Disturbances of the stomach are of different kinds and dependent upon different conditions. There may be simply loss of appetite or discomfort after eating, or nausea, flatulence, and vomiting; and these symptoms will be associated with chronic catarrhal gastritis or with a stomach that is anatomically normal. Sometimes, although there is occasional nausea and vomiting, the appetite continues good, or as part of an uræmic attack there will be constant vomiting.
The habitual dyspeptic disturbances are to be treated like other cases of gastric dyspepsia. A regulated diet, the vegetable bitters, the mineral acids, or the alkalies are sometimes of service. The repeated and persistent vomiting of uræmic attacks is a most distressing symptom and one often very difficult to control. The patients must be fed with small quantities of fluid food or of prepared meat. The most efficient remedies are those addressed to the condition of the circulation. Hypodermic injections of morphia, enemata of chloral hydrate, inhalations of nitrite of amyl, convallaria in small doses by the mouth, are all of service.
The anæmia from which the patients suffer is to be combated by the systematic use of iron and oxygen. Any efficient preparation of iron will answer, but it must often be given in considerable doses. Sometimes the bichloride of mercury in small doses answers better than iron. The oxygen should be inhaled for from five to thirty minutes twice a day.
The so-called uræmic attacks, although they have a general similarity, yet vary in their manifestations in different cases. In some cases the patient develops an unnatural restlessness and anxiety, an inability to sleep, now and then a sudden twitch of one of the facial muscles, and headache. Or a patient whose color is still good will only complain of pain in the epigastrium and moderate dyspnoea, and yet will be in bed and evidently seriously ill. Or a patient who has been troubled with dyspeptic symptoms and gradual loss of strength suddenly develops vomiting, intense headache, sleeplessness, a single convulsion followed by facial paralysis. A man with a previous history of chronic Bright's disease becomes persistently anæmic and dropsical; he has constant dyspnoea, cannot lie down, cannot sleep, and yet looks drowsy and stupid; is mildly delirious and has very little intelligence; then gradually becomes unconscious, then comatose, and so dies. Or there are first attacks of dyspnoea, either spasmodic or from exertion, but which are temporary and can be relieved. Then the dyspnoea becomes more constant and severe; the patient cannot lie down at all, all remedies become less and less efficacious, and the dyspnoea only ends with the life of the sufferer. In other cases a patient will suddenly become unconscious, although not comatose; he will lie flat in bed, the skin livid and bathed in perspiration, the respiration labored and rapid, with coarse râles all over the lungs, the heart's action rapid and feeble, the temperature perhaps a little elevated; or sudden and profound coma or noisy delirium or repeated convulsions may be the prominent features.
There is hardly a limit to the variety of the precise manner in which all these symptoms—restlessness, sleeplessness, headache, vomiting, delirium, convulsions, and coma—may present themselves. It is to be remembered that although all these symptoms are always dangerous, and often fatal, yet patients may pass through a number of such attacks before the fatal one arrives.
To relieve these attacks the most effectual remedies are opium, chloral hydrate, nitrite of amyl, convallaria, digitalis, caffeine, bloodletting, purging, sweating, and cathartics.
Opium is a very valuable remedy, but great judgment is required in selecting the preparation and the dose for each case. The old doctrine that opium is a dangerous drug for patients suffering from Bright's disease is perfectly true, but it is equally true that it is also a valuable remedy. Generally speaking, the more marked the uræmic attack the larger the dose of opium that will be borne. It is always well to try to obtain a free movement from the bowels, although this is not always possible.
In the milder cases the fluid extract of convallaria in ten-minim doses will often diminish the frequency of the heart's action, increase the production of urine, and improve the general condition of the patient.
In the earlier stages of dyspnoea five-grain doses of the iodide of potash with a little opium will sometimes keep the patient comfortable for months. For the severe attacks of dyspnoea dry cups over the chest and inhalations of oxygen are of service. In the worst and most uncontrollable dyspnoea it seems justifiable to keep the patient under the influence of ether or chloroform.