CLINICAL LECTURE-GASTRALGIA-CHONIC CA TARRHAL DYSPEPSIA-CATAR RHAL JAUNDICE. A Clinical Lecture Delivered at the Hospital of the University of Pennsylvania BY WILLIAM PEPPER, M.D., LL. D., Provost of and Professor of the Theory and Practice of Medicine and of Clinical Medicine in the University of Pennsylvania. REPORTED BY WILLIAM H. MORRISON, M.D. Gentlemen, I shall to-day bring before you certain cases of digestive troubles and shall pass them in rapid review. Our first patient is this man, aged 45 years, a quarryman by occupation. He is married and has a family of healthy children. His general health has been good until recent years. He has never had venereal diseases. His habits have been good, but he has been much exposed to cold and violent changes of temperature. About fifteen years ago, this man first had pain in the right hypochondriac region. This pain seemed to be increased by eating, and was relieved by vomiting. It came about two or three hours after eating, and continued until vomiting gave relief. Following this there would be great irritation of the stomach, with excessive thirst, calling for the use of large quantities of water, which were at once vomited. When the attacks first made their appearance they came about three or four o'clock in the afternoon and continued until night. In the interval between the attacks, he felt mofierately well. This pain has been felt almost every day for the past fifteen years. Before going further, let us analyze these attacks and try to learn their nature. Note in the first place that they are paroxysmal in character. The duration of each attack was consider able. The patient would eat his dinner at 12 o'clock, and the pain would begin to appear at 3 o'clock. It is, therefore, hardly correct to say that the pain was increased by eating. Siuce the attacks appeared the pain has been growing more severe, and now comes sooner after eatfng, but for a long time the pain came three hours after eating, when the gastric digestion was almost finished and when the stomach should be empty. It is also noted that this pain would be relieved by vomiting, and after this there would be great irritation of the stomach. The pain was also relieved by the ingestion of stimulant articles of food. Red pepper with water would relieve the pain. It was also relieved by pressure, and the patient found the most comfortable position to be on the face. You will not be at a loss to recognize in these spells of pain, attacks of gastralgia, or neuralgia of the stomach. This is shown by their paroxysmal character, by the fact that they occur not immediately after taking food, but come at the time when the gastric digestion is advanced and the stomach is becoming empty, and its coats are exposed to the acids resulting from the imperfect digestion of the food. Evidently there was with this gastralgia, an element of gastric catarrh, rendering the stomach irritable. The attacks of pain have increased in frequency since one year ago, and now he has an exacerbation of pain every day one hour after eating. The pain is most marked over the region of the pylorus, a little to the right of the median line. There is some tenderness on pressure at this point. During the attacks the pain spreads across the epigastrium and through to the back. The appetite has always been good, and at times it is voracious. It has never been unnatural and craving, as sometimes happens in this affection. The bowels are regular. He has to urinate very frequently, every forty-five minutes, and passes a small quantity of reddish urine. During the last year he has lost considerable flesh. One year ago his weight was 180 pounds; it is now 140 pounds. He has also lost strength. The urine contains neither albumen nor sugar. He was admitted to the hospital ten days ago. The day fol lowing admission, he had a sharp attack of pain, but since then he has been better. He has had no pain for the past week and has only vomited once since admission. Here then is an exceedingly well marked case of gastralgia. I do not dwell upon the diagnosis, for the attacks are so very characteristic. As to the cause of the attacks in this case, we are somewhat in doubt. The man's habits are good; his food is necessarily coarse, and he is much exposed. He is not intemperate in his use of tobacco, although he uses it every day. He partakes moderately of tea and coffee. It is not improbable that in the sensitive condition induced by the breaking down of the system from exposure, cold and damp, and from the catarrhal irritation of the stomach, that the moderate indulgence in these stimulants has been sufficient to excite the attacks of gastralgia. We do not find here, as we do in many cases of gastralgia, a definite cause. It is usually associated with a tendency to depression of vitality, and exhaustion of whatever form which makes the system, and particularly the nervous system sensitive and depressed. This man has been forced to work, and it is, therefore, not strange that the symptoms have continued. In this case, it is noted that there is paiu over the region of the pylorus. This is not constantly found in gastralgia. The epigastrium is often entirely free from increased sensibility. Gastralgia is, however, often associated with subacute inflammatory states of the lining membrane of the stomach. We then have a mixed case, and there may then be distinct local tenderness associated with the irritated state of the mucous membrane. This man has undoubtedly had from time to time catarrhal irritation of the mucous membrane of the stomach, but these attacks have not been very pronounced. The only condition which might be suspected in such a case as this, would be ulcer of the stomach, but it requires no discussion to eliminate that. The fact that blood has never been vomited, the character of the pain coming on not immediately on the ingestion of food, but some time later, the relief by stimulant articles and the moderate amount of tenderness would exclude this. In gastric cancer such spells of pain as these may occur. There has been no obstruction of the pylorus and the bowels have been regular, and this case has lasted so long that no idea of serious organic disease can be entertained. The prognosis in these cases is favorable, if control of the patient can be gained. In many cases, the conditions are as in this case. As soon as a little relief is gained, the patient is obliged to return to work. In many cases, the cure is facilitated by a change of the habits of life and change of climate. In such a case as this, we are limited to diet, drugs and general directions in regard to dress, rest, etc. In regard to diet we exclude all substances which like alcohol, tobacco, and the excessive use of coffee and tea, may help to keep up the irritated state of the mucous membrane of the stomach. For this man, I should recommend a diet something like this: For breakfast, mush and milk with a soft-boiled egg. At 10 o'clock, half a pint of milk with a tablespoonful of lime water. Dinner, a pint of milk, with stale bread and a small piece of meat. The milk may be heated, or mixed with boiling water. At 3 o'clock, milk and lime water again. Supper, hot water and milk, toast, a soft egg, or oysters. I thus give three light meals, and in the intervals, at about the time that the stomach has disposed of these three principal meals and become exposed to the gastric juice, I give small quantities of milk and lime water. This distribution of nourishment is often of great importance in the treatment of gastralgia. It is sometimes necessary to go further and put the patient on an absolute milk diet, giving a small quantity every hour and gradually increasing the quantity and lengthening the intervals. This diet should continue until all tendency to neuralgia is overcome. When this man came into the hospital, I ordered five grains of subnitrate of bismuth and pepsin with one-eighth of a grain of morphia before each meal. The pain was so excessive, and it was so important to check it at once, that I resorted to the use of morphia against my will, for I never like to use it where it can be avoided. I propose now to gradually withdraw the morphia. I shall now order powders containing six grains subnitrate of bismuth and pepsin and reduce the dose of morphia to one-twelfth of a grain. The morphia does not seem to have interfered with any of the functions. We shall be fortunate if the symptoms do not again come into prominence as the morphia is removed. They certainly would if we did not correct the diet. If you use opiates in any chronic case, it must be associated with such thorough hygienic treatment and regulation of diet, that all the time the fundamental disease is being subjected to radical cure. CHRONIC CATARRHAL DYSPEPSIA. The next patient presents another type of gastric disorder. He is 35 years of age, and by occupation a saloon-keeper, a moderate drinker, and comes complaining of stomach trouble of about two years duration. The symptoms have chiefly been failure of appetite, a heavily coated tongue, a bad taste in the mouth, constantly hawking and raising of mucous, frequent vomiting on first rising in the morning of glairy mucous and green colored liquid, weight and fullness in the epigastrium, a constipated state of the bowels and frequent headaches in the front and back of the head. At times there is soreness and tenderness of the eyeballs. During the past two years there has been a loss of flesh and strength, the weight having decreased twenty pounds in that time. The patient has grown pale, weak and easily tired. This is an equally typical picture of chronic catarrhal dyspepsia, where the lesion has been congestion, catarrhal inflammation with perverted secretion, not only in the stomach but also in the esophagus and pharynx. There has been more or less chronic pharyngeal catarrh connected with the dyspepsia. There is reason to suppose that there has been a further extension of the same kind affecting the fuuction of the liver, and that from time to time there have been spells of lithemia, resulting from the torpid and imperfect action of this organ and the imperfect assimilation of food. Before these troubles appeared the patient had been in the habit of eating all kinds of food and at very irregular hours, the morning meal often being substituted by liquor or beer upon a totally unprotected stomach. It is remarkable that this practice could be kept up so long without the appearance of dyspeptic |