twenty-four hours for several days in succession. The remedy should, therefore, be given continuously during at least the first three days in doses of ten to fifteen grains (0.6 to 1 gm.) every three or four hours, day and night. The choice of the salicylic preparation is frequently difficult to make. Salicylic acid, itself, is said to act somewhat more quickly than any of the other preparations, but it is decidedly more irritating to the stomach than all its congeners. It should, above all things, never be given in solution, as it is soluble in water only in the proportion of one to five hundred, and as its solution in alcohol is so irritating as to preclude its internal ad- ministration in this form. If salicylic acid is to be given at all it should, therefore, be given in the doses mentioned above in capsules or powders, with milk. Sodium salicylate may be employed either in solution or in powder or capsule in the same dose as salicylic acid; as its taste is rather disagreeable it is best, however, not administered in powder form. The most agreeable way of dispensing it is in a solution of peppermint water with simple syrup. Children should receive smaller doses of salicylic acid, or of sodium salicylate, than those specified above. Children up to one year should not have more than fifteen grains (1 gm.) of either salicylic acid or sodium salicylate in the twenty-four hours; children from two to six should not receive more than thirty grains (2 gm.) in the twenty-four hours; and children up to twelve not more than forty-five or, at the most, sixty grains (3 to 4 gm.) each day. ACUTE ARTICULAR RHEUMATISM 551 The best preparation of salicylic acid, the one that is the least Aspirin irritating to the stomach, bowel and kidneys, the one that hardly produces any of the toxic signs to be presently enumerated, even if given in very large doses, is aspirin. It may be given in thirty to forty-five grain doses (2 to 3 gm.) three or four times in the twenty-four hours; as its taste is not disagreeable it can be dispensed in powder form. In many cases of acute articular rheumatism in which large Poisoning from doses of salicylic acid, sodium salicylate or aspirin are given salic y lates symptoms of poisoning appear within a short time, manifesting themselves by visual disturbances, congestion about the head, buzzing in the ears, dizziness, nausea, vomiting. In especially idiosyncrasy- predisposed subjects having an idiosyncrasy against salicylic acid and its preparations, a single dose may produce violent symptoms of intoxication, headache, delirium, coma, retardation of the pulse, palpitation and drenching sweats. If these symptoms of intoxication appear one is often forced indications for to stop the administration of salicylates and to give other reme- stopP 111 ^ sali_ dies in their place. Occasionally only mild toxic symptoms will develop after the exhibition of one of the salicylic preparations. If the intoxication is not too severe it is always worth while to salol, sali- try to continue the salicylic therapy by using some other deriva- P n ® n > malakin, tive of salicylic acid, as salol (not in nephritis), saliphen, mal- cin, oil of akin, saligenin, salicin or oil of wintergreen, especially the lat- wmt ergreen ter in doses of twenty drops every two or three hours in milk or in capsule. The exhibition of salicylates by the percutaneous Percutaneous method, i. e., by means of ointments rubbed into the skin, is also a very useful mode of administration and one that can to ad- vantage be combined with the administration of salicylates by mouth. In cases in which symptoms of gastric irritation appear without any of the other signs of salicylic poisoning, the method of administering the drug by inunction alone is often effica- cious. Here ointments made of one part of salicylic acid to ten parts of lanolin, or of equal parts of oil of wintergreen and lanolin, are especially serviceable. Aside from the appearance of violent symptoms of intoxica- Contra-indica- tion in otherwise healthy subjects shortly after the exhibi- tic | ns Jo use of salicylates tion of salicylic acid preparations, there are distinct contra- indications to the use of these remedies, namely, cardiac disease, acute renal disease, congestion about the head and gastritis. If the patient is unable to take salicylic acid or its deriva- tives in large doses, then it is futile to continue their adminis- tration in small doses, and recourse is better had either to cer- tain other remedies to be now discussed or to local measures alone. 552 ACUTE ARTICULAR RHEUMATISM Remedies to replace sali- cylates Lactophenin Phenacetin Antipyrin Salipyrin Potassium iodide Guaiac vColchicum Alkalies Local treat- ment Hest of joints Meat and cold AlcoTiol dress- ing Alkaline washes Remedies that can in a measure replace the salicylates are, above all, certain of the coal-tar preparations, chief among them lactophenin, which may be given in ten to fifteen grain (0.6 to 1 gm.) doses, every four hours; phenacetin in five to ten grain (0.3 to 0.6 gm.) doses; or antipyrin in five to fifteen grain (0.3 to 1 gm.) doses, three or four times a day. A very useful anti- pyrin preparation is salpyrin, a combination of salicylic acid and antipyrin, which is used in the same doses as antipyrin. Guaiac, potassium iodid, colchicum and many other remedies that have at different times been recommended, nowadays no longer occupy a place in the therapeutic armamentarium to be employed against rheumatic fever. An energetic alkaline therapy instituted from the beginning of the disease and continued throughout its course, using alka- lies either alone or in combination with salicylates, is always useful. The patient should receive from five to fifteen grains (0.3 to 1 gm.) of bicarbonate of soda in a tumblerful of water or milk, four or five times a day. As a beverage lemonade or orangeade answers a similar purpose, for the citrates contained in lemon or orange juice are promptly converted into carbonates in the body. Local treatment in acute articular rheumatism is of much less importance than in chronic forms of articular disease. The chief object is to make the patient comfortable and this can best be done by arranging the pillows in such a way that cramp- ing and congestion of the affected joints are avoided, or by- applying rests or supports according to the requirements of the case. It is rarely necessary, nor can it be considered good prac- tice, to immobilize the affected joints, although, formerly, the adjustment of permanent splints, or even of casts, was in vogue. Some patients prefer hot applications, others are made more comfortable by the application of cold to the joints. Heat ap- plied by the hot air bath is usually most soothing, and if the house is wired for electricity a box lined with several incandes- cent globes can be placed over the joint several times a day with great relief to the sufferer. The thermophore (see index), hot water bags, or poultices are often grateful. A very effective dressing is the application of absolute alco- hol to the joints. A towel or several layers of gauze are soaked in absolute alcohol, applied to the affected joint and held in place by a loose bandage for eighteen to twenty-four hours. Simply wrapping the joint in cotton and bandaging loosely is of considerable benefit. Alkaline washes applied by means of cloths wrung out of a warm ten per cent, solution of soda and ACUTE ARTICULAR RHEUMATISM 553 covered with flannel and renewed every few hours are useful. Salicylic ointment and oil of wintergreen ointment, as described Salicylic oint- above, can always be applied to the joint provided there is no ment idiosyncrasy against salicylic acid poisoning. Aside from the application of wet, hot or cold cloths to the Hydrotherapy joints other hydrotherapeutic means are of very subordinate im- portance in this disorder. General baths, warm or cold, are of no benefit, may even do harm, and are, above all, very disa- greeable to patients, because they are thereby forced to move about and deprived of their rest. Cleansing baths are, there- fore, best given by sponging in bed. The element of rest is exceedingly important, especially in Rest in bed view of the frequent involvement of the heart. Any sudden exertion, getting up quickly, going to the toilet should, there- fore, be forbidden. Upon the appearance of signs of endocardiac involvement an ice-bag should be intermittently applied to the ice bag to pre- precordial region and the other measures instituted that have cor ium been described in full in the Section of Acute Endocarditis, on page 49. The temperature of the room should be kept between 60 and 65 degrees and the patient carefully protected from drafts and Room hygiene cold, especially moist air. If the house is moist, then the driest and most sunny room should be selected for the patient with rheumatic fever. The patient should wear a flannel night-shirt Clothing and sleep between blankets that are not too heavy and yet warm enough. In many instances the pressure of the blanket upon the affected joint is exceedingly trying to the patient. In such cases a suitable support should be arranged of wire or wood to protect the joints from such pressure. The diet should, in the beginning and during the stage of Diet fever, consist exclusively of milk. It can conveniently be given in the form of the milk-cream mixture described on page 27. Later when the appetite returns, the patient may receive other articles of food according to his tastes. While the importance of uric acid in the production of acute articular inflammations is very doubtful no harm can, nevertheless, be done by excluding from the bill of fare, during the acute stage of the disease, articles of food containing nucleins and articles containing extractives (purin bases), in other words all internal organs, young ger- minating plants, raw, rare, cured, smoked and corned meats, bouillons, meat extracts and gravies (see also Section on Uric Acid Di at lie sis). It is very important that sufferers from acute articular rheu- Treatment of matism should not get up too soon as there is always a tendency convalesence 554 to recurrences in this disorder. Sometimes the fever will become elevated several degrees during the stage of convalescence with- out any articular manifestations. In such cases the administra- tion of ten to fifteen grains (0.7 to 1 gm.) of salicylate of soda, or of aspirin, three or four times a day, for two or three days, is a useful measure to reduce the temperature and to prevent re- currence of articular troubles. In any event the patient should take small doses of salicylates, i. e., five to ten grains of sodium salicylate, or of aspirin, for several weeks after the fever has disappeared and all the articular manifestations have receded. Tetanue anti- toxin a specific prophylactic Effects in de- veloped te- timis Mode of action Indications for use of te- tanus antitoxin TETANUS. Tetanus antitoxin may be considered a specific prophylactic against tetanus. Given within a few hours after the premoni- tory signs of tetanus have made their appearance the remedy is occasionally efficacious. In fully developed tetanus, antitoxin is probably without value. It is very difficult to render conserva- tive judgment in regard to the curative virtue of tetanus anti- toxin in those instances of tetanus that run a protracted course and finally recover, because a considerable number of cases of tetanus progress towards spontaneous recovery without the ad- ministration of the antitoxin. The great majority of tetanus sufferers, however, that receive antitoxin in later stages of the disease succumb, nevertheless. Notwithstanding this ambiguous and largely negative evidence in regard to the efficacy of te- tanus antitoxin in fully developed tetanus the remedy should be given a trial, for no harm can ever accrue from its administra- tion, and it is possible that here and there an isolated case may be benefited by it. It appears that tetanus antitoxin possesses the power of neutralizing tetanus toxin while it is still circulating and before it has become permanently attached, so to say, to the ganglion cells of the central nervous system; when this attachment has occurred the remedy is apparently without effect. This pos- tulate would explain the value of the remedy as a prophylactic and its modifying influence upon the course of the disease if ad- ministered within twenty-four to thirty hours after the first signs of irritation of the cerebro-spinal axis have made their appearance, and its inefficacy in most cases if administered later in the disease. Tetanus antitoxin should, therefore, be used as a prophy- lactic measure in every case of trauma in which the wound is contaminated with dirt, especially manure, and particularly TETANUS 555 if dirt or manure particles have been carried deep into the tis- sues where they are deposited in a location that is protected from the air; for the tetanus bacterium leads an anaerobic existence and flourishes best in the absence of oxygen. For this reason punctured wounds produced, for instance, by stepping upon a rusty, dirty nail, and wounds produced by explosions which send dirt particles deep into the tissues, as in Fourth of July injuries, are especially liable to be followed by tetanus. Tetanus antitoxin is best administered near the place of in- Place of in- fection. If the injury is about the head, or in other regions 1 ectlon of the body where it is difficult to inject large quantities of fluid under the skin, then at least a portion of the antitoxin should be injected near the seat of the injury and the rest in some other part of the body. The best method of administering tetanus antitoxin is by hypodermic injection. The administration by lumbar puncture Administration is also very useful, provided it is carried out under aseptic pre- kypodermi- cautions ; for the antitoxin is more rapidly absorbed from the bar puncture subarachnoid space than from the subcutaneous layers of the skin and, moreover, diffuses more rapidly through the cerebro- spinal fluid than through the blood. Intra-cerebral injections By the intra- possess no particular advantage over the injection into the spinal method canal and constitute, moreover, a procedure of some magnitude that requires special surgical skill, whereas lumbar puncture is a simple procedure that any internist should be able to perform. The intravenous method of exhibiting tetanus antitoxin is Intravenous not without danger and serious accidents have been reported m J ectlons from this practice. Moreover, it possesses no particular ad- vantages over the subcutaneous method or administration by lumbar puncture, for the effect produced is only slightly more rapid. At least one hundred antitoxin units, and not more than two Number of an- hundred units, should be injected during the first twenty-four t lto ^ in ^^ to hours. (Behring.) Injections of one hundred units should be repeated on several successive days. An antitoxic unit is that amount of tetanus antitoxin that can neutralize ten units of tetanus toxin in the test tube; and a tetanus toxin unit (Gift Einheit) is the smallest quantity of tetanus toxin that can kill a guinea-pig, weighing about 250 gm., in three or four days. Bacelli and his school warmly recommend carbolic acid, ad- Carbolic acid ministered hypodermically, as a prophylactic and a cure for C J^Z erm " tetanus. I have had no personal experience with this mode of treatment, but the reports emanating from Italian clinics are so positive and so favorable that the method may be mentioned. 556 Local treat- ment of the wound General man- agement Rest, protected from external irritants Hot baths Bacelli injects on the first day, either as a prophylactic or even after the tetanus spasms have set in, a two per cent, solution of carbolic acid in such amount that about three grains of carbolic acid are injected in the twenty-four hours. On suc- cessive days the amount of carbolic acid is increased to three or four times this quantity. It is claimed that tetanus cases show a great tolerance to carbolic acid and that the drug, adminis- tered in this way, exercises a beneficial effect upon the most dis- tressing symptoms of the disorder and materially shortens the course of the disease, producing a cure in many cases. The local treatment of the wound is of the greatest import- ance. The principles that should govern this treatment are to open the contused part by wide incisions so that free access of air may be favored even to the deeper regions. A careful search for dirt particles should be made, fistulous tracts should be ex- plored and the whole area laid wide open. Various antiseptic dressings, carbolic acid, salicylic acid, bichloride, etc., may be used according to common surgical principles. Aside from the specific treatment with antitoxin and the local surgical treatment, the general management of the case is of importance. Most patients with tetanus wear themselves out and die as much from the exhaustion produced by the spasms as from any specific lethal action of the tetanus poison; for this reason it is of paramount importance to preserve the patient's strength by reducing the number and the severity of the tetanic convulsions, while, at the same time, maintaining the nutrition of the patient to the maximum degree. An essential element in the treatment, therefore, is to protect the patient from all extraneous irritants — noises, light, contact with people and excitement of any kind — for in tetanus reflex irritability is enormously increased and the sufferers react with spasms or convulsions to stimuli that would normally not in- fluence them at all. A tetanus patient should, therefore, be put to bed in a dark- room and should be left as much as possible to himself. Hot bathing, two or three times a day, in water slightly above body temperature, is a very useful adjuvant to the treatment. The patients can, to advantage, be kept in warm water, half an hour at a time, two or three times a day. I have had the im- pression that this treatment reduces the number of spasms and is successful in shortening the convulsions, especially if the patients are placed into hot water immediately upon the onset of spasmodic symptoms. The question of feeding is often a difficult matter, espe- TETANUS 557 cially if trismus is present. If there is much lockjaw, then the Diet and mode patient should be fed by rectum, as described in the Section on of feeding Gastric Ulcer, to be found on page 368, or, if necessary, through a nasal catheter. A patient with tetanus should receive large quantities of fluid, on the supposition that possibly the ingestion of much liquid will aid in diluting the circulating tetanus poison. Water should, therefore, be administered copiously by mouth and also by high enemata of warm physiological salt solution, fre- quently repeated. Immersion in hot water, coupled with free water drinking, unquestionably accelerates the lymph stream throughout the body and hence materially aids in keeping the toxin in circulation and possibly in preventing its attachment to the ganglion cells of the nervous system. Of remedies that can be given morphine occupies the first morphine place and it is good practice to keep the patient more or less under the influence of morphine throughout the course of the disease. The exact dose can hardly be stated. The patient should receive enough to control the spasms, so far as that is possible, and keep him quiet. If morphine fails to control the spasms, then chloral hydrate, chloral given in large doses of fifteen to twenty grains, four to six times hydrate a day,- by mouth or by rectum, should be substituted. Very violent spasms occurring despite the administration of morphine or chloral hydrate, can usually be controlled by a few whiffs of chloroform. If the chest muscles are in a state of rigid tetanic contraction, then, of course, it is very difficult for the chloroform patient to inhale at all, so that here chloroform inhalations cannot be given. In such cases hot compresses to the chest often aid in relieving the spasm and enable the administration of chloroform. Trional, tetronal, europhen, all given in doses of ten to thirty _ . , grains (0.6 to 2 gm.), three or four times a day are often effica- Tetronal cious. Tincture of thiosinamin, five to twenty drops (0.3 to Europhen 1.2 cc.) ; or the extract of cannabis indica one-eighth to one- Thiosinamin fourth grain (0.08 to 0.06 gm.) or the fluid extract, two to five S^ 8 * 18 *"" drops (0.1 to 0.3 cc.) ; antipyrin in five to fifteen grain (0.4 to Antipyrin 1 gm.) doses, repeated several times a day; bromide of sodium Bromides or potassium, finally, given alone or in combination with chloral hydrate, by rectum, in large doses of twenty to thirty grains (1.3 to 2 gm.) are the drugs that all merit trial and occa- sionally aid in controlling the most distressing symptoms. 558 DYSENTERY Definition Classification Catarrhal dysentery Tropical amebic dysen- tery Symptomatic dysentery No specific treatment Diet Calomel DYSENTERY. The term dysentery is employed to designate a number of disorders of different etiology that are all characterized by colic, tenesmus and the evacuation of small stools at frequent intervals, containing mucus and b^ood. One can distinguish between an epidemic and an endemic variety. In addition there are sporadic cases which are presumably isolated instances of the endemic variety. Epidemic dysentery is also known by the name of catarrhal dysentery and occurs chiefly when general hygienic conditions are very bad. Its course is milder and its mortality lower than in the endemic form. It is produced by different bacilli that are presumably introduced into the body through the drink- ing water. In the endemic variety, also known as tropical dys- entery, certain ameba must be incriminated with causing the dis- ease. Here the submucous layers of the intestine are usually affected, whereas in the catarrhal variety the surfaces of the mucosa show the first changes. In addition there are a number of forms of symptomatic dysentery that are produced by mechanical causes and that are due to a variety of intoxications. The treatment of all forms of dysentery is essentially the same and largely symptomatic, for we possess no specific treat- ment in the parasitic varieties. The diet should be non-irritating to the bowel and should leave a small residue. In the acute forms and until the severe colic, tenesmus, frequent diarrheas and the fever stop, the diet should be largely liquid and consist of milk preferably diluted with lime water, or strained gruels, or meat broths and soups. A very useful food is albumen water made by shaking the whites of twenty eggs in a pint or two of water, adding some sugar of milk and some flavoring extract. This quantity should be taken in divided doses in the course of twenty- four hours. In addition, the patients may have abundant water or lemonade or dilute wine. As soon as the acute symptoms subside a semi-solid diet may be permitted. A solid diet, however, should ^.ot be given until all blood and mucus have disappeared from the feces, and the diarrhea, the colic and tenesmus have been altogether relieved. The diet, in other words, does not differ materially from that advised in typhoid fever or in any other form of acute intestinal catarrh. Of medicaments that should be administered by mouth, calo- DYSENTERY 559 mel, given in small (one-fourth grain) doses throughout the dis- ease is the sovereign remedy. It acts beneficially both on account of its laxative and its antiseptic properties. Vegetable laxatives should not be given in this disease as they are apt to be too irri- Laxatives tating. Small doses of castor oil or of olive oil can do no harm. If there is much constipation, especially in the beginning, a brisk saline laxative is indicated. Very popular, especially in the tropical variety of dysentery, Ipecac is ipecac. In the different countries it is given in different ways. The most sensible and least harmful method of administering it is the one recommended by English physicians in the British colonies; viz: The patient is first given a hypodermic of one- fourth grain of morphine, hot turpentine stupes are then ap- plied to the abdomen and an hour after the administration of the morphine, one grain of the root of ipecac in capsule is given, followed by copious draughts of water. This dose is re- peated two or three times in one or two hour intervals. In this way large quantities of ipecac can be introduced without pro- ducing distressing retching and vomiting. In the acute form astringents may be given, chief among them Astringents tannin. It is best given in the form of tannalbin, in doses of / thirty to fifty grains a day in divided doses of ten grains each. Naphthalin, preferably in combination with calomel, acts very beneficially both upon the colic and tenesmus and the charac- ter of the stools. Kartulis recommends the following prescrip- tion: Naphthalin, 1.0 gm. Calomel, 0.5 gm. M. : Make ten such powders. S. — One powder every two hours. In addition to these remedies narcotics, opium and prefer- ably morphine, hypodermically, may have to be given as pallia- tives to relieve particularly distressing symptoms. The rectal administration of medicines is especially useful in . _. this disease, because in this way the seat of the trouble can be tion best reached. For very violent tenesmus small laudanum-starch enemata should be given. Laudanum, 10 drops Starch, 1 tablespoonful Lukewarm water, 200 cc. Or Cocaine, 1 gm. ; Water, 250 cc. 560 INFLUENZA Enteroclysis Chronic dysen- tery For severe hemorrhage and colic, sulphate of soda is useful 3 Sodium sulphate, 10 g. Water, 250 cc. Or a dilute solution of iron perchloride, or ice water alone r injected in small quantities into the rectum are all effective. More valuable than the use of enemata is treatment by entero- clysis, for it promotes cleanliness of the lower intestine and, at the same time, enables the application of healing remedies directly to the affected lining membrane of the bowel. The ordinary antiseptics like carbolic acid, corrosive sublimate or the salicyl- ates are too irritating. The same applies to silver nitrate whose astringent properties might otherwise be employed to the advant- age of the patient. Other antiseptic remedies are insoluble in water and can consequently not be utilized (iodoform, naph- thalin, etc.). The chief remedies that can be employed advant- ageously are tannin and quinine, the former to be used in half per cent, solution, the latter in warm solutions of the strength of , 1 to 1000 to 1 to 5000. From two to three litres of fluid should be used two or three times a day. The irrigating bag should not be elevated very high, as otherwise too great pressure may be ex- ercised upon the bowel wall and perforation occur. In chronic dysentery practically the same remedies are use- ful. Here again warm quinine solutions or solutions of tannin are very helpful. Internally, tannalbin, calomel and naphthalin are the chief remedies. Treatment exclusively symptomatic Antineuralgics INFLUENZA. The treatment of influenza, owing to the fact that we pos- sess no specific remedy, is exclusively symptomatic. Upon the onset of the first symptoms, energetic diaphoresis should be stim- ulated by hot baths, hot drinks, quinine, Dover's powder, as de- scribed in the Section on Acute Bronchitis. An influenza patient, however mild the onset of the symptoms, should be placed to bed and kept there until the temperature is normal. The diet should be bland and non-irritating, in other words, should con- sist of the ordinary fever diet (see page 509). Of remedies the ordinary antineuralgics are the most useful, for they make the patients more comfortable, reduce the sever- ity of all the symptoms and, above all, stop the distressing head- ache, backache and restlessness. It is always well to inaugur- ate the treatment with a full dose of calomel, followed by a saline laxative. The most useful remedy in my hands has been PERTUSSIS 561 aspirin in combination with quinine, of each five grains, to be Aspirin given every five hours for three or four days. Salipyrin and antipyrin are less safe on account of their effect upon the heart. Alcohol is always useful. A little whisky and water given Alcohol throughout the course of the disease aids materially in counter- acting the heart weakness and symptoms of nervous depression that so commonly supervene in influenza. Hydrotherapeutic means are of subordinate importance in the treatment of this disorder, owing to the comparatively short duration of the disease. There is no harm in using the above Hydrotherapy antipyretic drugs and no advantage is to be gained from at- tempting a reduction of the fever by the more complicated hydro- therapeutic measures. Symptomatically, hot bathing, in fact, is always more useful than cold hydrotherapeutic means and a hot bath given once or twice a day, with an ice bag or cold cloths to the head, is often helpful. The treatment of the complications is synonymous with the treatment of the organs affected and will be found discussed in the chapters on Digestive, Respiratory and Cardiovascular Dis- orders. PERTUSSIS. (By Dr. Frank Spooner Churchill, Chicago.) Two principles may be laid down in the management of principles whooping-cough, viz., take every precaution possible to prevent infants and children from contracting the disease; when once contracted, treat the individual, not the infection. Much can be done, in private practice especially, to guard Prophylaxi infants and young children against contracting pertussis. The popular idea that this disease is a trifling affair, that ' ' they have all got to have it and the sooner they have it the better, ' ' is for- tunately disappearing. Intelligent mothers now try in every way to prevent their children from contracting the disease. They guard them rigidly, and properly so, from exposure in this direc- tion. Infants and young children should not be allowed to play either indoors or outdoors with others who have whooping- cough. Weak, debilitated children, especially those with a tend- ency to respiratory troubles, tubercular or non-tubercular, should not be allowed to attend kindergarten or any public gathering of children, both because the time thus spent indoors ou.eht to be spent outdoors, and because there is great risk of contracting all contagious diseases at such gatherings. Nor should they be allowed to play with children who have in any way been exposed 562 PERTUSSIS to whooping-cough but have not yet manifested any signs of the disease themselves. The latter may be in the incubative stage of the infection and therefore capable of spreading it. All children with a suspicious cough, except those who have already had pertussis, should be excluded from contact with other children. The early diagnosis of whooping-cough is often a difficult matter and until one is sure that a hard cough is not a manifestation of this infection, a child with such a cough should be withdrawn from association with other children. A Xymphocytosis high percentage of lymphocytes is strong confirmatory evidence of the disease and justifies isolation, temporary at least; for it has been shown* that in over ninety per cent, of cases of per- tussis there is a marked lymphocytosis, even in the catarrhal stage before the development of characteristic symptoms, and that this lymphocytosis rarely if every occurs in other respira- tory affections accompanied with a hard cough. "We cannot emphasize too strongly the importance of these rigid precautions, especially for infants and young, weakly chil- dren among whom the disease is most severe and so often fatal. They should be guarded against it, at least until they are older when it will be a much less serious affair for them. It is of course impossible to observe this great care in the congested dis- tricts of our large cities, but even here more care can be exer- cised than is generally done. The practice of directing patients with whooping-cough to "return" to the clinic cannot be too strongly condemned. It is wrong to the other patients, it has a bad moral effect upon the students, confirming them in their lay idea that the disease is a trifling affair. The physician who practises this custom is criminally negligent. It must be remembered that pertussis is a self-limited dis- ease, runs a certain course and that we have no means of cut- ting it short. Obviously then, the indications are to keep the individual in the best possible fighting trim that he may have the strength to outlast the whooping-cough organism and to sus- tain the attack with as little damage to himself as possible. This is best done by careful attention to his general hygiene and diet. Medication is a matter of secondary importance. The patient should have an abundance of fresh air ; he should be out-doors as much as possible in the daytime and at night should sleep in a well-aired, well- ventilated room. He may sleep out-of-doors during the spring, summer and autumn months in the north temperate zone. In dealing with infants and young, General hy- giene and diet *Churchill. Journal A. M. A., 1900, XLVL, 1500. PERTUSSIS 563 debilitated children, however, care and judgment must be used in exposing them to the severe winter weather of a northern cli- mate. Large, well- ventilated, well-lighted rooms, one for the day and one for the night, are undoubtedly better for some of these patients than the indiscriminate application of the "fresh-air" treatment. Individual peculiarities must be heeded and the pa- tient treated accordingly. Those children who live in the con- gested districts of cities, and for whom fresh air, indoors or out- doors, is an impossibility, should be sent to a hospital and later to a convalescent home or camp in the country. A change of locality, as from sea-shore inland or vice-versa, climate is often of benefit, especially where the cough is unduly pro- longed. The Atlantic seaboard from Cape Cod south is especially desirable for such patients. The balmy air and comparatively warm sea bathing have a most beneficial effect upon them. Those who cannot have this change of environment will be much bene- fited by long hours spent in the parks, at the lake or river front where these localities are clean. Next in importance to fresh air for older children, and Nourishment equally important with it for infants, is the question of nourish- ment. Those infants fortunate enough to be at the breast should be kept there. Those not at the breast should have their diet carefully regulated and be put on cow's milk modified to the needs and capacity of the individual infant. It, is among this class of patients that whooping-cough is so serious and so often fatal, as has already been said. The disease wears out the baby either by itself or by the development of pneumonia or some other complication. Hence the maintenance of his nutrition is vital. The diet for older children should be largely liquid and Character of . the diet easily digested. Meals are necessarily irregular ; the child is so apt to lose a whole meal by a paroxysm coming on soon after eating that he must be fed again in a short time. He snouia re- main quiet for at least an hour after the hearty meals of the day. Paroxysms are apt to come on at evening soon after the child falls asleep, possibly due to the recumbent position; hence it is advisable either to give the evening meal earlier or to put him to bed later that digestion may be further advanced before the paroxysm comes on. The bowels should of course be kept freely open. Where Laxatives this cannot be done by a diet rich in fruits and vegetables, laxa- tives must be used. The fluid extract of cascara sagrada (aro- matic) is excellent for this purpose; it may be given in doses of ten to thirty drops one to three times a day, according to results. Phosphate of soda in drachm doses may be given every morning. 564 PERTUSSIS Stimulants and tonics The paroxysm Medication Belladonna A thorough clearing out of the intestinal canal once or twice a week is often of benefit; for this purpose one grain of calomel, in one dose, or a drachm of castor oil may be given in the morn- ing. Stimulants must be used in some cases even when no com- plications are present. Brandy is the best form of alcohol to give as it is less likely to upset the stomach than whisky. Strych- nine in doses of one-one-hundredth of a grain may be given to older children. Iron and cod-liver oil are often indicated in the later stages with considerable debility and anemia. THE TREATMENT OF THE PAROXYSM. There is little to be done when the paroxysm of whooping- cough is actually on in older children. Young infants, how- ever, should never be left alone during the paroxysmal stage on account of the danger of strangulation. They must be taken up during an attack, held face downward and often it is necessary to clear out the mucus from the throat with the finger. A severe paroxysm which threatens suffocation may be relieved by in- haling oxygen or ether. Intubation has even been done for such. Chloroform should not be used on account of the possi- bly weak condition of the heart so frequently present in whoop- ing-cough. Medication is of far less importance than the details of gen- eral treatment insisted upon above. A few drugs, however, do seem to diminish the number or severity of the paroxysms and these should be tried. They may be given (a) internally, (b) by inhalation, (c) by insufflation. (a) Internally. All the drugs in the pharmacopoeia have ap- parently been recommemli rl for the treatment of pertussis, but of them all only a few have wtood the test of time and experience. These are belladonna, quinine, phenacetine, antipyrine and bro- moform. It is better to delay the use of drugs until the paroxys- mal stage is well under way; one preparation at a time should be given a thorough trial; if benefit seem to come from its use continue it, if not, stop and try another. Some cases are so mild throughout that no medicine at all is necessary. The effects of this drug must be carefully watched. It should be given at first in small doses, one-fourth minim of the fluid extract to an infant eighteen or twenty months old, every four hours, gradually increasing to one-fourth minim every two hours. Atropine also may be given in the same way, begin- ning with about one-eight-hundredth grain. Undoubted benefit seems to follow the proper use of these preparations in most cases, but they must be pushed to the limit, until the flushed face and PERTUSSIS 565 dilated pupils are noticed. The best results are seen in hospital cases which are under constant supervision. This may be given to older children. It should never be Quinine given to infants. It must be administered in large doses, ten to fifteen grains daily to a child five or six years old. If it dis- turbs digestion it must be stopped. These preparations allay the' severity and frequency of at- Phenacetine tacks in many instances. They are particularly valuable where an an ipyTin much sleep is being lost and the child is in an irritable and fret- ful condition. They should be given always with a stimulant, brandy, whisky, coffee, caffein, etc. They may be given in fairly large doses; one grain every two to four hours to a six months old infant. To an infant eighteen to twenty months old, two grains every two hours may be given. For older children larger doses in proportion to the age are prescribed. It is recommend- ed by some to combine the bromide of sodium with these coal- tar products. I have had no personal experience with this method- This is one of the more recent preparations. It seems to be Bromoform of value in some eases. It is given in doses of one to three drops every two or three hours to an infant two years old, and three to five drops every two hours to a five-year-old child. All prepara- tions must be shaken before using and it may be given on a lump of sugar. I have found phenacetine the most satisfactory of the above drugs. It has been prescribed always with a stimulant, brandy, to weak, debilitated or exhausted children, caffein (one quarter grain) and sugar of milk (ten grains) to others. (b) Inhalation. The administration of drugs by this method and by insufflation is based on the theory of the local nature of pertussis and aims to allay the irritability of the respiratory mucous membrane. Inhalation is more effective than insuffla- tion. The preparations most commonly used are creosote, creso- lene and carbolic acid. Cresolene is especially valuable. It is used generally at night and may be evaporated on a special lamp or an ordinary croup kettle may be used. The windows of the bedroom may or may not be kept open, according to the effects produced. The possibility of poisoning from these drugs must be remembered and the urine watched. (c) Insufflation. But little has been accomplished by this method and it is seldom used at present. Quinine is most com- monly used, mixed with some bland powder (1:10), such as bicarbonate of soda, acacia, talcum or coffee. Antipyrine has also been used in this way. Cresolene 566 PAROTITIS The local application of cocaine to the larynx is dangerous and should not be done. Stage of decline The management of the stage of decline in pertussis requires but brief mention. The diet can now. be increased, more solid food being given. Life in the open air should be continued. The change of environment in prolonged cases has already been mentioned. But isolation should be continued for at least four weeks after the cessation of the paroxysms. The possibility of the development of tuberculosis at this time must be borne in mind. Complications The most serious complication of pertussis is broncho-pneu- monia. Its management is the same as that of pneumonia from other causes, being mainly supportive and stimulating. Rest in bed, an abundance of fresh air, baths, warm or cold, accord- ing to the child's temperature, his vigor and general condition; as nutritious a diet as possible and stimulants are the main prin- ciples to be laid down. Stimulants must be used freely ; brandy and strychnine are the favorite ones ; carbonate of ammonia and nitro-gycerine are also used. Inhalations of steam, plain or medicated with creosote, are of great help and should be freely used. While pneumonia is the most frequent complication during the winter months, gastro-intestinal trouble is of frequent occur- rence in infants during the summer weather, and is a serious matter. Proper feeding from the outset will do much to prevent its development. Once established its management is that usually adopted under such conditions: emptying and disinfect- ing the digestive tract, modification of the diet, etc. If vomiting is very persistent we have to resort to rectal feeding to keep up the patient's nutrition. Convulsions, severe hemorrhages, albuminuria, etc., are to be treated according to general principles. Hygiene Hydrotherapy PAROTITIS. (By Dr. Frank Spooner Churchill, Chicago.) Mumps is generally a mild disease, and but little active treat- ment is required. The patient should stay in the house, except during warm weather, until the acute symptoms have subsided. In the more severe cases, however, accompanied with high tem- perature and general constitutional disturbance, more energetic measures must be taken. He should then, of course, be kept in bed, the bowels kept freely open, baths as in pneumonia or typhoid may even be necessary in especially severe cases, and SCARLET FEVER o67 antipyretics may also be used. Phenacetine, prescribed as in pertussis, relieves the pain and general discomfort. Sweet spirits of nitre is also of value. Hot applications to the swollen and tender glands are often acceptable. A mouth-wash should Drugs be freely used, and for this purpose listerine is an excellent prep- aration. The diet must be liquid on account of the pain in Diet swallowing. Complications are rare in early childhood. Later, especially Complications in early youth, the most serious complication is an orchitis. If present the patient must be kept rigidly in bed, the gland being supported and hot or cold applications made. He should be kept in bed until the acute symptoms have subsided and on get- ting up a suspensory bandage should be worn for several weeks. Otitis and nephritis occur but rarely. They should be treated on general principles. As in all infections, the urine should be examined both during and after the acute stage of the disease. Suppuration of the parotid rarely occurs, but if it develop it should be treated on surgical principles. Children with mumps should be excluded from school and quarantined for three weeks from the beginning of symptoms. SCARLET FEVER. (By Dr. Win. L. Baum, Chicago.) In view of the high mortality during early life and the de- creasing susceptibility and danger with advancing years prophy- Prophylaxis laxis becomes a most important factor. Unfortunately, during the incubation period, the contagion may be spread. This is es- pecially true when a case appears in a family or in a school. The case should be isolated at once and the rooms frequented by the patient thoroughly disinfected. The room occupied by a patient can be disinfected by means of formaldehyde, although this method is not so satisfactory and thorough as is the washing of the walls and furniture with a 1-2000 bichloride of mercury solution, and the boiling of the bed linen, clothing, etc. In hospitals, the formaldehyde disin- fection is not so satisfactory. At the Cook County Contagious Hospital, where this method has been most thoroughly tried, cases of scarlet fever have been known to develop in a room subsequently occupied by patients suffering from other diseases. This was not the case where the bichloride washings were em- ployed. It is needless to say that the attendants should be iso- lated and exercise the greatest precautions in their relations to the family and others to prevent the spread of the disease:. 568 SCARLET FEVER Isolation Mouth disin- fection Sera Patients should not be allowed to leave the room until free from contagion and until desquamation be complete. Isolation should average at least six weeks. The minimum period of ex- clusion from school should be seven weeks. During the week preceding the discharge, the patient should have at least two baths in a solution of sublimate of the strength of 1-5000. The clothing should be disinfected with steam or by boiling. This is particularly true of clothing worn by the patient at the be- ginning of the attack. In one case isolation was carried out for eight weeks and it was thought every precaution had been taken. Four weeks after the patient's discharge his little brother was sent to the hospital. Five days previously the elder brother had, for the first time since discharge, worn the suit of clothes which he wore when first attacked, which clothes were the only articles that had escaped disinfection. Despite the claims made by certain authors and the antique use of belladonna, iodide of mercury and oil of eucalyptus as a prophylactic, there is no evidence that any medicinal agent will prevent infection. The patient should be placed in a room from which super- fluous furniture, such as carpets, pictures, etc., has been re- moved. The room should be kept at about 60° F. and well ven- tilated. There is no danger from air currents in the room. Bed coverings should be light. Care of the mouth, throat and nose is of the greatest impor- tance, since Hektoen has shown that streptococci enter through the tonsils. For this purpose sodium salicylate in 0.5 to 1.5 so- lution may be given in teaspoonful doses every two hours for the first four or five days, as suggested by Forchheimer. For a mouth wash a solution of boric acid, or one of potassium per- manganate 1-500 can be used. Much interest has lately been aroused by the employment of antistreptococcic serum. Its value must depend upon the as- sumption that the streptococcus is either the etiological factor, or that its presence is the cause of the toxic disturbances for whose control an antibody is necessary. Various serums have been employed. Marmorek's serum, which l have employed in the treatment of seventy-one cases, did not reduce the mortality or lessen the complications to any appreciable extent. Baginsky, whose early experience was of a similar character, later used the serum prepared by Aronson, reporting a series of sixty-two cases with a mortality oP 11.3 per cent., while sixty-three cases treated without the serum showed a mortality of 17.3 per cent. Escher- ich, of Vienna, uses a serum which differs from that of Aronson and Marmorek in that the streptotocci in immunizing the horse SCARLET FEVER 569 were taken directly from man and without raising their viru- lence by passage through the lower animals. The animals were immunized by cocci from many instead of a single source. The dose of this serum varies from 100 to 200 cc. In Escherich's re- port of 112 cases treated with this serum, lie claims that in from four to twelve hours the temperature dropped; the pulse and respiration slowed down; the stupor and delirium disappeared; the general condition improved and the eruption faded. The serum causes transient exanthemas in about 75 per cent, of the cases. Since the use of the serum ulceration of the throat and suppuration of the glands have been less frequent. One striking feature of Escherich's report is the following: Of 27 cases in- jected within the first forty-eight hours of the disease, none died ; 2 of 27 injected on the third day died, and 6 of 20 injected on the fifth day; a mortality ranging from nothing during the first and second day, through 7.4 per cent, the third; 17.4 per cent, on the fourth to 30 per cent, on the fifth day, a result striking in similarity to that following the use of antitoxin.* Owing to the difference in virulence of the various epidemics, and even of periods of the same epidemic, it is difficult to draw satisfactory conclusions as to the value of these methods of treatment. In my own service at the Cook County Hospital, comprising the period from February, 1895, to April, 1906, there were treat- ed 1672 cases with 125 deaths, or a mortality of 7.49 per cent., showing that the disease did not occur in a very virulent form during these years. A change in the epidemic was noted in De- cember, 1905 ; in the following four months there were 265 cases with a mortality of 13.6 per cent. Diet should, for the most part, be light, consisting chiefly of Diet milk-. The large quantity of water contained in it is of great value in these cases, especially toward the end of the third week, if there be no nephritis or other contra-indications. Diet can be gradually increased in quantity and variety. In the fifteen years elapsing since Jaccoud employed milk as a diet, he has not had a case of nephritis after scarlet fever. My own experience has not been quite as favorable. The early treatment should be directed towards securing free Eliminatlom elimination by way of the bowels and kidneys. This, when suc- cessfully accomplished, will in a large measure prevent the grave cardiac and renal disturbances. In many cases within a few hours from the first eruption, or even before its appearance, delirium or unconsciousness develop, ♦Zanghofer, v. Bokay and Quest report a similar experience following the use of the Moser, also a polyvalent serum. 570 SCARLET FEVER accompanied by suppressed or scanty urine. The urine is loaded Fulminant type with albumin, some casts and occasionally blood. These ful- minant cases should be treated by venesection and transfusion with normal salt solution. Water should be given from the onset in large quantities and diuretics employed. The best and safest is an infusion of birch leaves, 30 to 1000 cc. given in two table- spoonful doses every hour. This causes neither heart depression nor nausea, and usually results in a rapid increase in the kidney elimination. Baths The fever should be combated by means of the cold bath or sponging with cold water (antipyretics should never be em- ployed). The reasons for the use of baths may be best stated in the words of von Jiirgensen : ' ' The difference between the tem- perature of the body surface and the water that comes in con- tact with it are the determining factors. At the very moment that cold water comes in contact with the skin, deep respirations ensue, which not only cause a complete distention of the lungs, but must have a considerable influence upon the circulation. "The heart, which during the superficial breathing is work- ing under difficulties, is now relieved of the burden to a consid- erable degree, and receives more and a better quality of blood. Owing to this, its vitality and functional power increase. If the temperature of the body is increased, the number of the heart- beats decreases with the cooling caused by the radiation of heat to the water surrounding the body. The intervals between the single beats become longer, the diastolic storing away of the blood in the heart becomes greater, and the heart in this way becomes qualified for better work. At this point begins a more rapid and copious circulation throughout the entire system, and with it the possibility of throwing off the toxin.' ' The cold baths should last but a few minutes and the water should be at a temperature of about 65° F. Where the cerebral symptoms are marked the ice pack can be applied to the head and cold douches can be given to the back of the neck, and at inter- vals along the spinal cord. If the skin is cold and the tempera- ture high it denotes marked cardiac weakness and warm baths should be given. The contra-indications to the use of cold baths are cardiac weakness, organic disease of the heart, dyspnea due to stenosis of the upper air passages, hemorrhages from the nose, mouth, or a hemorrhagic diathesis; also when joint inflamma- tions are present. Urotropin Widowitz reports 102 cases in which urotropin was employed without a single case of nephritis ; others have used it, some with similar results and some claiming that it has no effect. The dose MEASLES 571 varies with the age of the patient and is given three or four days in the beginning of the attack, and for three days at the begin- ning of the third week. When nephritis develops the bowels should be kept free by Nephritis the administration of repeated doses of magnesium sulphate, and the infusion of birch leaves given in large quantities, or the mix- ture of iron and ammonium acetate. The latter seems to do well in those cases where the nephritis is associated with anemia. When uremic symptoms develop very hot baths at a temperature of 110° F. should be employed. In cardiac weakness camphorated oil given hypodermically is probably the best stimulant. Infusion of digitalis with strychnin can also be employed. The early infection of the nose in the case of very young The nose and children should be treated by dropping a few drops of a solu- throat tion of sodium bicarbonate, 1 to 200, into the nostrils ; older indi- viduals employing it in the form of a douche. After each douche a little sterilized vaseline should be applied to the nostril. The severe angina if pseudo-membranous is usually due to the pres- ence of the Klebs-Loeffler bacillus and 5000 units of antitoxin should be administered at once. Painful angina is much relieved by allowing the patient to swallow small pieces of ice and apply- ing the ice pack about the throat. Enlarged and suppurating cervical glands should be incised when there is fluctuation, or earlier when the tension becomes too great. The Crede ointment otitis has proven useless in the treatment of the enlarged glands. The ears should be examined frequently as an otitis media due to ex- tension of the inflammation from the. throat through the Eustach- ian tube is a quite common complication. Should an otitis de- velop, paracentesis should be done at once and the ear irrigated every two hours with a hot boric acid solution until the discharge ceases. Mastoid infections are extremely rare when this method of treatment is followed. MEASLES. (By Dr. W. L. Baum, Chicago.) The almost universal susceptibility to measles and the fact p rev ention that sooner or later almost every individual will be attacked give rise to the interesting question whether it be better to guard the public against this infection or allow general exposure in the hope that for a generation at least the disease will disap- pear? No one who has witnessed the ravages of a virulent epi- demic with high mortality and severe complications, and their 572 The sick room The nose and throat Fever Broncho-pneu- monia far-reaching influence upon the future of the patients, can for a moment question the advisability of protecting the public as much as possible, both by compulsory isolation of the indi- vidual attacked and such regulations as tend to limit the spread of the disease. Unfortunately the period of incubation, espe- cially during the catarrhal stage, is capable of spreading the contagion. During prevalence of measles in a certain district public school teachers should be instructed to send home all chil- dren suffering from conjunctivitis or coryza, with instructions that they be examined by a physician. The finding of Koplik spots and the subsequent isolation of the patient may limit the spread of the disease. Disinfection of rooms and clothing, as employed in diphtheria and scarlet fever epidemics, will protect the community. The patient with an attack of measles should be placed in a well aired room kept at a temperature of 65° F. The air of the room should be kept moist because of the universal involve- ment of the mucous membranes. Dry air increases irritability of the bronchial tubes and predisposes to the most dreaded of all measles complications — broncho-pneumonia. The room should be partially darkened to protect the eyes; once a day the light should be freely admitted to make a careful examination of the conjunctiva and cornea. As a rule the eyes need no further care, but where there is much irritation an ointment of the yel- low oxide of mercury, 1-100, can be applied to the lids. The nose should be treated by dropping a small quantity of a solution of sodium bicarbonate, 1-200, into each nostril and the subsequent application of vaseline or oxide of zinc ointment. The throat and mouth should be washed out with a mild anti- septic solution — boric acid solution, 1-100, or postassium per- manganate, 1-500. Laryngeal spasm should be controlled by the administration of a small quantity of Dover's powder suit- able to the age of the patient. In severe cases warm baths are indicated. When the stenosis is due to swelling of the mucous membrane or to the formation of a plug of mucus in the trachea and larynx, an emetic should be given at once; apomorphin given subcutaneously acts most promptly. If these do not give relief, intubation or tracheotomy should be employed. For the fever antipyretic drugs should not be employed. Baths at a temperature of 85° F., or sponging, will reduce tem- perature. If there be much nervous irritability small doses of potassium bromide can be given in conjunction with aconite. Measles patients who develop broncho-pneumonia, that most dreaded of all complications, should be at once isolated from other cases of the disease. A cold pack may be applied, but SMALLPOX 573 with small children care should, be taken that they do not be- come chilled. This tendency can be overcome by application of !n*at and friction to the extremities. The heart may be stimu- lated by the hypodermic use of camphorated oil. Where diarrhea is a feature of the eruptive stage treatment Diarrhea therefor is as a rule not necessary. Should it persist, small, fre- quently repeated doses of bismuth subgallate, with enemas of norma] salt solution every four hours, will usually relieve the condition. Extension of inflammation from the throat may lead to a suppurative otitis media. This if not relieved, leads to infection of the mastoid, necessitating operative interference. Weiss claims that by placing pledgets moistened with weak silver solution in the nostrils and carrying them backward by pressure, he has reduced the percentage of otitis in measles from 27 to 7 per cent. Should suppurative otitis develop, the drum should be incised and irrigations of hot boric acid, 1-100, or protargol, 1-300, every three hours should be employed and kept up until the discharge disappears. During the eruptive period the diet should consist of milk, Diet eggs, and foods easily assimilated; later this may be increased to the full, regular diet during the period of convalescence. The patient with uncomplicated measles should be isolated for at least twenty-eight days; cases with persistent discharge from the nose or ears, for a longer time. SMALLPOX. (By Dr. Heman Spalding, Chicago.) The treatment of variola should begin with a consideration of the proper application of known preventive measures. Meas- classification ures commonly employed and known to be efficacious in prevent- of P reventlv e ing smallpox are: 1. Notification of cases and suspected cases of smallpox to Boards of Health or Health Officers. 2. Quarantine and Isolation. 3. Disinfection of infected persons and premises. 4. Vaccination. Notification. That prompt preventive measures may be taken by the rightfully constituted health authorities or health officers in Beports to states, cities and towns, there should be state laws and city ordi- health officers nances enacted, requiring, under penalty, a prompt report to the health officer of all infectious diseases. Cities have health 574 SMALLPOX Early diagnosis Guards Personal care of physician Home disin- fection ordinances and health officers to whom reports can be made. Some towns and villages are not thus provided, and when they are not, reports should be made to the county health officer or the state board of health. Physicians should promptly report any suspected case of variola. Owing to the lack of opportunity ;.o see variola, the ablest of practitioners are liable to find it lifficult to make an early diagnosis of this disease. Any erup- i i ve disease not certainly understood should be promptly re- ported to the health officer as suspicious, throwing the respon- sibility of making a diagnosis upon that officer, who is, or should be, especially qualified for this work. It is the health officer's duty to see that the physician who reports a suspected Case of smallpox suffers no loss of confidence from the patient or his friends. The protection of the physician's interests is easily accomplished if the health officer is tactful and ethical, as he always should be. Quarantine and Isolation. If the victim of smallpox is to be treated at his home, as is the practice in small towns and the country, a strict quarantine of the house must be maintained. As no quarantine is effective if not complete, guards for the house must be stationed day and night, and no one except the attending physician or health officer allowed to enter or leave the infected house. The doctor should have a robe or a long rubber coat hanging outside the house to put on while visiting the patient, to be again removed upon coming out. He should then wash face, hands and hair in a 1 to 500 bichloride of mercury solution and sponge off his clothes and soles of his shoes with the same solu- tion. While in the house visiting the patient, the doctor should avoid, when possible, touching anything except the floor with the soles of his shoes. If there is no contact with anything in- fected, there is little liability of carrying infection to others. To quarantine smallpox in the house is expensive and less efficient in checking the spread of the disease than is the prac- tice of taking all patients to an isolation hospital. In the lat- ter practice the patient is at once taken to the hospital in a carriage or ambulance. Those suffering with the mild form of the disease, and even some of the severer cases, when found on the first day of the eruption, prefer to go in a carriage. At this period of the disease they usually are able to sit up and walk. All persons exposed to the case are vaccinated and the persons and premises disinfected with formaline and a free use of bichloride of mercury solution, 1 part to 500 of water. If the victim of the disease has remained home through the pustular SMALLPOX 575 stage of the disease, it is safer to burn the mattress and all bed covers used which cannot be immersed in the bichlo- ride solution and boiled. Nothing should be taken from the in- fected house, even to be burned, that has not first been wet with the bichloride solution. After the patient is placed in the hospital and the inmates of the infected house and the premises are disinfected, and if all the inmates have submitted to vaccination and will obey orders, no quarantine is necessary. All those exposed are required to Care of persons be at home where they can be seen at least every other day for expose eighteen days. In no other respect need their movements be re- stricted. They are advised to stay away from public gatherings and to remain at home as much as possible, to escape criticism from neighbors. The moment any of the exposed shows symptoms of the disease, he is placed in a room and the other inmates required to stay in the house. When the eruption appears, which occurs on the evening of the third or morning of the fourth day of the disease, the diagnosis is complete, and the patient now in turn is taken to the isolation hospital and the house is again disin- fected, but now there are no unvaccinated persons who are ex- posed. The house is free from smallpox and no further watching is needed. Disinfection. In addition to burning mattress and bed covers not easily Method of dis- disinfected by the soaking in a disinfecting solution and boiling, infection and the free use of the disinfecting solution, a formaldehyde dis- infection should be made as follows : The house to be disinfected is sealed and prepared as usual for sulphur disinfection by pasting strips of paper over cracks of doors and windows. All its surfaces are exposed as much as possible; closet doors are opened and their contents, together Preparation of with the contents of drawers, are removed, scattered about and rooms and con- the drawers left open; mattresses are set on end; pillows, bed- ding, clothing, etc., are suspended from lines stretched across the rooms, or spread out on chairs or other objects so as to ex- pose, all sides; books are opened and the leaves spread — in short, the rooms and their contents are so disposed as to secure free access of the gas to all parts as fully as possible. For every 1,000 cubic feet of space in the house, suspend Formalin by one edge an ordinary bed sheet (2x2^2 yards) from a line stretched across the middle of the rooms. Properly sprinkled, this will carry without dripping eight ounces of formalin — the 40 per cent, solution of formaldehyde gas — which is suf- ical inspectors 576 SMALLPOX ficient to disinfect 1,000 cubic feet of space. As many sheets as necessary are used, hung at equal distances apart. The ordi- nary rather coarse cotton sheet should be used in order to secure rapid evaporation. The house should remain sealed not less than eight hours. When an isolation hospital is to be built, or hastily provided as is usually the case, see to it that the structure is good enough to be occupied by the best citizens. It should be a place to which the mayor and members of the council would be willing to take members of their families if any should be stricken with smallpox. A proper method of handling smallpox is fairly revealed in the writer 's written instructions to medical inspectors with whom he has been associated in suppressing smallpox in Chicago, which reads as follows : Duties of med- ' ' Medical Inspectors must keep in close touch with the De- partment of Health, so they may be reached without delay when wanted. ''When notified of a suspected case of smallpox, the inspec- tor must go to the case forthwith. An hour's delay may result in many needless exposures. "The following suggestions as to conduct in the presence of smallpox should be observed so far as the circumstances of the case will permit with safety. The inspector must supply any deficiency in these instructions which the case may demand for the safety of the public. "On entering the house where there is a suspected case of contagious or infectious disease, do not remove your hat or overcoat; keep the overcoat buttoned. "Do not shake hands with any one in the house. Do not sit down or touch anything in the house, and especially avoid touching the patient or bed clothing. To expose the patient for examination, call upon the patient or some one present to re- move the clothing for you. When leaving the house, have some one open the door, so as to avoid touching any infected door knob. "Except to vaccinate the inmates of the house, it is not necessary to touch anything about the premises, except the floor with the soles of your shoes. If these precautions are observed there is no danger of carrying the disease to others. "When it is determined the case is one of smallpox, fill out the history blank provided for the purpose, telephone the in- formation to the department, and promptly mail the filled blank to the Chief Medical Inspector. Telephone instructions as to SMALLPOX 577 the disposal of the case, whether an ambulance or a carriage is needed, the amount of disinfecting to be done and the number of vaccinators needed. "In filling out the blank, secure a list of all who have in any way been exposed to the contagion since the first day of the sickness, learn if letters or laundry have been sent out of the house, and where and to whom sent. Give the vaccinal status of those exposed as far as you can. "It is the duty of the inspector to vaccinate, or see that some other medical inspector vaccinates, all who are known to be exposed to the infection; do not leave or allow this duty to be done by the family physician. It is the duty also of the inspec- tor to secure the consent of the patient or family for the removal of the patient to the isolation hospital. Do not leave this duty to the ambulance driver. "Until the ambulance comes the case must be made safe. If it is necessary to police the house to secure safety, do so. After securing the prompt vaccination of all exposed, it is the inspector's duty to see the exposed every other day for fifteen or twenty days. Repeat the vaccination every day for three days without waiting to see the result of the first trial. ' ' If there is doubt about the diagnosis, vaccinate the inmates of the house, make the case safe to others and see the patient later. "A medical inspector must be courteous and should be tact- ful in all his relations to cases of smallpox, the same as a doc- tor should be in his private practice. He should be a complete master of the situation, able to dispose of complications and duties as they arise, in a proper manner. It should not be bur- densome to do so, for the reward is always present, the con- sciousness that it is life-saving work. Use discretion and se- cure compliance with the ordinance without force. This can almost always be done, but if necessary the police power can be used to enforce compliance with the law. "You should read and familiarize yourself with the City Or- dinance relating to sanitary work/' Vaccination. All preventive measures against smallpox are insignificant Value of vac- by the side of vaccination. If vaccination and re-vaccination were cmation properly performed and universally applied, the consideration of palliative and curative remedies would be superfluous. Vac- cination, with re-vaccination until the susceptibility to vaccine is exhausted, is an absolute protection against an attack of small- pox. A person thus vaccinated cannot contract smallpox. 578 SMALLPOX Effects Age and peri- ods of revac- cination A successful vaccination is characterized by vesiculation, pustulation, mild and limited inflammatory area with febrile reaction. In about twenty days from the beginning of the vesicle the resulting scab comes off. This leaves a scar which is typical, if there is no extraneous infection to cause inflamma- tion and sloughing. Such a vaccination can be secured by using potent lymph which has been freed from pathogenic germs by mixture with glycerine. This vaccination is protective against smallpox for about ten years. Sometimes this single vaccina- tion is protective for a lifetime, but occasionally a person is again susceptible to a mild attack of smallpox in a little less than ten years from date of vaccination. Every child should be vaccinated before the age of six months, and again in from seven to ten years. The operation should be repeated at periods of seven to ten years during life to make sure the protective influence has not been partially exhausted. If it fails to take it gives no inconvenience and does no harm. If it takes, it proves that the former vaccina- tion is not now, at the time of the retrial, wholly protective. All persons not having had smallpox are susceptible to vaccinia at least once. Eepeat the operation a dozen times if necessary to secure a successful result. The statement that this or that one is insusceptible to vaccinia — and consequently .smallpox — is responsible for many deaths from smallpox. The writer saw a cashier of a bank die of hemorrhagic smallpox a few years ago, who had been vaccinated five times — all failures. His physician told him he was insusceptible to vaccinia and need not fear smallpox, — a bit of false professional advice which cost a useful man his life at the age of 33 years. Inert lymph or faulty technique are responsible for most failures to secure a typical result. To perform the operation, sterilize the skin, preferably of the left arm — the right if the subject is left-handed. If the subject is a girl, a place high up on the arm near the shoulder; in men and boys at the insertion of the deltoid. Use glycerinated lymph and blow the lymph — not with the breath, but with the rubber bulb furnished for the purpose — on the disinfected skin before scarifying. Take the arm in the hand, and by pressure make the skin on the upper aspect a little tense. Then with the point of a dull, sterilized needle, go right through the drop of lymph, and with slight pressure, irritate and abrade the skin, covered by the drop, until it is red. Lay bare the cutis vera, but do not bring blood. You cannot always avoid bringing a little blood, but if a dull needle is used with slight pressure SMALLPOX 579 blood will seldom flow. Scarify a space exactly one-eighth of an inch in diameter, this size: 4 Make but one mark. Vaccinia is a systemic disease, and a Technique of single inoculation should be as efficacious in producing vaccinia as a greater number, unless there is an interval of time between the vaccinations. The observations that have been made upon subjects with one, two, three or more scars, have led many to believe that two or more scars are more protective from small- pox than one scar. This I believe applies only where a period of time elapses between the production of a first, second and third scar. A dull needle is the best instrument to use for vaccinating; it is cheap, easily sterilized in a gas jet or flame of a lighted match, and does not terrorize children. For convenience and clearness of understanding the cura- tive and palliative treatment of smallpox, it is best to consider the treatment as applied to the disease in its various stages — the incubative stage, the invasion stage, the eruptive stage and the stage of desiccation. THE INCUBATIVE STAGE. During this stage nothing is known to be of any benefit in Treatment of staying the disease after the reception of the infection into the stag-e nCUbatlVe blood, except vaccination, and that is of use only when applied during the first three days after receiving the infective agent. Vaccination will always prevent the disease if applied the first two days after exposure to the same, and will, in the great ma- jority of cases, prevent the disease when made use of on the third day after exposure to the smallpox infection. On the fourth and fifth days, perhaps the sixth, if tried, vaccina- tion will modify the disease, but after this time it has no modify- ing effect. A person exposed to smallpox should be vaccinated without delay. Repeat the operation the next day, and continue to vac- cinate daily until you are sure one of the vaccinations is begin- ning to "take," then stop. By this method it is almost a cer- tainty that you will secure a successful vaccination in the first three days' period, which insures the safety of the individual. When this practice is followed three or four vesicles may and often do result, but it saves life. If one vaccinates the first day of exposure, and waits to see if it "takes" before making another attempt, it results in the case of failure in losing all chance of preventing the disease. In other words, we have three days or chances to prevent the disease, and use but one. It is safer to make good use of the three chances. If vaccination is not resorted to early enough to prevent 580 SMALLPOX Sustaining ef- forts Treatment of the stage of invasion the disease, the victim must meet one of the most formidable and deadly foes known to the human race. Anything that can be done to increase the power of resistance to disease should be done at this stage. Dr. I. D. Rawlings, of the Chicago Isolation Hospital, has practised and advocates the placing of a person known to be exposed to smallpox in training for the fight with the approach- ing disease. He forbids alcohol in any form — the popular prophylactic with the laity — and places the subjects upon a good nourishing diet; keeps them in the open air as much as possible, and gives them regular and helpful exercise. He pro- motes excretion by baths and such laxatives as may be needed. He aims to promote bodily vigor, and thus increase the resist- ing power against disease. The subject should be kept cheerful and hopeful by encouraging and reassuring advice. This is rational treatment. It fortifies the body against the exhausting influence of this truly frightful disease. Nothing further can be done during this incubative stage. THE STAGE OF INVASION. This stage — which usually lasts three days — exceptionally only two days, and occasionally prolonged to four days — is the initial febrile stage. All we can do in this period is to palliate distressing symptoms and promote comfort. For excessive fever, cool sponge baths, and ice to the head if the headache is severe. Some of the coal-tar preparations, as acetanilid, may relieve backache and headache. To aid excretion and help to reduce fever, liquor ammoniae, acetatis, two teaspoonfuls every two hours, is of some service. To relieve pain, codeine may be used. Convulsions in children in the beginning are best treated by hot baths, and, if persistent, chloral, well diluted with water to avoid irritating the stomach. The early pain in muscles and back is relieved by two or three capsules of acetanilid, grains iii; monobromate of camphor, grains ii, and citrate of caffein, grains i. Codeine may be added to this capsule if the pain is excessive. At this stage the nourishment should be cold milk, ice cream and water. As the stage of eruption approaches all the painful symp- toms become intensified. Fever high, frequently 106° F., severe backache, intense headache, nausea, anorexia and sometimes de- lirium. To relieve these distressing symptoms, morphine given hypodermically is the most effective, one-eighth of a grain, and repeat the dose in an hour or two if needed. The ice cap and morphine often relieve delirium. Bromides and chloral given SMALLPOX 581 for delirium are irritating to the sensitive stomach, while mor- phine is better borne. Cold sponge baths should be continued when the temperature is high, and if the patient is able to stand the exertion, and he usually is, he can be placed in a tub for a cold bath. On the evening of the third or morning of the fourth day the eruption on the skin appears, and all these distressing symp- toms, as a rule, cease. The headache and backache are gone and fever usually disappears. In severe cases the temperature may remain up for twenty-four or thirty-six hours before dropping to the normal. Exceptionally, the temperature may be con- tinuous throughout the course of the disease. THE ERUPTIVE STAGE. As the eruption appears little treatment will be needed for Treatment of a few days. The patient feels well, and the majority at this * ne eruptive time will get up and walk or sit up. This is the period in the disease when the patient will walk out and visit the doctor's office, or take a trip on the railroad to visit friends. He should be kept in bed and given nourishing food during the several days of comparative comfort he will now experience. At this time the appetite is quite good, and the patient can take with benefit to himself a pretty generous diet. Semi-solids can be given freely, such as oat-meal and cream, milk-toast, custard, soft boiled eggs, rice and baked apples. The mild cases never having fever after the invasion stage, can eat steak, chicken, fish, oysters and vegetables. About the second day of the eruption the papules appear vesicular and continue to grow larger and fill with serum until about the fifth day, when the contents turn white or milky in color. This is the end of the vesicular and the beginning of the pustular period. There is almost always absence of fever up to the beginning of the pustular period, and during the papular and vesicular periods the treatment, aside from feeding, is local — principally directed to the throat and mouth. The ves- icles in the mouth and throat, covered with the thin mucous Mouth and membrane, rupture early and leave superficial, sensitive and throat painful ulcers. If these lesions are treated promptly they will heal in advance of the skin eruptions. This is important, be- cause the patient then can and will take nourishment much bet- ter in the later and more severe stage of the disease. Any good antiseptic mouth wash or gargle can be used. Dobell's solution makes a good one. To this a little cocaine can be added if the mouth and throat are very sensitive and sore. This gargle can be used frequently. An atomizer can be used to throw the solu- tion deep into the pharynx. 582 SMALLPOX Conjunctiva Cannot abort pustules Critical pe- riod Conjunctivitis, which is frequently noted, is due to the pres- ence of one or more vesicles on the inner surface of the eye- lids. It is best not to open these vesicles, as the rough edges of the incision irritate the conjunctiva more than does the unbroken vesicle. Use in the eye freely a saturated solution of boric acid and firmly apply a compress and bandage to prevent use and movement of the eye. Movements of the eye increase the irrita- tion, .but the compress must be removed hourly, and the boric acid solution instilled into the eye. The vesicle may form upon the cornea, in such case there is danger of perforation and de- struction of sight from deep ulceration. By carrying out the above treatment for conjunctivitis much can be done to lessen the dangers from ulceration of the cornea. In this early stage all attempts to avert the approaching pustular stage have been futile. In our experience none of the numerous remedies recommended for internal administration, with a view to aborting the lesions, have in the slightest degree modified the course of the vesicle or pustule. Puncturing the vesicle and cauterizing with a view to lessen the pitting, is a doubtful procedure. Injecting the vesicle with 1 to 200 bichlo- ride of mercury solution, which has been advocated, proves to be useless. All kinds of applications to the skin have been use- less in our hands in lessening destruction of tissue. We wrap- ped a hand and arm with a thick covering of Fuller's earth, glycerine and oxychlorine, and kept it covered without disturb- ance from the beginning of the papular to the middle of the pustular period. No local treatment was given the other hand and arm. "When the dressing was removed it was found the lesions had gone on in their development the same in the arm treated as in the one receiving no treatment. Here also there was a complete exclusion of actinic rays of light, which has been lauded as capable of preventing the development of pus- tules. Of the red light treatment we will speak farther on. From the fifth day of the eruption on to the eleventh or twelfth day is the suppurative or pustular period of the eruptive stage. This is the period in which the majority of deaths occur. It is the time when the physician and nurse are most needed. Much can now be done for the comfort and safety of the pa- tient. Unremitting care and watchfulness on the part of the doctor and nurse will pilot to recovery through this distressing period many cases which appear hopeless. At the beginning of this period, in severe cases, the fever returns. This is probably a septic fever. There is an inflam- matory area about the pustule and much swelling. Burning and itching comes to torment the sufferer. The condition is simi- SMALLPOX 583 lar to that of a man affected with thousands of small boils, upon a large number of which he must lay his whole weight. The torture is extreme. In the confluent form the condition is somewhat similar to an extensive burn of the second degree. The indications for treatment during the pustular period of smallpox are : 1st. To allay pain and prevent shock and exhaustion. 2d. To support the patient. 3d. To hasten desiccation. 4th. To combat toxemia. 5th. To treat complications. Owing to the inflammatory condition about the pustules, the pain and distress of body at this period is very great. Fever, sleeplessness and often delirium fast exhaust the patient's strength. At this time bromide and chloral have been given to relieve pain and induce sleep. These drugs are not well borne, nor are they efficient for the purpose of relief of the condition present. The painful period of acute inflammatory condition of the skin lasts usually from the evening of the sixth day to the morning of the ninth, in severe cases a day or two longer. Dur- ing this time nothing gives so much relief from pain, itching, burning, sleeplessness and delirium as morphia, one-fourth grain, repeated if need be every four hours. If a larger dose is necessary to secure results, give it. It is well borne and affords sleep and comfort. If there is any pre-existing nephritis, mor- phia should be used cautiously, if at all. Nourishment must be administered, though there may be anorexia. A liberal quantity of milk, warm or cold as suits the patient, and ice cream are allowable. If the patient does not retain these, try milk with lime water, milk-punch, egg-nog and kumyss. If all food is rejected feeding by the rectum should be restorted to. In support of patient tonics and stimulants must be used, as indicated by the condition of the pulse and temperature. Strychnia should be given as early as the time when the pulse shows weakness. Begin with the one-fortieth of a grain every four hours, and increase to one-thirtieth grain, given with the same frequency. Brandy should be given for five or six days during the suppurative period, and longer if the patient is absorbing pus from the surface. Alcohol is un- doubtedly valuable in the treatment of septic cases and those who were addicted to drink before the attack. Tincture of the chlo- ride of iron and quinia are useful also in combating toxemia. Antistreptococcus serum was abandoned by us as useless after a fair trial. 584 SMALLPOX The cases of true hemorrhagic smallpox are practically hope- less. They all die in six, or at longest seven, days. I have seen but one live to the seventh day. The same supporting treatment given above applies to these cases. Ergot, adrenalin and antistreptococcus serum fail to aid, though they have their advocates. Local applications during the pustular period, that have been so extensively used, I do not approve of. To allay itching during the vesicular and pustular periods, water with menthol can be used, and sponging for cleanliness and reducing fever, but this readily dries and does retard desiccation. The smallpox lesion in its life history is like that resulting from vaccination. The natural history of the lesion is to fill with serum, turn pustular, dry up and scale off. Nothing should be done to retard this process. The application of continuous baths, poultices, plasters, oils or salves of any kind hinders desic- cation. We do not use these applications on a vaccination before desiccation, and why should we try them in the treatment of smallpox ? The mild cases are best treated by arranging so that their bodies are exposed to the sunlight and air. This hastens the drying-up process and shortens the period of pustulation. This treatment I would not advise for confluent cases with secondary fever in warm weather, as the heat of the sun adds to the dis- comfort, but in the discrete cases it is not uncomfortable and I believe it shortens the course of the skin lesions. Even the patients in the wards notice and remark about those near the windows recovering more speedily than those farther from the windows and sun's rays. From January 1, 1899 to January 1, 1903, there were treated in the Chicago Isolation Hospital 690 cases of smallpox, mostly of the mild type. They were placed in the sunlight as much as possible. The death rate was but 1.6 per cent. — a better showing than that recorded under the so-called Finsen ray or red light treatment, — the exclusion of the actinic rays of light by means of ruby red window glass. From January 1, 1903, to January 1, 1906, 1,289 cases were treated in the same hospital with a death rate of 10.5 per cent. The disease had changed to the severe type. This is a low death rate, considering the severe type of the disease. These patients, with the exception of about seventy in the red light ward, were given plenty of light and air in wards with large windows on both sides and one end. About seventy of these patients were put in a ward from which the actinic rays were rigidly excluded. This red light treatment not only proved SMALLPOX 585 worthless, but was harmful. The red light gives patients in delirium the impression often that the house is on fire. Pinsen claimed that this treatment, if begun the first day of the erup- tion, would prevent the formation of pus. In no instance in our experience (and we gave it thorough trial) did the treatment in any degree modify the course of the disease. The red light treatment for smallpox cannot be recommended. As the pustular period advances, the lesions rupture from the weight of the body, and the bed sheets stick to the raw surface of the lesions. The sheets should be dusted with a pow- der composed of boric acid and subgallate of bismuth. Sheets must be changed several times daily when the pustules begin to break down. Warn patients against scratching the face. Adults can be influenced not to scratch the lesions, but children cannot resist the itching, and should have their hands enveloped in cotton covered by sterile gauze. This will prevent scratch- ing. If the itching cannot be resisted, it is better to delay desiccation by applying carbolized vaseline 3 per cent., to which is added 2 per cent, menthol. Or oxide of zinc ointment, to which is added one drachm of campho-phenique to the ounce, and 2 per cent of menthol. If the pustules run together and become large blebs filled with pus, resembling the blisters from burns, the contents may be let out by incision and the dusting powder freely applied. This condition is often seen on the hands and wrists. THE STAGE OF DESICCATION. When the pustules are dried, forming scales, the patient Treatment of is readv for antiseptic baths, which loosen the scabs and dis- sta S e of desic- cation infect the surface of the body. The baths found most efficacious are bichloride of mercury 1 part to 1000 of water; and equally as good permanganate of potash enough to color the water a light pink. Then the protecting salves can be freely applied. As all pustules are dried now, salves will soften and hasten desiccation. Nourishment should now be given freely. Semi- solid diet, and in a few days solid food, can be taken with ad- vantage. The appetite is usually good, and a substantial diet can be given, including meats. If there is anything the patient needs now it is food, and he should have three meals daily and a lunch between meals. This is the stage when abscesses, boils, local surface infections, impetigo, erysipelas and gangrene are found, though gangrene of the scrotum has occurred in the pus- tular period. All complications of this kind should be treated the same as vvhen encountered unaccompanied with smallpox. Pneumonia, bronchitis, pleurisy, laryngitis and nephritis may occur. The diet must be restricted in case of nephritis. 586 YELLOW FEVER In mild cases no "pitting" remains after recovery. In the severe cases there is no treatment which we have tried that will prevent pitting. Smallpox, like other morbid processes, is a' disease of degree. Some will have small pustules with a com- paratively mild inflammatory manifestation. Some cases wiD even abort in the papular or vesicular period and escape the inflammation of the pustular period. If the pustules are large and well filled with pus, and if the epidermis is thick and tena- cious, the pus will be held down under the pressure until the inflammation extends through the cutis vera. Destruction of skin, with "pitting" is the result. To summarize: Smallpox is absolutely preventable by vac- cination. There is no known medicine which in any way modifies the disease once it is well started. The treatment consists in intelligent nursing and the use of such palliative and supporting remedies as are known to give and conserve strength. YELLOW FEVER. (By Dr. Albert J. Mayer and Dr. Urban Maes, New Orleans, La.) In yellow fever we are to-day, as with many other diseases, without a specific. The treatment is entirely symptomatic. In the antitoxin of Sanarelli, discovered in 1895, and published in 1897, it was hoped that a specific had been found, but experience showed its insufficiency. In order to intelligently treat yellow fever symptomatically it is necessary to touch briefly the various phases of the pathology of the disease as they arise. Primarily, we must remember that yellow fever is an acute, infectious, febrile disease caused by an, as yet, unknown organism. The toxins of this organism, circulating in the blood, have certain deleterious effects on the human economy, briefly, as follows: 1. They act as a medullary poison, exerting an early in- fluence on the vomiting centers. (This symptom is partially due to the capillary stasis in the stomach with mucous and sub- mucous hemorrhages.) 2. They produce vaso-motor paresis, hemolysis and disinte- gration of the capillary walls by fatty degeneration, which is part of the general steatosis. 3. They cause pathological changes (fatty degeneration) in the liver and kidneys, characterized by jaundice and usually by an acute desquamative nephritis. YELLOW FEVER 587 At the first appearance of the symptoms of the disease the Hygiene patient must be put to bed. Rest, both mental and physical, is an absolute requirement. The patient must not be allowed to raise his head off the pillow. Defecation and urination must be performed in the recumbent posture and the supply of fluids should be administered by means of a tube or feeding cup. The best observers are unanimous in agreeing that these statements are to be taken in their most literal manner and the physician cannot afford to deviate from them in the slightest particular from the first moment of attack. After being put to bed the patient is clad in the lightest of garments so arranged that in order to sponge him it will be un- necessary to put him to the slightest exertion. A tepid cleans- ing bath is given and the patient is placed in the best lighted and ventilated room in the house. Measures of hydrotherapy which may later become necessary must be done with the utmost gentleness, in fact some observers go so far as to claim that yel- low fever being a self -limited disease it is better to ignore the pyrexia on account of the accompanying disturbance of bath- ing. They believe that the pyrexia is far less dangerous than the moving of the patient. We think, however, that a certain amount of personal cleanliness adds to the comfort of the pa- tient and does much towards hastening convalescence. A mouth wash of some alkaline antiseptic solution as chlorate of potassium is of service in diminishing the tendency towards gingival hemorrhage besides alleviating the bad taste. Enemata of soap suds and water should be given every day or every other day according to indications, but care must be taken not to irri- tate the rectum as it may be our sole reliance for sustaining and treating the patient. From time immemorial the initial measure of treatment which The foot bath has stamped itself most emphatically upon the minds of the prac- titioners in the localities subject to the invasion of "Yellow Jack" has been the mustard foot-bath or the foot-bath a la Creole. A foot-tub is partially filled with warm water to which is added a pound of freshly ground mustard dissolved in cold water. This tub is placed in the bed ; the feet of the patient are then immersed. The patient and tub are covered with two or three woolen blankets. Every three or four minutes a pint of almost boiling water is added to the bath, the feet and legs of the patient being rubbed rather vigorously. The sudorific effect of the bath must be kept up for at least ten minutes and its effects aided by the giving of hot aromatic drinks, hot lemonades or teas. 588 YELLOW FEVER This has been in such universal use in New Orleans in the epidemics of '53, '65, '78, '97, that a physician is rarely called to see a case where this step has not been taken by some member of the household, and supplemented by wrapping in blankets and the administration of some hot, aromatic drink to serve as a diaphoretic and diuretic. There is no doubt that in its present form it is of decided value in relieving the head symptoms and the congestive phenomena of the first stage of the febrile paroxysm. (Matas.) If the case is seen early an initial purge of calomel in small doses should be given and followed, if the stomach permits, by some saline cathartic. After the first stage of the disease is passed and the caplliary stasis becomes marked, with nausea present, acting as an index of the congestion of the internal organs, it is not advisable to use this routine. The predisposition to gastric hemorrhage may be thereby augmented, consequently the laxative enema is preferable. The cephalalgia and rachialgia are best met by topical ap- plications, the ice-bag to the head and the mustard plaster or other counter-irritant to the loins. The coal-tar derivatives and other sedatives, such as codeine and morphine, are only men- tioned in this connection to be condemned. As has already been shown the toxins exert such a potent influence on the organs of elimination and circulation that it is unwise to tax them further. The remedies which have been lauded for the nausea are legion. The entire group of anti-emetics, including carbolic acid, cerium oxalate, cocaine, creosote and the much vaunted bichloride lemonade of Sternberg have proven non-efficacious. The sim- plest treatment is the best. "When cracked ice, carbonated drinks or iced dry champagne fail to relieve, it is the wisest plan to give the stomach absolute rest and supply fluids and other nutri- ment by rectal administration. That usually ominous sign "black vomit," or gastric hem- orrhage, is best met with perchloride of iron. (Guiteras.) This writer also claims that in hemorrhages from other mucous mem- branes (gingival, intestinal and uterine) this drug has given him the best results. His experience with adrenalin has not served to recommend its use. Ergot, digitalis and aconite have also been recommended but have not given good results. Coun- ter-irritation over the stomach, ice-bags, mustard plasters, blis- tering with cantharides or the actual cautery, and dry cups are of little value. Pyrexia Temperature is best controlled by hydrotherapy. The tub bath as used in typhoid is never employed in this malady, but YELLOW FEVER 589 sponging and packing are the measures most often resorted to. Enemata of cool water can also be used as a means of reducing the temperature and stimulating the patient. In addition they furnish the body with the fluid so necessary for the dilution and the elimination of the poisons of the disease. In Las Animas Hospital hydrotherapy was used to the com- plete exclusion of drugs, and striking results were obtained. Gorgas, of this hospital, says, "Generally when the temperature remains above 103° for any length of time I have the patients sponged every two hours with cold water." Because of the capillary stasis occurring in this disease the sponging is best accompanied by mild friction. Ice bags to the head and back of the neck are beneficial, insomuch as they are useful in the general scheme of hydrotherapy and are grateful to the patient. Here we again mention the whole group of antipyretic drugs to state that while they may have a certain limited field of use- fulness they are not to be recommended as a routine. The use of the cinchona group has long since been abandoned. The most grave condition with which we have to contend is complete suppression of urine. This should not be confounded with simple retention which can be relieved by catheterization. Anuria The possible occurrence of urinary suppression must always be borne in mind. Albuminuria, which appears in most cases on the third day, should, for safety's sake, be regarded as a fore- runner of this condition. Daily examinations of the urine are absolutely necessary. A scanty flow with an increasing albu- minuria and microscopic findings, indicative of the severity of the kidney lesion, calls for energetic measures on the part of the attending physician. Once such a state is established, therapeu- tics are of little avail ; consequently we should endeavor to fore- stall this condition by appropriate measures. When the stomach will allow, large draughts of hot or cold water, flavored or not, as best suits the patient, are to be given. The alkaline waters, such as Vichy (Celestin), Apolinaris and White Rock are of great value. The necessity of giving a large amount of fluids having been demonstrated, the rectum must be resorted to where the nausea proves intractable. Hypodermocly- sis and intra-venous infusion with normal saline solution have been used but it was the experience of Matas and others in New Orleans in '97 that when suppression actualfy existed even this was useless. The diuretic drugs, more particularly the citrate and acetate of potassium combined with the infusion of digitalis, still have a more or less deserved reputation in the hands of some practi- 590 YELLOW FEVER tioners. Their usefulness cannot be doubted in mild cases and when employed early in the attack. Dry and wet cups are also used. There is no disease in which we can less afford to dispense with the aid of a competent nurse. The value of her services can only be measured in terms of human life. With the innu- merable calls that are made upon a physician's time in yellow fever stricken communities the necessity of accurately recorded observations, especially of pulse, temperature and the organs of elimination in each case, are of the highest value. There is no doubt that the professional nurse is no small factor in the reduc- tion of the mortality of yellow fever. To quote from Osier, "Careful nursing and a symptomatic plan of treatment give the best results. ' ' Stimulants After the initial fever of forty-two to seventy-two hours' duration we have a secondary rise and it is in, or following, this stage that the patient is most often brought face to face with death. Stimulation with strychnia in doses of one-sixtieth to one-thirtieth grain hypodermically every three to four hours, supplemented by mild alcoholics, preferably in the form of iced champagne and Ducro's elixir, panopepton, and the digested beef essences, are indicated at the first signs of failing circula- tion. In this secondary fever, called the fever of auto-intoxica- tion by Sanarelli, various intestinal antiseptics, more particu- larly salol, were faithfully tried in Havana but, as shown by Gorgas and Guiteras at Las Animas in 1900, they are of doubt- ful value. Diet We have already spoken of the gastric irritability and what its persistence means. All physicians are agreed, and it may be laid down as a dogmatic fact, that during the first four days of the disease no nourishment should be given except water which may be supplied to the point of toleration. By the fifth day the crisis has usually passed, and we may then begin with milk in small quantities, plain, or with the addition of lime water. The quantity of nourishment is gradually increased with the addition of broths and strained soups. This liquid regimen should be continued until the beginning of the second week, when the patient may be allowed to sit up and begin a gradually increasing diet. Prophylaxis While the present prophylaxis of yellow fever has only been established since 1900, Finlay of Havana, as far back as 1881, had already given up the fomites theory and had begun to sus- pect that some blood-sucking insect acted as the intermediary host of the vellow fever organism. YELLOW FEVER 591 The peculiarities of the stegomyia fasciata, its methods of feeding, its universal presence in the zones liable to epidemics and its hibernation coincident with the disappearance of the disease in the zones of accidental infection, led him to direct his investigations towards that particular mosquito. In 1898 he announced the following conclusions, on which was based the work of later investigators and upon which rests our present system of scientific control: 1. That the germ of yellow fever is only pathogenic to human beings when introduced by inoculation. 2. That the regular process by which the inoculation of the germ is accomplished in Nature, is through the bites of the •culex mosquito (stegomyia fasciata), the insect having previously become contaminated through the act of biting a yellow fever patient within the first five days of his attack. 3. That although the bites of a recently contaminated mos- quito can produce at most only a very mild attack of yellow fever, or simply confer patent immunity without eliciting any obvious pathogenic manifestations, the bites of the same insect when its contamination dates back from several days or weeks, might produce severe or fatal attacks. 4. That the yellow fever mosquitoes after they have once become contaminated, retain the power of inoculating the disease during the rest of their lives. Carter's work* was to the effect: 1. That yellow fever was a house disease. 2. That a house infected with yellow fever was not infective until a certain period of time had elapsed. He fixed this period at from ten to twelve days. It remained for the United States Army Commission under Dr. Walter Reed, consisting of Reed, Lazier, Carroll and Agramonte, to show conclusively that the blame belonged to the female stegomyia fasciata, thus confirming Finlay. Later commissions, notably those of the Liverpool School of Tropical Medicine, the Hamburg School of Tropical Medicine, working parties of the United States Public Health and Marine Hospital Service, and independent investigators, especially Guiteras, working along these lines further fixed upon the stegomyia fasciata as the sole agent capable of transmitting the disease. Prior to 1901 sanitarians devoted their efforts in stamping out the disease in accordance with the theory of fomites, but the labors of the above mentioned scientists, and the work of Gorgas *New Orleans Medical and Surgical Journal, 1900. 592 YELLOW FEVER in eradicating the disease from Havana, its perennial home, showed clearly that the prophylaxis of the yellow fever lay in the destruction of the stegomyia fasciata, for in the words of Carroll, "No mosquitoes, no yellow fever." Prophylaxis Yellow fever, distinctly an acute, infectious disease, is trans- mitted from individual to individual, as far as we know, by the agency of the female stegomyia fasciata, aud therefor it can be eradicated as an epidemic by the destruction of this mosquito, and the individual can be safeguarded by being protected from the bites of an infected insect. In instituting prophylactic measures against yellow fever, we must bear in mind the following facts: 1. That the yellow fever patient is capable of infecting the stegomyia fasciata during the first three days of the disease only. (The yellow fever cadaver is not infectious.) 2. At least twelve days must elapse before the bite of an infected mosquito can transfer the active poison to a non- immune. 3. The period of incubation is from forty-one hours to live days and seventeen hours. (United States Army Commission.) 4. No direct transmission from patient to patient has ever been recorded except by experimental inoculation. 5. The infectious life of the stegomyia fasciata ranges from twelve days to fifty-seven days (Reed), to one hundred and ten days (Guiteras). In safeguarding the non-immune, it is obvious from the foregoing facts that the mosquito must be prevented from at- tacking the patient during the first three days of the disease. This is best accomplished by placing the sick person in a care- fully screened room, which has been freed from mosquitoes by fumigation, and under a mosquito netting which has at least 18 meshes to the inch. Further, the entire house, except the sick room, must be fumigated within twelve days of the onset of the fever, in order to destroy any stegomyias that may have become infected prior to the recognition of the disease. And finally, the entire house, including the sick-room, must be again fumigated after the recovery of the patient. When this pro- cedure is carried out, the danger to susceptible persons in the house and neighborhood is practically nil. This was the method pursued successfully in Havana by Gorgas, and his successors, except where it was possible, under a military regime, to re- move the patient in a screened conveyance to Las Animas Hos- pital. In cases of this nature, all the mosquitoes in the infected house were immediately destroyed by fumigation with pyre- thrum. The evolution of yellow fever prophylaxis as practiced YELLOW FEVER 593 on a large scale was best depicted in controlling the spread of the disease after it had gained a firm footing in New Orleans in 1905. The successful and remorseless war raged, not against the invisible and unknown foe of former years, but against the well-known striped or tiger mosquito, will live forever in the annals of preventive medicine and sanitary science, as the most brilliant achievement in the history of any nation. In all cases where possible the following routine was fol- lowed: A room adjoining that of the patient was carefully screened and sealed; it was then fumigated with sulphur (two pounds to the thousand cubic feet), and thoroughly aired. The patient was then transferred to this room and the remainder of the house fumigated in the same manner. In cases seen after the first three days of the disease the patient was transferred to another room if possible, and the room fumigated in order to kill the infected mosquitoes before they could get out to deposit their eggs after their essential meal of blood. This killing off of the infected mosquitoes in the room itself, and the neighboring buildings is the sine qua non in combating a yellow fever epi- demic. Unsuspected cases, and cases not easily recognized, as are not uncommon among children, sometimes furnish hidden foci which remain as a source of infection to the entire vicinity. In instances of this sort, wholesale mosquito destruction becomes im- perative. The breeding places must be ruthlessly destroyed. Guiteras, the greatest living student of yellow fever, recog- nizes three areas of infection. phylxSs Pr °" The focal zone in which the disease is never absent. This formerly included Havana, Rio, Vera Cruz, and the ports of the Spanish-American main. Thanks to the labors of the sanitary workers we can eliminate two of these, Havana and Vera Cruz. 2. The peri-focal zone or regions of periodic epidemics. This zone includes the port of the tropical Atlantic in America and Africa. 3. The zone of accidental infection between the parallels of 35° South and 45° North. The peri-focal and the zones of accidental infection can be protected from the introduction of the disease by efficient quarantine regulations preventing the ingress of infected persons from infected ports, and establishing such a period of detention that the disease may have time to de- velop before suspected non-immunes are allowed to enter a non- infected port. 594 SYPHILIS. (By Dr. F. Kreissl, Chicago.) The treatment of syphilis is both a local and a constitutional Local treatment Excision of chancre Cauterization of chancre Antiseptics lo- cally (1) With local treatment we attempt to destroy, or at least weaken, the specific virus wherever its initial presence is evi- denced by pathological lesions. This may be accomplished by cauterization or by excision of the venereal sore. According to Fournier excision gives an average of one suc- cess in five cases, the success depending upon the length of time between the appearance of the chancre and its surgical removal. Even if failure as an abortive procedure occurs, the excision of the chancre certainly renders the subsequent course of the dis- ease much milder. The cauterization of the venereal ulcer is less effectual as an abortive means. In fact, I do not believe that such is possible, but it unquestionably lessens the severity of the subsequent symptoms. Neither procedure is indicated when the adjoining lymphatics are already involved. The venereal ulcer should be treated on general surgical principles like any other wound. We employ mild antiseptic so- lutions like two per cent, carbolic acid, or 1 in 3000 bichloride of mercury for cleansing, followed by a thin layer of dusting powder on the dried surface. Most effective, but obnoxious on account of its odor, is iodoform used pure or with equal parts of boric acid. Instead of this dermatol, iodol, or europhen may be employed. Gauze compresses saturated with any of the above solutions may be applied several times a day to chancres with sluggish granulations showing little tendency to heal. Gan- grenous or phagedenic chancres require cauterizing with the Paquelin, followed by the application of the nitrate of silver pencil, or a ten per cent zinc chloride solution, or nitric acid. Sometimes cauterization will have to be preceded by a thorough curettage of the ulcer, both procedures requiring a general an- esthetic. As soon as the ulcer has a healthy appearance and one does not wish to commence with the constitutional treat- ment, it should be covered with Unna's mercury plaster mull, to be changed once or twice a day, depending on the amount of wound secretion. This plaster mull is applied even after the sore has healed, as long as the induration is noticeable. If phymosis has been caused by chancre, and if the latter is not ac- cessible to local treatment, we expose the ulcer by circumcision or by a dorsal division of the prepuce. SYPHILIS 595 Chancres in the vagina and on the cervix are exposed by a speculum and treated in the same manner as elsewhere, but the mercury is applied as ointment on a gauze tampon. The latter has to be omitted during pregnancy and in its stead vaginal balls of equal parts of cocoa butter and mercury ointment are inserted. Initial lesions in the mouth and on the tonsils require daily applications of a ten per cent, solution of bichloride of mercury in alcohol or ether. Venereal papillomata yield to the daily application of re- Resorcin 9.0 Sacchar. 1.0 Sig. Dusting powder. Or 9 Resorcin 5.0 Aqua distil. 100.0 Sig. Apply on gauze sponge. Or 9 Acid lactic Ether sulph. aa 10.00 Hydrarg. bichlor. cor. 0.10 Sig. Apply with a brush once a day. Very effective because one application usually suffices is: Plumb, causticum Solut. Kalin caustic (30 %) aa 7.50 Lithargyri 0.25 Sig. Apply with the point of a wooden stick. This mixture is applied to the whole growth and the healthy skin protected during the application. Papillomata resisting this treatment are curetted and cauterized with Paquelin. The condylomata around the anus usually disappear under calomel dusting powder and an isolating gauze pad. 596 SYPHILIS Indurated lymph glands are covered with, mercury plaster mull. Suppurations Suppurating glands have to be opened and treated in the following manner: After shaving and cleansing the region in the customary way and anesthetizing with ethyl-chlorid, an in- cision is made in the long axis of the bubo and carried down to the pus cavity; the latter is not only exposed, but its contents are squeezed out with the fingers by rather hard pressure all over the region. This is kept up for a minute or so until the fluid becomes free from pus and appears sanguinolent. The abscess cavity should not be irrigated, only the edge of the wound cleansed with boiling hot water. Now the wound is closed by an interrupted horsehair suture. No drainage is nec- essary. The region is cleansed with hot sponges once more and a gauze collodion dressing applied. Over this comes a com- pressing pad and bandage to be maintained for several days. The sutures are removed after ten days, at which time, if at all, healing by primary union has occurred. Onychia and paronychia require a daily local bath in bi- chloride of mercury solution in the strength of 1 in 2000, fol- lowed by a dusting with i* Calomel Talcum venet. Sig. Dusting powder. 2.0 20.0 Gummata (iummata which are not yet liquefied or not exulcerated are often absorbed by tincture of iodine or mercury plaster mull, or a ten per cent, calomel traumaticin applied daily. Calomel 5.00 Traumaticini 20.0 Sig. Shake well, apply with brush. Constitutional treatment An exulcerated gumma is treated like a phagedena ulcer; mucous patches in the mouth like ulceration therein. The constitutional treatment should be commenced as soon as the syphilitic character of the ulcer is with certainty established and the healing process retarded and in all secondary and ter- tiary manifestations of the disease. The sovereign remedy is mercury. It is administered: 1. By the mouth. 2. By in- unction. 3. By injection. SYPHILIS 597 Preceding the treatment attention should be paid to the con- dition of the gastro-intestinal tract, the diet regulated, the urine examined and the mouth and teeth put in the best possible con- dition. By mouth, mercury is given in pills or capsules, but we must Mercury by the remember the caustic action of the drug on the intestinal tract. mou yrum oxydulatum tannicum is very effective. Hydrargyrum oxyd. tannic, 2.50 Opii p., 0.25 Sacch. lact. 3.50 Lanolin 1.25 M. f. pill— No. 50 Sig. Four to six pills a day. Opium is added when the bowels are very loose. Hydrargy- rum oxydulatum tannicum is incompatible with carbonates and iodine preparations. Equally reliable as the above is $ Hydrarg. protoiodid. 1.50 Decoct, opii aq., 0.50 Lanolin 1.50 Sacch. lact. 4.50 M. f. pill— No. 50. Sig. Four to five pills a day. The prescription should call for a small number of pills, in order that they may be fresh. Those which are kept in stock are sometimes very old and get so hard that the gastro-intestinal juices are not able to dissolve them; many disappointing results are due to this fact. Mercury, given by mouth, should be taken immediately after a meal. In case of diarrhea its use must be discontinued and opium given. If the intestinal irritation recurs after the drug is resumed, this mode of treatment must be abandoned and in- unction or injections resorted to. More recently cypridol, a one per cent, solution of biniodide of mercury in oil, has been used. It is given systematically for three weeks in the first three months in doses of two capsules, three or four times a day after meals. For the following three months the same amount is given every alternate fortnight and after that eight days of each suc- ceeding month for three consecutive years. The claim is made 598 SYPHILIS Mercury by in- unction that it is not as irritating to the gastro-intestinal tract as the other preparations of mercury, which limits their value on ac- count of the small amount of the drug that can be administered by mouth. For inunctions unguentum hydrargyri is used, mixed with equal parts of unguentum petrolatum. It is dispensed in gelatin capsules or in paraffin paper, each containing two to three grammes of the ointment for an adult and one-half to one gramme for a child. 9 Unguenti hydrargyri Unguenti petrolati aa (Caps, gelatin) paraffin paper No. XII. Sig. Use as directed. 1.50 Disadvantages of inunctions Wherever possible easily accessible hairless portions of the skin are selected, and each inunction applied to new parts fol- lowing a set cycle as, for instance, First night — arms and forearms. Second night — both sides of chest. Third night — the loins. Fourth night — the abdomen. Fifth night — inner surface of thighs. Sixth night — no inunction, warm bath. Seventh night — inunction as on first night, etc., etc. In this way unnecessary cutaneous irritation is usually avoid- ed. (Eczema mercuriale — Folliculitis — Toxic Erythema.) The inunction should be made by the patient himself, but if made by anyone else rubber gloves should be worn. Each rubbing re- quires about twenty minutes, and it is a good plan to rub in small portions — about the size of a bean — of the ointment, this procedure to be repeated when the skin becomes dry. The disadvantages of this mode of treatment are its un- cleanliness; the irritating effect on the skin; the time consumed by each application; and the impossibility of an exact dosage. Most of the mercury contained in the ointment evaporates when brought in contact with the living body, the greater part of the vapors entering the system through the respiratory organs, the smaller part through the skin. This explains why patients treated under otherwise identical conditions sometimes are easily salivated and at other times do not seem to respond to the treat- ment at all. These different observations largely depend on the temperature surrounding the body after the inunction. In- SYPHILIS 599 stinctively older syphilologists ordered the inunctions to be made in superheated rooms and had the patients wrapped in flannel blankets for hours afterwards. Instead of the mercurial ointment, mercury plasters or the Mercury pla plaster mull spread over large areas of the body may be used ters to advantage, especially in children. It is renewed once a week. V Emplastr. hydrarg. oleinicum Emplastr. plumbi olein. aa 140.0 Hydrargy depur. for adults 60.0 for children 30.0 Sig. Plaster Another way of administering mercury externally is the Mercury baths bichloride of mercury bath, but, in order to be really effective, i. e., penetrate through the skin, it has to be given in connection with electri kataphoresis, which is accomplished by the electric two-cell bath. The quantity required for a bath varies from ten to fifteen grammes of bichloride of mercury. It is useful in the treatment of very young children, and of moist papular, pustular, and ul- cerating syphilitic lesions on the skin. For the subcutaneous application of mercury soluble and in- Mercury sub- soluble preparations are employed. They are injected hypo- cutane °usly dermically or intramuscularly. Best known and most generally used, among the soluble preparations, is the bichloride of mer- cury. It is prescribed in one per cent, to five per cent, solutions to which is added sodium chloride, which presents the precipita- tion of albuminates of mercury. Hydrarg. bichlor. corros 1.0-5.0 Natrii chlor. 1.0-5.0 Aqua distill. 100.0 Sig. Bichloride solution. Usually 1 cc, equal to 0.01 of bichloride of mercury, is in- jected in the gluteal region daily, or every other day, as the case may require. It is well to follow a certain routine in injecting. The injection should be given alternately in the left and right buttock, in and outside of a vertical line crossing its highest elevation, so that the solution is deposited in a new place each time. It should be injected slowly in order to avoid painful 600 SYPHILIS bruising and unnecessary destruction of tissue; a slight massage following the withdrawal of the needle will spread the fluid over a larger area. The syringe may be made entirely of glass or of glass with hard rubber trimmings, the needle of platinum- iridium — l 1 /^ to 1% inches long and narrow gauged. When using shorter needles the fluid is placed too close to the skin, causing inflammation, eventually even necrosis; while, when longer needles are used, as for intramuscular injections, these are followed by extremely painful infiltrations. With needles of the above length, I am able to deposit the fluid in the loose tissue right over the gluteal muscles, avoiding all these disagree- able features. What little pain is experienced ceases soon or is shortly checked by the application of heat. ■ The platinum- iridium-needle is preferable to a steel needle because the latter easily becomes corroded and punctured along its walls, allowing the solution to escape through these little holes into tissues close to the skin, producing the above inflammations. It is hardly necessary to say that the same antiseptic precautions as in or- dinary hypodermic injections should be rigidly observed, or to mention the yet quite rare possibility of an embolus, due to the puncturing of an injection into one of the large gluteal veins. Cypridol may also be injected hypodermically like bichloride of mercury in the dosis of 0.5 cc, equal to one one hundredth grain of the bichloride. The needle used must be of larger size on account of the oil passing through it. Otherwise the same rules as in bichloride injections apply to its application. Lang's "gray Of the insoluble mercury preparations Lang's "gray oil" oil " has stood the test of many thousand cases within the last twenty years. It is a compound of fat, oil and metallic mercury, dis- pensed as a fifty per cent, and a thirty per cent, liquid. The former consisting of two parts of mercury and one part each of lanolin and vaselin oil. Unguent cinereum lanolinat. forte 9.0 Olei vaselini 3.0 Sig. Oleum cinerum 50%. The fluid is slightly warmed and well shaken before being used. The dose for one injection is 0.05 cc, equal to 0.04 metallic mer- cury, and is administered in intervals of three days until a de- cided improvement in the symptoms becomes apparent, when but one injection a week is given and two more injections in an in- terval of two weeks after all symptoms have subsided. Rarely more than twelve injections are required to accomplish this end. SYPHILIS 601 The oil is deposited in the back about two inches from the dorsal spine. The needle is inserted almost parallel to and underneath the cutis. If this is observed the injection is almost painless and not followed by induration and inflammation. This is due to the lack of corrosive properties of the remedy and the very small quantity incorporated which precludes bruising or •destruction of tissue. Each following injection should be placed about two inches from the preceding one. If it is desired to in- ject more than 0.05 cc. this should be done in two equal parts of 0.05 cc. and in two different places. The advantages of the gray oil are, as said before, the small volume required for one application, the absence of reactive inflammation and the longer remanence of the preparation which establishes a reserve in the tissues to draw upon much longer than from soluble mercury solutions. But therein lies also the danger of an oversupply in the hands of those not familiar with the drug, the disease and the symptoms. Reviewing the various methods of administering mercury, Comparison of we can see the superiority of subcutaneous injections. They m e tnods of r J rf using mercury permit an exact dosage, guarding in this way against either mer- curial intoxication by an overdose, or insufficient action by loss of part of the drug on its route to the circulation. No inconve- nience in their application is experienced, no uncleanliness likely to call the attention of others to the ailment connected with it, and gastro-intestinal irritation and skin lesions are practically unknown. Simultaneously with the administration of mercury a tonic Tonics must be given. I have found peptomanganate of iron and the irontropon most valuable. Irrespective of the way mercury is incorporated, symptoms Mercurialism of mercurialism are occasionally observed; sometimes due to an overdose and at others to an individual idiosyncrasy. The mani- festations observed are stomatitis, gastro-intestinal irritation, toxic erythema, anemia, neurosis, and neuritis. As soon as these symptoms occur, the administration of mercury must be dis- continued. Most of the trouble soon passes off and the treat- ment may be resumed. In the cases of idiosyncrasy other reme- dies will have to be employed. Iodin is next to mercury and most used in combating syph- iodine prepara- ilis, especially the potassium iodid, the sodium iodide and the tions rubidiumiodide. The latter is comparatively free from the toxic qualities of the other two preparations. The dose varies from 1.0 to 10.0 and more pro die. It is given by mouth in liquid or , 602 SYPHILIS pills, excepting in intolerance of the stomach, when it is used in aqueous solution by rectum. Or Or Or Or 3 Potass, iodid, Sodium iodid, Eubid. iodid, 5.0-10.0 Aqua distill., 200.0 Sig. One to three tablespoonfuls in water, essence of pepsin, or milk, three times daily. Potass, iodid, 10.0 Sodium icd. Sacchar. lact., 5.0 M. Ft. Pill No. 50. Sig. Two to ten pills a day. lodism The most common symptoms of iodin intoxication (iodism) are severe headache, coryza, edema around the eyes, cough, acne and iodin exanthema. Should any of these symptoms appear the iodin medication must be discontinued. The addition of a grain of belladonna extract to fifty pills frequently prevents iodism. Potassium iodid is incompatible with calomel, forming a caustic compound and they should not be prescribed together. The iodid preparations are very effectual in the late forms of syphilis — serpiginous syphilide of the skin, gummata of the skin, fascia, muscles and bone syphilis, ulcerations of the pharynx and larynx, syphilis of internal organs and the cen- tral nervous system. They have to be used in malignant syphilis, instead of mercury, at least for a while preceding the adminis- tration of the latter drug and in all cases of idiosyncrasy for mercury. It is very effective with or without antipyrin for se- vere headache, pain in bones and joints preceding or accompany- ing the eruptive stage. Antipyrin, 2.0—3.0 Potassium iodid, 4.0 — 8.0 Aqua distill., 200.0 Sig. A tablespoonful in water, twit > or three times a day. SYPHILIS 603 It is the remedy of choice in syphilis of tuberculous, scrofu- ^^. d treat " lous, highly emaciated patients. In malignant syphilis, iodin preparations instead of mercury are used until the general con- dition of the patient permits the employment of the latter drug. The indications for the choice of iodine in these cases are easily recognized by the fact that in spite of the mercury the progressive nature of the lesions cannot be checked. In some very stubborn cases decided improvement will follow the combined administration of iodine and mercury after either of them em- ployed separately have failed to be effectual. How long to continue the treatment of syphilis depends on Duration of the views one holds regarding the nature of the trouble. Some believe in the temporary treatment, others in the continuous treatment, and the followers of Fournier in the chronic inter- mittent or interrupted treatment. While the adherents of the first method believe in treating only in the presence of visible lesions, the advocates of the second method administer mercury, or mercury alternating with iodine and other drugs, more or less continuously for a number of years, irrespective of the pres- ence or absence of luetic manifestations. The temporary treat- ment evidently is inadequate, while under the continuous method a tolerance for the specific drugs is established which weakens their therapeutic effect. The best results observed belong to the third method. The treatment should extend over a term of not less than three years, and in the absence of special indications not over five years. If injections or inunctions are used, the patient should first receive as many as are required to make the symptoms dis- appear, and then half as many more. Then comes an interval of about two months which, in the first year, may be utilized to give iodine for four weeks. Then again half as many injec- tions or inunctions as were given altogether in the first course, and this followed by four weeks of iodine medication and four weeks of rest. The same procedure is repeated once more. In the second and third year, unless the indications require a change from the routine, this course of treatment may be given twice each year, and in the fourth and fifth year one course only. Hereditary syphilis has to be treated upon the same prin- Hereditary ciples as the acquired form. As a result of the preventative mercurial treatment of a luetic mother apparently healthy chil- dren are frequently born. The same procedure ought to be tried where the mother appears healthy but the father is luetic INDEX Abortion of Malarial Attack, 547. Abscess of Lung, 303-306. of Prostate, 253. Acetanilid in Malaria, 548. in Muscular Rheumatism, 164. in Tuberculosis, 326. Achylia Gastrica, 398-401. Acidosis, 22,7. in Diabetes, 131. Aconite in Capillar)' Bronchitis, 293. in Endocarditis, 50. in Epistaxis, 274. in Grave's Disease, 107. in Hemoptysis, 309. in Palpitation, 69. in Pneumonia, 522. in Tonsillitis, 263. Acute Gastritis, 343. Laryngitis, 276-279. Peritonitis, circumscribed, 471-481. Acupuncture in Aneurism, 60. in Malaria Spleen, 549. in Muscular Rheumatism, 165. Addison's Disease, no-ill. Adenitis, tuberculous, 90. Adhesions in Appendicitis, 480. in Cholelithiasis, 502. Adonis Vernalis in heart disease, 33. Adrenal Extract in Addison's Disease, no-ill. Glands in Addison's Disease, no. Adrenalin in Acute Peritonitis, 471. in Gastric Ulcer, 376. in Hay Fever, 270. in Intestinal Hemorrhage, 440. in Rhinitis, 269. in Scurvy, 96. Agaricin in Night Sweats, 327. Air Inflation in Ileus, 429, 430. Albuminuria, drugs to reduce, 201. Alcohol as an Antipyretic, 509. as cause of Arterio-sclerosis, 53. Caloric value of, 138. Dressing in Rheumatic Fever, 552. for Mouth wash, 261. in Achylia Gastrica, 400. in Acute Gastritis, 353. in Acute Peritonitis, 471. in Bright's Disease, 214. in Cholelithiasis, 498. in Compensated Heart Lesions, 20. in Gout, 188. in Hyperchlorhydria, 396. in Hyposecretion, 400. in Influenza, 561. in Nervous Diarrhea, 460. in Nervous Dyspepsia, 418. in Night Sweats, 326, 327. in Obesity, 156. in Pertussis, 564. in Smallpox, 583. in Tuberculosis, 320, 325. in Typhoid Fever, 534. in Urethritis, 249. in Uric Acid Diathesis, 182. with Digitalis, 31. Alcoholism and Pneumonia, 527. Alimentary Constipation, 444. Aleuronat Bread, 126. Alimentary Glycosuria, 146. Alkalies in Acute Nephritis, 202. in Arterio-sclerosis, 55. in Bronchitis, 280. in Chronic Gastritis, 356, 361-362. in Coma, 145. in Diabetes, 136, 138. in Endocarditis, 50. in Gout, 188. in Hepatic Cirrhosis, 496. in Hyperchlorhydria, 397. in Muscular Rheumatism, 164. in Myocarditis, 48. in Nephrolithiasis, 227. in Pericarditis, 52. in Rheumatic Fever, 552. in Uremia, 238. Alkaline-Quinine Treatment, 169. Alkaline-Saline Waters in Intestinal Catarrh, 421. Wash in Rhinitis, 268. Waters, 40. Waters in Bronchitis, 284. Waters in Chronic Gastritis, 358. Waters in Hyperchlorhydria, 394, 398. Waters in Icterus, 486. Alloxuric Bases, see Purin Bases. Almond Bread, 127. Aloes in Cardiac Dropsy, 44. in Constipation, 454. in Hepatic Congestion, 40. Aloin for hypodermic purgation, 45^, Artificial Respiration, 304. Altitude in Anemia, 79. in Arterio-sclerosis, 54. in Bronchitis, 284. in Chronic Nephritis, 221. in Emphysema, 297. in Grave's Disease, 105. in Tuberculosis, 316-318. Alum Wash in Night Sweats, 326. Ambrosia, cause of Hay Fever, 269. Amebic Dysentery, 558. Ammonia in Asthma, 290. 6o6 in Heart Disease, 32. in Palpitation, 69. aromatic spirits of, in Heart Disease, 32. Ammonium Carbonate in Epistaxis, 277. Chloride in Bronchitis, 284, 289. ., Chloride in Pulmonary Hyperemia, 38. Amyl Nitrite in Angina Pectoris, 64. in Arterio-sclerosis, 56. in Palpitation, 69. Amylolytic Ferments, 366. Anacidity, see Achylia. Anal leeching, 40. in Epistaxis, 276. Analeptics, 32. in Anemia, 78. in Acute Peritonitis, 471. in Capillary Bronchitis, 294. in Cholelithiasis, 504. in Diphtheria, 543. in Emphysema, 299. in Epistaxis, 273, 274. in Hemoptysis 310. in Intestinal Catarrh, 418. in Palpitation, 69. in Pulmonary Edema, 302. in Pulmonary Infarct, 304. Analgesics in Cholelithiasis, 503. Anchylostoma, 467. Anemia, 71-86. after hemorrhage, 78. cerebral, 35. Anemia, Classification, 71. Anemia, progressive, pernicious, 71. simple, 76-80. Aneurism of Aorta, 56-62. Angina Pectoris, 62-65. Angio-neurotic Edema, 299. Anise in Chronic Gastritis, 363. Anise Seed as a Carminative, 463. Anodynes in Gout, 186. in Muscular Rheumatism, 164. Anodyne Ointments, 334. Anorexia in Simple Anemia, 78. in Tuberculosis, 329. Antacids in Gastric Ulcer, 372. Antiluetic Treatment in Endocarditis, 50. Antineuralgics in Aneurism, 61. in Gastralgia, 412. in Gout, 188. in Influenza, 560. in Muscular Rheumatism, 164. Antineuralgic Remedies, 144. Antipyretics in Diphtheria, 542. in Infectious Diseases, 508, 509. in Measles, 572. in Pneumonia, 523. in Tuberculosis, 326. in Typhoid Fever, 531, 532. Antipyrin in Cholelithiasis, 503. in Cystitis, 246. in Diabetes Insipidus, 195. in Fevers, 509. in Gastralgia, 412. in Gout, 188. in Hepatic Cirrhosis, 496. in Malaria, 548. in Pertussis, 565. in Pleurisy, 332. in Rheumatic Fever, 552. ., in Syphilis, 602. in Tetanus, 557. in Tuberculosis, 326. Antisclerosin in Arterio-sclerosis, 56. Antiseptics in Chronic Gastritis, 356. Intestinal, in Typhoid Fever, 531. Antiseptic Treatment of Infectious Diseases, 507. Antispasmodics in Angina Pectoris, 63. Antistreptococcic Serum in Scarlatina, 568. Antitoxic Unit, 555. Antitoxin, of Tetanus, 554, 555. of Diphtheria, 539-541. Anuria, 237. in Acute Nephritis, 201. in Yellow Fever, 589. Aortic Aneurism, 56-62. Insufficiency, 17. Stenosis, 17. Aortitis, Chronic, 53-56. Aperients, see Laxatives. Aphthous Stomatitis, 261. Apocodeine for Hypodermic Purgation, 456. Apomorphine in Acute Gastritis, 343. in Bronchitis, 282, 284. in Heart Disease, 38. Appendicitis, 471-481. Argyrol in Cystitis, 246. Aromatic Sulphates, 207. Arrhythmia, 70. Arterio-sclerosis, 53-56. Arsenic in Asthma, 288. in Chlorosis, 85. in Diabetes, 137. in Grave's Disease, 107. in Leukemia, 87, 88, 91. in Malaria, 548. in Myocarditis, 49. in Nervous Diarrhea, 460. in Osteomalacia, 194. in Pernicious Anemia, J2. in Simple Anemia, 79, 80. in Thyroidism, 103. in Tuberculosis, 324. Arsenic Waters in Anemia, 80. Arthritis Deformans, 162, 166-172. in Pneumonia, 530. in Obesity, 150. Arthritism, 161. Articular Rheumatism, Acute, 161. 150, 554. in Myocarditis, 48. Asafetida as a Carminative, 463. in Diabetes Insipidus, 195. in Palpitation, 69. Asiatic Pill in Pernicious Anemia, 73. Ascaris Lumbricoides, see Round Worm. Aspidium for Tape Worm, 465. Aspiration of Stomach Contents, 345. Aspirin in Rhinitis, 268. in Diabetes, 134. in Laryngitis, 276. 607 in Gout, 188. in Influenza, 561. in Pleurisy, 332. in Rheumatic Fever, 551. in Chronic Rheumatism, 169. Asthma, bronchial, 286, 290. Cigarettes, 289. in Emphysema, 296. Points, 287. uremic, 241. Astringents in Dysentery, 559. in Intestinal Catarrh, 417. in Intestinal Ulcer, 439. in Urethritis, 251. Atheroma, danger of digitalis in, 30. Athyreosis Chronica, 101. Atonic Constipation, 446. Atony of the Stomach, see Motor Insufficiency. Atrophic Cirrhosis of the Liver, 488-497. Atropine as an antidote to digitalis, 29. in Asthma, 288. in Bronchitis, 280, 284, 285. in Cholelithiasis, 503. for thirst in Diabetes, 132. in Gastric Ulcer, 372. in Hay Fever, 270. in Hyperchlorhydria, 397. in Ileus, 432. in Mercurial Stomatitis, 263. in Night Sweats, 327. in Osteomalacia, 194. in Pulmonary Edema, 301. in Rhinitis, 268. in Uremic Dropsy, 240. Autotoxemia in Anemia, 72, 76. Axial Rotation of the Bowel, 425. B Balsams in Bronchitis, 282, 284. in Cystitis, 244. in Tuberculosis, 328. Bandaging in Floating Kidney, 235. in Motor Insufficiency, 389. in Mucous Colitis, 443. in Tuberculous Peritonitis, 482. Banti's Disease, 90. Banting Cure for Obesity, 152. Bathing in Anemia, 79. in Arterio-sclerosis, 54. in Bright's Disease, 217, 218. in Capillary Bronchitis, 291. in Cardiac Dropsy, 42. in Diphtheria, 543. in Heart Disease, 25. in Icterus, 488. in Mucous Colitis, 442. in Neurasthenia, 404, 405. in Palpitation, 67. in Pharyngitis, 267. in Pleurisy, 333. in Muscular Rheumatism, 164. in Rhinitis, 267. in Tetanus, 556. in Uremia, 238. in Uric Acid Diathesis, 183, 184. in Smallpox, 585. Baths, Carbonated, 25. Medicated, 25. Salt, 25. Basedow's Disease, 104-109. Bed Sores, see Decubitus, 539. Belching, Nervous, 408. Belladonna in Acute Gastritis, 347. in Asthma, 289, 290. in Bronchitis, 2S0. in Cholelithiasis, 503. in Cystitis, 244. in Gastric Ulcer, 372. in Hay Fever, 270. in Hyperchlorhydria, 397. in Pertussis, 564. in Renal Colic, 232. in Rhinitis, 268. in Spastic Constipation, 446. Benzo-naphthol in Intestinal Catarrh, 416. as Mouth Wash, 261. Benzoic Acid in Cystitis, 244. in Nephrolithiasis, 231. Benzoin in Bronchitis, 282, 284. in Pulmonary Hyperemia, 38. Beta-naphthol in Intestinal Catarrh, 416. in Rheumatism, 169. Bier's Method in Chronic Rheumatism, 171. Bigeminal Pulse, 70. Bile in Icterus, 488. Acids in Bright's disease, 207. Acids in Cholelithiasis, 500. Acids in Icterus, 487, 488. Acids in Uremia, 238. Biliary Cirrhosis of the Liver, 488, 497. Bismuth Carbonate in Gastric Ulcer, 2>7Z- Cresolate in Intestinal Catarrh, 421. in Diarrhea, 459. in Hematemesis, 376. Phenolate in Intestinal Catarrh, 421. Salts in Intestinal Hemorrhage, 440. Salts in Intestinal Ulcer, 438, 439. Subnitrate in Bright's Disease, 207. Subnitrate in Flatulency, 463. Subnitrate in Gastric Ulcer, 373. Subnitrate in Intestinal Catarrh, 420. Subsalicylate in Intestinal Catarrh, 420. Sulphocarbolate in Intestinal Catarrh, 421. Bitter Almonds in Chronic Gastritis, 363. Bitters in Chronic Gastritis, 362. in Tuberculosis, 330, 331. Black Vomit in Yellow Fever, 588. Blaud's Pill in Chlorosis, 84. Bleeding, see Venesection. Blisters in Gout, 187. Bloodletting, see Venesection. Bone Marrow in Leukemia, 88. Bone Marrow in Pernicious Anemia, 74. Boric Acid in Hyperchlorhydria, 397. in Cystitis, 244. Bothriocephalus latus, see Tape Worm. Bougies in Urethritis, 252, 256. Boundary of tolerance in Diabetes, 121. Bowel Irrigation, 414. 6o8 INDEX Bradycardia, 70. Brain Ischemia in Aortic Insufficiency, 18. passive hyperemia of, 34-38. Brand Treatment in Typhoid Fever, 535. Brandy in Heart Disease, 32. Brayera for Tape Worm, 465. Bright's Disease, 204-222. Broken Compensation, 26-34. Bromelin in Chronic Gastritis, 365. Bromides in Aortic Insufficiency, 19. in Asthma, 289. in Diabetes, 134. in Diabetes Insipidus, 195. in Grave's Disease, 107. in Insomnia, 35. in Palpitation, 68. in Pulmonary Edema, 300. mode of action, 35. Bromoform in Gastralgia, 412. in Pertussis, 565. Bronchiectasis, see Bronchitis, Chronic. Bronchiolitis Capillaris, 290. Bronchitis, acute, 279-287. Capillary, 290-294. Chronic, 283-286. in Obesity, 148. Profunda, 290. Tent, 280. Broncho-pneumonia, 290-294. Buchu in Cystitis, 244. Cachexia thyreopriva, 101. strumipriva, 101. Cacodylate of Soda, see Sodium Cacodylate. Caffein Citrate in Heart Disease, 34. in Acute Nephritis, 202. in Heart Disease, 32. in Pertussis, 565. in Pleurisy, 336. Calcium Carbonate in Hyperchlorhydria, 398. in Nephrolithiasis Urica, 228, 229. in Osteomalacia, 193. in Uremia, 238. Calcium Chloride in Hemophilia, 98. in Internal Hemorrhage, 440. in Tuberculosis, 325. Lacto-phosphate in Rachitis, 192. Phosphate in Osteomalacia, 193. reduction in Arterio-sclerosis, 54. Calomel as a diuretic, 43. in Acute Gastritis, 344. in Acute Nephritis, 202, 204. in Cystitis, 243. in Dysentery, 558. in Gout, 187. in Hepatic Congestion, 40. in Icterus, 485. in Influenza, 560. in Intestinal Catarrh, 414, 416. in Laryngitis, 276. in Tonsillitis, 263. in Typhoid Fever, 531. Caloric Requirement, 113. Values, 113-117. Calorie, Definition of, 113. Calorimetric Methods, 113-118. Camphoric Acid in Cystitis, 244. Camphor in Hay Fever, 270. Camphor in Heart Disease, z 2 - in Hemoptysis, 310. in Palpitation, 69. in Rhinitis, 268. Cancrum Oris, 261, 262. Cannabis Indica in Asthma, 290. in Tetanus, 557. Cantharidal Plaster, 334. Capillary Bronchitis, 290-294. Capsicum in Hay Fever, 270. Caraway in Chronic Gastritis, 363. Seed as a Carminative, 463. Carbo Animalis, 463. Ligni, 463. Carbohydrates, caloric value of, 113. Carbolic Acid in Bronchitis, 284. in Hay Fever, 270. in Malaria, 548. in Pertussis, 565. in Septic Endocarditis, 50. in Tetanus, 555. Carbonated Baths, 25. Waters in Chronic Gastritis, 358. Carbonic Acid Baths in Bright's Disease, 217* Carbuncle in Obesity, 149. Carcinoma of the Stomach, 378-384. Cardamoms as a Carminative, 463. in Chronic Gastritis, 363. Cardiac Asthma, 286. Cirrhosis of the Liver, 488-497. Dropsy, 42-47. Edema, 42-47. Failure, 528. Gout, 185. Stasis, 34-42. Cardio-renal Disease, 197, 204. -Spasm, 407. Caries, dental, in Diabetes, 140. Carlsbad in Diabetes, 136. in Intestinal Catarrh, 421, in Obesity, 158. Salts in Gastric Ulcer, 371. Carminatives in Flatulency, 462, 463. Carniferrin in Chlorosis, 85. Cascara in Acute Nephritis, 204. in Constipation, 453. in Hepatic Congestion, 40. Castor Oil Enema in Constipation, 450. in Acute Gastritis, 346. in Acute Nephritis, 204. in Cardiac Dropsy, 44. in Icterus, 485. in Intestinal Catarrh, 414, 421. Catarrh, Acute Intestinal, 413-418. Chronic Intestinal, 418-423. of Bowels in Diabetes, 142. of Stomach in Diabetes, 142. Catarrhal Jaundice, 485-488. Stomatitis, 261. Catharsis in Acute Nephritis, 204. in Cardiac Dropsy, 44. 609 in Hepatic Cirrhosis, 495 in Palpitation, 69. in Pericarditis, 52. in Pleurisy, 335. in Pulmonary Edema, 300. in Pyelitis, 223. Cathartinic Acid for hypodermic purgation, 456. Cathartics, see Laxatives. Catheterization in Prostatitis, 253. Catechu in Intestinal Catarrh, 420. in Pyelitis, 223. in Scurvy, 96. Cauterization in Epistaxis, 273. , Cauterization of Syphilitic Chancre, 594. in Urethritis, 257. Cerebral Gout, 185. Cerium Oxalate in Vomiting, 239. Chalk in Gastric Ulcer, 374. Champagne in Heart Disease, 32. Chancre in Syphilis, 594-596. Charcoal in Flatulency, 463. Chenopodium for Round Worm, 466. Cheyne-Stokes breathing, 34. Chill, ; n Infectious Diseases, 508. Chloral, Contraindications to, 34. dangers of in Heart Disease, 34. in Asthma, 289. in Cholelithiasis, 503. in Delirium Tremens, 527. in Diabetes, 134. in Epistaxis, 275. in Insomnia, 34. in Palpitation, 69. in Renal Colic, 232. in Tetanus, 557. in Uremic Attack, 242. Chloralamid in Asthma, 289. in Insomnia, 36. Chloralose in Insomnia, 36. Chloretone in Insomnia, 36. Chlorides in Tuberculosis, 325. Chloride Restriction in Bright's Disease, 215. Chloroform in Aneurism, 62. in Angina Pectoris, 64. in Asthma, 289. in Cholelithiasis, 503. in Gastralgia, 412. in Palpitation, 69. in Pleurisy, 334. in Renal Colic, 232 in Rhinitis, 268. in Tetanus, 557. in Uremic Asthma, 241. in Uremic Attack, 242. in Vomiting, 240. Chloroform Water in Gastric Ulcer, ^73- Chlorosis, 81-86. Chinosol in Cystitis, 247. Cholagogues in Cholelithiasis, 499. in Hepatic Cirrhosis, 496. in Icterus, 487. Cholangitis, 497-504. Cholecystitis, 497-504. Cholelithiasis, 497-504. Acute Attack, 502. 5m Cholemia, 491. Christian Science, 287. Chronic Constipation, 444-456. Gastritis, 355-366. Intestinal Catarrh, 418-423. Peritonitis, 481-484. Rheumatism, 162. Cinchona in Chronic Gastritis, 363. Cinnamic Acid in Tuberculosis, 324. Cinnamon as a Carminative, 463. in Chronic Gastritis, 363. Cirrhosis of the Liver, 488-497. of the Liver in Obesity, 149. Climate in Anemia, 79. in Arterio-sclerosis, 54. in Asthma, 288. in Bronchitis, 283. in Chronic Nephritis, 221. in Emphysema, 296. in Grave's Disease, 105. in Hay Fever, 270. in Heart Disease, 24. in Pertussis, 563. in Tuberculosis, 316-318. Clothing in Acute Nephritis, 200. in Anemia, 79. in Cholelithiasis, 499. in Chronic Rheumatism, 166. in Floating Kidney, 236. in Intestinal Catarrh, 423. in Muscular Rheumatism, 163. in Palpitation, 57. in Pharyngitis, 267. in Rheumatic Fever, 553. in Rhinitis, 267. in Tuberculosis, 316. Cloves as Carminatives, 463. Cocaine, Administration Internally, 19. as Mouth Wash, 261. in Acute Gastritis, 347. in Aneurism, 61. in Asthma, 289. in Cystitis, 246. in Dysentery, 559. in Gastralgia, 19, 412. in Hay Fever, 270. in Rhinitis, 267. in Vomiting, 240. Codeine in Bronchitis, 280. in Insomnia, 36. in Muscular Rheumatism, 164. in Pulmonary Hyperemia, 38. in Smallpox, 580. in Tuberculosis, 328. Codliver Oil in Pertussis, 564. in Osteomalacia, 193. in Rachitis, 192. in Tuberculosis, 325. Coffee in Compensated Heart Lesions, 20. in Heart Disease, 32. in Hemoptysis, 310. in Chronic Nephritis, 214. in Palpitation, 69. Colchicum in Gout, 187-188. 6io in Rheumatic Fever, 552. Cold in Pericarditis, 51. in Pseudo-leukemia, 93. Colica Mucosa, 441-443. Collapse in Acute Peritonitis, 470. in Diphtheria, 543. Colocynth in Cardiac Dropsy, 44. in Gout, 187. Colombo in Intestinal Catarrh, 420. Colonic Flushing in Icterus, 485. in Intestinal Catarrh, 422. Irrigation in Flatulency, 464. Coma, Diabetic, 144, 145. Communal Protection in Pneumonia, 514, 515. Compensated Valvular Lesions, 17-26. Compress, see Priessnitz Compress. Compresses in Laryngitis, 2^. in Aneurism, 60. Condurango in Chronic Gastritis, 363. Congenital Heart Lesions, 17. Constipation, Chronic, 444-456. in Appendicitis, 477. in Chlorosis, 82. in Diabetes, 143. in Obesity, 149. Convallaria in Heart Disease, 33. Copaiba in Bronchitis, 282, 284. in Pyelitis, 223. Copper Salts in Tuberculosis, 324. Sulphate in Urethritis, 251. Corrosive Sublimate for Thread Worms, 467. Coryza Vasomotoria, 269-271. Cotarnine in Epistaxis, 274. in Hemoptysis, 311. Cough Drops, 283. in Pneumonia, 524. in Tuberculosis, 327-329. Syrups, 283. Counter-irritation in Appendicitis, 478. Cradin in Chronic Gastritis, 365. Cravings in Chlorosis, 82. Creosotal in Tuberculosis, 323. Creosote in Diabetes, 137. in Intestinal Catarrh, 416. in Pertussis, 565. in Tuberculosis, 322, 323. Cresolene in Pertussis, 565. Cretinism, 101-104. Croton Oil in Cardiac Dropsy, 44. Croup, 543- . Crystallose in Diabetes, 138. Cubebs in Bronchitis, 282, 284. Cupping in Acute Nephritis, 200. in Bronchitis, 29. in Dropsy, 46. in Pulmonary Edema, 300. in Pleurisy, 333. in Pneumonia, 524. Technique of, 39. Cusso for Tape Worm, 465, 466. Cutaneous Gout, 185. Cystitis, 242-248. Cystoscopy, 247-248. Decapsulation of the Kidneys, 222. Decompensated Valve Lesion, 20-34. Decubitus in Typhoid Fever, 539. Delayed Resolution in Pneumonia, 529. Delirium Cordis, 70. in Pneumonia, 527. Tremens, 527. Dermatol in Intestinal Catarrh, 421. Dermol in Intestinal Catarrh, 421. Disinfectants in Intestinal Ulcer, 439. Disinfection in Smallpox, 575. Dextrose in Hyperchlorhydria, 395. Diabetes and Uric Acid Diathesis, 185. Drugs in, 132-139. Insipidus, 194-196. in Organic Nervous Diseases, 146. in Medium Severity, 128-130. Mellitus, 1 18-147. Mild Type, 124, 125, 128. Neurotic, 146. Phosphaticus, 234. Severe Type, 131, 132. Syphilitic, 147. Diabetic Breads, 126, 127. Coma, 144, 145. Gangrene, 145. Test Meal, 121, 122. Diaphoresis in Hepatic Cirrhosis, 495. in Pulmonary Edema, 300. in Pleurisy, 332. Diarrhea, 456-461. Dyspeptica, 457. Gastrica, 456. Malarial, 413. Nervosa, 459-461. Uremic, 240, 413. Diastase in Chronic Gastritis, 366. Diet. n Achylia Gastrica, 399. n Acute Gastritis, 347. n Acute Intestinal Catarrh, 415, 416. n Acute Nephritis, 198-200. n Alimentary Constipation, 444, 445. n Angina Pectoris, 62. n Aneurism, 57. n Appendicitis, 475-476, 479. n Arterio-sclerosis, 54. n Asthma, 287. n Atonic Constipation, 446, 447. n Bright's Disease, 208-214. n Chlorosis, 82. n Cholelithiasis, 498, 505. Chronic Gastritis, 359. n Chronic Intestinal Catarrh, 418-420. n Chronic Nephritis, 208-214. n Chronic Rheumatism, 166, 167. n Chronic Stenosis of the Bowel, 437. n Chronic Uremia, 238. n Coma, 144. n Compensated Heart Lesions, 20-21. n Cystitis, 243. 6n in Diabetes of mild type, 125-128. in Diabetes of Medium Severity, 128-130. in Diabetes of severe type, 131-132. in Diarrhea, 458. in Diphtheria, 543. in Dysentery, 558. in Emphysema, 298. in Endocarditis, 51. in Failing Compensation, 27. in Fevers, 509-511. in Flatulency, 462. in Gastric Carcinoma, 379, 380. in Gastric Ulcer, 367, 370, 371. in Gout, 177, 183, 188. in Grave's Disease, 105, 106. in Hemophilia, 97. in Hemoptysis, 312. in Hepatic Cirrhosis, 493-495. in Hepatic Insufficiency, 493-495. in Hyperchlorhydria, 394-396. in Hyposecretion, 399. in Icterus, 485-486. in Ileus, 436. in Intestinal Ulcer, 438. in Leukemia, 89. in Measles, 573. in Membranous Enteritis, 443. in Motor Insufficiency, 386, 387. in Mucous Colitis, 443. in Muscular Rheumatism, 165. in Nervous Diarrhea, 460. in Nervous Dyspepsia, 412. in Nephrolithiasis Oxalurica, 233. in Nephrolithiasis Phosphatlca, 234. in Nephrolithiasis Urica, 227. in Obesity, 150-158. in Osteomalacia, 194. in Palpitation, 68. in Passive Hepatic Congestion, 40. in Pericarditis, 51, 52. in Pernicious Anemia, 72. in Pertussis, 563, 567. in Purpura, 99. in Pyelitis, 223. in Pyonephrosis, 223. in Rachitis, 190-191. in Rheumatic Fever, 553. in Scarlatina, 569. in Scurvy, 95, 96. in Simple Anemia, JJ, 78. in Smallpox, 581, 583. in Tetanus, 557. in Tuberculous Peritonitis, 481. in Tuberculosis, 313, 319, 321, 329, 330. in Typhoid Fever, 532-534. in Uric Acid Diathesis, 177-183. in Yellow Fever, 590. Digestibility of Foods, 347-354- Digestive Ferments in Chronic Gastritis, 364. in Chronic Carcinoma, 381. Digital Compression in Epistaxis, 273. Digitalein in Heart Disease, 31. Digitalin in Gastric Hyperemia, 41. in Heart Disease, 31. Digitalis, Cumulative Action, 28. Continued Use of, 29. Contraindications, 29. in Aortic Disease, 29. in Arterio-sclerosis, 56. in Atheroma, 30. in Acute Nephritis 202. in Acute Peritonitis, 471. in Delirium, 527. in Diagnosis of Myocarditis, 30. in Endocarditis, 50. in Gastric Hyperemia, 41. in Grave's Disease, 107. in Heart Disease, 28-30. in Palpitation, 69. in Pericarditis, 52. in Pleurisy, 336. in Pneumonia, 525. Intoxication, 28. Preparations of, 30. "Pure Principles" of, 29, 31. Tolerance and Susceptibility, 28. With Alcohol, 31. Digitophyllin in Heart Disease, 31. Digitoxin in Heart Disease, 31. Dilatation of the Stomach, see Motor Insuffi- ciency. Dionin in Bronchitis, 280. in Tuberculosis, 328. Diphtheria, 539-544- Antitoxin, 539-54*. in Urethritis, 255. Diphtheritic Urethritis, 255. Diuretics in Pericarditis, 52. in Pleurisy, 335. in Pulmonary Edema, 300. in Tuberculous Peritonitis, 482. in Uremia, 237, 241. in Yellow Fever, 589. Diuretin as a Diuretic, 43. in Heart Disease, 32. in Pleurisy, 336. Diseases of Metabolism, 1 13-196. Distoma Hematobium as Cause of Anemia, 72. Dizziness in Aortic Insufficiency, 18. Douches in Chronic Rheumatism, 171. Vaginal, in Urethritis, 252. Douching of Stomach in Achylia Gastrica, 400. in Constipation. 449. in Gastralgia, 412. Hyperchlorhydria, 396. in Hyposecretion, 400. in Motor Insufficiency, 389. Dover's Powders in Bronchitis, 279. in Capillary Bronchitis, 294. in Influenza, 560. in Laryngitis, 276. in Pleurisy, 332. in Rhinitis, 268. Drastics, see Laxatives. Dressings in Chronic Rheumatism, 167. Drink Restriction in Acute Nephritis, 198. in Aneurism, 58. 6l2 in Arterio-sclerosis, 54. in Compensated Heart Lesions, 2: in Diabetes Insipidus, 195. in Motor Insufficiency, 387. in Obesity, 155. Drink Restriction in Pleurisy, 336. Dropsy, Cardiac, 42-47. Drugs in Bright's Disease, 215, 216. Dulcin in Diabetes, 138. Dunbar's Serum in Hay Fever, 271. Dysentery, 558-560. Dyspepsia in Diabetes, 141. Nervous, 412. Dyspnea in Obesity, 148. Ecstasy of the Stomach, see Motor Insuffi- ciency. Eczema in Obesity, 149. Edema, Cardiac, 42-47. in Uremia, 240. of the Glottis, 240. Pulmonary, 299-303. Effervescent Salts in Constipation, 455. Elaterium in Cardiac Dropsy, 44. in Constipation, 450. in Pleurisy, 336. Electricity in Constipation, 450. in Diabetes Insipidus, 195. in Gastralgia, 411. in Grave's Disease, 107. in Ileus, 435. in Malaria Spleen, 549. in Motor Insufficiency, 390. in Muscular Rheumatism, 165. in Neurasthenia, 405. in Palpitation, 68. in Urethritis, 255. Electric Baths in Bright's Disease, 218. in Pleurisy, 333. in Chronic Rheumatism, 171, 172. Electrization of Stomach, Technique of, 390. Embryocardia, 70. Emetics in Bronchitis, 281. in Capillary Bronchitis, 294. in Gastritis, 343. Emphysema, Pulmonary, 294-299. Empyema, 339, 340. Endemic Cretinism, 101. Dysentery, 558. Endocarditis, Acute, 49-51. in Pneumonia, 529. Septic, 49. Syphilitic, 50. Endogenous Uric Acid, 174. Enemata in Cholelithiasis, 504. in Constipation, 450. in Ileus, 429. Nutritive, 369-370. Energy, from Food, 113. Enteritis Membranous, 441-443. Enteroclysis in Dysentery, 560. Enteroliths After Oil Treatment, 500. Enzymes, see Ferments. Epidemic Dysentery, 558. Epididymitis, 253-254. Epigastric Pain in Aortic Insufficiency, 19. in Hepatic Stasis, 39. Epistaxis, 271-276. Epsom Salt, 44. Epstein, Cure for Obesity, 152. Equivalents for White Bread, 126, 127. Ergot Injections in Leukemia, 89. in Diabetes, 195. in Epistaxis, 275. in Gastric Ulcer, 376. in Hematuria, 201, 232. in Hemophilia, 98. in Hemoptysis, 310. in Intestinal Hemorrhage, 439. in Pulmonary Edema, 301, 302. in Purpura, 100. Ergotine in Gastric Ulcer, 376. Erigeron in Hematuria, 232. Erythrol Tetranitrate in Angina Pectoris, 65 in Epistaxis, 274. Erysipelas Antitoxin in Leukemia, 89. Erythematous Stomatitis, 261. Eserine in Flatulency, 464. Ether in Heart Disease, 32. in Hemoptysis, 310. in Palpitation, 69. in Uremic Asthma, 241. Spray in Constipation, 449. Eucalyptol in Bronchitis, 285. in Pulmonary Gangrene, 306. Eucalyptus as Mouth Wash, 261. in Bronchitis, 284. in Malaria, 548. in Pseudo-leukemia, 93. for Inhalations, 306. Eudoxin in Intestinal Catarrh, 421. Euquinine in Malaria, 545. Europhen in Tetanus, 557. Exalgin in Gastralgia, 412. Exercise in Cholelithiasis, 499. in Chronic Nephritis, 222. in Constipation, 450. in Diabetes, 139. in Gastric Ulcer, 368. in Heart Disease, 22. in Hepatic Insufficiency, 495. in Intestinal Catarrh, 423. in Neurasthenia, 407. in Obesity, 150, 159. in Palpitation, 67. in Tuberculosis, 319. in Uric Acid Diathesis, 183. Exophthalmic Goitre, 104-109. Expectorants in Capillary Bronchitis, 294. Dangers in Heart Disease, 38. in Emphysema, 295. in Hemoptysis, 308. in Laryngitis, 276. in Tuberculosis, 328. Expression of Gastric Contents, 344. Exogenous Uric Acid, 174. Extractives in Compensated Heart Lesions, 613 Failing Compensation, 26-34. Fainting, in Aortic Insufficiency, 18. Fat, Caloric Value of, 113. Fattening Cure in Floating Kidney, 235. Fatty Degeneration of the Heart, 47-49. Heart in Obesity, 147. Fasting, in Heart Disease, 22. Fecal Obstruction of the Bowel, 424. Feeding, see Diet. Fel Bovis, see Bile. Fennel as a Carminative, 463. Ferments, Amylolytic, 366. Digestive in Chronic Gastritis, 364. in Achylia Gastrica, 401. in Hyposecretion, 401. Proteolytic, 364. Ferratin in Chlorosis, 85. Fetal Myxedema, 101. Fetor of Breath, 306. in Diabetes, 140. Fever Diet, 509-511. Treatment of, 507-509. Fibrinous Bronchitis, 285. Filaria, as Cause of Anemia, 72. Filipuncture in Aneurism, 60. Finsen Light in Smallpox, 584. Flatulency, 461-464. in Acute Peritonitis. 470. Floating Kidney, 234-236. Follicular Stomatitis, 261. Fomentations in Cystitis, 243. in Tuberculous Peritonitis, 482. Food, Composition of, 113-118. Foot Bath in Yellow Fever, 587. Footwear in Anemia, 79. Forced Feeding in Tuberculosis, 329. Formaldehyde in Night Sweats, 327. Formalin as Room Disinfectant, 575. Fowler's Solution in Asthma, 288. in Myocarditis, 49. in Pernicious Anemia, 7^. in Pseudo-leukemia, 91. in Purpura, 100. in Tuberculosis, 324. Franzensbad in Hepatic Hyperemia, 40. Fresh Air in Tuberculous Peritonitis, 481. in Smallpox, 584. Treatment of Tuberculosis, 313, 314. Fruit Cure in Uric Acid Diathesis, 181. Fumigation in Yellow Fever, 593. Furunculosis in Diabetes, 141. in Obesity, 149. Gall-duct Occlusion, 502. Gallop Rhythm, 70. Gall Stones, see Cholelithiasis. Stone Occlusion of the Bowel, 424. Galvano-cautery in Stomatitis, 261. puncture in Aneurism, 59. puncture in Leukemia, 89. Gangrene, Diabetic, 145. Gangrene of Lung, 303-306. Gangrenous Stomatitis, 261, 262. Gargles in Tonsillitis, 264. Gastralgia, 411. Gastric Atony, see Motor Insufficiency. Atrophy in Anemia, 72. Carcinoma, 378-384. Catarrh in Diabetes, 142. Dilatation, see Motor Insufficiency. Ectasy, see Motor Insufficiency. Hyposecretion, 398-401. Hyperchlorhydria, 393-398. Hyperesthesia, 411. Hypersecretion, 393-398. Lavage, 344-346. Neuroses, 401-412. Ulcer, 366-377. Gastritis, Acute, 343. Chronic, 355-366. Gastro-enterostomy in Gastric Carcinoma, 378. in Gastric Ulcer, Z77- Gelatin in Aneurism, 58. in Gastric Ulcer, 376. in Hemophilia, 98. in Hemoptysis, 311. in Internal Hemorrhage, 440. in Scurvy, 96. Injections, Technique of, 58, 59. Gentian in Chronic Gastritis, 363. Ginger as a Carminative, 463. Gingivitis in Diabetes, 140. Glandular Fever, Recurrent, 90. Glauber Salt, 44. Glottis Edema, 240. Gluten Bread, 126. in Obesity, 158. Glutoid Capsule, 417. Glycerin as a Mouth Wash, 260. Enema in Constipation, 451. in Cholelithiasis, 501. in Epididymitis, 253. in Nephrolithiasis, 231. Glycosuria, Alimentary, 146. Diabetic, see Diabetes, from Thyroid, 160. Goitre, Exophthalmic, 104-109. Simple, 109. Gomenol in Cystitis, 246. Gonorrhea, Female, 252. see Urethritis. Gonosan in Cystitis, 244. in Urethritis, 252. Gout, 173-188. Abarticular, 173 f. Acute Attacks of, 186-188. Atypical, 173 f. Cardiac, 185. Cerebral, 185. Cutaneous, 185. Incomplete, 173 f. Irregular, 173 f. Retrocedent, 185, 186. Rheumatic, 161. Vesical, 185. G'ranatum for Tape Worm, 465. 6i4 INDEX Grave's Disease, 104-109. Surgical Treatment, 108. Gray Oil in Syphilis, 600. Green Soap in Tuberculous Peritonitis, 482. Guaiac in Tonsillitis, 263, 264. in Rheumatic Fever, 552. Guaiacol in Bronchitis, 284. in Cystitis, 246. in Epididymitis, 253. in Chronic Rheumatism, 169. in Tuberculosis, 324. Gum Lesions in Diabetes, 140. Gumma in Syphilis, 596. K Habitual Constipation, 446. Hamamelis in Hemoptysis, 310. in Internal Hemorrhage, 440. Hardening in Rhinitis, 266. of Tuberculous Patients, 315. Haustus Colchici, 187. Hay Fever, 269-271. Headache in Aortic Insufficiency, 18. Heart Disease, 17-70. Failure in Typhoid Fever, 538. Tonics as Diuretics, 43. Tonics in Acute Nephritis, 202, 204. Tonics in Angina Pectoris, 64. Tonics in Capillary Bronchitis, 294. Tonics in Emphysema, 295. Tonics in Epistaxis, 273. Tonics in Hemoptysis, 307, 308. Tonics in Palpitation, 67. Tonics in Pneumonia, 525. Tonics in Pulmonary Edema, 300. Tonics in Pulmonary Infarct, 305. Tonics in Uremia, 240. Tonics, Indications for, 27-32. Helmitol in Cystitis, 244. Hematemesis in Gastric Carcinoma, 383. in Gastric Ulcer, 375, 376. in Heart Disease, 40. Hematoporphyrinuria after Sulphonal, 35. Hematuria, 232. in Acute Nephritis, 201. Hemoglobin in Chlorosis, 85. in Pernicious Anemia, 74. Hemophilia, 95, 97, 98. Hemoptysis, 306-312. Hemorrhage as Cause of Anemia, 76, 78. from the Bowel, 439, 440. from the Colon, 440. from the Stomach, see Hematemesis. from the Rectum, 440. in Typhoid Fever, 538. Hemorrhagic Diathesis, 95-100. Hemorrhoids in Obesity, 149. Hemostatics in Gastric Ulcer, 376. Hepatitis, Chronic, 488, 497. Syphilitic, 488-497. Hepatic Cirrhosis, 488, 497. Insufficiency, 488, 497. Insufficiency in Bright's Disease, 206. Herba Cochleariae in Scurvy, 96. Herniaria in Acute Nephritis, 203. in Cystitis, 244. Heroin in Bronchitis, 280. in Pulmonary Hyperemia, 38. Hetol in Tuberculosis, 324, 328. Hiccup in Acute Peritonitis, 470. Hirschfeldt Cure for Obesity, 152. Hodgkin's Disease, 90. Hoffman's Anodyne in Heart Disease, 32. Homburg in Obesity, 158. Home Treatment of Tuberculosis, 313, 314. Horseradish in Scurvy, 96. Hot Air Baths in Acute Nephritis, 203. in Bright's Disease, 218. in Cardiac Dropsy, 42. in Chronic Rheumatism, 171. Hydragogue Cathartics, see Laxatives. Hydrastis in Epistaxis, 274. in Gastric Ulcer, ^76- in Hemophilia, 98, 232. in Hemoptysis, 311. in Internal Hemorrhage, 439. in Purpura, 100. Hydrochloric Acid in Achylia Gastrica, 401. in Chronic Gastritis, 356, 359-361. in Diabetes Phosphaticus, 234. in Gastric Carcinoma, 381. in Hyposecretion, 401. in Intestinal Catarrh, 416. Hydrogen Peroxide in Scurvy, 96. in Stomatitis, 262. Hydrotherapy, General Principles of, 2i6f. in Acute Nephritis, 203. in Appendicitis, 478. in Bright's Disease, 216-221. in Bronchitis, 284. in Capillary Bronchitis, 291. in Chlorosis, 82. in Constipation, 448. in Diphtheria, 543. in Fevers, 508. in Grave's Disease, 107. in Hepatic Cirrhosis, 495. in Hepatic Insufficiency, 495, 496. in Influenza, 561. in Intestinal Catarrh, 422. in Measles, 572. in Motor Insufficiency, 391. in Neurasthenia, 404, 405. in Obesity, 160. in Parotitis, 566. in Pernicious Anemia, 72. in Rachitis, 193. in Rheumatic Fever, 553. in Scarlatina, 570. in Tuberculosis, 326. in Typhoid Fever, 534-537. in Uric Acid Diathesis, 184. in Yellow Fever, 588, 589. Hygiene of Sick Room, 516-520. in Measles, 572. in Osteomalacia, 194. in Parotitis, 566. in Pertussis, 562. in Rachitis, 189. in Chronic Rheumatism, 166. in Scarlatina, 567. 568. 6i5 in Scurvy, 96. in Smallpox, 574, 575. in Yellow Fever, 587. Hyoscine in Grave's Disease, 107. Hyoscyamus in Asthma, 289, 290. in Bronchitis, 280. in Gout, 187. in Pulmonary Edema, 301. Hyperacidity in Gastric Ulcer, 372. Hyperchlorhydria, Gastric, 393-398. Neurotic, 410. Hyperemia of Brain, 34-38. of Lungs, 38. Hyperesthesia, Gastric, 411. Hypersecretion, Gastric, 393, 398. Hyperthyroidism, 102-103. Hypertrophic Cirrhosis of the Liver, 488-497. Hypnosis in Palpitation, 69. Hypnotics in Heart Disease, 34. Hypochlorhydria, see Hyposecretion. Neurotic, 410. Hypochylia, see Achylia. Hypodermic Purgation, 456. Hypodermoclysis in 7\cute Peritonitis, 469. in Ileus, 436. in Pernicious Anemia, 76. Hypophosphites in Tuberculosis, 325. Hyposecretion, Gastric, 398-401. I Ice-bag in Appendicitis, 478. .in Aortic Insufficiency, 19. in Cholelithiasis, 504. in Endocarditis, 50. in Hepatic Hyperemia, 39. in Hemoptysis, 309. in Palpitation, 68. in Pleurisy, 334. in Rheumatic Fever, 553. Ichthoform in Intestinal Catarrh, 417. Ichthyol in Urethritis, 255. Icterus, Catarrhal, 485-488. Idiosyncrasy against salicylates, 551. Idiotism, Myxedematous, 101. Ileus, 423-437. Immobilization of Joints in Rheumatism, 167. Incision in Cardiac Dropsy, 45. Indican, 207. Infantile Myxedema, 101. Infarct, Pulmonary, 303-306. Influenza, 560, 561. Infusion in Acute Peritonitis, 469. in Uremia, 242. Inhalations in Bronchitis, 280. in Laryngitis, 277. in Pertussis, 565. in Tonsillitis, 264. in Tuberculosis, 327. Injections in Chronic Rheumatism, 168. in Cystitis, 245, 246. in Epistaxis, 272. in Lung Abscess, 305. in Pulmonary Gangrene, 306. in Syphilis, 599. in Urethritis, 250. Insomnia in Heart Disease, 34. in Pneumonia, 526. in Tuberculosis, 331. Insomnia, Veronal in, 36. Instillations in Cystitis, 245. Institution Treatment of Neurasthenia, 404^ of Tuberculosis, 313. Insufflations in Laryngitis, 278. in Pertussis, 565. Insufficiency of the Cardia, 410. of the Pylorus, 410. Intermittent Pulse, 70. Intertrigo in Obesity, 149. Interval Operation in Appendicitis, 479-481- Intestinal Antisepsis in Bright's Disease, 2o6> in Diabetes, 137. in Hepatic Insufficiency, 493. in Intestinal Catarrh, 416, 417. Catarrh, Acute, 413-418. Catarrh, Chronic, 418-423. Hemorrhage, 439, 440. Occlusion, see Ileus. Parasites, 464-468. Parasites in Anemia, 71, j6. Stenosis, see Ileus. Ulcer, 437-440. Intestine, Passive Congestion of, 40, 41. Intubation in Diphtheria, 544. in Pertussis, 564. Intussusception of the Bowel, 424. Inunctions in Acute Peritonitis, 470. in Diphtheria, 543. in Phlebitis, 304. in Tuberculous Peritonitis, 482. in Syphilis, 598. Iodides in Aneurism, 58. in Angina Pectoris, 65. ' in Arterio-sclerosis, 55. in Diabetes, 136. in Endocarditis, 51. in Gout, 188. in Pulmonary Edema, 300. in S3'philis, 602. Iodine in Appendicitis, 478. in Bronchitis, 281. in Grave's Disease, 108. in Leukemia, 88. in Muscular Rheumatism, 165. in Pleurisy, 334. in Vomiting, 240. Iodoform in Cystitis, 246. in Pseudo-leukemia, 92. Iodoglobulin, 104. Iodo-glycerin in Palpitation, 68. Iodol in Urethritis, 256. Iodothyrin, 104. Ipecac in Acute Gastritis, 343. in Bronchitis, 282, 284. in Dysentery, 559. in Heart Disease, 38. in Hemoptysis, 308. Iron Cacodylate in Pseudo-leukemia, 92, Citrate in Chlorosis, 84. in Anemia, 80. 6i6 in Chlorosis, 83. in Diabetes, 137. in Dysentery, 560. in Grave's Disease, 107. in Hepatic Insufficiency, 495. in Intestinal Hemorrhage, 440. in Osteomalacia, 194. in Pernicious Anemia, 74. in Pertussis, 564. in Pseudo-leukemia, 92. in Purpura, 100. in Scurvy, 96. in Simple Anemia, 79, 80. in Smallpox, 583. Peptonates in Chlorosis, 85. Iron Waters in Anemia, 80. in Chlorosis, 85. Irrigations in Appendicitis, 476. Irrigation of the Bowel in Ileus, 428. in Acute Gastritis, 346. in Constipation, 450. in Diphtheria, 542. in Icterus, 487. in Intestinal Catarrh, 414, 422. in Flatulency, 464. Irritability in Aortic Insufficiency, 18. Isodynamics, Law of, 114. Isolation in Smallpox, 574. Itching in Icterus, 488. Jaborandi in Cardiac Dropsy, 42. lalap in Cardiac Dropsy, 44. in Constipation, 454. in Cystitis, 243. in Pleurisy, 336. Jambul in Diabetes, 135. Jaundice, see Icterus. Juniper Oil in Pyelitis, 223. K Keratinized Pills, 417. Kidneys, Passive Hyperemia of, 41. Kinking of the Bowel, 425. Kino in Intestinal Catarrh, 420. Kissingen, in Hepatic Hyperemia, 40. in Obesity, 158. ILactic Acid in Arterio-sclerosis, 54. in Diabetes, 137. in Rachitis, 190. Lactophenine in Gastralgia, 412. in Rheumatic Fever, 552. in Tuberculosis, 326. in Typhoid Fever, 532. Lacto-phosphates in Rachitis, 192. Lacunar Tonsillitis, 263. Laryngitis, Acute, 276-279. Laudanum, see Opium. Lavage, Gastric, 344-346. in Achylia Gastrica, 400. in Gastric Carcinoma, 381, 382 in Hyperchlorhydria, 396. in Hyposecretion, 400. Lavage in Ileus, 427-428. in Motor Insufficiency, 388-389. in Palpitation, 69. in Vomiting of Uremia, 240. of Renal Pelvis, 224-226. Lavender Oil for Inhalation, 306. Laxatives in Acute Gastritis, 346. in Anemia, 241. in Cholelithiasis, 504. in Constipation, 452-456. in Dysentery, 559. in Flatulency, 462. in Ileus, 433. in Mucous Colitis, 442, 443. in Pertussis, 563. Lead Acetate in Cystitis, 247. in Gastric Ulcer, 376. in Hemophilia, 98. in Hemoptysis, 310. in Intestinal Hemorrhage, 440. in Urethritis, 251. as Cause of Arterio-sclerosis, 53. Asthma, 286. Leeching, Anal, 40. in Appendicitis, 478. in Cerebral Hyperemia, 36. in Epistaxis, 276. in Gout, 187. in Pleurisy, 333. in Pneumonia, 524. in Pulmonary Edema, 303. in Tonsillitis, 264. Technique of, 36, 37. Lemons in Hemophilia, 97. Leucocytes in Appendicitis, 474. Leucocytic Leukemia, 87. Leucocytosis in Pneumonia, 525. Leukanemia, 86. Leukemia, 86-89. Leucocytic, 87. Lymphatic, 87. Lymphocytic, 87. Myelogenous, 87. Splenic, 87. Leiter Coil, Description of, 19. in Appendicitis, 478. in Aortic Insufficiency, 19. in Cholelithiasis, 503. in Diphtheria, 542. in Endocarditis, 50. in Gastric Ulcer, 368. in Ileus, 435. in Pericarditis, 51. in Tonsillitis, 263. Levulose in Coma, 144. in Diabetes, 138. Ligation of Extremities in Epistaxis, 273. in Aneurism, 61. in Hemoptysis, 310. Lime Salts in Rachitis, 190. Water in Bright's Disease, 211. Water in Bronchitis, 285. Water in Chronic Gastritis, 358. in Rachitis, 192. Liniments in Aneurism, 61. 617 in Flatulency, 464. in Gout, 186. in Pneumonia, 524. in Chronic Rheumatism, 167, 168. in Muscular Rheumatism, 165. Linseed in Cystitis, 243. Lithemia, 173 f. Lithium Salts in Nephrolithiasis Urica, 230. Liquids in Diabetes, 132. Liquorice in Bronchitis, 283. Liquid Restriction, see Drink Restriction. Liver, Cirrhosis of, 488-497, Extract in Diabetes, 137. Extract in Hepatic Cirrhosis, 496. Passive Hyperemia of, 38. Lobelia in Asthma, 289, 290. Lockjaw, see Tetanus. Lotions in Gout, 186. Lozenges in Tuberculosis, 328. Lues, see Syphilis. Lumbar Puncture in Uremic Attack, 242. Lymphatic Leukemia, 87. Lymph Gland Extract in Leukemia, 88. Lymphocytic Leukemia, 87. Lysidin in Nephrolithiasis, 231. M Magnesia Usta in Flatulency, 463. in Hyperchlorhydria, 397. in Gastric Ulcer, 372. Magnesium Citrate in Cystitis, 243. Sulphate, 44. "Sulphate in Hemophilia, 98. Sulphate in Hypodermic Purgation, 456. Sulphate in Muscular Rheumatism, 164. Sulphate in Tonsillitis, 263. Malakin in Rheumatic Fever, 551. Malaria, 544, 549. as Cause of Anemia, ^2. Malarial Diarrhea, 413, 458. Male Fern for Tape Worm, 465. Manganese in Chlorosis, 85. Marienbad in Diabetes, 136. in Hepatic Hyperemia, 40. in Intestinal Catarrh, 421. in Obesity, 158. Maritime Prophylaxis in Yellow Fever, 593. Marriage in Hemophilia, 97. Marmorek's Serum in Scarlatina, 568. Massage, Effect on Blood Pressure, 23. Effect on Circulation, 23. Effect on Respiration, 23. of the Heart, 23, 24. of the Bowel in Ileus, 434. of the Stomach, 390. in Aneurism, 58. in Appendicitis, 478. in Cardiac Dropsy, 42. in Chlorosis, 82. in Cholelithiasis, 499. in Chronic Nephritis, 222. in Chronic Rheumatism, 172. in Constipation, 448. in Diabetes, 139. in Gout, 187. in Heart Disease, 23. in Muscular Rheumatism, 165. in Neurasthenia, 405. in Obesity, 159. in Phlebitis, 304. in Uric Acid Diathesis, 183. Swedish, 23. Measles, 571-573- Megaloblasts, 71. Megalocytes, 71. Megalogastria, 384. Membranous Enteritis, 441-443. Menthol as Mouth Wash, 260. in Aneurism, 61. in Hay Fever, 270. in Intestinal Catarrh, 416. in Pruritus, 488. in Rhinitis, 258, 269. in Tonsillitis, 264. Mercurial Purgatives. 453. Stomatitis, 261, 262. Mercurialism in Syphilis, 601. Mercurol in Urethritis, 255. Mercury Baths in Syphilis, 599. Bichloride in Cystitis, 246. in Diabetes, 136. in Ileus, 427. in Syphilis, 595. Injections in Syphilis, 599. Inunctions in Diphtheria, 543. Inunctions in Syphilis, 598. Ointment in Tuberculous Peritonitis, 482. Plasters in Syphilis, 599. Meteorism in Ileus, 435. in Pneumonia, 528. in Typhoid Fever, 538. see Flatulency. Methylene Blue in Malaria, 548. in Pyelitis, 224. Milk, as a Diuretic in Acute Nephritis, 202. Cure in Diabetes, 129. Diet in Failing Compensation, 27. Diet in Renal Congestion, 41. Powder, 370. Sugar as a Diuretic, 43. Mineral Acids in Hemophilia, 97. Waters in Bright's Disease, 210. Waters in Bronchitis, 289. Waters in Cholelithiasis, 498. Waters in Chronic Gastritis, 357, 358. Waters in Chronic Nephritis, 210. Waters in Chronic Rheumatism, 170. Waters in Constipation, 455. Waters in Diabetes, 136. Waters in Emphysema, 297. Waters in Hyperchlorhydria, 396, 398. Waters in Icterus, 486, 487. Waters in Intestinal Catarrh, 421. Waters in Hepatic Hyperemia, 40. Waters in Nephrolithiasis, 230. Waters in Obesity, 158. Waters in Pernicious Anemia, 74. Waters in Uremia, 238. Waters in Uric Acid Diathesis, 182. Mitral Insufficiency, 17. 6i8 Stenosis, 17. Mixed Treatment in Syphilis, 603. Morbus Maculosus, 98. Morphine Habit, 18. in Acute Gastritis, 347. in Aneurism, 61. in Angina Pectoris, 64. in Asthma, 289. in Bronchitis, 283, 284. in Emphysema, 299. in Epistaxis, 275. in Gastralgia, 412. in Gastric Ulcer, 376. in Hay Fever, 270. in Hemoptysis, 309. in Muscular Rheumatism, 164. in Palpitation, 69. in Pericarditis, 51. in Pleurisy, 335. in Pneumonia, 524. in Pulmonary Infarct, 304. in Renal Colic, 232. in Tetanus, 557. in Tuberculosis, 328. in Uremic Attack, 242. Motor Insufficiency of the Stomach, 384-392. Mosquitoes and Malaria, 549. and Yellow Fever, 590-592. Mouth Washes, 260. Mucous Colic, 441-443. Mud Baths in Chronic Rheumatism, 171. Mumps, see Parotitis, 566, 567. Muscular Rheumatism, 162, 163-165. Mustard Foot Bath in Rhinitis, 268. in Chronic Gastritis, 363. Plaster, 333. Myelogenous Leukemia, 87. Myocarditis, 47-49. Acute, 48. Chronic, 49. in Articular Rheumatism, 48. Myrrh in Scurvy, 96. Myrtol in Pulmonary Gangrene, 306. Myxedema, 101-104. Myxedematous Idiotism, 101. N • Naphthalin in Dysentery, 559. in Thread Worms, 467. Narcotics in Bronchitis, 285. in Capillary Bronchitis, 294. in Gastric Ulcer, 375. in Intestinal Catarrh, 417. in Tuberculosis, 328. Nauheim in Heart Disease, 23. in Obesity, 159. Nephritis, 197-222. Acute, 198-204. Interstitial, 197, 204-222. Parenchymatous, 197, 204-222. Scarlatinal, 571. Nephrolithiasis, 226-234. Oxalurica, 233. Phosphatica, 233, 234. Urica, 227-232. Nervous Belching, 408. Diarrhea, 459-461. Dyspepsia, 412. Vomiting, 409. Neuralgia in Diabetes, 143. see Antineuralgics. Neurasthenia, in Aortic Insufficiency, 18. see Gastric Neuroses. Neuroses, Gastric, 401-412. Night Sweats in Tuberculosis, 326. Nitrites in Angina Pectoris, 64. in Arterio-sclerosis, 55. with Digitalis, 30. Nitroglycerin in Angina Pectoris, 64 in Arterio-sclerosis, 56. in Epistaxis, 274. in Pneumonia, 522. with Digitalis, 30. Noma, 262. Nose Bleed, see Epistaxis. Notification in Smallpox, 573-574. Nuclein, as Source of Uric Acid, 173, 174. Nursing, Directions for, 517, 519. Nursing, in Yellow Fever, 590. Nutmeg as a Carminative, 463. in Chronic Gastritis, 363. Nutrition, Laws of, 113-118. Nutritive Enemata, 369, 370. Nux Vomica in Chronic Gastritis, 363. in Motor Insufficiency, 391. in Palpitation, 68. Oatmeal Cure in Diabetes, 129. Obesity, 147-161. and Emphysema, 298. and Uric Acid Diathesis, 185. Complication of, 147-149. Occlusion of the Bowel, see Ileus. Oertel Cure, 23. for Obesity, 152. Oertel's Theory of Drink Restriction, 20. Oidium Albicans, 261. Oil Cure in Motor Insufficiency, 391. Injections in Constipation, 451. Injections in Ileus, 429. Injections in Mucous Colitis, 442. Ointments in Acute Nephritis, 200. in Aneurism, 61. in Chronic Rheumatism, 168. Oleoresins in Tuberculosis,' 328. Olive Oil in Cholelithiasis, 500. in Gastric Ulcer, 375. in Nephrolithiasis, 232. Open Air Treatment in Tuberculosis, 3x3, 314. Opiates in Bronchitis, 2.80. in Cholelithiasis, 503. in Hemoptysis, 307, 310. Contraindications to, 35. Danger in Heart Disease, 34. - Danger in Pulmonary Hyperemia, 38. Danger in Renal Disease, 18. in Acute Peritonitis, 469. in Aortic Insufficiency, 18. 6lQ in Appendicitis, 476-478. in Bronchitis, 283, 284. in Cerebral Ischemia, 18. in Cystitis, 243. in Diabetes, 133-134. in Diarrhea, 459. in Epistaxis, 275. in Gastric Ulcer, 376. in Hay Fever, 270. in Hemophilia, 98. in Ileus, 430-432. in Intestinal Catarrh, 417, 422. in Intestinal Hemorrhage, 439. in Intestinal Ulcer, 439. in Mucous Colitis, 442. in Nervous Diarrhea, 461. in Nervous Dyspnea, 18. in Renal Colic, 232. in Rhinitis, 268. in Spastic Constipation, 446. in Tuberculosis, 328. in Uremia, 240. in Uremic Attack, 242. Orchitis, see Epididymitis. Orexine in Chronic Gastritis, 363. Organic Iron Preparations, 84. Peroxides as Intestinal Antiseptics, 207. Organotherapy in Hepatic Cirrhosis, 496. Orphol in Intestinal Catarrh, 421. Orthoform in Gastric Ulcer, 372, 374. Orthopedics of Rachitis, 193. Orthopedic Treatment in Chronic Rheuma- tism, 172. Osteomalacia, 193, 194. Otitis in Measles, 573. in Scarlatina, 571. Oxidizing Treatment in Hepatic Insufficien- cy, 495- Oxygen in Capillary Bronchitis, 294. in Coma, 145. in Emphysema, 299. in Pulmonary Infarct, 304. in Leukemia, 88. in Pneumonia, 525. in Uremic Asthma, 241. Oxyuris Vermicularis, see Thread Worms. Pain in Appendicitis, 473. in Pneumonia, 523. Palpitation, 65-69. in Aortic Insufficiency, 19. Pancreas Preparations in Diabetes, 137. Pancreatin in Bright's Disease, 212. in Chronic Gastritis, 365. Pancreon in Chronic Gastritis, 365. Papain in Chronic Gastritis, 365. Paquelin Cautery in Stomatitis, 261. Paracentesis of Abdomen, Technique of, 46, 47- in Pulmonary Edema, 303. in Dropsy, 46. of Pericardium, 47, 52, 53. of Pleura, 47. Paradox Pulse, 70. Paraldehyde in Insomnia, ^6. Parasites, Intestinal, 464-468. Parotitis, 566, 567. Peliosis Rheumatica, 98. Pelletierine for Tape Worm, 465. Pepo for Tape Worm, 465. Pepper in Chronic Gastritis, 363. Peppermint as a Carminative, 463. for Mouth Wash, 261. Pepsin in Achylia Gastrica, 401. in Chronic Gastritis, 364. in Hyposecretion, 401. Peptonate of Iron, 85. Perforation of the Bowel in Typhoid Fever, 539- Perforative Peritonitis, 468. Pericardial Exudates, 52-54. Pericardiotomy, 52. Pericarditis, 51-53. in Pneumonia, 527. Peritonitis, Acute Circumscribed, 471-481. Acute Diffuse, 468-471. Chronic, 481-484. Tuberculous, 481-484. Peritonsillar Abscess, 263. Perityphlitis, 471-481. Peronin in Bronchitis, 280. Pertussis, 561-566. Peru Balsam in Bronchitis, 282, 284. Petit's Triangle, 201. Pharyngitis, Acute, 265, 269. Phenacetin in Diabetes, 134. in Gout, 188. in Malaria, 548. in Muscular Rheumatism, 164. in Pertussis, 565, 567. in Rheumatic Fever, 552. in Tuberculosis, 326. Phenols in Diabetes, 137. Phlebitis, 304. Phosphates in Tuberculosis, 325. Phosphoric Acid in Diabetes Phosphaticus, 234. Phosphorus in Leukemia, 88. in Osteomalacia, 193. in Pseudo-leukemia, 91. in Rachitis, 193. Physiological Constipation, 444. Physostigmine in Flatulency, 464. Pichi Pichi in Cystitis, 244. Pilocarpine in Acute Nephritis, 203. in Bronchitis, 279. in Cardiac Dropsy, 42. in Croup, 543. Piperazin in Nephrolithiasis, 231. Plasmon Bread, 126. Plasters in Angina Pectoris, 64. in Bronchitis, 281. in Muscular Rheumatism, 165. in Pericarditis, 51. in Pleurisy, 333. Pleuritis, 331-341. Plugging of Nares in Epistaxis, 273. Pneumonia, 51 1-53 1. Jacket, 524. 620 Pneumatic Chamber, 297. Pneumothorax, 339, 340. Pneumotomy, 305. Popophyllum in Cardiac Dropsy, 44. in Constipation, 454. in Hepatic Congestion, 40. Polyuria, Hysterical, 195. Symptomatic, 194. Pomegranate for Tape Worm, 465. Potassium Acetate in Acute Nephritis, 202. Acetate in Bronchitis, 280. Acetate in Pleurisy, 336. Bromide in Asthma, 289. Bromide in Tetanus, 557. Bromide in Valve Lesions, 35. Carbonate in Bronchitis, 280. Chlorate in Salivation, 43. Chlorate in Scurvy, 96. Chlorate in Stomatitis, 261. Chlorate in Thrush, 262. Citrate in Bronchitis, 280. Iodide in Angina Pectoris, 65. Iodide in Arterio-sclerosis, 55. Iodide in Asthma, 288. Iodide in Bronchitis, 285. Iodide in Diabetes, 136. Iodide in Pneumonia, 522, 524. Iodide in Pseudo-leukemia, 91. Iodide in Rheumatic Fever, 552. Iodide in Syphilis, 602. Nitrate in Asthma, 289, 290. Nitrate in Angina Pectoris, 65. Permanganate in Chronic Gastritis, 356. Permanganate in Scurvy, 96. Permanganate in Stomatitis, 262. Permanganate in Thrush, 262. Potato Cure in Diabetes, 129. Poultices, 39. in Angina Pectoris, 64. in Appendicitis, 478. in Muscular Rheumatism, 165. in Pericarditis, 51. in Pleurisy, 334. in Tonsillitis, 264. in Tuberculous Peritonitis, 482. Predigested Foods in Icterus, 486. Pregnancy as a Cause of Anemia, 72. Priessnitz Compress in Acute Gout, 346. in Acute Nephritis, 203. in Appendicitis, 478. in Bronchitis, 281. in Constipation, 449. in Diarrhea, 459. in Gastric Ulcer, 368. in Neurasthenia, 404. in Pericarditis, 51. in Pleurisy, 334. in Tonsillitis, 263. in Tuberculous Peritonitis, 482. Progressive Pernicious Anemia, 71. Prophylaxis of Acute Nephritis, 198. of Angina Pectoris, 62. of Asthma, 288. of Bronchitis, 279. of Chlorosis, 81. of Cholelithiasis, 497, 498. of Chronic Rheumatism, 166. of Cystitis, 243. of Diabetes, 145. of Diabetic Coma, 144. of Diabetic Gangrene, 145. of Diarrhea, 456. of Endocarditis, 49. of Gastric Ulcer, 367. of Gastritis, 355. of Gonorrheal Urethritis, 248, 249. of Gout, 188. of Gouty Attack, 186. of Hay Fever, 270. of Hemophilia, 97. of Hemoptysis, 307, 308. of Infectious Diseases, 507. of Malaria, 549. of Measles, 571. of Muscular Rheumatism, 163. of Nephrolithiasis, 227. of Palpitation, 67. of Pertussis, 561-562. of Pharyngitis, 266. of Pneumonia, 512-516. of Pulmonary Infarct, 303. of Pyelitis, 222. of Pyonephrosis, 222. of Rachitis, 189. of Rheumatoid Arthritis, 166. of Rhinitis, 266. of Scarlatina, 567, 568. of Scurvy, 95, 96. of Smallpox, 573-579- of Stomatitis, 260. of Tetanus, 554. of Tonsillitis, 263. of Uremic Attacks, 238. of Yellow Fever, 590-593. Prostatitis, 253. Protargol in Urethritis, 250. Proteids, Caloric Value of, 113. Proteolytic Ferments, 364. Pruritus Ani, 467. in Diabetes, 141. in Icterus, 488. Pseudo-Angina Pectoris, 65. -Hay Fever, 269, 270. -Leukemia, 89-93. -Rheumatism, 161. Psychic Treatment in Bright's Disease, 219. Psychoses of Heart Disease, 34. Ptyalin in Chronic Gastritis, 366. Ptyalism, 261, 262. Pulmonary Abscess, 303-306. Edema, 299-303. Edema in Pneumonia, 528. Edema in Uremia, 240. Emphysema, 294-299. Gangrene, 303-306. Infarct, 303-306. Insufficiency, 17. Stenosis, 17. Tuberculosis, 312-331. Pulse in Appendicitis, 473. 621 Pumpkin Seed for Tape Worm, 465, 466. Puncture of the Bowel in Flatulency, 464. in Ileus, 435. Purgation in Icterus, 485. Purgatives, Mercurial, 44. see Laxatives. Vegetable, 44. Purging in Appendicitis, 478. in Uremia, 237. Purin Bases, 20, 182, 206 f. Purpura, 95, 98-100. Rheumatica, 98. Simplex, 98. Putrid Bronchitis, 284. Pyelitis, 222, 224. Pyloric Insufficiency, 410. Pylorospasm, 408. Pyoktanin in Cystitis, 247. Pyonephrosis, 222-224. Pyorrhea in Diabetes, 140. Pyramidon in Gastralgia, 412. in Tuberculosis, 326. Quarantine in Smallpox, 574. Quassia in Chronic Gastritis, 363. for Thread Worms, 467. Quinic Acid Salts in Gout, 188. Quinine Bimuriate in Malaria, 545. Citrate in Chlorosis, 84. Hydrobromate in Heart Disease, 19. -Idiosyncrasy Against, 547. in Aortic Insufficiency, 19. in Chronic Rheumatism, 169. in Diabetes, 137. in Diarrhea, 413. in Dysentery, 560. in Endocarditis, 50. in Fever, 509. in Influenza, 560. in Leukemia, 88. in Malaria, 544-548. in Muscular Rheumatism, 164. in Myocarditis, 48. in Pericarditis, 51. in Pertussis, 565. in Pseudo-leukemia, 91. in Rhinitis, 268. in Typhoid Fever, 532. in Scurvy, 96. in Smallpox, 583. Sulphate in Bronchitis, 279. Valerianate in Heart Disease, 19. Rachitis, 188-193. Radium in Urethritis, 256. Rectophore, 253. Rectal Feeding in Appendicitis, 476. in Fever, 511. in Gastric Ulcer, 367-369. in Ileus, 436. in Motor Insufficiency, 387. in Tuberculosis, 328. Irrigation in Gastric Ulcer, 368. Purgation, 456. Recurrent Glandular Fever, 90. Red Light in Smallpox, 584, 585. Reduced Iron in Anemia, 80. in Chlorosis, 84. Reduction Cure, Art of, 154. Science of, 151-154. in Chronic Rheumatism, 172. see Obesity. Reflexes from Appendicitis, 480. Regurgitation of Food, 410. Resorcin in Intestinal Catarrh, 416. in Thrush, 262. Resorts in Cholelithiasis, 499. Rest Cure in Floating Kidney, 235. in Palpitation, 67. see Weir-Mitchell Treatment. in Acute Nephritis, 200. in Acute Peritonitis, 469. in Aneurism, 57. in Appendicitis, 475. in Capillary Bronchitis, 293. in Cardiac Dropsy, 42. in Chlorosis, 81. in Cystitis, 243. in Diphtheria, 543. in Endocarditis, 49. in Epididymitis, 253. in Failing Compensation, 26. in Gastric Ulcer, 368. in Gout, 186. in Grave's Disease, 105. in Heart Disease, 22. in Hemoptysis, 308. in Hepatic Insufficiency, 495. in Intestinal Catarrh, 423. in Intestinal Ulcer, 438. in Motor Insufficiency, 388. in Nervous Diarrhea, 460. in Nervous Dyspepsia, 413. in Pernicious Anemia, J2. in Pulmonary Infarct, 304. in Rheumatic Fever, 553. in Scurvy, 95. in Simple Anemia, 78. in Tetanus, 556. in Tuberculous Peritonitis, 481. in Tuberculosis, 313, 318. Rhubarb in Cardiac Dropsy, 44. in Constipation, 453. in Hepatic Congestion, 40. Restriction of Liquids, see Drink Restriction. 20. Retrocedent Gout, 185, 186. Rhatany in Intestinal Catarrh, 420. Rheumatic Fever, 550-554. Rheumatic Gout, 161. Pleurisy, 331. Rheumatism, 161-172. Acute Articular, 161, 550-554. Chronic, 162. Denfiition, 161. Gonorrhceal, 161. Infectious, 161. Muscular, 162, 163-165. 622 Rheumatoid Arthritis, 162, 166-172. Synonyms, 162, 163. Rhinitis, Acute, 265-269. Rice Cure in Diabetes, 129. Rickets, see Rachitis. Rigid Diabetes Diet, 121, 122. Renal Asthma, 280. Renal Calculus, see Nephrolithiasis. Colic, 232. Hemorrhage, 232. Roborat Bread, 126. Rochelle Salt, 44. Room Disinfection, 575. Round Worm, 466. Rubidium Iodide in Syphilis, 601. Rumination, 410. Saccharine in Diabetes, 138. Salicin in Rheumatic Fever, 551. Salicylate poisoning, 551. Salicylates in Cholelithiasis, 500, 503. in Chronic Rheumatism, 169. in Diabetes, 134. in Endocarditis, 50. in Epididymitis, 254. in Hepatic Cirrhosis, 496. in Icterus, 487. in Muscular Rheumatism, 164. in Pericarditis, 52. in Pleurisy, 332. in Rheumatic Fever, 550-552 . in Tonsillitis, 263. in Uremia, 238. Salicylic Acid in Cystitis, 247. Acid in Chronic Gastritis, 356. Acid in Fevers, 509. Acid in Hay Fever, 270. Acid in Intestinal Catarrh, 416. Acid in Night Sweats, 327. Ointment in Rheumatic Fever, 553. Saligenin in Rheumatic Fever, 551. Saline Cathartics in Cardiac Dropsy, 44. Cathartics in Constipation, 453, 455. Waters, 40. Waters in Achylia Gastrica, 401. Waters in Acute Nephritis, 204. Water? in Bronchitis, 284. Waters in Chronic Gastritis, 358. Waters in Hyposecretion, 401. Waters in Icterus, 485, 486. Waters in Uremia, 240. Saliphen in Rheumatic Fever, 551. Saiipyrin in Rheumatic Fever, 552. Salisbury Diet, 177. Salivation from Calomel, 43. Salol in Chronic Rheumatism, 169. in Cystitis, 243. in Icterus, 488. in Intestinal Catarrh, 416. in Muscular Rheumatism, 164. in Pleurisy, 332. in Pyelitis, 223. in Rheumatic Fever, 551. in Tonsillitis, 263. Salt Baths in Bright's Disease, 217. Baths, Technique of, 25. Enemas in Constipation, 450. Enemas in Ileus, 429. in Chronic Gastritis, 356. Restriction in Heart Disease, 22. Restriction in Nephritis, 215. Salts in Pleurisy, 336. Sand Baths in Chronic Rheumatism, 171. Santal Oil in Bronchitis, 282, 284. in Cystitis, 244. Santonin for Round Worm, 466. for Thread Worm, 467. Sapo Kalinus in Pseudo-leukemia, 92. in Tuberculous Peritonitis, 482. Sarcomatosis of Lymph Glands, 90. Sassafras as a Carminative, 463. Scarification in Dropsy, 46. in Epididymitis, 254. in Laryngeal Edema, 240. Technique of, 39. Scarlatina, 567, 571. Scarlet Fever, see Scarlatina. Schoenlein's Disease, 98. Schott Treatment, 23. Scopolamine in Pulmonary Edema, 30 r. Scottish Douche in Chronic Rheumatism, 171. in Constipation, 449. Scrofula, 90. Scurvy, 95-96. Secondary Anemia, see Simple Anemia. Seidlitz Powder in Constipation, 455. Self-massage in Constipation, 448. Senega in Bronchitis, 283. Senna in Cardiac Dropsy, 44. in Constipation, 453. in Pleurisy, 336. Serum of Thyroidectomized Goats, 105. Sick Room ' Hygiene, 516, 520. Sidonal in Gout, 188. in Nephrolithiasis, 231. Silver Nitrate in Cystitis, 246. in Gastric Ulcer, 372. in Hyperchlorhydria, 397. in Intestinal Catarrh, 421. in Intestinal Ulcer, 439. in Scurvy, 96. in Stomatitis, 261, 263. in Urethritis, 257. Simple Anemia, 76-80. Goitre, 109. Sitz-baths in Constipation, 448-449. in Cystitis, 243. in Epistaxis, 276. Skin Lesions in Diabetes, 141. in Obesity, 149. Smallpox, 573-586. Smelling Salts in Hay Fever, 270. in Palpitation, 68. Smoking in Constipation, 447. in Diabetes, 132. in Nervous Dyspepsia, 413. Soap Enema in Constipation, 450. Sodium Acetate in Bronchitis, 280. $2$ Acetate in Pleurisy, 336. Arseniate in Asthma, 288. Arseniate in Tuberculosis, 324. Sodium Benzoate in Bronchitis, 282. 284. Benzoate in Cholelithiasis, 504. Benzoate in Nephrolithiasis, 231. Benzoate in Pyelitis, 223. Biborate as Mouth Wash, 260. Biborate in Hyperchlorhydria, 398. Bicarbonate in Achylia Gastrica, 401. Bicarbonate in Bright's Disease, 212. Bicarbonate in Bronchitis, 280. Bicarbonate in Chronic Rheumatism, 169. Bicarbonate in Coma, 145. Bicarbonate in Gastric Ulcer, 372. Bicarbonate in Hyperchlorhydria, 397. Bicarbonate in Hyposecretion, 401. Bicarbonate in Nephrolithiasis Urica, 228. Bicarbonate in Tonsillitis, 263, 264. Bromide in Grave's Disease, 107. Bromide in Heart Disease, 19. Bromide in Palpitation, 68, 69. Bromide in Tetanus, 557. Bromide in Valve Lesions, 35. Cacodylate in Asthma, 288. Cacodylate in Leukemia, 88. Carcodylate in Pernicious Anemia, 74. Cacodylate in Pseudo-leukemia, 91. Carcodylate in Pulmonary Edema, 302. Cacodylate in Tuberculosis, 324. Chloride, see Salt. Cinnamate, 324. Citrate, 280. Glycocholate in Bright's Disease, 207. Glycocholate in Cholelithiasis, 500. Iodide in Arterio-sclerosis, 55. Iodide in Syphilis, 601. Nitrate in Hemoptysis, 309. Nitrate in Angina Pectoris, 65. Salicylate as Mouth Wash, 261. Salicylate in Chronic Rheumatism, 169. Salicylate in Diabetes, 134. Salicylate in Gout, 188. Salicylate in Myocarditis, 48. Salicylate in Pleurisy, 332. Salicylate in Rheumatic Fever, 550. Salicylate in Tonsillitis, 263. Sulphate as Laxative, 44. Sulphate in Dysentery, 560. Sulphate in Grave's Disease, 107. Sulphate in Hemophilia, 98. Sulphocarbolate in Pyelitis, 224. Somnolence in Heart Disease, 34. Southey Trocars in Dropsy, 45. Spasm of the Cardia, 407. of the Pylorus, 408. Spastic Constipation, 446-447. Specific Treatment of Infectious Diseases, 507 Specifics in Typhoid Fever, 531. Specific Sera in Scarlatina, 568. Spinal Sponging in Neurasthenia, 405. Spigelia for Round Worms, 466. Splenectomy in Leukemia, 89. Pseudo-leukemia, 93. Splenic Anemia, 90. Extract in Leukemia, 88. Leukemia, 87. Tumor in Malaria, 549. Splenomegaly, 94. Sponging in Icterus, 488. in Typhoid Fever, 536. Spinal, 405. Sporadic Cretinism, 101. Sprays in Diphtheria, 542. in Hay Fever, 270. in Tonsillitis, 264. Squills in Pleurisy, 336. in Pulmonary Hyperemia, 38. Starvation in Acute Nephritis, 199. in Acute Peritonitis, 469. in Appendicitis, 475. in Diabetes, 129. in Nervous Dyspepesia, 412. Steatorrhea in Diabetes, 142. Stegomyia Fasciata in Yellow Fever, 591. Stenosis of the Bowel, see Ileus. Stomach Tube, 344. Passive Congestion of, 40, 41. Stomachics in Achylia Gastrica, 401. in Chronic Gastritis, 362. in Gastric Carcinoma, 381. in Hyposecretion, 401. in Tuberculosis, 330, 331. Stomatitis, 259, 263. in Diabetes, 140. Stramonium in Asthma, 289, 290. Strangulation of the Bowel, 425. Strapping in Pleurisy, 335. Strontium Bromide in Grave's Disease, 107, Strophanthus in Atheroma, 30. in Heart Disease, 33. Strychnine in Bronchitis, 282-285. in Heart Disease, 32. in Hemoptysis, 310. in Smallpox, 583. Stupes in Intestinal Catarrh, 417. Stupor in Heart Disease, 34. Stypticine in Epistaxis, 274. in Internal Hemorrhage, 440. Sugar Substitutes, 128. Sulphocarbolates in Bright's Disease, 207. Sulphonal in Diabetes, 134. in Insomnia, 35. Sulpho-saline Waters in Chronic Gastritis, 358. in Intestinal Catarrh, 422. Sulphur in Constipation, 455. Sulphuric Acid in Hemophilia, 97. in Night Sweats, 326. in Purpura, 100. Sulphur Waters in Bronchitis, 284. Sun Baths in Chronic Rheumatism, 171. Sunlight in Smallpox, 584. Suppositories in Cystitis, 244. Suprarenal, see Adrenal. in Heart Disease, 32. Surgery in Acute Diffuse Peritonitis, 468. in Aneurism, 59. in Appendicitis, 471-475, 479-481. in Bright's Disease, 222. in Bronchiectasis, 286. 624 in Cardiac Dropsy, 45. in Cholelithiasis, 501-502. in Cholecystitis, 505. in Chronic Peritonitis, 481. in Chronic Rheumatism, 172. in Epistaxis, 272. in Floating Kidney, 235. in Gastritis, 378, 379. in Gastric Ulcer, 377. in Hepatic Cirrhosis, 497. in Hepatic Insufficiency, 497. in Ileus, 423. in Lung Abscess, 305. in Motor Insufficiency, 392. in Nephrolithiasis, 232. in Prostatitis, 253. in Perityphilitis, 471-475. in Pulmonary Gangrene, 306. in Pyelitis, 224. in Tonsillitis, 264, 265. in Tuberculosis of the Peritoneum, 483-484- Suspensory in Epididymitis, 254. Sweating by Steam, Technique of, 42. in Acute Nephritis, 203. in Cardiac Dropsy, 42. in Chlorosis, 86. in Chronic Nephritis, 218, 219. in Croup, 543. in Diabetes Insipidus, 196. in Diphtheria, 542. in Muscular Rheumatism, 164. in Pleurisy, 333. in Pulmonary Edema, 300. in Rhinitis, 268. in Uremia, 237, 241. Swedish Massage, 23. Movements in Constipation, 450. Syphilis, 594-603. and Rachitis, 189. as Cause of Anemia, 72. Syphilitic Diabetes, 147. Hepatitis, 488-497. Urethritis, 256, 257. Syphonage of Stomach, 345. Tachycardia, 70. Tenia Mediocanellata, see Tape Worm. Solium, see Tape Worm. Taka-diastase in Chronic Gastritis, 366. Talcum in Gastric Ulcer, 374. Talma Operation, 497. Tamponade in Epistaxis, 273. Tannalbin in Intestinal Catarrh, 420. in Intestinal Ulcer, 439. Tannic Acid in Hemoptysis, 310. in Intestinal Catarrh, 420. in Intestinal Ulcer, 439. in Salivation, 43. in Scurvy, 96. Tannigen in Hematuria, 232. in Intestinal Catarrh, 420. in Intestinal Ulcer, 439. in Pyelitis, 223. in Uremia, 240. Tannin in Diarrhea, 459. in Dysentery, 560. Tannoform in Night Sweats, 327. Tape-worm, 464-466. in Pernicious Anemia, 71. Tapping, see Paracentesis. Tartar Emetic in Acute Gastritis, 343. in Bronchitis, 282, 284. in Heart Disease, 38. Tea, Diuretic, 43, 202. in Compensated Heart Lesions, 20. in Chronic Nephritis, 214. Temperature in Appendicitis, 473. Terrain Cure, 23. in Obesity, 159. Terpine Hydrate in Bronchitis, 282. Terpinol in Bronchitis, 282. Test Meal, Diabetic, 121, 122. Tetanus, 554-557- 3 1, Antitoxin, 554, 555. Tetany in Motor Insufficiency, 387 Tetronal in Tetanus, 557. Thermophore, 39. in Cholelithiasis, 503. in Ileus, 435. in Muscular Rheumatism, 165. Theobromin as a Dieuretic, 43. in Heart Disease, 32. in Pleurisy, 336. Thicol in Tuberculosis, 523. Thiosanamin in Tetanus, 557. Thirst in Acute Gastritis, 343. in Acute Peritonitis, 469. in Appendicitis, 475. in Gastric Ulcer, 368. in Ileus, 436. Thoracentesis in Pleurisy, 336-339. Thread Worm, 467. Thrush, 261^ 262. Thyme as a Carminative, 463. Thymol as Mouth Wash, 261. for Anchylostoma, 467. for Thread Worms, 467. for Uncinaria, 467. for Chronic Gastritis, 356. Thymus in Grave's Disease, 105. in Simple Goitre, 109. Thyreoglobulin, 104. Thyroid Gland, 101-109. in Cretinism, 101. in Grave's Disease, 105. in Myxedema, 102. in Obesity, 160. in Simple Goitre, 109. Thyroidism, 102-103. Thyroidin, 104. Tobacco as Cause of Arterio-sclerosis, 53. in Compensated Heart Lesions, 20. Smoke in Asthma, 290. Tolu in Bronchitis, 282, 284. Tonics in Diabetes, 133. in Syphilis, 601. Tonsillar Abscess. 263. Tonsillitis, 263-265. 62 5 Tracheo Bronchitis, 279-283. Tracheotomy in Diphtheria, 544. Transfusion in Pernicious Anemia, 74. Technique of, 74, 75. Tricuspid Insufficiency, 17. Stenosis, 17. Trigeminal Pulse, 70. Trional in Insomnia, 36. in Tetanus, 557. Trophic Disorders in Diabetes, 144. Tropical Dysentery, 558. Truneczek Serum in Arterio-sclerosis, 56. Tuberculin, 321, 322. in Leukemia, 89. Tuberculosis of Epididymis, 254. of Lungs, 312-331. of Peritoneum, 481-484. Tuberculous Urethritis, 256. Tufnell Diet in Aneurism, 57. Tumor in Appendicitis, 474. Turkish Bath in Bronchitis, 279. Turpentine for Inhalations, 306. in Bronchitis, 282, 284. in Hemoptysis, 311. in Pulmonary Gangrene, 306. in Purpura, 100. in Renal Colic, 232. Typhoid Fever, 531-539- U Ulcer Gastric, 366-377. of. the Bowel, 437-440. Ulcerative Stomatitis, 261. Uneinaria, 467. Urate Deposits, 175. Urea in Hepatic Cirrhosis, 496. in Nephrolithiasis, 231. Uremia, 236-242. Acute Attack, 241, 242. Uremic Asthma, 286. Diarrhea, 413, 458. Urethran in Uremic Attack, 242. Urethritis, Acute, 248-257. Coli Bacillus, 255. Gonorrheal, 248-254. Non-infectious, 248. Posterior, 252. Staphylococcus, 255. Streptococcus, 255. Syphilitic, 256, 257. Tuberculosa, 256. Uric Acid, Destruction of, 177. Diathesis, 173-188. Effect of Diet on, 175. Elimination of, 177. Endogenous, 174. Exogenous, 174. Pathology of, 173-176. Retention of, 174. Solvents, 230. Transformation of, 174. Urichemia, I73f. Urinemia, 237. Urocine in Gout, 188. Urotropin in Cystitis, 244, 245. in Nephrolithiasis, 231. in Pyelitis, 223. in Scarlatina, 570. in Urethritis, 255. Uva Ursi in Acute Nephritis. 203. in Cystitis, 244. Vaccination in SmaUpox, 577-579. Valerian in Aortic Insufficiency, 19. in Diabetes, 134. in Diabetes Insipidus, 195. in Grave's Disease, 107. in Palpitation, 69. in Uremic Asthma, 241. Valerianate of Quinine in Malaria, 545 Valvular Disease, 17-47. Lesions Compensated, 17-26. Lesions Decompensated, 26-34. Vasodilators in Angina Pectoris, 63. Variola, see Smallpox. Venesection in Cerebral Hyperemia, 36. in Chlorosis, 86. in Emphysema, 298. in Epistaxis, 274, 275. in Pneumonia, 522. in Pulmonary Edema, 303. in Pulmonary Hyperemia, 38. in Pulmonary Infarct, 305. in Uremia, ,242. Technique of, 37. Veratrum in Epistaxis, 274. in Pneumonia, 522. Veronal in Insomnia, 36. Vesical Gout, 185. Vesication, 39. Vicarious Epistaxis, 272, 276. Hemoptysis, 307. Vichy in Diabetes, 136. in Intestinal Catarrh, 421. in Obesity, 158. Vinegar Enema in Constipations, 45