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Divide in chart, No. xij. Sig. At night, one powder every fifteen minutes until three have been taken. Administer in dilute claret, or port or sherry wine.

As an antipyretic from gr. v to gr. x should be given every ten minutes until the temperature has been reduced, or 40 to 50 grains have been taken, when the same dose is repeated at longer intervals, until the desired effect is obtained.

IF your patient suffers from eructations of gas from stomach, flatulency, heartburn or colic, give a fluid drachm of Seng, repeated every half hour until relieved; then give one or more fluid drachms until the cause is removed.

THE AMERICAN MEDICAL
ASSOCIATION.

THE American Medical Association will hold its next annual meeting at Baltimore in May, 1895, and it is expected that an unusually large number of physicians will be in attendance. Delegates and members will be present from all the important cities in the east and south, but by far the greatest number will come from the western cities. To transport so many, special trains will be run, and those who do not use the special trains will have the choice of several roads. The Baltimore and Ohio Railroad will naturally attract a large contingent of those coming east, south and north, because of its excellent facilities, its extensive service and principally because all its trains from the west and south are run via Washington. This will be a great induce

ment to the visiting members and delegates accompanied by their wives and daughters. Besides this, those coming from points between New York and Washington will have the opportunity of using the Royal Blue express trains, which are composed of vestibuled Pullman cars running very rapidly and all with no extra charge. In addition to this, those who attend this convention and do not come via Washington can run over to that city on the forty-five minute trains, which are said to be the fastest trains in this country, if not in the world. Particulars as to rates and other information may be obtained from any of the following agents of the road; or will be mailed by addressing the Baltimore and Ohio Railroad, Baltimore, Md.

A. Agents Boston, 211 Washington St. J. Simmons, New Eng. Pass. Agent, Chicago, 193 S. Clark St.-W. W. Picking, City Pass. Ag't; Cincinnati, Grand Cent. Depot - Geo. B. Warfel. A. G. P. A., Cleveland, Ohio, 143 Superior St. W. M. McConnell, Pass. and Ticket Agent. New York, 415 Broadway – C. P. Craig, Gen. East'n Pass. Agent. Philadelphia, 833 Chestnut St.-Jas. Potter, Dist. Pass. Agent. Pittsburg, Pa., Cor. Fifth Ave. and Wood St.-E. D. Smith, Division Pass. Agent. San Francisco, Cal., No. 9 Mills Building Peter Harvey, Pacific Coast Agent. St. Paul, Minn.-J. V. Cherry, Trav. Pass. Agent.

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MEDICAL JOURNAL

A Weekly Journal of Medicine and Surgery.

VOL. XXXII.-No. 14. BALTIMORE, JANUARY 19, 1895. WHOLE NO. 721

ORIGINAL ARTICLES.

ON STOMACH DISTENSION.

READ AT THE SEMI-ANNUAL MEETING OF THE MEDICAL AND CHIRURGICAL FACULTY OF MARYLAND, HELD AT CUMBERLAND, MD., Nov. 21 AND 22, 1894.

By H. Salzer, M. D.,

Baltimore.

IN using the term "Distension of the Stomach," I wish to emphasize the difference between a temporary or functional and a lasting or organic dilatation of the stomach. The former is based upon lack and decrease of elasticity and muscular tonus; the latter upon pathological changes in the entire organ, such as grave atony, atrophy of the mucosa and muscularis, narrowing of the pylorus, or a combination of these conditions. The latter will very seldom let the stomach return to normal size and proportions, the former will, if its decreased elasticity is not further taxed above its limit and if muscular and nerve power have become normal.

Distension of the stomach being a temporary affection, the symptoms are also temporary. Among them head symptoms are most frequently prominent. Sick headache, pulsating temples, insomnia, general depression and vertigo are foremost subjective complaints. Nausea when present might be a very prominent symptom, or only form part of the general complaint. It often has the character of seasickness, as though it depended upon a more or less impaired fixation of the viscera. The dyspeptic symptoms are more or less obstinate constipation, sour stomach, caused in some cases by real hyperacidity, that is, hypersecretion of free mu

riatic acid, but more frequently by faulty formation of abnormal amounts of organic acids, lactic acid, butyric acid, etc. Further symptoms are, more or less painful oppression in the epigastrium, particularly one to three hours after eating, though sometimes directly after meals.

Eructations are frequent and often wished for, as they give great relief. They are often odorless and tasteless, caused by swallowed atmospheric air, which is retained by spastic constriction of both cardia and pylorus; they are less frequently caused by fermentation and then observed later on, four to five hours after meals. It cannot be said that this fermentation and the formed ptomaines are the cause of the head symptoms. In the majority of the cases in question, neurotic alterations are greatly in play with the distension of the stomach as well as with another abnormity which forms the most frequent complication, viz.: dislocation of the stomach itself as well as of the neighboring organs, especially the right kidney, and this mostly in the first degree. Where you are just able to have the lower half of the kidney in your hand during inspiration and feel it slip back during expiration, you have mostly a loose, not a floating kidney, together with a distended or temporarily dilated stomach.

Of over 600 patients who have consulted me during the past two years about their digestive organs and of whom I have kept records, over 200 belong to this group, and I think it of importance to the general practitioner to make himself familiar with this type of disease; as I can show that he can easily do so without the use of the stomach tube and time-taking analysis.

Before entering into the clinical details, I wish to say a few words important for the etiology of the affection. The fact that we sometimes find renal descensus of the mildest type accompanied by the most lamentable symptoms, and then again meet with a floating kidney, movable almost through the entire abdomen, without creating scarcely any unpleasant symptoms, must convince us that it is not the floating or wandering kidney alone which causes. the distress, but that abnormities in other organs must be considered responsible for the sufferings.

Experience has shown me that where only stomach distension and a milder degree of intestinal atony were the complication with loose kidney, good results could be obtained by systematic treatment, whilst in those cases where the floating kidney was complicated with dilatation or grave gastro-intestinal atony, therapeutical measures seemed of no avail. The former always showed intermissions of good health, the latter kept the patient in almost constant greater or lesser agony. It cannot be denied that in such extreme cases, nephrorrhaphy (sewing of the kidney to the abdominal wall) and its fixation by it, has shown some very good results. Sulzer states that of 80 nephrorrhaphies, 40 were perfectly cured and obtained permanent relief. Here the gastro-intestinal distensions and atony, which in my opinion had caused the distress, had certainly been corrected by fixation of the kidney. There is no doubt that in other cases the gastro-intestinal abnormities are purely complications, not solely depending on the kidney position, but both are results of unknown factors; especially where lack of tonus and muscular and ligamentous relaxation are

present also in other abdominal organs, for instance, the uterus and ovaries.

Our surgeons would be of valuable assistance in throwing more light upon this question by very carefully ascertaining the condition, size and position of the stomach and larger intestines before the operation, and especially at different periods after the operation. To my knowledge this has not been done. as yet.

In two cases showing very movable, wandering kidney, discovered accidentally, and not causing any distress whatever, stomach distension and gastro-intestinal atony were absent, and it seems therefore plausible that the merely wrong condition of the digestive organs cause the distress; they may or may not be dependent on the kidney position, while the latter can be abnormal without affecting the position and functions of neighboring organs; though this seems to be the exception. The co-existence of wandering kidney with dilated stomach and gastro-intestinal atony, and of loose kidney in milder forms with stomach distension, seem to be the rule.

The subjective complaints of this combination are enumerated above. Let me say something about the physical signs and point out only the practical ones.

Inspection seldom reveals much in distension. To make the latter conspicuous by inflation is not advisable and not necessary. I have seen a very intense, real dilatation overlooked despite carbonic acid inflation, and the use of the rubber balloon ought to be left to those very familiar with the work.

Palpation is of very great importance, especially in the case of renal descensus. It needs some education of the hand for this examination. To do it properly it is best to proceed thus: Have the patient lie on his back with knees drawn up, stand at the right side, put the thumb of the right hand in the region of the right kidney and lay the fingers on the right hypochondrium, directly at the costal margin, feel your way very gently towards the thumb. In palpation the first rule must be not to feel what is immediately under the fingers, but for re

sistance in the depth, in this instance, whether the depth between the fingers and thumb is empty or not. One must, so to say, learn to listen with the fingers. If you feel the space perfectly empty, request the patient to take a deep, slow inspiration. In a normal condition nothing will fill the space between the thumb and fingers, but contracted muscles, felt immediately under your fingers, which you will easily distinguish. But when you feel the kidney-shaped body come between your thumb and fingers during inspiration, hold it lightly during expiration; let the muscular contractions. subside and let the object held slip back into its position, and you may be sure it was the kidney.

It would be proper to repeat the examination on the left side. I prefer to have the patient move to the other side of the bed and repeat there exactly the same manipulation.

The reproach of making a floating kidney by this method of examination would be absurd. You might as well accuse the gynecologist of making a prolapsed uterus by pulling it down to the entrance of the vulva. You will not be able to feel and hold the kidney unless it is loose. It may frequently occur that the kidney of a patient may be felt during normal breathing and then again you may not be able to detect it the next day, or even the next hour, except by the above method. It is a peculiar fact that a loose and floating kidney is much more frequent in the right than in the left side; I found a proportion of ten to one.

Percussion is of the greatest importance in detecting the stomach distension. It has to be done as immediate percussion, making a succession of taps upon the epigastrium. Use the precaution of giving the patient a laxative one day previous to the examination and have the transverse colon empty; examine, if possible before dinner, when the stomach is mostly empty; have the epigastrium free from clothing and tap with quick elastic taps with the finger-tips over the region where the stomach touches the soft abdominal walls. region begins under the xiphoid process

This

and reaches down to from one to two inches above the navel, but in distension and dislocation, sometimes several inches below the navel. Laterally it begins about two inches to the right of the median line and goes to the left as far as the papillary line.

If the tap with your finger is not followed by a splashing sound or movement, let your patient drink a half pint of water very slowly and lie down again. With healthy persons you will scarcely be able to detect the presence of the liquid, but with patients of our group you will be able to find out the amount of distension by the extent of the region in which you can produce a distinct. splash by your taps.

If the splashing region is very long but narrow you have one of those perpendicular stomachs frequently met with in women who are very fond of tight lacing. Such a stomach is inclined to considerable distension. If it reaches low down but not high up, scarcely above the navel, you have in all probability a case of gastroptosis, a stomach dislocated downward, and alike inclined to distension. If you have a splash area extending almost over the entire district given above, you have a very much distended stomach, and you ought to convince yourself whether you have not a real dilatation with serious pathological conditions.

So far the pressing out of the stomach contents by syphon or pump and subsequent analysis have been the only diagnostic means. I think the following method will be fully sufficient to differentiate comparatively light affections of this kind from the graver ones :

16

Give your patient early, on a perfectly empty stomach, a hypodermic injection of to 12 grain of apomorphine. I have always found this quantity sufficient and it never produces any unpleasantness whatever. Before you give the injection, have at hand a tumbler of lukewarm water and two dishes, a small one and a larger one. A few minutes after the injection, make your patient, who has now a light nausea, spit up a few drops out of the empty stomach into the small dish. This requires a little, but by no means

distressing, retching. Now have the patient drink a tumbler of lukewarm water and collect in the larger dish what he vomits. If the latter contains particles of food from the previous night, you have in all probability a case of real dilatation, but if it contains food taken twenty-four hours and more before the injection you have a case of undoubted dilatation caused by more or less serious organic lesions. If the large dish, however, contains only the water drunk after the injection, with the addition of some bile, giving it a yellowish tint, or some stomach juice, giving it a greenish color, or more or less mucus, the distension found by the splash is based on comparatively innocent reasons.

The immense diagnostic value of the empty stomach in the morning was pointed out by Boas, who has been foremost in paying proper attention to the atony of the stomach.

Even if the vomiting brings up large masses of frothy, white of egg-like mucus, this would, as well as the greenish color, indicate only neurotic disturbances. The yellowlsh tint caused by bile is simply the result of the retching and shows very often when the stomach tube is used.

I have tried this method with my own stomach as well as with others, and found it to answer in every respect the same purpose as the pressing out of the stomach contents through the tube, or the Einhorn bucket, which is a torture, especially while withdrawing it. Of course, for those who are experts, the use of the tube will always remain of the same value, but for the practitioner the apomorphine method is a splendid substitute.

Of

The few drops in the small dish are very valuable to show whether the patient is suffering from hyperacidity, and especially whether sour stomach is due to formation of organic acids or to hypersecretion of muriatic acid.

A little strip of Congo-paper dipped into the small dish will not change its color in the majority of cases. If it changes into dark blue, it shows the presence of free hydrochloric acid, when the stomach is perfectly empty; this

means hyperacidity or neurotic hypersecretion. In the four cases in which I used this method, the paper remained red. One of the patients on a previous occasion had shown the acid when the tube was used. This shows, it appears, that the apomorphine method is even less irritating than the tube, for the gaining of the stomach contents. Of course in those exceptional cases where the stomach still contains food particles, the Congo test has no value. Such cases should be turned over to hands familiar with all diagnostic and operative

measures.

The perfect absence of food particles, the distinct splash and the renal descensus felt in your hand, give you a precise clinical picture as to the cause of most of the symptoms enumerated above, and you can treat your patient in a clear, systematic way.

Before entering upon therapeutics, I wish to say that I have personally seen very few cases of distended and atonic stomachs without renal descensus since I have paid close attention to this point. Those I have in my journal have organic lesions at the root; especially glandular gastritis caused by habitual over-eating and drinking.

Concerning the reasons for the coincidence of renal descensus with stomach distension, it is impossible to say anything. Therefore the causal indications for treatment can only be sought in general principles known to increase muscular and nerve force. The best hygiene is the best causal treatment. Outdoor exercise in summer and winter is the most desirable factor. A very moderate and gradually increased use of the bicycle has been of the greatest value.

Beginning with from five to ten minutes, let even the expert rider not make more than from two to three miles a day, dismounting at intervals to walk by the side of his wheel, especially wherever there is uphill or otherwise hard riding. A great advantage in bicycling is the fact that the patient must watch the wheel and thus cannot always be aware that he is working for health. Doubtless the great value of well-conducted watering places, like Carlsbad,

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