COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX641 33834 RC801 .R25 1911 Diseases of the stom RECAP ilii'iiiiijiiim,;,!! uhiiii'iiiii'li I ill! !| ; i; , .1 'i < 1 ; 1 r: !J : j 1 ii H i Columbia Winihtv^it^ 19(1 in tlje Cit j> of Mt\3} |9orfe CoUcge of ^ijpsiciang anb ^urgeong 3^ef erence i^itirarp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/diseasesofstomacOOreed DISEASES OF THE Stomach and Intestines BY BOARDMAN REED, M. D. MEMBER OF THE AMERICAN IVIEDICAL ASSOCIATION, AMERICAN CLIMATOLOGICAL ASSOCIATION, AMERICAN ACADEMY OF MEDICINE, FOREIGN MEMBER OF THE FRENCH SOCIETE D'ELECTROTHERAPIE ; CONSULTING GASTRO-ENTEROLOGIST TO THE POTTENGER SANATORIUM, MONROVIA, CAL. ; CONSULTING PHYSI- CIAN TO THE COREY SANATORIUM AND HOSPITAL, ALHAMBRA, CAL.; LATE PROFESSOR OF DISEASES OF THE GASTRO-INTESTINAL TRACT, HYGIENE AND CLIMATOLOGY IN THE DEPARTMENT OF MEDICINE OF TEMPLE UNIVERSITY ; LATE PHYSICIAN-IN-CHIEF TO THE SAMARITAN HOSPITAL; LATE PHYSICIAN TO THE AMERI- CAN ONCOLOGIC HOSPITAL, PHILADELPHIA, ETC. ILL USTRA TED THIRD EDITION THOROUGHLY REVISED AND LARGELY REWRITTEN NEW YORK E. B. TREAT & COMPANY 241-243 West 230 Street 1911 Copyright, 1904, 1907, 1911 BY E. B. TREAT & COMPANY THE QUINN & BOOEN CO. PRESS PREFACE TO THIRD EDITION. In the nearly seven years since this work first appeared, the number of important papers published on the special group of subjects which it covers, has been enormous. The task of go- ing through them all in order to bring the present edition up to date has been correspondingly great. Professor Stanley P. Black, of the University of California, has kindly consented to revise the chapters on the examination of the urine and feces, and his eminence as a pathologist is an assurance that it has been well done. To Dr. W. P. Millspaugh, lecturer on gastro- intestinal diseases in the same institution, has been delegated the duty of reviewing the countless books and papers which have appeared in various languages concerning ulcer, carci- noma, etc., and his collaboration with me in revising the parts of this book relating thereto has been a most valued service. So great and life-saving have been the advances in the Surgery of the Stomach and Intestines, and in the closely allied subject of Intestinal Obstruction, that the revision of the chapters on these has been intrusted to an experienced and scholarly surgeon, Dr. James P. McReynolds, lately of Philadelphia, who has almost entirely rewritten a large part of them. Dr. F. M. Pottenger, the distinguished expert in tuberculosis, has generously placed at my disposal the large amount of interest- ing clinical material in his sanatorium for tuberculous cases at Monrovia, Cal. ; and Dr. J. E. Pottenger, the pathologist of that institution, has kindly aided in collating for me the statistics of the same. Dr. F. E. Corey, of the Alhambra Sanatorium and Hospital, has rendered assistance in studying cases which have been under our joint care there. To all these gentlemen I return my grateful thanks. Important changes with many large additions have been made in most of the chapters, and a number of them have PREFACE TO THIRD EDITION been largely, some of them entirely, rewritten. A new chapter has been added on Arteriosclerosis, in which its relations with gastro-intestinal affections have been discussed in the light of our present knowledge, including reports of some original ob- sewations on blood-pressure by the author. BoARDMAN Reed. Alhambra (Los Angeles), Cal., December, 1910. PREFACE TO SECOND EDITION. So short a time has elapsed since the appearance of the first edition of this work that extensive changes in it have not been found necessary. Note has been taken, however, of the more important advances and improvements in the special field which it aims to cover. New material has been added to eighteen of the lectures and alterations have been made in the text where required. In several particulars prominence was given in the first edition to views which were then in advance of current medical opinion; and some of these provoked adverse criticism in cer- tain quarters. They included ( i ) the recognition of eye-strain as a cause of gastro-intestinal symptoms; (2) the advocacy of a very large dependence upon hygiene and diet as well as upon electrical and other mechanical methods of treatment in pref- erence to routine drug-giving; (3) advising the avoidance in so far as practicable of instrumentation in the stomach and suggestions as to possible methods for determining approxi- mately the motor and secretory functions of that viscus with- out even the use of the tube, when exactness is not necessary; and (4) recommending a cautious use of tuberculin in the diagnosis and treatment of tuberculosis of the digestive organs. During the last two years the trend of medical thought has been in these directions more and more, and especially with regard to the employment of tuberculin, there is now a preponderance of opinion in favor of it as shown by communications from many leading clinicians in both Europe and America. To Dr. Harold Brunn of San Francisco I am indebted for a revision of the lecture on the Surgery of the Stomach and In- testines and for making the additions to it necessary to bring it into fuller accord with the present status of that subject. BoARDMAN Reed. Los Angeles, Cal., November, 1906. PREFACE The majority of physicians now in practice have had no opportunity of learning the newer methods available in the diagnosis and treatment of diseases of the digestive system; hence books describing them are necessary. These methods are better than the old ones because far more accurate and efhcient. They are indispensable to the successful management of many of the prevalent gastro-intestinal affections. Yet books upon this subject have been multiplying during the last ten years, and it may well be asked, Why add to the num- ber? The question would be justifiable, since the subject has been treated most ably and exhaustively by several American writers, to say nothing of the works by foreign authors — Ewald, Boas, Riegel, et al., which have been translated into English. I could not hope to rival them in completeness and erudition, nor in the profundity with which they have consid- ered some of the many as yet unsolved pathologic problems in this field. There does not at present, however, exist in the English language any work which, in a single volume, treats of the whole subject of diseases of the stomach and intestines from the standpoint of our present knowledge. Not only general practitioners, but also specialists in other lines who find it necessary to keep informed in a general way with regard to digestion and nutrition, have discussed with me what they desire to have in such a book. They want a not too PREFACE bulky volume, which should contain brief, but easily intelligible, descriptions of the simplest reliable tests for the necessary ob- jects of study in the gastric contents and feces, as well as the most practicable, and especially the least disturbing, methods of determining the position, size, and motility of the stomach, colon, etc. — /. e., demonstrating dilatation or displacements of any of the abdominal viscera, including abnormal mobility of the kidneys — together with a brief statement of so much of the pathology and aetiology of the different gastro-intestinal affections as is certainly known; besides a full account of the symptoms and diagnosis, and especially an ample consideration of the treatment. To meet these requirements the single- volume work must necessarily omit much of interest, such as historic observations, speculative discussions as to mooted points in aetiology and pathology, and the bibliography of this special subject, which has now grown to vast proportions. In this volume of lectures the attempt has been made to furnish such a book as is above outlined — a plain and unpreten- tious, but practically complete, clinical guide to the diagnosis and treatment of the diseases in question. I am fully con- scious of its many imperfections, for which the indulgence of readers is craved. It embodies, however, the results of much personal experience during a long and busy practice, and an earnest effort honestly to record and interpret this experience. Furthermore, while duly conservative as to advising the abandonment of old and well-tried remedies, I have in these lectures given such credit as seemed due to the most recent innovations in the way of therapeutic resources for the diseases under consideration, especially the applications of electricity in all its forms, including the electrostatic currents and x-rays; also the violet rays, radium, etc., as well as mechanical vibra- PREFACE tion, manual therapy, hydrotherapy, exercise (active and passive), and all the approved hygienic measures, particularly an unusually full consideration of the exceedingly important subject of diet. The lectures are based in part upon those delivered to my classes in the Department of Medicine of .Temple College, Philadelphia, and in part upon the " Talks to General Practi- tioners " contributed by me to the International Medical Magazine during the five years that it was under my editorial management. All of these have been carefully revised, and many of them almost entirely rewritten. A still larger number of the lectures have been prepared expressly for the present work, including a special one entitled, A Symptomatic Guide to Diagnosis. This unique feature, it is hoped, will prove useful to both students and practitioners. I am under obligations to my associates. Dr. W. E. Rahte and Dr. George O. Jarvis, for valuable assistance in preparing this and several of the other lectures. Thanks are due also to my colleague, Prof. W. Wayne Babcock, for permission to incorporate in the lecture on Dis- placements of the Colon his particularly interesting illustrated paper upon that subject, and to my colleague. Prof. A. Robin, for contributing toward several of these lectures, including especially those upon Examination of the Feces and upon Bacteria and Animal Parasites in the Gastro-intestinal Tract, which were mainly written by him. I am also indebted to Dr. G. Morton Illman, my clinical assistant at the Samaritan Hospital, for aid in getting up the section on The Blood in Gastro-intestinal Diseases. The clear and succinct lecture on Diseases of the Rectum and Anus has been very kindly con- tributed by that well-known proctologist. Dr. Collier F. PREFACE Martin, instructor in Rectal Diseases at the Philadelphia Polyclinic. To my friend and former teacher, Prof. C. A. Ewald of Berlin, and to Prof. Sidney Martin of London I am under particular obligations for permission to reproduce a number of choice illustrations from works written by them, also to several other medical friends and to various makers of surgical instruments for the use of electrotypes illustrating special ap- paratus or other objects of interest. Specific credit is given under each illustration. Messrs. E. B. Treat & Co. of New York, the publishers of this volume, are entitled to praise for the very creditable dress in which it appears and for the courteous assistance which they have rendered me at every stage of the work. BoARDMAN Reed. CONTENTS PART I ANATOMIC, PHYSIOLOGIC, CHEMIC, AND DIAGNOSTIC DATA Lecture I. Anatomy of the Digestive Tract PAGE The Pharynx — The Esophagus — Abdominal Cavity — The Stomach — The Gastric Glands — Conclusions — The Blood- Vessels of the Stomach — The Veins and Lymphatics — The Intestinal Canal — The Duodenum — The Cecum — The Colon — The Sigmoid Flexure — The Rectum — Struc- ture of the Stomach and Intestines — The Liver — The Pancreas ......... 29 Lecture II. The Nerve Supply of the Digestive Organs and the Relations of the Spine to the Vaso-Motor Nerves Secretory Nerves — The Vaso-Motor Nerves and the Spine — Course and Direction of the Spinal Nerves — Points of Emergence from the Spine of Special Vaso-Motor Nerves 47 Lecture III. The Physiology of Digestion^ Absorp- tion^ AND Defecation Salivary Digestion — Gastric Digestion — Intestinal Digestion — Absorption — Defecation . . . . . . 54 PART II METHODS OF EXAMINATION Lecture IV. The Interrogation of the Patient Importance of a Full History — Systematic Questioning — How to Detect Dietetic Sins — Pain or Discomfort — Bowel Movements — The Genito-Urinary System ... 65 CONTENTS Lecture V. The Physical Examination of the , Patient PAGE General Considerations — Inspection — Palpation — Ausculatation and Percussion — Instruments for Determining the Size and Position of the Viscera . . . . . -73 Lecture VI. The Author's Method of Outlining THE Stomach and Determining the State of its Motor Function — Other Methods of Exam- ining THE Viscera A Combination of External Methods — Experiments with Dif- ferent Methods of Determining the Size and Position of the Stomach — A New Pleximeter — The Determination of the Gastric Motor Power — Inflation of the Stomach and Colon — Summary of Author's Method — Radiographs of the Viscera — The Capacity and Motor Power of the Stomach — Tests of the Capacity of the Stomach — The Salol Test of Gastric Motility — Other Methods of Test- ing the Motility of the Stomach 90 Lecture VII. The Examination of the Secretory Function of the Stomach — Instruments Used for the Extraction of the Stomach Contents How to Introduce the Tube into the Stomach with the Least Possible Embarrassment of the Patient — Preparation of the Patient — Introducing the Tube — Training of Irritable Throats — The Kuttner Aspirator . . . . .108 Lecture VIII. Test Meals and Preparations for Testing the Stomach Contents Concerning Test Meals — The Ewald Breakfast — The Test Dinner — The Lactic-Acid Free Meal — No Single Test Meal Conclusive — An Objectionable Method of Getting the Stomach Contents — The Macroscopic Examination of the Stomach Contents — Bile, Blood, Feces, or Pus in the Stomach Contents — The Fluidity of the Stomach Contents — Filtering the Stomach Contents . . .117 CONTENTS Lecture IX. Qualitative Tests of the Stomach Contents PAGE Tests for Lactic Acid — Tests for the Other Organic Acids — Tests of the Salivary Digestion — Tests for the Pepsin and Rennet Ferments — Tests for Albumin, Propeptone, and Peptones — An External Method of Testing for Gas- tric Acidity — Significance of Increased Tympany after Administering Sodium Bicarbonate .... 126 Lecture X. Quantitative Estimations and Micro- scopic Examinations of the Stomach Contents The More Important Quantitative Tests of the Stomach Con- tents — Quantitative Test for Lactic Acid — Quantitative Test for Fatty Acids — Microscopic Examination of Stom- ach Contents . . . . . . . .135 Lecture XL The Urine in G astro-Intestinal Dis- ease — Uranalysis an Aid in Estimating the Secretion of HCl Uranalysis Indispensable in Gastro-Intestinal Affections — Re- lation between Urinary Acidity and HCl Secretion — Importance of Estimating the Chlorides — The Determi- nation of the Chlorides ...... 143 Lecture XII. The Urine, Continued: Significance of Indicanuria and Tests for It Indicanuria, High Acidity, etc. — A Quick Test for Indican — Approximate Quantitative Test for Indican — Test for the Total Amount of Solids . . . . . .148 Lecture XIII. The Urine, Concluded: Tests for Uric Acid, Urea, and the Acidities — Laboratory Outfit Tests for Uric Acid — Folin-Hopkins Method of Determining the Amount of Uric Acid — Urea — Test for the Total Acidity — Freund and Topfer's Test for the Urinary Acid- ities — Biliary Pigments and Acids — Acetone and Dia- cetic Acid — Lieben's Iodoform Test for Acetone — Lab- oratory Outfit . • 153 CONTENTS Lecture XIV. The Examination of Feces; and the Blood in Gastro-Intestinal Diseases PAGE The Feces in Health — The Microscopic Examination — The Color — Various Foreign Substances to be Looked for — Microscopic Examination — The Blood in Gastro-Intestinal Diseases — To Obtain a Specimen of Blood — The Tech- nique of the Examination — Blood Counts — To Estimate the Hemoglobin — Lead Colic Diagnosed from Other Pains by the Blood 162 Lecture XV. A Symptomatic Guide to Diagnosis Anorexia, or Impaired Appetite — Breath, Fetor or Foul Taste in Mouth — Bulimia, or Excessive Appetite — Constipation — Debilit}^ — Defecation, painful — Discolorations of the Skin, Jaundice or Bronzing — Diarrhea — Depression Mental or Nervous — Emaciation — Eructations — Excita- bility, Undue — Flatulency, Gastric or Intestinal — Head- ache — Hemorrhage, or Loss of Blood or Altered Blood, by Mouth or Rectum — Insomnia, or Impaired Sleep — Irrita- bility of Temper — Nausea, or Vomiting — Oppression or Weight in Stomach — Pain Referred to the Right H^^po- chondriac Region or Lower Edge of Liver — Pain Referred to the Region of the Stomach — Pallor of Skin — Ptj^alism, or Salivation — Regurgitation, or Rumination — Succession of Splashing Sounds in the Abdomen — Tenderness on Pressure over the Epigastrium — Tenesmus — Tongue Coated or Furred — T3'mpany, Abdominal — Vertigo . 179 PART III METHODS OF TREATMENT Lecture XVI. Prophylaxis: Personal Hygiene and Food Requirements Personal Hygiene — The Hygiene of Eating and Drinking — Definition of Food — Alcohol and Food Accessories — Classification of Foods — Proportions of Different Foods in the Normal Diet According to' Various Authorities — Some Recent Experiments Concerning Food Requirements 191 CONTENTS Lecture XVII. General Considerations Concerning Diet and Dietotherapy PAGE Relative Importance of Dietetics — Resting the Stomach — Wegele's Estimate of Dietetics — Diseased Stomachs Need Rest — Summary of Precautions — Dietetic Faults the Most Frequent Causes of Gastro-Intestinal Disease — The Arrangement of Meals with Relation to Rest and Exer- cise — Regularity in Times of Eating Essential . . 204 Lecture XVIII. The Diet in Irritative and Atonic Conditions Classification of Diseases with Regard to Dietetic Treatment — The Diet in Irritative Conditions — The Diet in Atonic Conditions — The Diet in Diarrhea and Constipation — Proper Cooking and Thorough Mastication — Dangers in Overrestriction of the Diet — Diet in the Uratic Diathesis 216 Lecture XIX. Sugar, Spices, etc., in Gastro-Intestinal Cases The Most Difficult Point in a Difficult Subject — -An Experi- ment Worth Trying — Why the Sweets often Disagree after a Dinner — The Spices, Condiments, and Beverages — The Spices, etc.. Drugs, not Foods — The Alcoholic Liquors — Coffee and Tea — ^Water, Milk, etc. . . 226 Lecture XX. The Author^s and Other Progressive Series of Diets Classes of Cases for which Specified Diets are Indicated — Diet Directions of Leube and Penzoldt — Leube's Diet Scheme — Penzoldt's Diet Tables for the Gradual Train- ing of the Digestive Capacity ..... 234 Lecture XXI. Feeding by Other Routes than the Mouth The Technique of Rectal Alimentation — Boas' Formula for a Nutrient Enema — The Injection of Food Subcutaneously 248 CONTENTS Lecture XXII. Methods of Treatment in Gastro- intestinal Diseases PAGE Therapeutic Methods — Overdosing and Overdoing in Thera- peutics ......... 253 Lecture XXIII. The Remedial Value of Active Exer- cises Including Outdoor Games, Gym- NASTICSj ETC. Exercise Indispensable — Various Kinds of Exercise — Special Forms of Gymnastics Recommended . . . . 259 Lecture XXIV. Passive Exercises, Including Massage — The Rest Treatment Massage and Swedish Movements — HCl Increased by Mas- sage — Cases of Hyperchlorhydria Produced by Massage — Cases of Hyperchlorhydria Aggravated by Massage — In- dications for Massage of Abdomen — The Rest Treatment 268 Lecture XXV. Electricity, Galvanic, Faradic, and Static — High-Frequency and Polyphase Currents Electricit)^ — The Continuous Current, or Galvanism — The In- duced Current, or Faradic Electricity — Static Electricity — High-Frequency Currents — Polyphase Currents . . 278 Lecture XXVI. Various Forms of Electric and Hy- dro-Electric Currents Applied Directly within THE Bowel Hydro-Electric Applications within the Bowel — Measures to Combat Possible Collapse from Sudden Emptying of the Bowel — The Hydro-Electric Method in Muco-Membra- nous Enteritis ........ 286 Lecture XXVII. Other Direct Methods of Treat- - iNG the Intestines Carbon Dioxide in Diseases of the Rectum and Colon — Turck's Colonic Treatment — Turck's Method of Doing Lavage of the Colon — Flushing of the Colon — Technique of Ad- ministering Oil Enemas ..*... 296 CONTENTS Lecture XXVIII. Vibration^ Manual Therapy, and Other Mechanical Forms of Treatment PAGE The Advantages Claimed for Mechanical Vibration — Manual Therapy — Counter-irritants — Heat and Cold — Mydriatic Procedures — Phototherapy — Similarity of the Effects of the Different Mechanical Methods .... 304 Lecture XXIX. Intragastric Methods of Treatment — Lavage, Intragastric Spray, etc. When and How to Wash out the Stomach — The Intragastric Douche and Spray . . . . . . .312 Lecture XXX. Intragastric Methods, Continued — Intr.4gastric Electricity As Simple as Lavage — Intragastric Electrodes — The Author's Modification of the Einhorn Electrode — Effect of Intra- gastric Electricity upon Secretion — Action of Faradic Cur- rents on Secretion — Reports of Two Illustrative Cases — The Technique of Applying Electricity Intragastrically . 321 Lecture XXXI. The Medicinal Therapy of Diseases OF THE Stomach and Intestines The Administration of Acids — The Place of Hydrochloric Acid in the Treatment of Diseases of the Stomach — Re- ports of Cases — Later Experience with HCl . . .331 Lecture XXXII. Digestants, Alkalies, and Natural Spring Waters The Digestants — A Series of Experiments — Confirmatory Clinical Evidence — Useless Pepsin Compounds — Pancre- atic Preparations — Alkalies in Gastro-Intestinal Disease — The Alkaline Mineral Waters — The Effect of Alkalies before and after Meals — The Sodium Chloride Waters 345 Lecture XXXIII. Tonics, Stimulants, and Sedatives The Nerve Tonics — Alcohol Rarely Necessary — The Relief of Pain and Insomnia Produced by Disease of the Stomach CONTENTS PAGE or Bowels — Iron and Its Principal Preparations — The Ferruginous Mineral Waters — The Bismuth Preparations and Cerium Oxalate — The Bland Oils .... 354 Lecture XXXIV, Antiseptics, Astringents, and Laxa- ^ TivES — Minute Doses of Certain Drugs Antiseptics — Astringents — Laxatives and Purgatives — The Usefulness of Certain Drugs in Minute Doses — Cuprum Arsenite ......... 361 PART IV THE GASTRO-INTESTINAL CLINIC Lecture XXXV. Introductory — The Classification OF Diseases Diseases of the Stomach and Intestines not always Separable . 371 Lecture XXXVI. Gastric Atony, or Myasthenia Gas- TRicA. (Motor Insufficiency; Mechanical Insufficiency) Relative Importance of Atony, Dilatation, etc. — Various De- gress of Atony — ^^tiology — Symptomatology — Diagnosis — Simple Tests of Gastric Motility — Treatment . . 378 Lecture XXXVII. Dilatation of the Stomach. (Di- latAtio Ventriculi; Gastrectasis) Acute Gastrectasis — The Etiology of Chronic Gastrectasis — Symptomatology — Complications and Consequences of Gastric Dilatation — Tetany . . . . . .386 Lecture XXXVIII. The Diagnosis of Dilatation of THE Stomach Differential Diagnosis ....... 396 Lecture XXXIX. Treatment of Dilatation of the Stomach i'rognosis — Treatment — Dilatation from Pyloric Spasm — In- tragastric Electricity — ^Treatment of Atonic Dilatation — The Treatment of Gastric Tetany .... 405 CONTENTS Lecture XL. Splanchnoptosis^ or Downward Dis placements of the abdominal organs generally (Nephroptosis^ Gastroptosis^ and Enter- oPTOSis) ; Movable Kidney PAGE Movable Kidney — Nephroptosis — ^^tiology — Symptomatology — Diagnosis of ^Movable Kidney — Treatment of Mova- ble Kidnc}' — Strapping the Abdomen for Displacements — Other Remedial Measures . . . . .415 Lecture XLL Splanchnoptosis, Continued: Dis- placements AND Distortions of the Stomach Gastroptosis — xEtiology — Sj'mptomatology — Diagnosis — Prognosis — Treatment — Volvulus of the Stomach — Hour- Glass Contraction — Abnormally Small Stomachs — Con- genital Anomalies of the Stomach — Congenital Stenosis of the Pylorus ,..,.... 429 Lecture XLIL Splanchnoptosis, Continued: Dis- placements OF THE Colon Coloptosis — The Symptoms of Coloptosis — Diagnosis — Treat- ment — Importance of Correcting Displacements . . 440 Lecture XLIIL Splanchnoptosis, Continued: Dis- placements OF THE Liver, Spleen, and Small Intestines — General Considerations Concerning Displacements, etc. Hepatoptosis — Movable Spleen — Displacements of the Small Intestine — Symptoms — Treatment — Some Statistics of Displacements, etc. — Abdominal Displacements as Causes of Pelvic Disease ........ 456 Lecture XLIV. Displacements, etc., of the Abdom- inal Viscera, Concluded, with Reports of Illustrative Cases Reports of Cases of Displacements of the Stomach, Colon, etc. — Pronounced Gastroptosis — Dilated Stomach, Movable Kidney, etc. — Comparison of the Results from Surgical and Mechanical Treatment — Conclusions .... 464 contents Lecture XLV. Acute and Subacute Gastritis PAGE Patholog}' of the Gastric Inflammations — Simple Acute Gas- tritis — Symptoms — Diagnosis — The Treatment of Acute Gastritis — Medicinal Remedies — Subacute Gastritis . 471 Lecture XLVL Acute and Subacute Gastritis, Con- cluded: Sympathetic, Toxic, Phlegmonous, and Infectious and Parasitic Gastritis Sympathetic Gastritis — Toxic Gastritis — Patholog}^ — Symp- toms — Diagnosis — The Treatment of Toxic Gastritis — Phlegmonous, or Purulent Gastritis — Patholog)' — Sj'mp- toms — Diagnosis — Treatment — Infectious and Parasitic Gastritis . . . . . . . . . 479 Lecture XLVII. Chronic Asthenic Gastritis; (Chronic Gastric Catarrh) Different Forms of Chronic Gastritis — Chronic Hypertrophic Gastritis — The Patholog)' of Chronic Gastritis in Gen- eral — Symptomatology — Diagnosis — Prognosis . . 485 Lecture XLVIII. The Treatment of Chronic As- thenic Gastritis (Chronic Gastric Catarrh) The Treatment, Dietetic and Hygienic — Beverages — Mechani- cal Forms of Treatment — Lavage — ^Washing the Stomach Downward — diodes of Stimulating the Gastric Muscles — Medicinal Treatment ...... 496 Lecture XLIX. Chronic Sthenic Gastritis (Acid Gastric Catarrh) JEtlolog)' — Patholog}^ — Symptomatology- — The Diagnosis from Ulcer — Microscopic Examination ..... 504 Lecture L. The Treatment of Chronic Sthenic Gastritis (Acid Gastric Catarrh), and of Hydrochloric Acid Excess The Treatment of Acid Gastritis — The Diet — Intragastric Electricity — Other Methods of Applying Electricitj^ — The Medicinal Treatment — The Treatment of Hj^per- chlorhydria . . , . , . . . -513 CONTENTS Lecture LI. Excessive Secretion of Gastric Juice (Hyperchlorhydria, or Hyperchylia^ Gas- TROXYNSIS^ ReICHMANN's DISEASE^ ETC.) * PAGE S_vmptomatolog5^ — Differential Diagnosis of the Forms of Hj'persecretion — Treatment — The Medicinal Remedies — Alkalies and Alkaline Spring Waters — An Excess of Or- ganic Acids ......... 526 Lecture LIL Round Ulcer of the Stomach ^tiolog}^ — The Incidence of Ulcer as to Sex and Age — Pa- thology — Sj^mptomatology — Complications — Sequels of Gastric Ulcer ........ 533 Lecture LIII. The Diagnosis of Ulcer of the Stomach Hemorrhage from the Stomach — The Diagnosis from Ulcer of the Duodenum — Differential Diagnosis . . . 543 Lecture LIV. The Treatment of Gastric Ulcer — Erosions of the Stomach Treatment, Prophylactic and Curative — Massage— Medicinal Measures — Treatment of Complications and Sequels — Erosions of the Stomach . . . • . . . 549 Lecture LV. Round Ulcer of the Duodenum ^Etiology and Pathology — The Symptoms of Duodenal Ulcer — Diagnosis — Complications and Sequels — Treatment . 559 Lecture LVI. Tubercular Ulcerations in the Stom- ach AND Intestines Tubercular Ulcers of the Intestines — Sj^mptomatolog}^ — Diag- nosis — Prognosis — Treatment — The Tuberculin Treat- ment — Dr. Pottenger's Method — Hygienic and Climatic Measures, etc. ........ 567 Lecture LVII. Syphilis of the Stomach and In- testines Syphilitic Chronic Gastritis — Syphilitic Gastric Ulcer — Syph- ilitic Ulcers of the Intestines — Syphilitic Neoplasms of the CONTENTS PAGE Gastro-Intestinal Tract — Treatment of Syphilitic Disease in the Stomach and Intestines ..... 578 Lecture LVIII. Intestinal Ulcers Generally — Hem- orrhage FROM THE Stomach and Intestines Various Other Forms of Intestinal Ulceration — Symptoms of Intestinal Ulcer — Treatment of Intestinal Ulcer — Hemor- rhage from the Stomach and Intestines — Significance of Blood in Vomit or Stools — The Source of the Larger Gas- tric Hemorrhages — Less Frequent Causes of Hematemesis — The Source of Blood Found in the Stools — Blood in both Vomit and Stools — The Modified Weber Test — ^The Iron Test for Blood — Treatment of Gastro-Intestinal Hemorrhage 585 Lecture LIX. Carcinoma and Other Tumors of the Stomach Frequency and Incidence of Carcinoma — The Varieties of Can- cer — The Secondary Pathologic Manifestations — Compli- cations, Sequelae, etc. — Gastrocolic Fistula — Symptom- atology of Gastric Carcinoma — Cancer of the Cardia — Sarcomas of the Stomach — Benign Tumors of the Stomach ......... 602 Lecture LX. The Diagnosis of Carcinoma of the Stomach Histologic Changes in Gastric Cancer — Carcinomatous Ulcer — The Differential Diagnosis of Gastric Cancer from other Abdominal Tumors . . . . . .621 Lecture LXI. The Differential Diagnosis between Carcinoma and Round Ulcer Cancer of the Cardia Differentiated from Ulcer — Chief Diag- nostic Points — Carcinomatous Ulcer — The Therapeutic Test 630 Lecture LXII. The Treatment of Carcinoma and Other- Tumors of the Stomach Treatment with X-Rays — Case Reported by Dr. W. J. Mor- ton — Reports from Drs. Einhorn, Coley, and Snow — Early CONTENTS PAGE Diagnosis Indispensable — Indications for an Exploratory- Incision — Operative Treatment — The Use of the X-Rays, Radium, etc., in Cancer of the Stomach — Medicinal and Palliative Treatment — Dietetic Treatment — Treatment of Accompanying Gastritis and Its Results — Measures against the Debility, etc. — To Relieve the Pain — Treat- ment of Sarcoma and Benign Tumors .... 636 Lecture LXIII. Tumors of the Intestines Carcinoma and Sarcoma — .Etiology — Metastases — Pathology — Symptomatology — Course and Complications — Diag- nosis — Differential Diagnosis betw^een Tuberculosis and Carcinoma of the Cecum — Other Diagnostic Points — Prognosis and Treatment — Benign Tumors of the Intes- tines — Treatment . . . . . . . .652 Lecture LXIV. Intestinal Obstruction Classification — Dynamic or Paralytic Obstruction — Mechanical Obstruction — Invagination — Intussusception of Meckel's Diverticulum — Volvulus — Hernia — Strangulation by Knotting, Kinking, etc. — Obturation, Obstruction, Gall Stones, Enteroliths, Worms, Hardened Feces, Polypi, Tumors, Displaced Organs, etc. — Pathology — Differential Diagnosis of Acute Ileus — Prognosis — Treatment — Chronic Intestinal Obstruction — Chronic Intussusception — -Strictures from Carcinoma or Healed Ulcers — Tuber- cular Ulcers and Grovi^ths — Treatment of Chronic In- testinal Obstruction ....... 668 Lecture LXV. Acute Catarrh of the Intestines ( Enteritis Acuta) Symptomatology — Diagnosis — Treatment — The Diet . . 707 Lecture LXVI. Chronic Catarrh of the Intestines (Enteritis Chronica) Pathology — Symptomatology — Diagnosis — Treatment . '715 contents Lecture LXVII. Appendicitis, Its Symptoms, Diag- nosis, ETC. PAGE The Different Forms of Appendicitis — Pathology — Symptoms — Diagnosis — Physical Signs — Clinical Course — Chronic Catarrhal Appendicitis — The Prognosis under Different Methods of Treatment 728 Lecture LXVIIL The Treatment of Appendicitis The Radical Surgical Method — The Conservative Method — The Ochsner Plan, or Surgico-Starvation Method — Ochsner's Description of his Method — Murphy's Method — Richardson's Results — Deaver's Recent Work — Ochsner's Statistics — Deductions from the Foregoing — A Symposium on Appendicitis — Richardson's Conservative View — The Treatment of Acute Catarrhal Appendicitis — Treatment of the Severer Forms of Acute Appendicitis — ^The Treatment of Chronic Catarrhal Appendicitis — Report of Author's Case — Further Considerations Regarding the Management of Appendicitis — Unfavorable Condi- tions for Operation ....... 743 Lecture LXIX. Constipation Etiology — The Differential Diagnosis between Atonic and Spastic Constipation — The Stools in Atonic and Spastic Constipation . . . . . . . . .766 Lecture LXX. Constipation, Continued: Prognosis AND Treatment Penzoldt's Diet for Atonic Constipation — Changes of Climate 774 Lecture LXXL Diarrhea Etiology — The Treatment of Diarrhea — Complicating Condi- tions — The Appendix often Involved in Diarrhea — The Diet in Chronic Diarrhea — The Nervous Forms of Diar- rhea . . . . . . . . . . 784 contents Lecture LXXII. Dysentery PAGE Definition — Catarrhal Dysentery — Sporadic Dysentery — The Treatment of Catarrhal Dysentery — Bacillary Dysentery — Secondary Diphtheritic Dysentery — Diagnosis of Bacil- lary Dysentery — Complications and Sequels — Treatment of Bacillary Dysentery — ^Amoebic Dysentery — Chronic Dysentery — The Pathology of Chronic Dysentery — Com- plications — The Treatment of Chronic Dysentery . . 793 Lecture LXXIIL Membranous Catarrh of the In- testines (CoLiCA Mucosa, Myxoneurosis Intes- TINALIS MeMBRANACEa) ufEtiology — Diagnosis — Treatment — DieteticTreatment — Form of Diet Recommended — Comments on the von Noorden Method — The After-Treatment — Treatment of Colica Mucosa in True Enteritis ...... 809 Lecture LXXIV. Excessive Eructation and Gastro- intestinal Flatulency in General Belched Gas often from the Intestines — Chronic Appendicitis as a Source of Flatulency — Infection of the Alimentary Tract from the Mouth, Nose, and Throat — The Treat- ment of Flatulency ....... 822 Lecture LXXV. Gastric Neuroses, Secretory and Sensory The Nervous Secretory Derangements of the Stomach — Ner- vous Hypochlorhydria or Gastric Subacidity — Nervous Anacidity of the Stomach — Sensory Disturbances of the Stomach: Gastralgia, Gastric Hypersesthesia, etc. — Gas- tric Hyperassthesia — Other Abnormal Sensations in the Stomach — Derangements of the Appetite — Bulimia and Akoria — The Buccal Reflex — The Proper Food Ration — Anorexia and Hyperkoria ...... 830 Lecture LXXVI. The Motor Neuroses of the Stomach Spasm of the Entire Stomach (Gastrospasm) — Spasm of the Cardia — The Treatment of Cardiospasm — Spasm of the CONTENTS PAGE Pylorus (Pyloric Cramp, Pylorospasm) — Peristaltic Rest- lessness (Hyperperistalsis) — Nervous Eructations — Ner- vous and Reflex Vomiting — Treatment of Reflex Vomiting — Pernicious Vomiting of Pregnancy — Nervous Atony of the Stomach — Insufficiency of the Cardia, Rumination, Regurgitation, etc. — Insufficiency of the Pylorus . .851 Lecture LXXVIL Neuroses Continued — Nervous Dyspepsia (Gastro-Intestinal Neurasthenia) Symptomatology — Diagnosis — Treatment in General — Diet — Drug Treatment . . . . . . . .871 Lecture LXXVIII. Neuroses of the Intestines Enteralgia, Intestinal Colic, Enterospasm and Meteorism — Tympanites, or Flatulency — Peristaltic Unrest — Atony and Paralysis of the Intestines — Peristaltic Unrest of the Intestines — Paralysis of the Intestines — The Treatment of the Intestinal Neuroses — Treatment of Peristaltic Un- rest of the Intestines — Treatment of Paralysis of the In- testines .......... 879 Lecture LXXIX. Diseases of the Rectum and Anus Examination of the Patient — The Symptoms and Their Sig- nificance — Technique of the Examination — The Digital Examination — Inspection of the Anus — The More Impor- tant Instruments Required — The Rectal Relations of Con- stipation — Fecal Impaction — The Early Symptoms — The Treatment — Hemorrhoids — Varieties — The Injection Treatment of Hemorrhoids — A Palliative for Bleeding — Fissure of the Anus — Pruritus Ani — Abscess — Varieties — The Symptoms — Diagnosis of Ischio-Rectal Abscesses — The Treatment of Complications — Fistula in Ano — Diag- nosis — A Majority of Fistulas non-Tuberculous — Pro- lapse — Etiology — Treatment — Stricture of the Rectum — Varieties and Etiology — Diagnosis — Treatment — Ulcera- tions of the Rectum — Varieties andiEtiology — The Symp- toms — The Treatment — Benign Tumors of the Rectum — CONTENTS PAGE — Symptoms — Diagnosis — Treatment — Malignant Tu- mors — The Etiology — Symptoms — The Diagnosis — Treatment — The Massey Method — Sarcoma . . . 892 Lecture LXXX. Bacteria and Animal Parasites in THE Gastro-Intestinal Tract The Intestinal Parasites — Diagnosis of the Ova — Amoeba Dys- enteriae — Ankylostoma Duodenale — Treatment of Round and Tapeworms -931 Lecture LXXXL Gastro-Intestinal Affections in Relation to Other Diseases Anaemia and Chlorosis — Influence of Displacements of the Viscera upon the Blood — Influence of Constipation and Other Gastro-Intestinal Affections — The Relation of the Gastro-Intestinal Functions to Tuberculosis — Impaired Digestion Conducive to Tuberculosis — Free HCl often Present — The Motor Function mostly Depressed — Fre- quent Intolerance of the Usual Remedies — Need of Strengthening the Motor Function — Conclusions — Catar- rhal Affections of the Respiratory Tract — Nervous De- rangements, Neurasthenia, Insomnia, etc. — Diseases of the Liver and Genital Organs — Diseases of the Heart — How Digestive Faults Injure the Heart — Therapeutics of Sec- ondary Cardiac Affections — Diseases of the Kidneys and Diabetes — Influence of Bright's Disease and Diabetes on Digestion 953 Lecture LXXXII. Arteriosclerosis and Its Relations to the Affections of the Gastro-Intestinal Tract Arteriosclerosis of the Abdominal Vessels — Diagnosis — Clinical Observations on Blood-Pressure by the Author — Proph- ylaxis and Treatment 97^ Lecture LXXXIII. The Surgery of the Stomach and Intestines Surgery of the Stomach — Gastric Ulcer — Perigastric Adhesions — Cicatricial Stenosis of the Cardiac Opening of the Stom- ach — Stenosis of Pylorus — Hour-Glass Stomach — Cancer CONTENTS PAGE and Sarcoma of the Stomach — Wounds of the Stomach — Duodenal Ulcer — Tuberculosis of the Intestines — Intes- tinal Tumors — Intestinal Obstruction from Calculi, Intestinal Concretions, Intussusception, Volvulus, Intes- tinal Flexure, Adhesions and Bands, Meckel's Divertic- ulum, Hernia 986 LIST OF ILLUSTRATIONS FIG. I. 2. 3- 4- 5- 6. 7- 10. II. 12. 13- 14- 15- i6. 17- i8. 1 9. 20. 21. 22. 23- 24. 25- 26. 27. 28. 29. 30. 31- 31a 31b 32. 33 34- 35 36. 37 38. Cross section of squamous epithelium from mucosa of tongue Coronal section of the trunk Stomach in natural position Posterior surface of the stomach and its relations . Position of organs in upper part of abdomen. Front view Position of organs in upper part of abdomen. Back view A cardiac gland from dog's stomach .... Pyloric gland from section of dog's stomacli Glands from cardiac end of stomach .... Glands from pyloric end of stomach .... Injected intestine showing central lacteal and capillaries in Glands and lymphoid tissue from appendix vermiformis Glands and goblet cells from the colon Einhorn's gastrodiaphane Turck's gyromele Electric gastroscope Outlines of gastric tympany Reed's pleximeter Flexible stomach tube with fenestrum attached Flexible stomach tube, with funnel attached The Kuttner aspirator Kuttner aspirator with tube attached Burette for quantitative analysis . Yeast. From a photograph Bacillus butyricus .... Sarcinae ventriculi .... Pathogenic micro-organisms of the intestines Various crystals in feces Stool in chronic colitis Crystals of bismuth sulphid, fat-droplets, etc. Microscopic appearance of normal feces Microscopic appearance of test-diet feces Fermentation tubes after Strassburger Chair exercise for arm and trunk muscles Second position of the same . Forward and backward body-bending . Rotary movement of the trunk while sitting Pulley exercise for arm and trunk muscles Same with low attachment of the pulleys Central galvanization illustrated llus PAGE 30 31 32 32 33 33 34 34 35 36 41 42 43 86 87 88 94 97 109 no 114 IIS 135 141 141 141 169 170 171 172 176 176 176 263 263 264 265 266 267 279 LIST OF ILLUSTRATIONS FIG. 39. The static electric machine 40. Herschell-Dean triphase apparatus .... 41. Cleaves' electrode for hydro-electric applications . 42. Rose's apparatus for generating carbonic dioxide 43. Turck's apparatus for pneumatic gymnastics 44. A vibrator .......... 45. Li^vage of the stomach. Inserting the tube 46. Lavage of the stomach. Pouring solution into funnel 47. Turck's stomach sprinkling tube 48. Einhorn's intragastric spray apparatus .... 49. Einhorn's intragastric electrode ..... 50. Reed's intragastric electrode 51. Stomach of normal size ....... 52. The stomach dilated, but not displaced .... 53. Area of tympany in case of gastrectasis with gastroptosis 54. Palpation of movable kidney ...... 55. Splanchnoptosis with marked gastroptosis, coloptosis, etc 56. Area of tympany in case of gastroptosis . 57. Anomalcras course of first portion of ascending colon . 58. Elongation and displacement of sigmoid flexure 59. The sigmoid loop touches lower border of left kidney 60. Exaggerated and displaced sigmoid loop 61. V-shaped course of the transverse colon . 62. Exaggerated V-shaped course of transverse colon 63. Anomalous direction of transverse colon . 64. Downward displacement of Hver and intestines . 65. Mucoid and cystic degeneration of gastric mucous membran 66. Gastric catarrh : fatty degeneration of glands 67. Atrophy of mucous membrane of stomach with polyposis 68. Fibrosis in gastric catarrh 69. Columnar cells, etc., in case of chronic acid gastritis . 70. Yeast fungi and columnar epithelium from case of chronic gastritis 71. Magnesium phosphate crystals from stomach in case of chlorhydria 72. Pyloric end of stomach, showing ulcer on posterior wall 7^. Perforated chronic ulcer .... 74. Carcinomatous ulcer of duodenum 75. Cancer of posterior wall of stomach . 76. Diffuse cancer of stomach yy. Boas-Oppler bacilli ..... 78. Cancer of the pylorus .... 79. Cancer of the cardia .... 80. Section from carcinoma of the pylorus . 81. Ulcerating carcinoma of the rectum . 82. Intussusception of the jejunum PAGE 282 284 289 297 299 306 316 .317 318 319 32s 324 398 399 401 422 431 434 445 447 448 449 450 451 452 458 487 489 490 491 508 acid hyper- LIST OF ILLUSTRATIONS FIG. PAGE 83. Ileocolic intussusception 674 84. Invaginated Meckel's diverticulum 677 85. (a) Ileum with Meckel's diverticulum, (b) Diverticulum in- vaginated into ileum 678 86. Secondary intussusception of ileum due to invaginated divertic- ulum 679 87. Meckel's diverticulum invaginated into its own lumen . . 679 88. Invaginated Meckel's diverticulum with complication . . 680 89. Two stages of complicated invagination of Meckel's divertic- ulum 681 Invagination beginning above the diverticulum ..... 682 Knotting of loops of the ileum 685 Constriction of small intestine by omental adhesion . . . 686 Various forms of constriction by club-shaped diverticulum . 688 Tuberculous stricture of ileum . 702 Colloid cancer and tubercle 703 Tuberculous stricture' of ileum 704 Amoeba dysenterige 803. The nerves, blood-vessels, and lymphatics of stomach . . 826 Martin's conical speculum ........ 898 Bodenhamer's bivalve speculum 89S Tuttle's pneumatic proctoscope 8^9 Martin's fistula knife . 916 Kelly's dilator for female urethra* 921 Short electrodes for external use 929 Long rectal electrode for internal use 929 The more common intestinal parasites 939 Amoeba coli mitis or vulgaris 941 Ankylostoma duodenale • . . 943 Eggs of Uncinaria americana from feces 944 Trichina spiralis . . 950 Trichocephalus dispar 951 Ovum of Trichocephalus dispar . . . . . . . 952 PART I anatomic, physiologic, :hemic, and diagnostic data DISEASES OF THE STOMACH AND INTESTINES LECTURE I ANATOMY OF THE DIGESTIVE TRACT For the proper recognition and treatment of enlargements, contractions, or displacements of the digestive organs, and, indeed, of their disorders generally, it is important to have a perfect understanding of their normal size and position as well as of their relation to each other. Without attempting to go fully into the anatomy of these organs I will present to you a brief summary of its essentials. Other elementary data, especially physiologic, will also be useful. Those of you who desire to study the subject thoroughly will of course refer to comprehensive works on the anatomy, histology, physiology, and physiologic chemistry of the digestive system, and the following account can therefore be very much condensed. The digestive tract begins with the mouth and pharynx and the adjacent salivary glands. The tongue and teeth also play a large part in the processes of digestion. The pharynx is behind the nose in its upper part and behind the mouth in its lower part, these cavities opening directly into it. It extends from the base of the skull above to the lower part of the cricoid cartilage opposite the sixth cervical vertebra. At this point it joins the esophagus, forming with the latter a continuous muscular tube lined with mucous membrane. It measures about 45^2 inches (11.3 cm.) from above downward. It is widest opposite the cornua of the hyoid bone and nar- rowest at its point of juncture with the esophagus. In its 30 ANATOMIC, PHYSIOLOGIC, CHEMIC, DIAGNOSTIC DATA lower part the cavity is entirely obliterated, the walls being in contact except during the act of swallowing. The esophagus extends from the lower end of the pharynx to the cardiac orifice of the stomach. Its length is from 9 to 10 inches '(22.86 to 25.4 cm.). It is narrowest at its junction with the lower end of the pharynx and is again constricted where it passes through the diaphragm to enter the stomach opposite the upper border of the eleventh dorsal vertebra. At Fig. I. — Cross section of squamous epithelium from the mucosa of the tongue. its beginning, opposite the sixth cervical vertebra, it lies in the middle line in front of the vertebral column. It then follows the cer\'ical and dorsal curves of the vertebral column, but curves also to the left in the neck, and finally, after passing along the right side of the thoracic aorta, turns again to the left in passing through the diaphragm. ANATOMY OF THE DIGESTIVE TRACT 31 Abdominal Cavity. — In this are included the stomach and small and large intestines as well as the liver and pancreas. All of these digestive organs as well as the spleen, which is included among the latter by some writers, and the omentum, kidneys, and various other structures are invested with a thin Fig. 2. — Coronal section of the trunk (from a model in the mu- seum, University College), i, heart ; 2, stomach in transverse section ; 3, gall-bladder ; 4 and 6, duodenum ; 5, liver ; 7, colon ; 8, diaphragm ; 9, lungs. — From Sidney Martin's " Diseases of the Stomach." serous membrane called the peritoneum. This lines the ab- dominal walls and covers the viscera, forming a closed sac. The stomach is a pear-shaped pouch lying in the epigastrium and left hypochondriac regions. About one-sixth only of It is on the right of the median line. When normal its size is about 12 inches (30.48 cm.) long and 4 to 5 inches (10.16 cm.— 12.70 cm.) wide in vertical diameter, the antero-posterior diameter being a little less. It weighs 4 to 5 ounces (ii3-4 to )2 ANATOMIC, PHYSIOLOGIC^ CHEMIC^ DIAGNOSTIC DATA 141.75 grms.) and in health its average capacity is a little more than three pints (1600 to 1700 c. c. according to Ewald). The stomach has two orifices: the cardiac where the esophagus enters it, and the pyloric where it joins the duoderAim; also two borders, the greater and lesser curva- tures, and two surfaces, the anterior and posterior. Its large end is called the fundus and its smaller end the pyloric portion. The cardiac opening lies about 4 inches (10.16 cm.) behind the seventh left chrondrosternal juncture, at about the Fig. 3. — Stomach in natural posi- tion, showing structures in con- tact with the anterior surface. The circle represents the position of the duodeno-jejunal flexure. — T/^ane. Fig. 4. — Posterior surface of the stomach and its relations. St= supra-renal body. Spl.fl.=splenic flexure of colon. The circle shows position of the duodeno-jejunal flexure. — Thane. level of the eleventh dorsal vertebra. It is a little above and behind the apex of the heart. It is fixed in its position there by the phrenico-gastric ligaments and the esophagus. ^ The pyloric is lower and nearer the surface than the car- diac end and is very movable. It is normally to the right of the median line between the sternal and parasternal lines oppo- site the upper border of the first lumbar vertebra, and between 1 Holzknecht and others who have studied numerous stomachs in healthy young persons by means of the x-ray, now hold that the pylorus is lower than here pictured and described. ANATOMY OF THE DIGESTIVE TRACT 33 Lung Outline of Stomach Liver Gall Bladder Umbilicus Colon Fig. 5. — Position of the organs in the upper par.t of the abdomen. Front view. The highest points of the liver and fundus are somewhat too high in the figure. — After Luschka} Outline of_ Stomach Spleen Left Kidney Descending Colon Lung Liver —Duodenum Pa7icreaS Ascending Colon Fig. 6. — Position of the organs in the upper part of the abdomen. Back view. — After Ltisckka. 1 H. von Luschka, " Die Lage der Bauch-Organe des Menschen.' Carlsruhe, 1873, Plates I and II. 34 ANATOMIC, PHYSIOLOGIC, CHEMIC, DIAGNOSTIC DATA Fig. 7. — A cardiac gland from the dog's stomach (Klein and Noble Smith), d, uioatri of the gland; b, fundus of one of the tubules; e, epithelium; /, parie- tal cells; ■ ' . .^M mM " '^:/'5j- ■'■,■:#•-? J ' ,,^# ^l^*":.^:.;:::] % !.*&• ":-•;/*• lii^ ^teiid ^B '■ ; i-,--?-.'^:;-?.-'^ ('':J<',V-'-:'s::{ii'^^sS ■ ' ^ifaasxsB^^fsl^^SMKIIIl^S K;*^ ^^^ ^"^^^^F ^ ;='v::";>v'j^ p^^^^B ^^^^^v^ ^ ' — -• '"^_ .^s. j^ Fig. 9. — Glands from the cardiac end of the stomach. near the lower border of the seventh rib, where it curves to the right across the middle line, normally, to a point a little lower than midway between the tip of the ensiform cartilage and the umbilicus, and terminates at the pylorus. The diameter of the $6 ANATOMIC, PHYSIOLOGIC, CHEMIC, DIAGNOSTIC DATA pyloric opening is about one-half inch (1.3 cm.), this being the narrowest part of the digestive canal. The gastric glands comprise three varieties of secreting cells, viz.: i, the cylindric cells which form the mucous layer of the lining membrane and extend part of the way into the gland ducts : 2, cuboidal cells with a granular protoplasm and spherical nucleus called by Heidenhain chief or central cells; and 3, the border, parietal or oxyntic cells. The first secrete \ • - Fig. 10. — Glands from pj'loric end of stomach. mucus only, so far as known; the second, according to Heiden- hain and others, secrete the ferments of the gastric juice, pepsinogen and rennin zymogen ; and the third are now be- lieved, upon the same authority, to secrete the HCI only. The border cells which furnish HCI are found chiefly in the middle part of the stomach with a less number in the fundus, and the chief or central cells, which furnish the gastric ferments, pre- dominate in the pyloric region; indeed, according to some ANATOMY OF THE DIGESTIVE TRACT 37 authorities, these are the only secreting cells in the pyloric portion, though both kinds of cells exist in the gland tubules of the fundus. THE MINUTE ANATOMY OF THE STOMACH The minute anatomy of the stomach was exhaustively studied by Mall in a paper published in vol. i. of the Johns Hopkins Reports, entitled " The Vessels and Walls of the Dog's Stomach," and I cannot do better than reproduce here the summing up which he therein makes of his most important investigations : Conclusions. — i. " From a histologic standpoint the mu- cous membrane of the stomach may be divided into three zones — the pyloric, with no border cells; the middle, with many border cells ; and the fundus, with but few border cells. 2. " Digestion of the different portions of the mucous membrane with weak HCl shows that the middle zone digests most easily, the fundus less quickly, and the pyloric, as a rule, not at all. Assuming that the rapidity of digestion of the different portions is in proportion to. the quantity of pepsin present, it makes it probable that most pepsin is formed in the middle zone. Although it has been proved that pepsin is formed in glands which do not contain border cells, in gen- eral it may be stated that the amount of pepsin formed by the different glands is in proportion to the number of border cells. 3. " The degree of acidity of the mucous membrane is In proportion to the number of border cells present. It is reason- able to suppose that the formation of acid in any portion of the stomach aids materially in the formation of pepsin in the same part. This is very essential, because acid favors the formation of pepsin from pepsinogen. Since border cells are only with the greatest difficulty digested in acid, we cannot ascribe to them the power to secrete pepsin; and since the morphology of the central cells varies during digestion and rest, and they are so easily digested upon the addition of acid, 38 ANATOMIC, PHYSIOLOGIC^ CHEMIC^ DIAGNOSTIC DATA we must conclude with Heidenhain that the former are probably concerned in the production of acid and the latter in the production of pepsin, 4. " When the stomach is forcibly distended it is found that the dilatation is mostly at the expense of the fundus. This seems also to be the case when the stomach is naturally filled with food. Although the middle zone is practically not stretched when the stomach is filled, distention seems to favor circulation through this part, because the blood-vessels are more easily injected in a moderately distended, than in an empty, stomach. 5. " In the intestine it is found that the longitudinal and circular muscle-fibers are antagonistic. In the stomach the pyloric valve is closed, after the muscle-cells are dead, by a fold of mucous membrane being thrown into the lumen. This may take place in a living stomach. A contraction of the circular muscle tends to strengthen this valve, while the con- traction of the longitudinal muscle tends to weaken it, because with the contraction of the longitudinal muscle there is always an accompanying relaxation of the circular muscle. Under ordinary circumstances it seems as though the stomach reduced its lumen by simultaneous contraction of both longitudinal and circular muscle-fibers. What complex motions take place during peristalsis are absolutely unknown. It is, however, a remarkable fact that a bundle of the circular fibers (oblique fibers) are parallel with the longitudinal fibers, which are increased in number in the middle zone. A solution of this problem seems within the range of experimentation. 6. " The Blood-vessels of the Stomach. — The celiac axis supplies, besides the stomach, also the spleen and the liver. With a given pressure within the aorta, variation in the resist- ance in the capillaries of the spleen and the liver will have a marked effect upon the circulation through the stomach. The portion of the stomach (middle zone) supplied by the gastric artery is to a less extent under the control of these side influ- ences than is that which is supplied by arteries arising from the ANATOMY OF THE DIGESTIVE TRACT 39 main branches to the spleen and to the hver. It must be again stated that there are, in all probability, many other influences which play most important parts in the distribution of blood. 7. " Around the two curvatures of the stomach there is a complete circle of anastomosis, which has a tendency to equal- ize the pressure in the arteries penetrating the muscle-walls. But the anastomoses arising therefrom have only a tendency to make gradual gradations, and not an equal pressure throughout. The additional set of anastomoses within the submucosa are, again, not sufficient to equalize the flow throughout the whole mucosa. After ligating arteries, as well as by examining the mucous membrane, during digestion and rest, it is found that no sharp lines can be drawn. 8. " The blood-vessels are arranged in such a manner that from any portion of the submucosa about one-fourth of the blood may go to the muscle-coats and three-fourths to the mucosa. It is therefore probable that when the flow is poured to one side it is diminished to the other, and vice versa. There is, however, a tendency to equalize this by the submucous anastomoses. 9. " Since there is but one set of arteries to the mucosa, there must be but one sort of circulation, which may vary in degree only, ^^"ithin the mucosa the arrangement is such that the portion of the gland which is deepest receives the blood richest in O. The mucous membrane, omitting the muscularis mucosse, lies between two venous plexuses. Contraction of the muscle-fibers between the glands and those of the muscularis mucosse should diminish the volume of the mucosa. This would have a tendency to empty the glands, as well as to press blood from the two venous plexuses, especially the lower. WHiether or not there is a force within the mucosa which can augment the circulation seems at present impossible to deter- mine by experiment. The arangement of the parts is very suggestive. 10. " The Veins and Lymphatics. — The rich plexus of veins within the submucosa is sufficiently large to hold 40 ANATOMIC, PHYSIOLOGIC^ CHEMIC^ DIAGNOSTIC DATA a considerable quantity of blood. Tbis must be the case when the valves within the veins coming from the stomach are temporarily closed. When the valves are closed, a con- traction of the circular muscle is sufficient to drive all the blood from the underlying- veins. It is therefore possible that a rhjfthmical contraction in any part of the stomach may favor the circulation through its walls. 11. " The arrangement of the lymphatics is much the same as that of the veins, and the foregoing consideration (lo) applies equally well to them. AVhen we consider the resistance to be overcome while the lymph passes through so many net- works before the cisterna chyli is reached, it makes it plausible to state that the circulation is favored by muscular contraction. 12. " Since the blood which leaves the stomach must pass through the capillaries of the liver, it is necessary that it be constantly under a comparatively high pressure. This pressure is also dependent upon the spleen and the intestine. If the pressure is high, a regurgitation into the stomach is impossible on account of the presence of valves. 13. " In a stomach in which the vessels are all equally dis- tended the rapidity of circulation in the celiac axis would be 263 times that in the capillaries. The area of the section of the celiac axis is 0.0592 square cm.; the immediate branches to the stomach, 0.0348 square cm. ; to the spleen and liver, 0.0244 square cm. All the-capillaries of the stomach : mucosa, 6.4524 square cm.; muscle-coats, 2.7214 square cm.; total, 9.1738 square cm.; 9.I738-^o.0348=263. " A like estimation shows that the rapidity of circulation in all the capillaries is 1-63 of that in the arteries penetrating the muscle-walls; while if the capillaries of the muscle-walls are excluded, the rapidity in the capillaries of the mucosa rises to 1-44. " Considering the glands on an average 0.05 cm. long and 0.003 1-3 cm. in diameter, excluding the necks, the area of all the glands would be 8671 square cm., or thirty-eight times the area of mucous membrane. A like estimation of the capil- ANATOMY OF THE DIGESTIVE TRACT 41 laries, considering each capillary 0.04 cm. long, gives for them a total area of 17 18 sc[uare cm., or 7^ times the mucous sur- face. The secreting surface is five times that of the blood- supply." (See Fig. 98, page 826.) THE ANATOMY OF THE INTESTINES, LIVER, ETC. The intestinal canal is about 30 (914.4 cm.) feet long, ex- tending from the pylorus to the anus. About 25 feet or upwards of four-fifths of it constitute the small intestine — the Fig. II. — Injected intestine showing central lacteal and arrange- ment of capillaries in villus. duodenum, jejunum, and ileum — the remainder comprising the cecum, colon, and rectum. The duodenum, 10 to 12 inches (25.40 cm.— 30.48 cm.), is the widest part of the small intestine, being i^ to 2 inches (3.84 cm.— 5.08 cm.) in diameter. It curves underneath the pancreas and lies behind the tranverse colon. It is the most 42 ANATOMIC, PHYSIOLOGIC, CHEMIC, DIAGNOSTIC DATA fixed part of the small intestine, though its first portion, about 2 inches (5.08 cm.) long, is more movable than any of the Other four parts into which it is usually divided. The remain- der of the small intestine — including the jejunum and ileum — follows .^no definite or constant course, its folds appearing now here and now there, and ends at the juncture with the cecum in the right iliac fossa, the entrance being guarded by the ilio- cecal valve. Fig. 12. — Glands and lymphoid tissue from the appendix vermiformis. The cecum, or head of the colon, is about 2^ (6.35 cm.) inches long by 3 inches (7.62 cm.) in breadth. It gives origin to the appendix vermiformis, which usually comes off on the inner and posterior side near the ilio-cecal valve and varies in length from i to 6 inches (2.54 cm. --i 5.24 cm.) averaging about 4 inches (10.16 cm.). It varies much also in width. ANATOMY OF THE DIGESTIVE TRACT 43 but averages about one-fourth inch (.63 cm.). The appendix is most frequently twisted upon itself and usually points to- ward the spleen lying between the end of the ileum and its mes- entery, but sometimes lies behind the cecum, ascending parallel with it. The colon includes the ascending, transverse, and descend- ing portions. The first and third usually have a vertical course Fig. 13. — Goblet cells and glands from the colon. in the adult, and the second a nearly horizontal one, but has several curves, including a marked convolution near its left flexure. The usual length of the ascending portion from the cecum to the hepatic flexure is 8 inches (20.32 cm.). The transverse portion averages 20 inches (50.80 cm.) in length, but varies greatly in different cases. It is also the most mov- able portion of the colon and is very frequently displaced downward. The descending portion from the splenic flexure to the beginning of the sigmoid flexure is usually Sy^ inches 44 ANATOMIC, PHYSIOLOGIC, CHEMIC, DIAGNOSTIC DATA (21.62 cm.). This is the most fixed part of the colon. The ascending colon is somewhat narrower than the cecum and both the transverse and descending portions are smaller than the ascending. The transverse portion of the colon is usually in apposition with the stomach, having its convexity forward as w*ell as slightly upward under normal conditions. The sigmoid flexure begins at the termination of the descending colon in the left iliac fossa, and curving to the right toward the middle line, joins the rectum at the point where the meso-rectum ceases, opposite the third sacral seg- ment in the median line. The sigmoid loop averages 173/2 inches (44.48 cm.) in length and lies mostly in the pelvis. The rectum, beginning at the termination of the sigmoid, is usually divided arbitrarily into three portions, the first portion according to that division being included here, following the description of Morris, in the sigmoid loop. The re- maining portions constitute the rectum proper and extend from the third piece of the sacrum to the anus. The first of these portions follows the course of the sacrum and cocc5'x terminating at the tip of the latter, and is 3^ inches (8.92 cm.) long; the second (formerly called the third) extending thence to the anus, turns backward and downward and is about i/^ (3-84 cm.) inches long. The cecum, transverse colon, and sigmoid flexure are wholly covered by the peritoneum; the second, or lowest, portion of the rectum has no peritoneal attachment at all. Structure of the Stomach and Intestines. — The walls of the stomach as well as of the small and large intestine comprise four coats, a peritoneal or serous, a muscular, a submucous, and a mucous coat. In the stomach the muscular coat consists of three layers, a longitudinal, a circular, and an oblique. In the intestines the muscular coat has two layers, an external longitudinal and an internal circular la3^er, the latter being the thicker of the two. The mucous layer in both stomach and intestines is lined with cylindric epithelium. On the other hand, the mucous membrane in the esophagus, pharynx, and ANATOMY OF THE DIGESTIVE TRACT 45 mouth is covered by a stratified squamous epithelium. The mucous membrane in the upper respiratory tract is, for the most part, hned with ciHated columnar epithelium. The com- paratively small olfactory region in the nose has an unciliated columnar epithelium. Unciliated columnar epithelial cells, therefore, found in the vomit or wash water of the stomach in any considerable numbers, must have had their origin in that viscus except wdien there has been a possibility of regurgitation from the duodenum; squamous or ciliated columnar epithelial cells, found in fluids coming from the stomach, may be safely declared to have had their origin in the regions above and to have been swallowed. The liver is situated on the right side of the abdominal cavity, directly underneath the diaphragm, occupying the right hypochondriac and epigastric regions and extending commonly into the left hypochondriac region. In front it is in apposition with the fifth, sixth, seventh, eighth, and ninth costal cartil- ages, and to the left it is in contact with the anterior abdominal wall below^ the sternal notch (Morris). On the right side it extends from the seventh to the eleventh rib. Its posterior surface is opposite the ninth, tenth, and eleventh dorsal verte- brae. It is a movable organ, sinks with each inspiration, and is liable to be permanently displaced, especially downward. A deep inspiration in the standing position forces the lower bor- der below the ribs, but when the patient is recumbent the anterior border is usually half an inch above the last rib. At the left it extends to a point i^^ inches (3.84 cm.) beyond the left border of the sternum at the level of the fifth rib. In front, in the median line, its lower border is half-way between the xiphoid cartilage and the umbilicus. Its upper border, hav- ing a slight concavity upw^ard, reaches in the mammary line on the right side to the level of the fifth rib. The under sur- face of the left lobe is directl}^ over the cardiac end and a part of the anterior wall, of the stomach. The right lobe covers the right kidney and the hepatic flexure of the colon, as well as the descending second part of the duodenum. The quadrate 46 ANATOMIC, PHYSIOLOGIC^ CHEMIC^ DIAGNOSTIC DATA lobe of the liver is over the pyloric end of the stomach and the first ascending part of the duodenum. The pancreas lies transversely across the body, behind the stomach, in the epigastric and left hypochondriac regions oppo- site the first and second lumbar vertebrae. It measures usually 5 to 6 inches in length (12.20 to 19.24 cm.) and is half an inch to one inch thick (1.27 to 2.54 cm.). Its weight is from 25^ to 3^ ounces {yy.yz to 108.82 grms.). The pancreas has commonly been divided into four portions : head, neck, body, and tail; the head being at the right end, around which the second part of the duodenum curves, and the tail at its left extremity where it comes into contact with the lower part of the inner surface of the spleen. The anterior surface of the pancreas is somewhat concave, corresponding with the con- vexity of the posterior surface of the stomach, with which it is in contact. The posterior surface is in apposition with the aorta, the superior mesenteric vessels, and the crura of the diaphragm. These various structures separate the pancreas from the spine. The left kidney and suprarenal capsule are also in direct apposition with the posterior surface of the left part of the body of the pancreas. The inferior surface is bounded below by the fourth part of the duodenum and the beginning of the jejunum. The head of the pancreas bends somewhat downward and is in contact behind with the common bile diict, the vena cava, the left renal vein, and the aorta. In front of the head of the pancreas are found the superior mes- enteric and pancreatico-duodenal ^'essels and the transverse colon. The duct of the pancreas is called the canal of Wir- sung, and runs from left to right nearer the posterior surface, turning in the head downward, backward, and to the right to meet the common bile duct. With the latter it passes oblicjuely through into the duodenum, though occasionally the canal of Wirsung opens by itself into the latter part of the intestine. There is also usually an accessory pancreatic duct known as the duct of Santorini, which opens separately into the duodenum about one inch above the other opening. LECTURE II THE NERVE SUPPLY OF THE DIGESTIVE ORGANS AND THE RELATIONS OF THE SPINE TO THE VASO-MOTOR NERVES AccoRDiXG to ]\Iorris ^ the nen-es supplying the stomach are the two pneumogastrics and the sympathetic. The right vagus passes over the posterior surface and the left supplies the anterior. The stomach is intimately connected with the sympathetic system of nerves through the' solar plexus. The nervous supply of die intestines is from the superior mesenteric plexus and lower part of the solar plexus. The branches follow the blood-vessels forming Auerbach's and Meissner's plexuses. The anatomy and physiology of the nervous system are by no means yet fully worked out and especially with regard to the vaso-motor nerve fibers supplying the viscera the work of investigation is still going on, while the results of different physiologists are not always in accord. In these lectures I shall not attempt to go deeply into the details of such investiga- tions, quoting the views of the dift'erent authorities and the arguments by which they are upheld, but shall simply give you in brief the facts which seem fairly well established. Secretory Nerves. — It is both maintained and denied that there are special secretory nerves distributed to the glandular structures, but Pawlow and his pupils " seem to me to have finally proved beyond cjuestion that there are in the vagi, apart ^ " Human Anatomy," by Henry Morris, M. A. and M. B., P, Blakiston's Son & Co., Philadelphia, 189S. '"The AVork of the Digestive Glands," by Professor J. P. Pawlow, J. B. Lippincott Company, Philadelphia, 1902. 47 48 ANATOMIC, PHYSIOLOGIC^ CHEMIC^ DIAGNOSTIC DATA from the vaso-motor fibers, nerve fibers the stimulation of Avhich produces a secretion of gastric juice. It had long before been accepted as a settled fact that the salivary glands at least are supplied with a special secretory- nerve, though this also is now disputed in some quarters. Paw- low brings forward results of experiments which tend to show that there are probably also nerves whose particular function it is to inhibit secretion. Nature displays a wonderful plen- itude of resources and whatever structure or combination of structures, however intricate, can aid in performing any func- tion, is generally supplied. The Vaso-Motor Nerves and the Spine. — My preceptor in medicine, the late Dr. Matthew J. Grier, was accustomed in the seventies to apply mild galvanic currents through the points of emergence of the nerves on either side of the spinal column with one electrode stabile over the stomach, and in this way produced highly favorable results, not only upon symptoms referred to the spine itself and affections of the general nervous system, but also in many cases upon disease in the parts to which such nerves were distributed. During the past thirty-two years I have confirmed the value of the method in many hundreds of cases. Professor H. C. AVood used to teach the usefulness in certain chronic diseases of alternate hot and cold water douches to the spine, and various applications of heat and cold to the spine are in common use. Move recently much success has been claimed for various methods of stimulating the spinal nerves near their emergence from the spine by mechanical devices designed to produce pressure with vibration and also by a species of massage or finger pressure over these parts, con- tinuous or intermittent accordingly as contraction or dilation of the peripheral vessels may be desired. Dr. John P. Arnold in particular is an enthusiastic advocate of this latter method.' The clinical successes achieved in all these ways are con- firmatory of the conclusions of physiologists that vaso-motor '/«^. Afed. Ma£-. for May, July^ and August, 1903. NERVE SUPPLY OF THE DIGESTIVE ORGANS 49 nerve fibers pass out from the spinal cord with the spinal nerves as well as with the pneumogastrics and some of the other cranial nerves, and are distributed thence to the periphery of the body and to the viscera. Those nerves which control the caliber of the arterioles include the vaso-constrictors, stimulation of which contracts the vessels, and the vaso-dilators, which have an opposite effect. Both of these .are efferent nerves which carry impulses outward to their peripheral endings from the vaso-motor center in the medulla. Vaso-constrictors and vaso-dilators pass from their respect- ive portions of the vaso-motor center down through the ante- rolateral columns of the spinal cord and through centers in the anterior horns of the latter outward to join the anterior bun- dles of the spinal nerves, thence to ganglia of the sympathetic chain of nerves, and again to the vessels which they supply. There are also other vaso-motor fibers which are afferent or ingoing nerves called the reflex constrictors and reflex dilators. Both the latter convey sensory impressions from the periphery of the body or the viscera to certain groups of cells in the ganglia in the posterior branches of the spinal nerves and thence into the cord passing upward in the anterolateral columns of the latter to the vaso-motor center in the medulla, or through the ganglia of the cranial nerves more directly to the same center. Excitation of the peripheral endings of the reflex constrictors or reflex dilators produces a stimulation of the corresponding part of the vaso-motor center with a resulting contraction or dilatation respectively of the vessels in the peripheral regions from which such nerves take their ori- gin, whether these are in-the external parts or the viscera. The afferent vaso-motor nerves are near enough the surface, before passing into the spinal cord, to be influenced by heat or cold, pressure, or by vibration whether produced by electricity or special mechanical devices when applied over them on either side of the cord. Course and Direction of the Spinal Nerves. — The follow- 50 ANATOMIC, PHYSIOLOGIC^ CHEMIC^ DIAGNOSTIC DATA ing, quoted from Morris ^ will make clearer the course of the spinal nerves. The table showing the distances traveled by the nerves (especially the lower ones) before emerging from the spinal column will be of especial interest and practical value to those of you who treat the viscera through the spine : '' From their superficial origin, both anterior and posterior roots proceed towards the intervertebral foramina, and unite near the outer limits of the foramina into single trunks. The ganglia on the posterior roots are placed, in the case of the majority of the nerves, within the foramina immediately inter- nal to the point of junction of the two roots. The ganglia of the first and second cervical nerves are placed on the laminae of the atlas and axis. The ganglia of the (first and second) sacral and coccygeal nerves are placed within the spinal canal. " The roots of the first spinal nerve ascend slightly to reach the interval between the atlas and the occipital bone. " The second and third nerves pass horizontally outwards, the fourth passes obliquely downwards and outwards, and the remaining nerves pass out with increasing degrees of obliquity, the intraspinal course of the nerve-roots increasing in length as the series is followed downwards. " It follows from the above statement that the lower nerve- roots are directed almost vertically downwards, and as the spinal cord ends at the level of the second lumbar vertebra, while the series of intervertebral foramina is continued to the lower end of the sacrum, the nerve-roots passing within the vertebral canal beyond the cord form a great sheaf of fibers, the Cauda equina. The distance of the points of emergence (superficial origins) of certain of the nerves from the corre- sponding intervertebral foramina is given in the following table. This table gives the measurements made by Testut in a subject of eighteen years. The length of the spinal cord was in this case forty-one centimeters." '" Human Anatomy," Blakiston's & Co., Philadelphia, i8q8. NERVE SUPPLY OF THE DIGESTIVE ORGANS 51 Right Side Left Side mm. m.ra. Third pair of cervical nerves 18 17 Fifth ... 25 25 First ' thoracic " ... 33 32 Fifth " " . . 47 47 Tenth " " . . 68 68 Twelfth ' ... III no First lumbar " 114 114 Second " " , . 138 134 Third " " . . 151 151 Fourth ' " " . . 163 164 Fifth " . . 181 180 First sacral " . . 18S 188 Fifth . . . 280 280 Remembering that a millimeter is equal to one-twenty-fifth of an inch, or 10 mm. to nearly half an inch, it will be seen from the foregoing table that the fifth cervical nerves leave the spine an inch below their origin in the cord, and the fifth sacral nerves eleven inches below their point of origin. Points of Emergence from the Spine of Special Vaso-Motor Nerves. — The cerebral blood-vessels are said to be more or less under the control of vaso-motor centers in the spinal cord chiefly in its second and third dorsal segments. Efferent fibers pass from these through the sympathetic nerves to the superior cervical ganglion. From this both constrictor and dilator fibers pass along the internal carotid artery to the vessels in the brain. Vaso-constrictor nerve fibers for the salivary glands have their origin in the second and third segments of the thoracic part of the spinal cord, enter the sympathetic chain, pass on to the superior cervical ganglion, and thence are distributed to the parotid, submaxillary, and lingual glands. Vaso-dilator fibers for the parotid gland arise in the nucleus of the ninth cranial nerve and accompany the latter, passing through the jugular foramen to the otic ganglion, whence they proceed along the inferior maxillary branch of the fifth nerve and its auriculo-temporal branches to the gland. Vaso-dilator fibers originating in the nucleus of the seventh 52 ANATOMIC, PHYSIOLOGIC, CHEMIC, DIAGNOSTIC DATA or facial nerve follow the latter and thence pass through the chorda tympani to the submaxillary ganglion, emerging from the cranium through the stylo-mastoid foramen. From the submaxillary ganglion dilator fibers are distributed to the sub- maxillary and lingual glands. Vaso-constrictor fibers for the stomach emerge from the spine with the fifth, sixth, seventh, eighth, and ninth dorsal nerves through the intervertebral foramina and pass with the visceral nerves to the semilunar ganglion ; thence along the blood-vessels to the vessels of the stomach itself. Vaso-dilator fibers originate in the nucleus of the tenth or pneumogastric nerve and proceed by the way of the semilunar ganglion to the gastric blood-vessels. Vaso-constrictor fibers for the small intestines pass from those segments of the spinal cord from the sixth dorsal to the second lumbar, through the visceral nerves to the solar plexus, and thence to the blood-vessels of the duodenum, jejunum, and ileum. The dilator nerves of the same part arise in the nucleus of the pneumogastrics and go to the solar plexus. Thence they are distributed to the blood-vessels of the small intestines. The vaso-motor nerve supply of the liver has the same origin as that of the small intestine, and that of the pancreas and spleen varies but slightly from the same. The vaso-motor mechanism of the colon has in part the same and in part a different origin from that of the small intestines. The constrictor fibers arise in the same part of the cord — sixth dorsal to the second lumbar segment — and enter the inferior mesenteric ganglion before their distribution to the blood-ves- sels of the various portions of the large bowel. Dilator fibers for the colon originate in the same segments of the cord as well as in the nucleus of the pneumogastrics. They pass via the visceral and pneumogastric nerves to the solar and inferior mesenteric ganglia, and thence to the blood-vessels of the colon. The sigmoid flexure and rectum receive vaso-constrictor nerve NERVE SUPPLY OF THE DIGESTIVE ORGANS 53 fibers which, arising in the tenth dorsal to the fourth lumbar nerve-roots, pass to the hypogastric plexus, and thence along the hypogastric nerves to the vessels of the parts. The dilator fibers for the vessels of the same region arise much lower dow^n, in the first to the fourth sacral segments of the cord. They proceed then to the corresponding sacral ganglia, and thence through the visceral branches of the sacral nerves to the vessels of the sigmoid flexure and rectum. It is noteworthy that the vaso-constrictors for the sigmoid flexure and rectum, and also those for the principal genital organs of both sexes, come from the lumbar nerve-roots, while the vaso-dilators for the same two sets of organs come from the sacral plexus. This accounts for the often observed inti- mate sympathy between the lower bowel and the sexual appa- ratus. Whenever one is disturbed the other is rarely normal. LECTURE III THE PHYSIOLOGY OF DIGESTION, AB- SORPTION, AND DEFECATION Salivary Digestion. — Digestion begins in the mouth with mastication and insahvation. These two processes are among the most important of those which prepare the food for assimi- lation. Their importance is little miderstood by the laity, and by no means sufficiently emphasized by writers upon diseases of the gastro-intestinal tract. Physicians do not always pay sufficient heed to them in their directions to patients concern- ing diet, etc. Man in his primitive condition was obliged to chew his food with unusual thoroughness because it was crude, coarse, very often tough and uncooked. With ad- vancing civilization our cooks have been constantly endeavor- ing to lessen and lighten the work of the muscles of mastication and salivary glands, thereby increasing the labor of the stomach and intestinal glands and multiplying digestive maladies. Nature has so arranged matters that the act of mastication promotes the secretion of the salivary glands and possibly also that of the gastric, pancreatic, and intestinal glands by a reflex influence. The function of the salivary glands — the parotid, submaxillary, and sublingual — is to secrete the saliva. The latter is a thin liquid of alkaline reaction of the sp. gr. of 1,002- 1,009. The quantity secreted in twenty-four hours is from 2 to 4 pints (946 to 1892 c. c.) ; Bidder and Schmidt say 1400 to 1500 c. c. The saliva contains a diastatic enzyme called ptyalin, which has the property of changing starch into a form of sugar, maltose, with usually a small amount of grape sugar. This conversion begins in the mouth during the act of chewing, and the longer the latter is continued the more com- 54 PHYSIOLOGY OF DIGESTION^ ABSORPTION^ DEFECATION 55 pletely is it effected. Usually, the process is merely com- menced in the mouth, and when the gastric contents are not too highly acid, is carried further forward after the food reaches the stomach. Under normal conditions, when the percentage of HCl in the gastric juice is not too high, this salivary digestion or starch conversion goes on in the stomach for some thirty minutes or more when, under even the most favorable conditions, it is commonly terminated by the increas- ing acidity of the stomach contents. When the latter are exceedingly acid, as in marked cases of hyperchlorhydria, sali- vary digestion may be checked at once, and the conversion of the starch into maltose cannot then be completed until the con- tents of the stomach are passed on into the intestines, when normally the pancreatic juice, aided by the bile and intestinal juice, complete the process. However, when there is present in the stomach a marked excess of HCl, the pyloric outlet remains closed much longer than normal and the unconverted starch is subjected to the danger of fermentation for an excep- tionally long period. Aggravated flatulency then results. Boas gives the following proportions of HCl and other acids as effective in checking or stopping entirely salivary digestion in the stomach : Checked by Stopped by Hydrochloric acid 07 per cent. .12 per cent. Lactic acid i " " .15 " " ^"ty"^ " i 2 - " .4to Acetic " ) •5 The saliva serves other useful purposes in softening or pul- pefying and lubricating the food, dissolving the salts in it, and imparting to it an alkaline reaction. The saliva, upon reaching the stomach, also stimulates the secretion of the gas- tric juice. Gastric Digestion is performed by the gastric juice, an acid liquid of the sp. gr. of 1,002-1,003. It contains HCl, pepsin, and rennin (the milk-curdling ferment), and, as has been recently demonstrated, a small quantity of a substance which 56 ANATOMIC, PHYSIOLOGIC^ CHEMIC^ DIAGNOSTIC DATA has the property, to some extent, of emulsifying fats. No reli- able data are at hand as to the total quantity of gastric juice secreted, but Griinewald estimated it at 1580 c. c, that is, about three pints. The normal percentage of HCl in the gastric juice has been variously estimated, but may be accepted as approximately o. i to 0.2. At the height of the digestion of a light breakfast, such as the test breakfast originally prescribed by Ewald, a little more than one-half of the HCl present should be in the free form and somewhat less than half com- bined with the proteid food. The HCl of the gastric juice has a decided antiseptic action for many bacteria, but, as should be carefully borne in mind, does not interfere at all with the development of the yeast germ, which is responsible for a large share of the usual gastric fermentation. Gastric enzymes exist primarily in the forms of pepsinogen and rennin zymogen, which in the presence of HCl are changed respectively into the active forms of pepsin and rennin. Pepsin, in the presence of sufficient free HCl, converts proteid or albuminoid food ele- ments into the more soluble propeptones and peptones. Gelatin is also changed by this compound into gelatin-peptone, and elastine into elastine-peptone. Other mineral acids can be substituted for HCl and will enable the pepsin to effect the same changes, but much less efficiently; and in a still lower degree, lactic, acetic, and butyric acids are also capable of substituting the HCl. The rennin zymogen is the most con- stant constituent of the gastric juice, and in conditions of disease has been found to persist generally even after the entire disappearance of HCl and pepsin. The property of rennin is to produce a light flaky coagula- tion of milk. It should not be forgotten in this connection that a denser coagulation may be produced in milk by HCl alone. The motor function of the stomach is of the greatest assist- ance to the action of the gastric juice. The churning move- ments keep the contents in constant motion, and mix the gas- tric juice through all parts of the mass, bringing it into con- PHYSIOLOGY OF DIGESTION, ABSORPTION, DEFECATION 5/ tact with every portion of it, while the propulsive movements empty the stomach. The pylorus normally opens rhythmically every few minutes during digestion, and the more liquid con- tents are then expelled by contractions of the muscles of the antrum pylori. With lowered gastric motility digestion does not go on efficiently, even with a normal or excessive secretion of the HCl and pepsin: Indeed, an excess of HCl usually tends to a lessened peptone production. On the other hand, there may be a complete absence of secretion without serious dis- turbance of nutrition or great inconvenience to the patient, provided the gastric motility is w^ell maintained, so that the stomach contents are promptly propelled into the duodenum, where the other digestive juices can have access to them. It is noteworthy in this connection that an excessive secre- tion of HCl, which often causes a prolonged spasmodic closure of the pylorus with long-delayed emptying of the stomach, pro- duces usually more serious symptoms, more distress to the patient in the beginning, and a greater number of important sequels in the end, than does a deficiency of the same secretion, provided always the latter fault is compensated for by an active gastric motor power and functionally efficient intestinal digestion. Experiments performed in Pawlow's laboratory indicate that the closure of the pylorus is determined by the reaction of the contents of the duodenum. When these are rendered acid by excessive acidity of the chyme, the pylorus closes by reflex action. When the duodenal contents again be- come neutral or alkaline, the pylorus opens to admit a fresh portion of chyme. Intestinal digestion, in so far as is yet definitely known, is comprised in the action of the pancreatic juice, the bile, and the succus entericus or intestinal juice. The pancreatic juice is secreted by the pancreas and finds its way into the duodenum through the duct of Wirsung; the bile secreted by the liver and stored up in the gall-ljladder flows through the cystic and com- mon bile ducts and enters the duodenum commonly through the same opening as the pancreatic juice. Some recent inves- 58 ANATOMIC, PHYSIOLOGIC^ CHEMIC^ DIAGNOSTIC DATA tigators ha\'e reported evidences that an internal secretion of the spleen assists the action of the pancreatic juice, probably by converting the trypsin zymogen into the active proteolytic ferment called trypsin. All of the three digestive juices above described, which meet and perform their functions in the in- testine^ are more or less alkaline and gradually neutralize the acidity of the gastric juice. They are active in an alkaline, neutral, or slightly acid medium, but not in a highly acid one. Free HCl, even in small proportion, has been shown to inhibit pancreatic digestion. This helps to explain the injuri- ous results to nutrition of an excessive secretion of HCl. All of these three secretions likewise have some fat-emulsifying power; this work is done chiefly by the pancreatic and intes- tinal juices, but goes on much more rapidly in the presence of bile. The secretion of the pancreatic juice in man is now believed to be continuous to some extent, accumulating in the excretory ducts of the pancreas between the digestive periods a small amount, but being secreted much more abundantly during digestion. Various kinds of stimuli, mechanical and chemical, are efficient in exciting the secretion of this juice, but the chief one is the presence of an acid chyme in the duo- denum. The amount of the daily secretion of the pancreatic juice has never been accurately determined. It is the most active of all the digestive secretions. It combines the proper- ties of both the saliva and gastric juice, having the power of converting starch into sugar or completing that process when partly effected in the stomach, and also has a greater proteo- lytic or albumin-digesting power than the gastric juice, besides tlie ability to emulsify fats and produce changes in milk analagous to, but not identical with, its coagulation by rennin. The bile, a yellow or brownish liquid, is a continuous secre- tion from the cells of the liver. It is alkaline, and the quan- tity formed daily has been estimated at from i to 2^ pints (473 to 1 182 c. c). Bile is to be considered as an excretion as well as a secretion. It contributes somewhat to the proc- esses of intestinal digestion, being a stimulant to the peristaltic PHYSIOLOGY OF DIGESTION^ ABSORPTION, DEFECATION 59 apparatus, and assists in maintaining the normal bowel func- tions besides aiding in the splitting up of the fats by forming soaps with the solid neutral ones. Antiseptic properties have been claimed for the bile, and though this claim has been dis- puted, it probably lessens somewhat the activity of certain of the intestinal bacteria. Bile also assists in the assimilation and absorption of fats. Besides secreting the bile, the liver possesses other vitally important functions in the normal metabolism or tissue changes, including the destruction of poisonous substances introduced into the digestive system from without or formed within the body. All the blood from the digestive organs must pass through the portal vein and be brought into contact with the hepatic cells before passing on to the heart. According to the theory of auto-intoxication, now sufficiently well estab- lished, the liver is the great defender of the system against the numerous poisons constantly formed during the metabolic processes. Urea is now known to be produced largely, if not chiefly, in the liver. Moreover, glycogen is formed in the same gland from the digested carbohydrates as well as from pro- teid food, and is stored up there to be reconverted into sugar and then distributed to the system as needed. This peculiar function is believed to be possessed to some extent also by the muscles and perhaps other tissues. Absorption. — Pure water is scarcely absorbed at all from the stomach, but diluted alcohol is freely absorbed, as are also solutions of the sugars when in a concentration of 5 per cent, or higher. Peptones are only slowly and with difficulty ab- sorbed by the stomach. In the small intestine all the soluble products of digestion, peptones, sugars, and emulsified fats are readily and rapidly absorbed through the medium of the lacteals of the lymphatic system and in part directly into the blood. In the large intestine absorption is much less active and proceeds more slowly, but still takes place to a considerable extent. Hence the loss to the system of a too prolonged em- ployment of colonic irrigation. 60 ANATOMIC, PHYSIOLOGIC^ CHEMIC^ DIAGNOSTIC DATA Absorption in the intestine takes place chiefly through the vilH and the soHtary glands. The former are limited to the small intestine, none of them being found in any part of the colon. The solitary glands are most numerous in the ileum, but rqany of them are also irregularly scattered throughout the various parts of the large intestine. ' Pohlman infers from the limited number of any specialized organs for ab- sorption in the colon, and particularly in view of its well-known absorbing power, that its whole mucous membrane has the power of absorption, as is the case with that of the stomach for a limited number of substances. The villi and solitary glands are thus tersely described by Pohlman •} " The villi, little cone-shaped protuberances in the mucous membrane, have a dense network of blood capillaries just underneath their epithelial covering, while a lacteal duct occupies the center of the cone. The solitary glands have a dense lacteal plexus beneath the membrane and a limited supply of blood capillaries. All the blood capillaries of the intestinal tract are radicles of the portal vein, while the lacteal ducts and capillaries are radicles of the abdominal lymphatics. The villi, however, are the principal organs and carry the bulk of the peptones and sugars into the circulation directly, while the emulsified fats absorbed are poured by the way of the lacteals and abdominal lymphatics into the receptaculum chyli, and from there through the thoracic duct into the left sub- clavian vein." Everything ingested, excepting fats and water, must pass through the liver before it can be taken up for the uses of the body. Only a small amount of the fats are broken up into fatty acids and glycerin, the chief part of such food ingested being first emulsified and absorbed in that form. The large intestine is able to absorb not only digested foods, but also to some extent undigested nutriments such as solutions of albumin, etc. Hence the utility of nutritive enemas. 1 Article on Absorption, Wood's "Reference Hand-Book," vol. i., New York, I goo. PHYSIOLOGY OF DIGESTION^ ABSORPTION^ DEFECATION 6l Defecation. — The feces are what remain of the food and drink after aU has been absorbed that should be. The process of absorption having gone on continuously, the ingesta, which are fluid throughout the whole course of the small intestines, gradually assume the solid form as they pass through the cecum and colon until by the time they have reached the sigmoid flexure they should be in the form of a putty-like semi- solid mass, and in passing through the rectum they normally become molded into the sausage form. In conditions of health there is usually a movement of the bowels — that is a discharge of feces from the rectum — once in twenty-four hours, although there may be two or three in the twenty-four hours, or one only in each two or three days in conditions which seem to approximate those of health. When the bowel movement occurs, as is most usual, in the morning, the feces accumulate during the night in the descending colon and are arrested in the sigmoid flexure by the superior sphincter of the rectum. When the accumulation is sufficient to make the act of defecation necessary, the pressure upon the superior sphinc- ter causes the latter to yield and a portion of the feces enter the rectum. If this warning is unheeded the fecal matter returns to the sigmoid flexure, and this process may be re- peated several times before the pressure becomes so urgent that it can no longer be resisted. In some cases, however, when the peristaltic action is less vigorous than usual, the repeated calls to stool may be disregarded and the rectum thus become tolerant of the accumulation of feces. Thus the rec- tum is gradually overdistended and weakened until a very obstinate form of constipation results. In the lower part of the rectum there is an internal sphincter in addition to the external sphincter at the anal orifice. The muscle forming the inner sphincter is an involuntary one, while the external sphincter, composed of striated muscular fibers, is to a large extent under the control of the will, though it may relax in spite of the will if the pressure upon it is exceedingly great. The innervation of the colon is in part from the sympathetic 62 ANATOMIC, PHYSIOLOGIC^ CHEMIC^ DIAGNOSTIC DATA and in part from the lower spinal nerves. The vaso-constrictor nerve fibers, as already described, rise from that part of the cord between the sixth dorsal and the second lumbar segment. The v^.so-dilator fibers of the colon rise from the same part of the spinal cord and from the pneumogastrics. The vaso- constrictor nerves supplying the sigmoid flexure and rectum come from the tenth dorsal to the fourth lumbar segments of the cord, while the vaso-dilators for the same parts originate between the first and fourth sacral segments of the cord. Both motor and inhibitory nerve fibers supply the muscles of the rectum, some coming from the lumbar plexuses and others from the interior mesenteric and hypogastric plexuses of the sympathetic system. What has been called the defecation center is now usually located in the second segment of the lumbar part of the cord. There is also known to be a nervous connection between the cerebral centers and the muscles of the rectum. Interference with normal defecation may arise from either atony of the peristaltic muscular apparatus leading to a deficiency of expulsive force, or from irregular spasmodic con- tractions of the circular muscular fibers producing what is now known as spastic constipation ; also from displacements of the intestines or neighboring viscera, tumors, etc.^ This subject is discussed at length under the head of Constipation and also in Lecture LXIV. on Intestinal Obstruction. 1 Adhesions of parts of the bowel to other parts after surgical operations or attacks of inflammation, are other causes of constipation. PART II METHODS OF EXAMINATION LECTURE IV THE INTERROGATION OF THE PATIENT Importance of a Full History. — It is always advisable, when practicable, to obtain from patients detailed- accounts of their past and present symptoms, with the chief facts in the family history. Indeed, this is often a very necessary preliminary, if you are to make such an examination as shall lead you to a correct diagnosis in any very obscure or chronic case of ill health. Though this series of lectures deals predominantly with diseases and derangements of the organs concerned in the processes of digestion, you cannot be expected to know in advance that any individual case which claims your attention is a stomach or intestinal case. The fact that the patient thinks so by no means proves it. The real lesion may be else- where, and, even with the fullest possible history obtainable from the patient, you may sometimes be misled. You may be induced thereby to examine exhaustively the entire digestive tract, carrying out the tests of the gastric juice, feces, etc., without finding there the origin of the trouble, its seat being elsewhere ; but you are much less likely thus to waste your time and put the patient to unnecessary expense, if you institute the most searching inquiries beforehand concerning all the functions and systems of the body. Naturally the exigencies of a large practice will render it impracticable to examine minutely every part of every patient's body, to say nothing of analyses of the secretions and excre- tions and thorough examinations of the blood. But whenever a patient has long complained of symptoms which, being only temporarily relieved by remedies, point to some chronic lesion 65 66 METHODS OF EXAMINATION or derangement in any part of the system, it is necessary to make a full and careful incjuiry into his condition and antecedents. Let us suppose he complains of constipation, headache, and nervousness with insomnia — a very frequent combination — and that no permanent relief has been afforded by cholagogues, laxatives, sedatives, or hypnotics. Indeed, the hypnotics not only generally fail to do more than palliate temporarily, but often finally aggravate such cases. You may think of a possible brain lesion, such as a chronic meningitis, cerebral tumor (gumma), etc., but should also suspect a toxsemic neurasthenia or arteriosclerosis resulting from a faulty diet and too little physical exercise, with probably excessive mental work, worry, dissipation, or sexual irregu- larities. When the patient is at or beyond middle age, arteriosclerosis will be the most probable cause, especially if the superficial arteries are hardened or tortuous. In the case stated, the family history will tell you whether or not there is a tendency to gastro-intestinal disorders, for such a tendency is notoriously likely to be inherited, or whether the patient's forebears have had specially vulnerable nervous systems. The personal history, if fully elicited by skillful questioning, may reveal at least a suspicion of syphilis or tuberculosis, which would direct your inquiries and examina- tions particularly toward the brain, though even such a history would not exclude neurasthenia of autotoxsemic origin as the active cause of the trouble. The less dexterous and expert a physician is in the technical arts which are indispensable to a good diagnostician, and the more deficient his training in, or facilities for, thorough labora- tory work, the greater the help he may derive from an unusually full and minute account of the history and symp- tomatology of any case. The gastro-enterologist should be able usually to diagnosticate a well-marked type of gastric ulcer or acid gastric catarrh, for example, after making a physical examination and testing the stomach contents, even without having heard a word of the family or personal history or THE INTERROGATION OF THE PATIENT (>y symptoms; yet most specialists regularly obtain and record a full history, and you would do well, in doubtful cases at least (in new cases especially), to get all the help possible from the same source. Besides the name, age, residence, and occupa- tion, ask the present weight of the patient, the best former weight, and how long a time the loss or gain has been going on. Inquire as to the health of the parents, or, if dead, the age and cause; also as to the health of brothers and sisters. Ask when the patient first began to be out of health and about previous acute illnesses. Note down systematically all the salient medical facts with which the patient is able to acquaint you, recording particularly the answers given regarding the state of the chief functions and the persistent or frequently re- curring symptoms, before proceeding to make your examina- tion. The patient usually has his own theory as to the proper diagnosis, and will often try, though perhaps unconsciously, to impose this upon you by magnifying or emphasizing such symptoms as seem to bear it out, and minimizing, or even neglecting altogether, any mention of those referring to organs or functions which he deems healthy. Keeping your own mind as free as possible, therefore, from bias, you should make inquiries as to all the leading functions before deciding upon the diagnosis. A good rule to follow, in important cases, is to begin at the head and ask questions likely to elicit informa- tion regarding the condition and activities of the various parts in a certain order, beginning with the brain and spinal cord, then inquiring about the upper respiratory tract, lungs, etc., the heart and circulation, the digestive system, and the genito-urinary apparatus. Systematic Questioning. — Taking these up in order, you should inquire as to the memory and capacity for sustained mental effort ; as to the sleep, whether sound and ample, or in any way imperfect, and if so in what way; as to any tendency to headaches, and if so, whether they always follow some special provocation, such as imprudence in eating or drinking, 68 METHODS OF EXAMINATION overfatigue, etc., or recur at intervals, as in migraine, without any apparent exciting cause ; further as to backache, numbness or tinghng in the extremities, etc. Next you should inquire as to any history or present existence of catarrh in the upper respiratory passages, cough, asthma, former attacks of influenza, pneumonia, pleurisy, or bronchitis. Coming to the circulatory system, you should ask whether there is, or has been, palpitation of the heart, pain in the pre- cordia, shortness of breath on exertion, cold extremities, oedema of the feet or ankles, etc. The digestive system requires particular attention, since derangements here are more common than those of any other functions, and may affect directly or indirectly all the other systems. You should inquire concerning the appetite for each of the three usual meals, whether abnormally great, slight at first but increased somewhat after beginning to eat, or absent, with or without a disgust or loathing for food; any peculiar taste in the mouth mornings ; whether there is unusual thirst or lack of it, the number and character of meals taken daily, as well as the hours of the day when they are eaten, how punct- ually they are taken then, and the time usually spent in eating them — which is often a better way to put the question than to ask bluntly whether the patient eats slowly, with thorough chewing, or fast with incomplete mastication. Another in- direct method of learning whether or not there is poor mastica- tion, perhaps the most frecpent cause of indigestion, is to inquire whether much fluid is taken with meals, and, if so, whether it is used to help wash down the food or only after the boluses of the latter liave been swallowed. It is well, too, that the patient should be asked about the condition of the gums and teeth, and the ability of the latter to do the work required of them. How to Detect Dietetic Sins. — All methods of finding out a patient's pet dietetic sins will now and then fail, but one of the surest (with the exception of resorting to frequent lavage) THE IXTERROGATIOX OF THE PATIENT 69 is to get him to jot down regularly what is eaten or drunk at each meal as well as the tidbits and the extra lunches between meals at teas, receptions, etc. — both the various articles and the amounts of each ingested. There are dyspeptics who, though they have (as the Germans say all persons have) the stomachs they deserve to have, will tell pretty nearly the truth, when obliged to put down the facts thus in black and white. This method is practicable after treatment has been regularly begun, but in recording the history at the outset, you will of course have to depend largely upon the usualh^ rather vague general answers to your questions as to what is commonly eaten. However, by asking specifically, for example, at how many meals meat is eaten each day, the kind and how cooked, as well as what desserts, what beverages, — if alcoholic ones, the kinds and quantities, and if coffee or tea, how much and how strong, — you can generally get some idea as to the prevailing habit or tendencies of the patient regarding diet. Pain or Discomfort. — You should incjuire particularly con- cerning any discomfort or pain during or after meals, whether in the esophagus, gastric region, or elsewhere in the abdomen. If difficulty in swallowing is complained of, ask as to its exact location and degree of persistency, or if occasional only, the times of recurrence, and whether the food sometimes comes up again (regurgitation) on account of it; also whether liquid readily passes into the stomach even when solids do not. If pain occurs, ask whether before or after eating, and if after, ascertain exactly to what part of the epigastrium it is referred and if felt also in the back, how long after and whether after all meals as a rule, or after large ones orly, or after particular kinds of food, or apparently regardless both of the amount and the quality of food or drink taken. Ask especially about the kind of pain or discomfort, whether burning, sharp, stabbing or boring, or whether dull and slight, or merely a sensation of fullness or weight — a bearing-down feeling. If there is no pain, find out if the patient is drows}'- after meals. Nausea and Vomiting. Eructations. — Inquire as to nausea 70 METHODS OF EXAMINATION and vomiting, and if either or both occur, ascertain definitely when and under what circumstances, the same as concerning pain. Ask then whether blood, any reddish substance or altered blood resembling coffee grounds, is ever present, either in the matters vomited or in the stools. Question closely as to the habit of eructation or belching, but as some patients belch unconsciously, ask the same question also of some other member of the family. I once sat next at table to a lady who rarely finished a meal without bringing up more or less noisily a quantity of gas from her stomach, yet later, when, being called upon to prescribe for her, I inquired as to eructations, she replied that she was not troubled in that way. Still, patients are, as a rule, only too painfully aware of the symp- tom, and eager to have it relieved. Wdien eructations are complained of, learn whether or not the eructated gas has any taste or smell, and if so what kind — also whether belching freely usually relieves any associated gastric pain. Bowel Movements. — Question with special care about the action of the bowels, whether there are daily normal evacua- tions or any derangement in the direction of either constipa- tion or diarrhea. It is absurdly insufficient to be satisfied with the answer that the bowels are " regular." An instance is on record of a woman who made this answer, and later it was found that she had one movement a week, which occurred regularly every Sunday n:orning before she went to church. Ask as to the number, color, character, and form of the stools passed daily or every other day, whether or not mixed or covered with blood, mucus, or pus ; as to the presence in the stools of altered blood, resembling coffee grounds. A further point of diagnostic importance to be elicited in regard to blood accompanying stools is whether it is bright red, showing an arterial origin, or dark red but fresh looking, pointing then to a source low in the bowels and usually signifying hemorrhoids. Inquire further as to any abnormality accompanying defeca- tion, such as discomfort, pain, or straining. If diarrhea be reported, ascertain whether it consists of merely one or two THE INTERROGATION OF THE PATIENT ^l loose Stools ill the morning (the so-called morning diarrhea) or whether the loose movements are more frequent, and likely to occur at any time of the day or night. In such cases learn definitely about the color, odor, and character of the stools, whether very thin, like dishwater, gruel-like, soft and mushy, putty-like, or fully formed — sausage-shaped ; also if formed, whether of normal size or small and narrow — of finger or lead- pencil size — as in spastic constipation. Flatulency. — Inquire regarding the presence of gas in the bowels, the times when it most frequently occurs, the odor of it, whether particularly offensive or nearly odorless, the amount of it, whether slight or so great as to maintain an almost constant rumbling and occasional loud explosions, so as to keep the patient out of society. Ascertain further re- garding the reaction of the system to the gas formed, that is, whether it passes rapidly through the intestines and out at the anus with or without an accompanying stool, or is long re- tained in some one or more pouches which are greatly over- distended, with pain and at times violent colic through ir- regular contractions — cramp pains — or merely sufficient to produce much discomfort by day with insomnia or broken sleep at night. The Genito-urinary System. — Whatever your suspicions or provisional diagnosis may be, you should neglect none of the chief systems of the body in your interrogation of the patient. The answers may bring out very unexpected symptoms, thus leading you to examine or have examined, and possibly find an important lesion in, a region which would otherwise have been wholly neglected with the result of an incorrect diagnosis. Inquire concerning micturition, its frequency by day or night, and any accompanying pain, discomfort, delay or diffxculty; and in the case of men, the character of the stream passed, also as to pain in the region of the bladder or rectum, referable to either hemorrhoids or a diseased prostate gland or trouble in the seminal vesicles. In the case of both men and women, do not fail to ask particularly regarding sexual matters, except 72 METHODS OF EXAMINATION when the patient is an unmarried woman. An enormous amount of disease affecting every one of the other systems has its origin in faulty sexual hygiene, and, delicate as the subject is, the physician who ignores it must very often leave undiscovered the cause and nature of the trouble he is attempt- ing to remedy, with a resulting failure which is harmful always and sometimes disastrous to both his patient's health and his own reputation. Excessive sexual indulgence is doubtless common enough, and the cause of considerable disease; but masturbation, the abnormal excitation of sexual passion with- out the normal satisfaction of it, incomplete coition, that is, the act interrupted to prevent conception, and other perversions or abuses of the reproductive instinct, are all exceedingly prevalent and result indispLitably in a very large amount of ill health. If you will question all married persons as to the number of children they have had, the intervals between pregnancies, and, when these have been exceptionally long, as to any methods practiced for preventing conception, you will be surprised at the number of respectable and otherwise excellent and intelligent married couples wdio have for years been resorting to the coitus interruptns, with a resulting wrecking of the health of one or both, including nearly always the nervous and digestive systems. In the case of women, besides interrogating as to urinary symptoms, you will, of course, inquire concerning pains in the lower back and pelvic region, and very fully as to the menstrual function, whether regular and at what intervals, the amount and character of the blood lost, the duration of the periods, and whether painful or not. When there is suspicion of masturbation or abnormal sexual excitation in any form you will need to exercise much discre- tion in each case as to whether it is better to ask questions upon the subject with all possible delicacy, or to convince your- selves by other means such as an examination of the genitals. Masturbation usually produces certain changes in them and can often be recognized also by other signs. LECTURE V THE PHYSICAL EXAMINATION OF THE PATIENT General Considerations. — After a full and systematic inter- rogation of the patient, you may or may not have ground for suspecting some of the digestive organs to be involved. If the chief complaint has been of indigestion, or of any irregu- larities or abnormalities connected with the digestive functions, whether it be of a dry mouth, pointing to deficient or defective saliva or, at the other end of the alimentary canal, difficult or painful defecation, it will be desirable to make an examination of the entire digestive system, for deficient saliva impairs the digestion and piles usually result from an overworked liver. The cause of the trouble, even in these cases, however, will often be found elsewhere. It may be a consequence of heart disease, tuberculosis, or a disorder of the nervous system acting refiexly upon the stomach or intestines. After an exploration of the gastro-intestinal organs and testing the stomach, if no abnormality appears to exist in any of them, you will naturally look further for the cause of the malady. A constant coldness of the hands and feet would indicate derangement of the circulation, but by no means necessarily heart disease. Much oftener it is due to a contraction of the arterioles resulting from an excess in the blood of xanthin bases or other toxic products of a faulty assimilation, and in all such cases some of the digestive processes are imperfectly performed. But, on the other hand, there may be serious disease in one or more parts of the digestive system even when none of the symptoms seem to point in that direction. For instance, 73 74 METHODS OF EXAMINATION persistent or frequent insomnia, in the absence of pain any- where in the body, should awaken suspicion of a digestive derangement, especially of excessive secretion of HCl, sluggish intestinal functions, flatulency, etc., and pain in the lower back in women or other complaints in them dependent upon a dis- placement of one of the pelvic organs, should lead to a careful search for a downward displacement of the stomach and trans- verse colon with or without a coincident ptosis of the kidneys and others of the abdominal organs, since these latter displace- ments very frequently precede the trouble in the pelvis, produc- ing by a direct pressure a malposition of the uterus. Whenever you have reason to think, that some part of the digestive system is at fault, you should proceed to an examina- tion of the organs connected therewith in an orderly and thorough manner, carefully recording the results. Inspection. — Every examination properly begins with in- spection. Naturally you will first look the patient over care- fully and note his appearance, the tint of the skin and condi- tion of nutrition generally — i. e., whether he is of 'full habit and plump with smooth rosy skin and pink cheeks, or, on the contrary, thin, emaciated, wrinkled prematurely, pale or sallow, etc. You could scarcely fail to notice also whether the expression is one of cheerfulness and contentment or whethei it shows pain, anxiety, worry, or depression. Dyspeptics are most likely to present the latter aspects, especially if their dyspepsia depends upon an organic lesion or serious functional derangement of long standing, though in some cases of hysteria and in a smaller percentage of cases of neurasthenia with sympathetic disturbance of the digestion, there may for a long time be good general nutrition with a well-rounded form and the bloom of health. A similar robust appearance may coexist with gastric catarrh or round ulcer of the stomach in their earlier stages. As a rule patients who have suffered for several years with decided indigestion whether from organic or so-called functional, reflex, or sympathetic causes, show a lowered nutrition, not possessing either a ruddy complexion THE PHYSICAL EXAMINATION OF THE PATIENT 75 or the usual amount of adipose tissue, but there are many ex- ceptions, especially as to adiposity. After such a general inspection, you should look carefully into the oral cavity and note very particularly the condition of the lips, tongue, teeth, gums, and pharynx. The tongue may sometimes be clean and natural looking in spite of the fact that a considerable catarrhal process exists in the stomach or intestines, and in general its appearance may depend upon the condition of the pharynx or upon that of any of the structures below. It is probable, too, that catarrh of the duodenum, quite as often as a similar process, in the stomach, is accompanied by a furring of the tongue. Whenever, how- ever, the tongue is coated, there is trouble somewhere requiring attention — either, as is most usual, in the alimentary tract, or else deficient excretion through the kidneys relative to the amount of poisons to be excreted. If it results from a catarrhal inflammation in the pharynx, it is still important, since the latter, when allowed to run on, tends ultimately to involve, both by continuity and by infection through the swallowed mucus, the esophagus, stomach, and intestines. Without a sufficient number of properly opposed teeth to do good chewing, there cannot be a satisfactory digestion. De- caying teeth and diseased gums are often the unsuspected cause of troublesome inflammatory conditions in the stomach. I have encountered numerous cases of chronic gastritis which yielded promptly after the mouth had been cleared of rotten stumps of teeth, or a purulent process in the gums had been cured. Boas reports cases of gastric catarrh which were treated ineffectually for years, but quickly responded after remedying a chronic inflammation of the pharynx. The uncovered thorax and abdomen should next be closely inspected, never neglecting the precordial region, since heart disease so generally disorders the digestion, producing a stasis in the liver and viscera with constipation, hemorrhoids, etc. Note whether the apex beat is in its normal site in the fifth interspace inside the nipple line, or further out or lower 76 METHODS OF EXAMINATION down, as in hypertrophy or dilatation, and also whether there is bulging of the chest wall directly over the heart, increase in the width of the intercostal spaces on the left side, or a forward projection of the lower end of the sternum, as may often be seen^n marked cardiac enlargements. Inspection of the abdomen, though inferior to palpation and percussion, is one of the useful methods of examination and often affords valuable information. It should never be neglected when any digestive disorder is suspected. Even with- out inflating the stomach or colon (procedures the technique and results of which I shall discuss later) much can be learned by a critical survey of the entire region bared of covering. The relaxed, flabby, and pendulous abdomen of the woman who has borne many children, or been formerly very obese, but subsequently lost her flesh through ill health, not through exercise, will contrast markedly with the firm, symmetrically rounded form of the woman, young or old, who, whether she is a nullipara or a multipara, and whether she was at one time obese or not, has kept her trunk muscles in good condition by physical training as well as by the avoidance of tight corsets and of all luxurious enervating habits. If there is not too thick a layer of adipose tissue, and any of the viscera happen to be distended with gas, their outlines may frecjuently be de- termined by inspection without the help of palpation or percus- sion. Inspection may reveal a separation of the recti abdom- inalis muscles, especially when the patient is obese and the in- testines are full of gas. There is often a bulging outward then of the abdominal wall between the separated muscles. If the patient stands up while the abdomen remains exposed to view, any marked existing sagging (ptosis) of the viscera may be recognized. Such a displacement includes often the stomach, colon, and small intestines, with frequently one or both kidneys (the right one especially), and sometimes the liver and spleen may be recognized by the prominent bulging which would then show below the umbilicus (splanchnoptosis). Skilled palpa- tion in such cases will generally demonstrate the right kidney THE PHYSICAL EXAMINATION OF THE PATIENT T] (and sometimes both kidneys) to be movable. Exceptionally the liver and spleen will also be found to be displaced down- ward, but it is rare that any one of these ptoses occurring by itself, except those of the stomach and intestines, is visible. A far advanced tumor of one of the viscera may also, some- times, be manifest at a glance. In thin persons peristaltic movements may often be observed over the stomach and intes- tines, particularl}^ when the motor function has been in some way disturbed. Note particularly the appearance of the abdominal veins, whether or not swollen and tortuous and the amount of such swelling and tortuosity. The latter condition is significant of an obstruction to the return of the portal blood from the abdominal structures, and indicates frequently cirrhosis of the liver, though pressure from tumors may sometimes produce the same condition. The presence of fluid in the peritoneal cavity (ascites), when in large amount, may be detected by inspection, the whole abdomen being symmetrically enlarged, especially in its lower part when the patient stands, and in the flanks more particularly when he is lying on the back, although when the accumulation is extremely large, the abdominal walls may be so fully distended that there is little change in their appearance in the two different positions. The bulging below the line of the umbilicus, in cases of general sagging of the viscera (splanchnoptosis), differs from the swelling in a case of moderate ascites chiefly in that the bulging in the former is more central and does not change so greatly upon the recum- bent position being assumed. Palpation. — Palpation is one of the most important methods of examination and is a difficult one in which to become expert. Good training and much experience are both necessary to fit the clinician for accomplishing accurate results by means of it, but the art, once acquired, is of the greatest value, especially in the exploration of the abdominal viscera. For palpation in this region, place the patient in a recumbent position with the knees flexed over a pillow. To palpate well you will need to 78 METHODS OF EXAMINATION keep your lingers soft and smooth on their pahnar surfaces and be sure that they are warm; for nothing is so hkely to provoke embarrassing resistance through involuntary contrac- tions of the muscles overlying the parts being explored as coldness of the palpating fingers. Feel very gently first over the surface with the flat of one hand constantly in contact with the abdomen, employing at first the lightest touch, and then afterward, when the parts have become more accustomed to the manipulations, gradually insinuate the tips of your fingers deeply down into the cavity, until finally you may often be able with one hand superimposed over the other, to bring them into contact successively with the various structures upon the back wall of the abdomen. This should enable you to recognize marked abnormalities of these structures, including the appendix vermiformis, as to size, position, and degree of hardness, also to determine the existence, situation, and size of tumors in the abdominal cavity. Xote any unusual resistance, but be very careful not to be misled by contractions in the recti muscles. Indeed, the condition of the abdominal muscles generally, as to their relative tonicity and reflex excitability, varies greatly in different patients, as well as in the same patient at different times. This has important bearings upon the diag- nosis and treatment. In persons of normal nerve tone it should be possible by diverting their attention, as by conversa- tion during gentle palpation, to obtain sufficient muscular relaxation for very satisfactory results. One may then feel through even the well-developed recti muscles and determine the condition of structures beneath them. When there is marked flabbiness of all the muscles, as in many persons with ptoses, without unduly heightened reflexes, palpation is un- usually easy and fruitful in results. On the other hand, various degrees of increased reflex excitability will be found in the abdominal muscles of patients, and in some this is so extreme that upon the first attempts at palpation the muscles instantly stift'en, becoming board-like in their rigidity. In THE PHYSICAL EXAMINATION OF THE PATIENT 79 these cases palpation reveals almost nothing except the bare fact that there is a peculiarly excitable nervous and muscular system, from which you may generally infer the existence of neurasthenia with probably also spastic constipation, and very often, though not necessarily, excessive secretion of HCl in the stomach. But even in these cases you may often succeed after the patient's nervousness has been calmed. By gentle friction with well-warmed hands over the abdomen and patiently persisting, it is frequently possible to make finally a fairly satisfactory palpation, even when at first the slightest pressure of the finger tips was opposed by a vigorous muscular contraction. To map out and explore by palpation the less deeply placed organs of the abdominal cavity the left hand should be used to push the organ toward the palpating hand and hold it in position, while the fingers of the latter are made to pass lightly over and around it. By a form of this bimanual palpation either kidney can be very easily felt, when sufficiently movable to appear even in part below the ribs. To examine the right kidney, the examiner sits on the right side of the patient. His left hand is pressed against the site of the kidney from behind while his right hand is pushed, gently but deeply, down into the abdominal cavity from in front just to the right of the median line and directly under the level of the lowest rib, the fingers of this hand being directed downward and outward. Then, if the kidney be not loose, the fingers of the two hands will meet with nothing but the anterior and posterior walls of the trunk between them. But if the kidney is movable it may be recog- nized and grasped as it emerges from behind the ribs during a full inspiration, and, returning, can again be felt to pass through the fingers with expiration. The pressure should be light during inspiration so as to let the kidney descend, but strong at the end of inspiration to retard the kidney's return. To examine the left kidney the physician should be on the left side of the couch or examining table, and the positions of the bands are reversed. A movable or prolapsed kid- 8o METHODS OF EXAMINATION ney is often very sensitive and should not be roughly handled. For a fuller account of the method of palpating the kidneys with an illustration of the method, see Lecture XL., on Mov- able Kidneys. The position and size of the stomach and its pyloric end can sometimes be made out by palpation alone, and it must be our main dependence for the determination of the thickness of the walls of these structures. The same is true as to the colon, especially its transverse portion, which is often pal- pable. Fecal concretions and accumulations may usually be felt in patients who are not too stout. Downward dis- placements of the liver and spleen (which, however, occur only exceptionally, while the right kidney, in women particularly, is very frecjuently thus displaced) may be recognized by palpation as well as by percussion. Unusual mobility of the tenth rib through a lack of its proper attachment to the rib above will be found at times in neurasthenic persons, and is considered by Stiller a valuable sign of what he holds to be a con- genital tendency to neurasthenia and relaxed muscles gen- erally.^ Supplementing palpation by pressure with the finger-tips assists in making the diagnosis of various abdominal diseases. When such pressure causes acute pain over small circumscribed areas it must always awaken the suspicion of ulcer; or it may signify appendicitis when the tender spot is over McBurney's point in the cecal region. If the sensitive area is in the epigas- tric region, especially just below the ensiform process of the sternum, or if it is over or to the left of the tenth, eleventh, or twelfth thoracic vertebra, the ulcer, if present, would usually be in the stomach; if a little to the right of the median line in front, and somewhat lower down, it would be more likely to indicate duodenal ulcer in any case presenting other symptoms of ulcer in that locality, including the passage of stools con- taining altered blood. An acutely sensitive spot over the 1 Arch.f. Verdaimngskrankh., vol. vii. p. 375. THE PHYSICAL EXAMINATION OF THE PATIENT 8 1 cecum, especially if near McBurney's point, might signify either ulcer or appendicitis, though it might mean merely catarrh of the cecum. In the case of even chronic catarrhal appendicitis a swelling can usually be made out by the skilled diagnostician in a patient who is not very stout. A lesser degree of sensitiveness to pressure, particularly if more diffused, would suggest the possibility of a chronic catarrhal inflammation of the viscus underneath, though it might be due to a hyperaesthetic condition of one of the plexuses of the sympathetic, or indicate nothing more serious than a highly-wrought and oversensitive nervous system. But in the latter case you would generally find a similar hyper- sesthesia over most parts of the abdomen and possibly even over the thorax or arms. Palpation over the spinal vertebrse and ever the regions on either side of the vertebrae, where the spinal nerves emerge from the intervertebral foramina, is also highly important in many cases. All authorities upon diseases of the stomach recognize the importance of palpation over the lower dorsal spine in suspected gastric ulcer. When ulcer is present in the stomach there are nearly always spots painful to pressure, either over or more frequently to the left of one or more of the vertebrae between the eighth dorsal and the first lumbar. In my experience these spots are oftenest found just to the left of the eleventh or twelfth dorsal vertebrae. It does not, however, seem to be generally recognized that chronic disease in any part of the gastro-intestinal tract is likely to be accompanied by sensitiveness to pressure over or along the side of the spinal vertebrae corresponding to the points of emergence of the spinal nerves which contain fibers supplying the viscera involved. The late Dr. Hammond, in his work on " Diseases of the Nervous System," devoted much space to an account of the nerve affection known in that day as spinal irritation, and in the course of that account called atten- tion to the fact that, when any portion of the spine :s sensitive to pressure, the viscera supplied by nerves passing out from the 82 METHODS OF EXAMINATION spine in the same region are often found to present abnormal conditions. He quoted from numerous authors views similar to his own, and all seem to have considered the coincident visceral disturb- ances as results rather than causes of the spinal condition. Dr. Hammond ^ quoted one writer as follows : " Mr. J. R. Player was among the first English physicians, if not the very first, to call attention to the fact that eccentric derangement of function may be the result of irritation of the spinal cord. Thus he says : ' Most medical practitioners who have attended to the subject of spinal disease must have ob- served that its symptoms frequently resemble various and dis- similar maladies, and that commonly the function of every organ is impaired whose nerves originate near the seat of disorder. The occurrence of pain in distant parts forcibly attracted my attention, and induced frequent examination of the spinal column; and after some years' attention I considered myself enabled to state that in a great number of diseases morbid symptoms may be discovered about the origins of the nerves which proceed to the affected parts, or of those spinal branches which unite them; and that, if the spine be examined,, more or less pain will commonly be felt by the patient on the application of pressure about or between those vertebrae from which such nerves emerge.' " Dr. Hammond himself gave the following directions for carrying out an examination of the spine : " To ascertain Avhether or not the tissues outside of the spinal canal are in a state of hyper?esthesia, the pressure should be applied with gradually increasing force, b)' means of the thumbs applied to the spinous processes and the intervertebral spaces, as recommended by Flint. The examination should be thorough and extend throughout the whole extent of the vertebral column. The fact that the patient denies the ex- istence of tenderness should have no weight with the physi- '" Diseases of the Nervous System," by Wm. A. Hammond, M. D., New York, 1876, p. 387. THE PHYSICAL EXAMINATION OF THE PATIENT 83 cian." Continuing, Dr. Hammond described the case of a lady who had been treated several years unsuccessfully for dys- pepsia and denied having any spinal tenderness. He found three very tender spots on her spine, and applying local treat- ment to them, effected a cure. Dr. Still, originator of the so-called osteopathic treatment, seems to have enlarged upon these observations of Hammond, Player and others relative to the spine and spinal nerves, and, combining with their methods other manipulations, including some of those usually employed by masseurs, sought to establish a new system of medical practice from which medicines should be entirely excluded. But already his followers have found the system too narrow, and a number of their schools are now beginning to teach materia medica, just as the ablest and most con- scientious homeopaths have abandoned an exclusive depend- ence upon infinitesimals. Dr. John P. Arnold has called attention to a novel objective sign which may be recognized upon palpation over the sensitive regions alongside the spinal vertebrse, and sometimes in such regions which are not sensitive to pressure, though in all cases he maintains that the part of the body sup- plied by the vaso-motor nerve fibers emerging in the corre- sponding intervertebral space will be found to present some abnormal condition. The peculiarity described by him is, in such cases, a somewhat doughy, and in chronic ones, a gristly, tense, cord-like feeling of the band of longitudinal muscular fibers which are found on either side of the spine. This abnormality is supposed by Arnold to be due to a con- gested or infiltrated condition of the muscle while the cord itself is anaemic, probably, in chronic cases. Hammond believed the spinal cord to be ansemic in such cases. The findings obtained by a careful palpation over the spine should thus assist in directing our attention to the organ or part of the body which may be suspected of being diseased. You should make it a rule to examine carefully the spines of all chronic invalids by pressing deeply with the finger-tips (or with the thumbs, as Flint advised) close to the vertebrae 84 METHODS OF EXAMINATION and then exert gentle traction in a lateral direction outward from the spine on either side. The patient should be lying upon his right side while you palpate along the left side of the vertebrae, and should then change to his left side in order that you may palpate upon the right side of the latter, so that the tissues may be in the utmost condition of relaxation practicable. In both cases you will find it best to stand in front of the patient and reach over his upper side to make palpation along the region of the upper side of the spinal column. In numerous patients, especially those suffering from digest- ive derangements, you will be likely, while palpating in the way described, to recognize in the longitudinal muscles run- ning parallel and close to the spine the tense, cord-like sen- sation above mentioned. If, simultaneously with your recogni- tion of such a condition, the patient complains of sensitiveness in the same regions, the accuracy of your finding will be at once confirmed. By noting in Lecture II. concerning the anatomy and physiology of the nerve supply of the stomach and in- testines to what part of the tract the vaso-motor nerves are supplied which emerge from that segment of the spine near which the tenderness and signs above described can be made out, you will be enabled to direct your suspicions to the organ or part thus supplied. For example, if you can find this sign by palpating alongside of any of the lower dorsal vertebrae, and, especially if there is sensitiveness also to pressure in the same place, you should suspect some disease in the stomach, or possibly in the small intestines; but it might signify disease in the liver or pancreas, either alone or in conjunction with an involvement of the stomach and small intestines, since the vaso-constrictors which supply all of these organs are found in some of the spinal nerves, from the fifth dorsal to the second lumbar. THE PHYSICAL EXAMINATION OF THE PATIENT 85 AUSCULTATION AND PERCUSSION Auscultation plays a comparatively small part in the exami- nation of the abdominal organs, yet it can be made to afford information of value. When one drinks, a swallowing sound may often be heard over the ensiform process and normally about seven seconds later a second sound caused by the passage of the liquid into the stomach. But in cancerous or other ob- struction of the cardiac orifice of the stomach, as well as in the case of obstruction of the esophagus from any cause, Ihere is usually a delay in the passage of food or drink into the viscus, and auscultation with a stethoscope of the second swallowing sound generally shows then a prolongation by eight to ten sec- onds of the ordinary time required for this sound to be audible after the subject has swallowed. When the obstruction is marked, the swallowing sounds may not be heard at all. But this sign is not very reliable. The first sound is very often not audible in health, and the second swallowing sound may ex- ceptionally be delayed in health, and instances are on record of its having been heard at the normal time when cancer of the cardia was present, though probably in an early stage. Auscultation of percussion and friction sounds (called aus- cultatory percussion and auscultatory friction) afford a very delicate method of determining boundaries, as will be described in Lecture VI. under the head of Summary of Author's Method. Percussion is the most convenient and generally serviceable of all the methods of determining the size and position of the abdominal organs, and when with this are conjoined in- spection and palpation, as well as auscultation of the splashing sound elicited by light tapping with the finger tips (clapote- ment), sufficiently exact results are as a rule obtainable for all clinical purposes. A more particular description of percussion appears in Lecture VI. , under the title of " The Author's Method of Outlining the Stomach," etc. Instruments for Determining the Size and Position of the Viscera. — Numerous ingenious forms of apparatus have been 86 METHODS OF EXAMINATION (IcNi'sed with the idea of accomplishing these results more accurately. Einhorn's gastrodiaphane, one of the best of these, consists of a small electric lamp placed at the extremity of what is virtually a stomach tube, through which pass rheophores connecting the lamp with a battery outside. After the patient, with bared abdomen, has drunk one or two glasses of water the instrument is introduced into the stomach, the room having first been darkened, and the current is turned on. Fig. 14. — Einhorn's gastrodiaphane. When the abdominal wall is not too thick, a glow of light can then usually be seen over and for two or three inches around the situation of the lamp. By having the patient assume differ- ent positions, the lamp can generally be caused to fall to the lowest part of the stomach and move from side to side, so as to show appnjximately the lower boundary of the stomach. Certain authors maintain that while this is, on the whole, a sat- isfactory means of mapping out the stomach, it is liable to mislead by the glow^ of light appearing most conspicuously some inches above, below, or to one side of the actual site of the lamp. It is a pretty method for class demonstration, and is very con N'incing to the friends of patients who might other- wise be skeptical as to the accuracy of a diagnosis of enlarge- ment or displacement of the stomach. The gastrodiaphane has pnjvcd (jf value according to my experience, especially as an aid in determining whether a tumor felt in the region of the stomach is in the anterior or posterior wall. When it is THE PHYSICAL EXAMINATION OF THE PATIENT 8/ in the former, and the lamp can be placed behind it, there appears a shadow in the patch of transmitted light. (See Figure No. 14.) Dr. F. B. Turck of Chicago has invented a revolving sound with a piece of sponge fastened to its distal extremity, for the purpose of cleansing effectually the walls of the stomach in cases of stubborn gastric catarrh, in which the secretions are often very viscid and adherent. This, by means of a simple crank mechanism attached to the upper end of the sound, is made to revolve and in doing so is moved from one end of the stomach to the other, following first the greater and then the lesser curvature. The inventor observed that the instrument, as it wabbled its way around inside the organ, Fig. 15. — Turck's gyromele. could be very plainly palpated from the outside by the exam- iner while an assistant turned the crank. In this manner the instrument, which Turck named the gyromele, affords prob- ably the most exact and reliable information obtainable with regard to the boundaries of the stomach. (See illustration.) In my earlier examinations of gastric cases I made use of the gyromele frequently, but with increasing experience in the employment of the convenient and altogether satisfactory methods described hereinafter, I now rarely find myself in need of any intragastric instrument to determine with an all-sufficient exactness the position and size of the stomach. Both the electrodiaphane and the gyromele have been used 88 METHODS OF EXAMINATION to assist in determining the position and size of various por- tions of the colon. With a reasonable amount of skill in the manipulation of them, they may prove very useful for these purposes, even though not often indispensable. By inflating the colon with air after emptying it thoroughly of feces, its posi- tion and the size of its different parts can usually be made out with sufficient accuracy, when the stomach has previously been filled with fluid. However, in doubtful cases in which extreme precision in diagnosis is important, and especially when there is reason to suspect very anomalous displacements, you should Fig. i6. — Electric gastroscope. know how to avail yourselves of the confirmatory results ob- tainable by these very ingenious instruments. A great variety of instruments has been designed for the inspection of the rectum and sigmoid flexure. Illustrations of some of the more useful ones are given in the lecture devoted to Diseases of the Rectum and Anus. For the examination of the colon generally the x-rays can be employed after previ- ously injecting one or two quarts of warm water containing in suspension subcarbonate of bismuth, about one ounce to the quart. All the bismuth salts, however, are now believed to be capable of producing toxic effects in very susceptible per- THE PHYSICAL EXAMINATION OF THE PATIENT 89 sons, when administered in the extremely large doses nec- essary for good x-ray pictures, numerous cases of poisoning by them having been reported; but the subcarbonate is prob- ably the safest of them. Magnetic oxide of iron has recently been recommended as a substitute for bismuth in x-ray work. It is said to be wholly free from toxic properties. By means of the x-rays the conditions existing in the lower colon, as to position, etc., can be very clearly made out when a soft rubber rectal tube, having a flexible cable inside of it, has been previously introduced. Various other instruments have been invented and are sometimes employed by gastrologists in the examination of the stomach and other viscera and for testing their motor power, but most of these are not indispensable. The gastro- scope, a metal tube devised with the idea of affording a view of the inside of the stomach, is not safe for general use, and even specialists rarely introduce it. It can give information of value in some cases, but cannot be introduced even by the most expert without causing the patient much pain and in- volving some risk. An illustration of an improved electric gastroscope is herewith shown. However, since the publica- tion of the earlier editions of this work an improved esophago- scope has been invented, which, very cautiously employed, can aid much in the recognition of disease in the esophagus, with only a little risk to the parts. Needless instrumentation, like needless surgery, it seems scarcely necessary to say, should be avoided, and I here describe and recommend the simplest methods which will effect the object in view. The soft, flexible tube is indispensa- ble in many cases for testing the gastric contents as well as for lavage, and patients soon learn to tolerate this when deftly used, but they are not always so easily reconciled to more formidable intragastric apparatus. LECTURE VI THE AUTHOR'S METHOD OF OUTLINING THE STOMACH AND DETERMINING THE STATE OF ITS MOTOR FUNCTION- OTHER METHODS OF EXAMINING THE VISCERA The subjoined extracts from a paper written by myself^ while engaged at work in Professor Ewald's clinic in the Augusta Hospital in Berlin, during the year 1895, explain further the reasons for seeking to acquire exact knowledge concerning the stomach and its functions by the simplest and least disturbing methods, and also describe the combination of such methods which I have found entirely satisfactory. Fifteen years of experience with these methods have confirmed the opinions then expressed. With the exception of the soft rubber tube recjuired to perform lavage in cases of stubborn gastric catarrh or dilatation and to extract the gas- tric contents for the purpose of analysis, I do not advise phy- sicians in general practice as a rule to employ instruments within the stomach. Those of you, however, who have not acquired sufficient expertness in percussion and its various modifications may find an advantage in other methods, and in the cases of patients who present none of the symptoms of ulcer or cancer and swallow the soft tube without difficulty, may safely venture upon introducing either the gastrodiaphane or gyromele to clear up a doubtful diagnosis. Under similar conditions and restrictions only do I advise you to use for the treatment of obstinate cases of gastralgia, deficient gastric motility, or other appropriate cases, the method of intragas- "^Med. News, January 18, i8g6, and Berh'ner kli'n. Wochenschr., 1896, No. 43. 90 METHOD OF OUTLINING THE STOMACH 9I trie electrization for which special electrodes have been devised by Stockton, Ewald, Einhorn, myself, and others. With the same cjualification, you may also find it safe and help- ful at times to employ an intragastric spray apparatus. But this will be discussed under the head of treatment later on. Here follow the extracts from the paper above referred to : The Use of a Stomach Tube Sometimes Impracticable " There are many cases of gastric disease in which, for one reason or another, we cannot employ even the soft tube, and still less the sound, or any of its ingenious modifications and amplifications. " Besides the contra-indications, we are obliged to take into account the foolish dread which many nervous patients have of this trifling procedure (the introduction of the stomach tube) amounting sometimes to an insuperable obstacle. " In order to reach as accurate a diagnosis as possible in such cases, I have been obliged to make the most of the various methods which do not include the employment of any instru- ment inside the stomach. Trusting that the mode of system- atizing such methods which have proved useful in my own work may be helpful to others, I venture to submit a descrip- tion of it. . ." A Combination of External Methods. — " We pass on to a study of clapotement (eliciting a splashing sound by tapping with the fingers) and percussion. It is to the value of the com- bined employment of these two procedures, according to a certain order, that I desire to call attention especially. Both are separately well described in the works of Ewald, ^ Boas," and other standard treatises on diseases of the stomach, and during recent years there have been numerous contri- butions to current medical literature on abdominal per- cussion. The most notable of these is a paper by Dehio,^ i"Diseasesof the Stomach, "by Prof. C. A. Ewald, M. D., New York, 1893. ^"Diagnostik u. Ther. der Magenkrankheiten," by Dr. E. Boas, 1894. '"Zur ph^'sikalischen Diagnostik der mechanischen Insufficienz des Magens," by Dr. Dehio. Separat Abdruck aus' den Verhandlungen des Congresses f. Innere Medicin. 92 METHODS OF EXAMINATION ill which he gives directions for percussing with the patient lying on the back, as well as standing, after drinking various portions of water. He states that the normal empty stomach is entirely within the thorax, and not accessible to percussion, but that the drinking of one-quarter of a liter of water pro- duces in the erect position a dull area, which extends ii^ cm. below the lower end of the corpus sterni; then by drinking the same quantity a second time, the dullness is extended 2.7 cm. further downward, and so on, until, after the person has taken a whole liter, he finds in the majority of cases the lower border of stomach dullness a few centimeters above the level of the umbilicus. He points out also that from the different degrees of distensibility thus indicated we may infer much as to the motility of the stomach. " On the other hand, Jaschtschenko,^ at about the same time, took quite the opposite view of the matter. He sharply criticizes Traube, whose conclusions were similar to those of Dehio above cited, and declares that the empty stom- ach is percussible, and that filling it gradually with water causes an extension of the dullness upward, but not downward. Neither of these two writers makes any mention of clapote- ment. " Obrastrow,- of Kiel, writing on this subject in 1888 an elaborate and valuable paper which I had not seen till the present article had been nearly finished, gave a full exposition of clapotement, but had not at that time as much faith in the accuracy of the information to be obtained by a delicate per- cussion as he has evidently since accjuired, judging by an able contribution which has just appeared from his pen.^ " Certain it is that even the normally small healthy stom- ach under usual conditions, when empty as well as full, pre- ' " Die Grenzen des Magens und des Darmcanals," by Dr. P. Jascht- schenko, Si. Petersburger iiied. Woch., 1888, No. 29. ' " Zur phys. Untersuchung des Magens und Darms," von Dr. Obrastrow, Deutsches Archiv.f. kltnische Mediciti, December 7, 1888. ^ " Ueber die phys. Untersuchung des Darms," von Dr. Obrastrow, Archiv.f. Verdaunngs Kraiikhciten, 1895, B. i., Heft 3. METHOD OF OUTLINING THE STOMACH 93 sents a portion of its anterior surface in contact with the front wall of the thorax, and to a small extent with the front wall of the abdomen below the ribs; and except in conditions of marked obesity it is not generally very difficult to determine both the upper and lower borders of that portion in contact. But stomachs which are thus almost entirely covered by the ribs are rare, at least in civilized communities, and physicians are seldom called upon to prescribe for them. " Physicians are most interested in abnormal stomachs, which nearly always extend far enough below the ribs to afford us the opportunity of testing their condition by all the usual methods of physical exploration. " My own experience has convinced me that stomachs, like noses, may vary considerably in size and yet be within normal limits, but that when they extend in the empty condition much lower than a point midway between the sternum and umbilicus, they are generally pathologic. That experience includes the examination of about 300 persons by the methods now under consideration ; 225 of these were examined in the course of my practice in Atlantic City, and the remainder in the Polyclinic of the Augusta Hospital in Berlin during the present winter, through the courtesy of Professor Ewald and his chief assistant, Dr. L. Kuttner. By the kindness also of Dr. Oesterreicher, pathologist at the same hospital, I have been permitted to witness numerous autopsies in the cases of persons who had had various forms of gastric disease, as well as a few whose stomachs were normal as to their size and position." Experiments Carried Out by the Author in Ewald's Clinic, — " In a number of the cases in Ewald's clinic, in which by external examination I had diagnosticated and designated by chalk lines on the abdomen gross departures from the nor- mal in the way of displacements, dilatation, or both, the stomach was afterward inflated with air and in some in- stances illuminated by the electric lamp from within, with a substantial verification of the results previously obtained. 94 METHODS OF EXAMINATION " Experiments were made by me in a series of six cases of gastrectasis in Ewald's clinic with a view of ascertaining whether by clapotement and percussion together it is possible to determine positively when the stomach has emptied itself. The patients reported in the morning, fasting. In each of these cases when the splash was obtainable and percussion in the 4^^ '■"m 1 / / \ |3 l^-'--' V > JH Ik Fig. 17: — Outlines of gastric tympany on percussion in a case of displace- ment and dilatation of the stomach. erect position demonstrated dullness in the lower segment of the stomach, I was able afterward by means of the tube to bring up a considerable quantity of the undigested remnants of a previous meal. Then after carefully emptying the stom- ach by aspiration the former tests were again employed, and this time with negative results. " Tn a number of other (doubtful) cases that were required to present themselves in the morning fasting, the presence of fluid in the stomach was suspected, and to determine the ques- tion I practiced clapotement and percussion, but failed to METHOD OF OUTLINING THE STOMACH 95 obtain a splash or to detect dullness over the lower part of the gastric area in the erect position. The tube was then used, but nothing obtained except three or four grams of a pale, thin solution, consisting mostly of saliva. " In this simple manner, therefore, we may test the motil- ity of any given stomach frec|uently, at various intervals after various kinds of meals, with very little difficulty or inconve- nience to the patient, especially after the boundaries have once been accurately determined. " Numerous experiments have also been made by me to determine whether the stomach fills upwards or sinks lower after the taking of food or drink in successive portions. The results have been somewhat various, as might be expected, according to the muscular energy of the stomach tested. In the cases of gastrectasis and all cases of weak motility, there has been a depression of the lower border after each glass of water except when it was already at the lowest point attainable, and then there was a demonstrable widening of the organ on either side. Since beginning this particular investigation, I have, unfortunately, not been able to find many normal stom- achs, but the few presumably healthy ones examined filled upw^ard, without the lower border as a rule showing any noticeable depression after drinking several successive glasses of water, thus confirming the observation of Jaschtschenko rather than those of Dehio and Traube. In some casQS, hov/- ever, in which there were no other signs of weakness, the area of dullness' increased both upward and downward after drinking. " It is best to examine the patient at a time when the stom- ach should be entirely empty — that is, in the morning fasting, or six hours at least after the last meal. But this is not always practicable, and after a light breakfast or a very moderate luncheon a healthy stomach will usually be found by the tests of clapotement and percussion to have voided its contents into the intestines at the end of two hours. Even when these tests show that gastric digestion is still incomplete we may in many 96 METHODS OF EXAMINATION cases, nevertheless, satisfy ourselves with sufficient accuracy as to the size, position, and motility of the organ; but in cases of difficulty or obscurity it is safest to examine the second time under -the best possible conditions. " If upon examining a patient six hours at least after his last meal we obtain the splash by clapotement, we can infer deficient motility. Noting at the same time the lowest point where the splash can be distinctly heard, we may infer, as a rule, that the lower boundary extends at least to about that level. " We should then percuss the abdomen with the patient in various positions to verify the results of clapotement and map out the boundaries. " If no splash should be obtained, before proceeding to ad- minister w^ater it is well to percuss with the patient first recumbent, and afterward, in the erect position, to determine the apparent stomach boundaries while the viscus is still empty. Note these mentally or mark them on the body. " Then have the patient drink one-eighth to one-quarter liter of water, and try again to obtain the splash. If it is obtained distinctly after the smaller amount of water men- tioned, it raises a question as to the motility, and will also show where to percuss with especial care and delicacy for the lower border. "For the adept in percussion the fingers may suffice to bring out the finer differences in tone, but with a good per- cussor and pleximeter the task is greatly simplified." A New Pleximeter. — " The cut of a new pleximeter devised by myself will be found below. It is wholly made of rubber of medium hardness and is very easily carried in the pocket. The smaller end serves ordinarily as the handle, but in map- ping out spaces very accurately or in percussing in narrow spaces, as between the ribs or over the clavicle, especially in children, it is better to reverse the ends and percuss over the smaller part. (See Figure No. 18.) " Any one of the rubber-tipped percussors usually found in METHOD OF OUTLINING THE STOMACH 9/ the instrument-stores can be used satisfactorily with this pleximeter." Mapping out the Boundary, — " Having ah'eady made out the apparent boundaries with the stomach empty, we percuss again with it partl}^ filled while the patient stands, or, in the case of persons who are in bed or very weak, sitting upright Fig. i8. — Reed's Pleximeter. will usually suffice to bring the fluid contents in contact with the front wall of the abdomen and thus develop a zonp of dullness. In going over a new case in this way it is best to give one glass of water at a time, when, if the stomach is atonic, the area of dullness usually extends downward with each successive glass; but if entirely strong, it extends upward only or mainly. " One can begin either above or below, and should then percuss carefully in the median, left parasternal, and mam- millary lines from the level of the nipple to the pubes in any doubtful case. Having determined the highest and lowest points of the anterior thoracic and abdominal surface with v\diich the stomach is in contact, we should percuss perpendic- ularly across the oblique curved line joining these points and forming the left lateral boundary of this epigastric area. Then the right lateral boundarv separating the stomach from the ascending colon should be made out in like manner. With the patient erect and the stomach well filled, this is usually a simple matter, the ascending and descending colons and their flexures nearly always emitting a more or less tympanitic note, even when partly filled. If the precaution has been taken to have the colon previously emptied, the contrast with the dull note over the full stomach will be, of course, still more marked. 98 METHODS OF EXAMINATION Having the patient lie first on one side and then on the other during the percussion may help to clear up a doubtful question. Filling the colon with air b}- the double-bulb rubber syringe in the usual manner will emphasize strongly the contrast w^ith the dull stomach-area in the erect position, and filling the colon with tepid water while the patient is recumbent reverses the contrast in a very striking manner, though this is not a feasible undertaking with all patients, since some cannot retain the liquid long enough. " The determination of the upper border or stomach-lung boundary is the most difficult part of the procedure. Usually, however, by trying alternately light and strong percussion, there will be obtained a marked difference in the two qualities of the resonant tone, that over the stomach being more tympanitic. Still it recjuires much skill to make this out quickly and positively. Occasionally, in exceptional cases wdiere the stom- ach contains very little gas, we may fail at one examina- tion and succeed readily at a second one. This line is some- times more easily determined after a meal, since then such gases as are present are forced to the upper part and produce more tympany. One needs to bear in mind such possible dis- turbing factors as' a greatly enlarged spleen or enlarged left lobe of the liver; also left-sided pleurisy filling up the half- moon-shaped space of Traube with exudation." In some cases in which there is only a slight or small degree of motor insufficiency, especially in obese persons, it is diffi- cult or impossible to obtain a splashing sound by the usual manipulations alone. By causing such patients to contract and relax alternately while the physician makes the tapping movements with his finger-tips, the splashing may often be elicited. The Determination of the Gastric Motor-Power. — The above-described combination of external methods will enable you to map out the boundaries of the viscera in nearly all cases without even introducing a tube into the stomach, and having done this, to ascertain at any time when the stomach is METHOD OF OUTLINING THE STOMACH 99 empty or contains a large or small amount of fluid. It is then manifestly going only a step further to determine the relative motor power of the latter organ. The presence, extent, and loudness of a splash afford valuable evidence as to the motility, for in a normal stomach there is no splash, and the weaker the walls the greater the splash, but with the data above mentioned you can determine the motor power as ab- solutely as by the Leube method of extracting the contents with the tube at various times after a definite kind of meal. For, knowing where the lower boundary of the stomach is, with this knowledge, and the aid of percussion and the splash, you can decide with almost as much exactness as with the tube when the viscus has emptied itself. The time required by the stomach to empty itself determines its motility. Three hours after the Ewald test breakfast, con- sisting of a dry roll and ten ounces of water, the gastric coi> tents should have passed on into the bowel; and seven hours after the test dinner none of it should be left in the stomach. A longer retention of either meal signifies a weakened motility, or else obstruction at or near the pylorus. INFLATION OF STOMACH AND COLON, ETC. The principal addition to the above-described methods as originally prescribed by me is preliminary inflation, of the stomach with either air forced in through a tube, or carbonic acid gas (CO2) formed within the viscus by sodium bicarbon- ate and an acid. Formerly I inflated by pumping in air, but as this required an extra introduction of the tube, and I found long ago that moderate inflation with COo, when properly managed, involved no danger, while it was of very decided assistance in facilitating the process of mapping out the boundaries, I have since employed it in nearly all my important cases after roughly determining the upper and lower limits without it. The patient is asked to drink a solution of half to a level teaspoonful of sodium bicarbonate lOO METHODS OF EXAMINATION in a goblet of water/ Then, if becanse of there being little or no free acid in the stomach, insufficient inflation results, 8 to 12 drops of strong chemically pure hydrochloric acid, according to the amount of soda used, may be dissolved in another glass of water and taken by the patient. After a momentary kneading of the epigastrium the two chemicals combine and the stomach is inflated with the disengaged COo, so that a tympanitic note is produced by even very light per- cussion anywhere over it. This procedure has been employed by me thousands of times without any unpleasant results, but is likely to distend atonic stomachs somewhat, increasing their apparent size, and it is therefore desirable to percuss and try to elicit the splash both before and after inflation. It will be noticed that I do not follow the directions laid down by most other authors as to the choice of an acid to form with soda the COo. These recommend tartaric acid, which is effective but often purges, and this is not always desirable. Summary of the Author's Method. — Percuss and try to obtain the splashing sound with the patient first recumbent and then in the erect posture; also before and after administering successive glasses of water. If a splashing sound can be obtained, the lowest point where it can be heard will indicate approximately the position of the greater curvature. When there is doubt or difficulty in dis- tinguishing the percussion notes obtained over it and the ad- joining structures, inflate the stomach and then percuss again. Very delicate and precise results can be obtained by ausculta- tory friction, with the help of a good phonendoscope or bin- aural stethoscope. In auscultatory percussion, the ear pieces of the instrument being in their places, the other end is held by an assistant or by the patient in the desired locations, while ' The amounts of soda here advised are much larger than those neces- sary to neutralize the specified quantities of HCl (which would be i gram HCl to .86 grams HNaCOs), but there is usually some acid in the stomach, and in any case an excess of soda is safe. METHOD OF OUTLINING THE STOMACH lOI the examiner percusses lightly in various directions from it. The differences in pitch and cjuality of sound are thus greatly exaggerated. In auscultatory friction the instrument is held in like man- ner while the finger tip, pencil, or other similar object is rubbed over the skin. The sound thus produced is heard distinctly so long as the rubbing is made over the hollow organ over which the stethoscope is placed and not more than two or three inches away from it, while upon crossing the boundary to another organ, even an inch away from the stethoscope, it is no longer heard. Compare the findings from these various percussions under the following different conditions : I. The stomach and transverse colon being both empty except gas, with the patient recumbent, tympanitic notes, nearly always different in pitch and Cjuality, will be heard over these two viscera, while occasionally a still higher pitched sound may be heard lower down over the coils of the small intestine. The boundary above, between stomach and heart, can then be generally made out except in fleshy persons (who are not often sufferers from serious gastric disease), or when there is very little gas in the stomach. In these cases inflation will be necessary, and this will also greatly intensify the difference between the percussion notes over the stomach and colon. II. With the same conditions except that the patient is standing the results should be much the same, though since the gas rises to the highest part of the stomach, there is often a greater tympany there. This facilitates the determination of the boundary between the stomach and heart and between the stomach and lungs. If there should be even a very mod- erate amount of fluid remaining in the stomach, it will give a narrow zone of dullness at its lowest part. III. With the colon empty and the stomach containing two glasses of water, you will have the same findings as before while the patient is recumbent, except that the tympany over. 102 METHODS OF EXAMINATION the stomach should be more marked even without inflation, but upon the standing" position being assumed, the condition is iinmediately and strikingly changed. There is now a de- cidef\ zone of dullness across the lower portion of the region over the stomach, while the note over the intestines remains tympanitic, as before. After finishing percussion further useful information may be gained by trying clapotement again with the two glasses of water in the stomach. While the patient is lying on the back, as before described, make repeated tappings with the fingers over different parts of the epigastric region. If a loud splash is easily obtained over a wide area, the stomach walls are atonic — its motility bad. If, in addition to much splash- ing in it, the organ has been found to be enlarged, there is gastric dilatation, which is more or less extensive according to the extent of the area over which the splash can be pro- duced. The use of the phonendoscope will enable you the more readily to determine this area, though you may some- times be misled by it, since a splashing sound may often be heard through it at some little distance from the place where it is actually produced. Clapotement is less reliable than percussion for the determination of boundaries, but the two methods may both be employed when accuracy is desired, so as to have one confirm or correct the other. Radiographs of the Viscera. — In the case of a patient with thin abdominal walls, a powerful x-ray apparatus in the hands of an expert will often produce a radiograph in which the outlines of the stomach can be clearly made out, provided a solution containing one dram of bismuth subcarbonate has been administered twice or thrice a day, some time before meals, for two days preceding. When Turck's gj-Tomele has been previously introduced into the stomach the result can be made still more satisfactory. The metal cable of this, inclosed within a tube, makes a sharp contrast with the surrounding part of the picture, and nearly always the gyro- mele may be depended upon to follow, and thus outline dis- tinctly, the greater curvature of the stomach. By repeated METHOD OF OUTLINING THE STOMACH IO3 injections of a sufficient cjuantity of bismuth or, which is safer, magnetic iron oxide, into the bowel the colon may be sufficiently coated with this material to assist in obtaining a fairly good radiograph of that viscus : but as in the case of the stomach the previous introduction of an elastic metal sound will give more definite results relative to the course of the colon, even if it cannot show its size or caliber. See p. 88 as to the dangers of bismuth. In a patient with a not too sensitive intestinal mucous membrane, you may determine the position of the colon in its various parts by filling it from below with a warm weak solution of salt (5 i to the cjuart), while he lies on the back or left side with the hips elevated. By injecting enough of the salt solution you may be able to obtain a dull percussion note, or by auscultation with the stethoscope or phonendo- scope while you tap over the different parts, you may hear gurgling or slight splashing sounds over the course of the colon, especially if it be dilated. For the success of this procedure it is necessary that the stomach should be wholly empty, so that any splashing sound could arise nowhere except in the colon or cecum. The Pottenger Method of Outlining Organs. — Dr. F. M. Pottenger of Los Angeles has described a remarkable refine- ment of examination which he calls " Light Touch Palpa- tion." By a touch so light that it barely indents the skin, the various solid viscera, such as the heart and liver, and in some cases the stomach, following a meat can be accu- rately outlined. It is a very simple method and depends upon the fact that organs and parts of organs differing in density, offer different degrees of resistance to the palpating finger. The doctor's own description of it should be read in full.^ I can personally vouch for the value of this method. Of late (1910) I have been employing it as the preferable procedure in beginning an examination for determining espe- cially the lateral and lower boundaries of the stomach. These can usually be made out in this way in a minute or two, and ^So. Cal. Practitioner, Dec. '09. I04 METHODS OF EXAMINATION the findings are rarely changed by the time-consuming method of percussion after inflation, etc., already described. The colon can sometimes be outlined in the same way though not so certainly unless full of hard feces. V CAPACITY AND MOTOR POWER OF THE STOMACH Tests of the Capacity of the Stomach. — Among these there are some involving difficult mathematical calculations which require time and trouble out of proportion to the value of the information thus obtained. When the boundaries of the stomach are accurately determined, its capacity can usually be inferred with sufficient exactness. One method of attempt- ing to ascertain the capacity of the stomach, I mention here only to condemn. It is rec|uiring the patient to drink as much water as possible, keeping a strict account of the arhount taken and inferring thence what the capacity of the viscus is. This is not only an injurious method which by frecjuent practice could easily overdistend and dilate the stomach, but is also a nearly useless one, the amount of fluid which any person can be induced to drink at one time depending quite as much upon the tolerance of the gastric mucous membrane and the amount of discomfort which a patient is willing to bear, as upon the capacity of the stomach. Moreover, another element of uncertainty in such a test is the patulousness of the pylorus. In some persons the pylorus remains tightly closed during the whole time of the experiment, while in others the normal rhythmic opening of the same would permit of the escape of a considerable part of the fluid ingested during the time of observation. In still other cases the pylorus is stiffened by disease in such a way that it is continuously open, not being capable of complete closure, and in such caSes a large part of the liquid ingested for the test would pass out during the experiment. The salol test of gastric motility is not now much depended upon by the best authorities. Other Methods of Testing the Motility of the Stomach. — Dehio has a patient drink one-fourth of a liter of water and METHOD OF OUTLINING THE STOMACH IO5 then determines by percussion the position of the greater curvature of the stomach. Then in succession three like cjuantities of water are given and the position of the greater curv^ature is determined after the drinking of each portion. When the motihty is normal, the stomach does not distend downward to any noteworthy extent, but the greater the motor insufficiency the lower will the stomach descend after each additional glass of water. This is a method of value and can be easily applied in most cases. The presence of a loud splashing heard over a large part of the stomach is one of the surest evidences of weak motor power in the viscus. Carnot ^ has recently recommended a simple method for determining in case of delayed emptying whether or not there is obstruction at or near the pylorus. After the fasting stomach has been washed out, the patient drinks a pint of water and stands or sits upright for an hour. If the delayed emptying has been due to atony or dilatation even with no existing obstruction, much of the water would be found still in the stomach at the end of the hour. Then, on another morning the experiment is repeated with the patient reclining on the right side so as to make the pylorus surely the most dependent part and enable the water to escape easily by gravity provided the pylorus be patulous, but other- wise not. If now the stomach has emptied itself within the hour the second time but not the first time, there is no stenosis at or near the outlet and atony exists. If it does not empty even while the patient lies on the right side, the pylorus or possibly ihe small intestine is obstructed. There is, however, a possible exception. In a case of hyperchlorhydria there might be food stagnation from pyloro- spasm while the water would still pass out in the normal time. Another method is to introduce the tube at various intervals after some definite meal has been eaten — for example at five, six, seven, and eight hours after the Leube test dinner — to ascertain whether any fluid is then in the stomach. If at the '^Press,e Medic ale, 1909. I06 METHODS OF EXAMINATION end of fi\'e hours only a small quantity of chyme remains, the motility would be shown to be good, especially if, at the end of six hours, the stomach should be found to be com- pletely empty. If food remains should be found at longer intervals after such a meal, they would indicate the probability of muscular insufhciency or deficient motility in the stomach, and the longer the time after the meal when such remains could be found the greater would be the muscular insufficiency to be inferred ; yet, on the other hand, a deficient secretion causing very imperfect digestion can also delay the emptying of the stomach. There is an obvious fallacy, therefore, in this last method of testing the motility, and it really renders it untrustworthy unless a careful account be taken at the same time of the other conditions present. At least two other condi- tions besides the strength of the gastric musculature affect the length of time during which a meal remains in the viscus. These are the efficiency of the digestive glands and the pro- portion of acid present, not to speak of a possible mechanical obstruction at the pylorus. When the percentage of HCl and pepsin is so low that digestion proceeds very slowly and an abnormally long time elapses before the coarser particles of the food are dissolved, the emptying of the stomach may be much delayed, especially when mastication has been imperfect, since the pylorus does not readily open to permit of the ex- pulsion of bulky particles not in solution. Again when the contents of the stomach are abnormally acid, whether from an excessive secretion of HCl by the gastric glands, the ingestion of an excessive amount of acid with a meal, or the develop- ment even of very large amount of organic acids in the stomach from fermentation of the food, there is frecjuently such a spasmodic closure of the pylorus as delays very markedly the time of emptying ; and when there is a thickening of the structures about the pylorus, whether from h3^pertrophy of the muscle, the scar of a healed ulcer or a malignant growth, a narrowing of the outlet results with consequent delay in the expulsion of the gastric contents. The chief value, then, of canwing out this method of Leube, METHOD OF OUTLINING THE STOMACH 107 which has been considered the most rehable of the tests for gastric motihty, is that thereby you may learn that there is, or is not, present some decided fault in the stomach — either in its secretory or motor functions or both. When by this test such a fault is discovered to exist, it becomes your duty to search further and ascertain the real cause. E. g., when you wash out six hours after a hearty dinner and find a large quantity of semi-digested food with a very offensive odor suggestive of the swill barrel on a hot day, you can infer that the gastric secretion is deficient, and that probably the motor power is so also, since the amount of fermentation evident would be prima facie evidence that it must be at least con- siderably below normal. On the other hand if the tube readily brings away at the same interval after a generous dinner of meats and vegetables a large amount of perfectly digested fluid, especially if it has little odor, but tastes very sharply acid, and an analysis reveals HCl excess, you can decide that the case is one of hyperchlorhydria with likely a spasm of the pylorus delaying the emptying of the stomach, rather than deficient motor power in the gastric walls. But in a less marked case, showing a small amount of poorly digested stomach contents at the end of seven hours, with only a moderate deficiency of HCl and the ferments and not much evidence of fermentation, the diagnosis as to the gastric mo- tility would remain in doubt. For the purpose merely of testing the gastric motor power, the simpler methods above described are manifestly about as reliable as any. THE EXAMINATION OF THE SECRE- TORY FUNCTION OF THE STOMACH LECTURE VII INSTRUMENTS USED FOR THE EXTRAC- TION OF THE STOMACH CONTENTS How to Introduce the Tube into the Stomach with the least possible Embarrassment of the Patient. — For diagnostic purposes you will usually introduce the familiar soft, flexible, rubber tube in order to bring up a sample of the stomach con- tents either an hour after the Ewald test breakfast of bread and tea or water, or two to four hours after a mixed meal consisting of either meat or eggs and a more generous al- lowance of carbohydrates, as will be found explained fully, further on, in the section devoted to test meals. It is customary with many physicians to make use of the tube first for washing out the stomach, wdiich is usually a somewhat tedious procedure and likely to be a trying one to the novice. Extracting a sample of the stomach contents, on the other hand, is a comparatively simple and little troublesome task in a majority of cases when skillfullv performed. This is especially true when a good aspirator is deftly used and the attempt is not made to extract all of the stomach contents, as is practiced by many specialists and taught in nearly all treat- ises upon the subject of stomach diseases. Even with the best intention it is often impossible to empty completely the stomach with the tube, some ounces of fluid nearly always remaining; and even if practicable it is not often desirable, particularly with a new patient. The knowledge of the gastric motility thus obtained is often inaccurate and misleading and io8 SECRETORY FUNCTION OF THE STOMACH IO9 at all events could be obtained in other ways more easily and satisfactorily. (See preceding lecture on "The Author's Method of Outlining the Stomach and Determining the State of its Motor Function.") To empty the stomach as completely as possible takes much more time and subjects the inexperienced patient to decidedly more annoyance than is necessary. But in patients used to the tube as much as possible should be extracted, since this may secure somewhat greater accuracy in the chemical find- in2:s. _ ^ Fig. 19. — Flexible stomach tube with fenestrum attached. Select for first use ordinarily a tube not too large (not over a No. 28 or 30, French), highly polished, of medium flexi- bility and with a conical end, having an opening directly in the end, and at least one fenestrum on the side, about three- quarters of an inch above. It should have in it also some- where two or three inches of glass tubing as a window. You will need larger tubes when extracting the stomach contents in cases of gastric catarrh or of food stagnation; also, if you should wash out at any time other than before breakfast. As a lubricant for the tube, warm water answers well as a rule, though olive oil, butter, or glycerine is often used. Wetting the tube in ice water helps usually to prevent spasm of the glottis. Preparation of the Patient. — It is best to prepare the new 1 lO METHODS OF EXAMINATION patient for the introduction of the tube l3y a feW words of prehminary explanation. If he has not been frightened con- cerning the procedure by an exaggerated account of it given by some fooHsh friend, the difficulty will be far less than when such a prejudice has been created against it. The less said be- forehand about your intention to take up the stomach contents the better. My own rule is to ask the patient to eat a stale roll and drink a goblet and a half of water at 8.15 a. m., and be at my office at, say, five minutes after nine with- out mentioning for what purpose such a light meal is to be Fig. 20. — Flexible stomach tube, with funnel attached. taken. Caution is given not to take any other food or drink, or any medicine, that morning until after reaching my office. Then when the patient comes, he is told that I would like to have a few spoonfuls of his stomach contents and that he will need to swallow one end of a small and flexible rubber tube for that purpose. No display of the tube is made beforehand, and every effort is made to prevent the development of any excitement or fear. Then by 9.15, one hour after the patient began to eat his test breakfast, all should be in readiness for the actual extraction. Having secured then the proper mental state, which should be as nearly as possible one of composure, devoid of excite- ment and apprehension, slip around the patient an apron, SECRETORY FUNCTION OF THE STOMACH III preferably of thin rubber cloth and large enough to cover the body down to the knees. This should pass outside the arms (so as to prevent the hands involuntarily grabbing the tube at a critical moment) and be buttoned or tied behind the back. Then place him in a sitting position, in a good light, and sit down yourself in a lower chair in front, but a little to his right, so that if he should chance to vomit, you would not be in the way. Tell him now to open his mouth widely, hold his head bent a little forward (not far back, as most patients incline to hold it), and breathe regularly w^ith unusual deepness; that the only reason, as a rule, why some persons are uncomfortable when they first take a tube is that their respiration is em- barrassed as a result of a reflex irritation from the nerves of the throat, and that this can be usually avoided by breathing very deeply. Show him what you mean by taking a few strong inspirations yourself and, if doubtful of him, ask him to breathe as desired for a few moments before you introduce the tube. Introducing the Tube. — Then, taking hold of the tube as you would a pen, about six inches from the stomach end, pass it carefully back over the center of the tongue into the pharynx. Use your sight, and not a finger of the other hand, to guide the end of the tube down through the middle of the pharynx into the esophagus. The moment it reaches the pharynx the patient must be induced to make several rapidly repeated swal- lowing movements, which will facilitate its entrance into the esophagus, down which it will glide easily with the gentlest pushing on your part, provided the patient continues breathing at least as deeply as normal and makes swallowing motions between times. Even without the swallowing the tube can in most cases be easily and safely pushed on into the stomach if full inspirations are kept up. You will generally have difficulty in getting a tube into the stomachs of hard drinkers or heavy smokers, and will often fail altogether with them. Very nervous or hysterical women are also troublesome usually, but will occasionally sur- 112 METHODS OF EXAMINATION prise you by the ease with which they swallow the little instru- ment for the first time ; sometimes, however, one with extraor- dinarily heightened reflexes about the pharynx and very weak will 'power is unable to resist the impulse to seize and pull out the tube the moment it enters the esophagus, or even when it has already passed into the stomach and self-control for a second or two longer would enable a sample of the stom- ach contents to be obtained for analysis. In such cases it is indispensable that the hands be either well pinioned by a snug- fitting apron or held in the hands of an attendant, under the guise of sympathetic support. It is unusual for patients to complain of any serious nausea as the result of the introduction of a tube, and I should say that not more than one in twenty is excited to vomiting by it. The annoyance usually is from embarrassed respiration, the patient feeling as though he could not breathe. There is ap- parently in these cases a real obstruction of the air passages, a result, according to Vierordt, of a spasm of the glottis. This can generally be overcome by voluntarily bringing into action the auxiliary respiratory muscle? and making rhythmical forced inspirations. This relieves in a double way, ( i ) by diverting the attention of the patient from the passage of the tube and thus lessening the tendency to reflex spasmodic action, and (2) by powerfully expanding the lungs so as to obtain the entrance of air in spite of the contraction. Training of Irritable Throats. — You will see cases occasion- ally in which efiforts at deep inspiration will fail and the con- tractions of all the muscles about the pharynx and larynx will be so powerful that it will be impossible at first to insert any sort of a tube into the esophagus. In these very difficult cases I have often succeeded, after a few minutes of patient persever- ance in the process of educating the oversensitive pharynx to the presence of the tube. This is best effected as follows : Tell the patient that you desire merely to accustom his throat to the novel sensation of having a tube in contact with it and that you will not attempt to pass it into the stomach until SECRETORY FUNCTION OF THE STOMACH IT3 after due notice. Then while the patient holds his mouth wide open with the tongue well forward, carry the end of the tube back and let it impinge gently against the posterior wall of the pharynx. There will be immediately a reflex contraction of all the parts, but continue to hold the tube there for a few seconds before withdrawing it. After a little delay insert the tube in the same way again and repeat this procedure three or four times if necessary, calling the patient's attention mean- while to the fact that he has nothing to fear, as you do not intend to push the tube on further without notice. In this way the patient regains confidence and his morbid dread of the tube is largely overcome. After such a brief preliminary training it is generally quite practicable to pass the tube into the stom- ach successfully and often with very little inconvenience. Most stomach tubes have rings marked around them to indi- cate how far they should be introduced. The idea is to push the tube on until the ring comes to the teeth. This is a poor dependence. The distance from the teeth to the bottom of the stomach varies in even healthy persons according to their height and peculiarities of build, and in conditions of displacement or dilatation of the organ, which are exceedingly common, espe- cially in women, the tube may have to enter from one to possibly seven or eight inches beyond the mark. There are two ways of determining how far to introduce the instrument. The easier is to try it first at an inch or so above the mark, and if no fluid can be made to flow, gradually push it further, even if it is recjuired to pass it to a point six or eight inches beyond the mark. When liquid will flow in, it must return if the tube has been passed to just the right point and not beyond it. To pass it too far is as bad as not far enough, since the end may then curl up and the opening emerge above the level of the contents. The surer way is to determine first by one of the methods previously described where the bottom of the stomach is, and then, having measured the tube over the outside of the body, the distance necessary to insert it is readily seen. 114 METHODS OF EXAMINATION Some authors speak of the possibihty of the entire tube's being swallowed so as not to be recoverable without an opera- tion. This could never happen with inexperienced patients, who are always trying rather to force the instrument out; and only the grossest carelessness could make it possible with an experienced one. The long tubes now mostly in use, reach- ing two to four feet outside the mouth, could not pass entirely into the stomach unless intentionally swallowed. With those having a bulb on them for the purpose of forcing air through when clogged, or a soft rubber funnel at the outer end, the accident would, of course, be out of the question. As to the contra-indications for the tube, they will be few when you have become so expert as to be able to introduce it without letting the patient become unduly excited. But it will be wisest never to resort to its use soon after a hemorrhage Fig. 21. — The Kuttner Aspirator, from any internal organ, in cases of aneurism, in advanced lung disease, in serious forms of uncompensated heart disease, in conditions of great physical debility from any cause, or in the acute stage of gastric ulcer. The Kuttner Aspirator. — Various kinds of pumps or aspir- ators may be employed for the purpose of emptying the stom- ach. The best is the kind in use in Ewald's clinic, and is the SECRETORY FUNCTION OF THE STOMACH 115 invention of Kuttner, long Ewald's first assistant. These are now to be had at some of the instrument makers in the United States, and a cut of one is herewith shown. I imported one in 1895, and was the first writer in this country to describe and recommend it. It is similar to the Politzer air bag, only larger, of thicker rubber, and without any valve at the top. It is first compressed with the hand, and, while held so, the nozzle is introduced into the end of the tube. Then, when allowed to Fig. 22. — Kuttner aspirator with tube attached. expand, after being carried down to a point below the level of the lower border of the stomach, sufficient suction is exerted, with the help of siphonage, to empty the contents of the stom- ach with a minimum of disturbance or inconvenience to the patient. If the tube should be blocked with mucus in passing down, as sometimes happens, no contents will flow out. In this case you should disengage the bulb, and attach it to the tube again without compression. Then, by compressing it, you will force Il6 METHODS OF EXAMINATION its contained air downward through the tube and thus clear out the obstruction. The air thus forced into the stomach causes little or no inconvenience though, exceptionally, enough of it may return with the fluid contents to fill the bulb and prevent a complete emptying. You should then detach the bulb again and introduce it compressed. This, provided the tube has been inserted just far enough, rarely fails to bring up either all the contents, or 15 to 30 c. c, which are enough for all the neces- sary tests. If not, the difficulty may be that the stomach con- tents have passed prematurely into the duodenum as a result of excessive peristaltic action or pyloric insufficiency.^ lit is now a well-established fact that normally when there is an adequate secretion of HCl, the pylorus rhythmically opens and closes at short intervals during gastric digestion, but that when the HCl is insufficient, the pylorus remains too continuously open, so that at least the liquid parts of the gastric contents pass out too rapidly. LECTURE VIII TEST MEALS AND PREPARATIONS FOR TESTING THE STOMACH CONTENTS Concerning Test Meals. — In order to determine the secre- tory activity of the gastric glands it is customary to make chemic and microscopic tests of samples of stomach contents obtained as nearly as possible at the height of the digestive process, w^hich is about one hour after the Ewald test breakfast, or from two or four hours after mixed meals including meat, vegetables, bread, etc., the exact length of time depending upon the size of the meal. About two hours and a half after the average hearty American breakfast answers well. When vomiting chances to occur, especially at a suitable interval after eating, the vomitus' can be utilized for the purpose of the ex- amination. This, however, will generally give less accurate results, since the fact of vomiting presupposes an exceptionally disturbed condition of the stomach at the time and moreover it is rare that the patient happens to vomit at the period when digestion is at its height. Ordinarily, therefore, test meals of some kind are employed for the purpose of obtaining samples of the stomach contents for examination. The Ewald Breakfast. — A convenient meal, and that which is in most frequent use in both Europe and America, is the Ewald test breakfast. It consists, according to Ewald him- self, of an ordinary stale roll and one-third of a liter — about two-thirds of a pint — of fluid. The fluid may be either water or weak tea, without sugar or milk. Tea is that most usually ordered by Ewald and his assistants at their clinic in Berlin. A goblet and a half of water, not ice cold, answers the purpose quite as well, and is what I usually order for my own patients. 117 Il8 METHODS OF EXAMINATION In place of the roll, two moderate slices (or a little less than two ounces) of stale bread, or even half a dozen water crackers, not soda crackers, will suffice. Such a meal should, under normal conditions, uniformly digest into a thin grayish liquid at the end of one hour from the time the patient begins to eat, and it is then you should withdraw the contents for examination and chemical analysis. The Test Dinner. — Leube and Riegel have recommended and used largely a test dinner to be taken in the middle of the day. It consists of 400 c. c. (13 fluid ounces) of soup, 60 grams (2 ounces) of beef, and 50 grams (i^ ounces) of wheat bread or a roll. Sometimes a potato is added. The time for the examination of this meal is about three hours afterward. The ordinary American generous mixed breakfast, with meat, bread or rolls, potatoes and coffee, approximates closely the Leube test meal, and in the case of new patients who present themselves for the first time two to three hours after such a meal, you may find it convenient to empty the stomach at once for the purpose of analyzing the contents, thus gaining, without delay, important and sufficiently reliable information. But when such patients can return at another time, you should have them, if possible, take subsequently the usual Ewald test breakfast, which affords valuable data for comparison espe- cially since it has come to be accepted as the standard the world over. Do not make the mistake which is sometimes made of at- tempting to take up such a mixed meat meal at the end of one hour, since it will then be so little digested as not to pass through any ordinary tube without great difficulty. Pouring water into the tube may facilitate the process, but spoils the results of the analysis. Moreover, testing the stomach con- tents before digestion has reached its height would not afford results of value. The Lactic-Acid-Free Meal. — The only other test meal of which it is worth while to tell you is the Boas non-lacteaJ one TEST MEALS AND TESTING STOMACH CONTENTS HQ for the purpose of testing for lactic acid in suspected cancer of the stomach. Boas advises washing- out the stomach at bed- time to remove all traces of previous food, and then, in the morning following, the patient takes six to eight ounces of thin, well-cooked oatmeal porridge, which is prepared and served without milk, cream or sugar. An hour afterward this is brought up in the usual way. Boas' idea was that all breads, rolls, etc., contain milk enough to contaminate the product with lactic acid. But the view formerly advanced by him, that even a very small percentage of lactic acid formed in the stomach is a sign of gastric cancer, is no longer accepted. Boas, however, still maintains, and with much clinical evidence in his support, that a decidedly large amount of this acid in the stomach, when not introduced with the food, must raise a strong suspicion of the existence of carcinoma. It is only exceptionally in the worst forms of chronic gastric catarrh, with great stagnation and an unusually excessive amount of fermentation, that a large proportion of lactic acid is found in the stomach without the presence of cancer. Lactic acid can- not by the usual simple tests be demonstrated in the stomach contents in the presence of free HCl. No Single Test Meal Conclusive. — No one of these test meals is sufficient of itself to determine accurately the secretory activity of the gastric glands. The Ewald test breakfast is nearly identical with the first breakfast of a large proportion of people in Germany, except that as a rule many eat butter with their bread and drink coffee instead of tea, while a certain proportion of persons add one or two eggs. This small meal, therefore, tests with substantial accuracy the secretory activity of the gastric glands in Germany and in many parts of Europe where the inhabitants habitually break their fast in the morn- ing with such a light repast. In the United States, where most persons begin the day with a hearty meal including nearly always either meat or eggs, it does not supply to the stomach its accustomed early morning food. When a person whose usual breakfast consists of a large beefsteak, two cups of I20 METHODS OF EXAMINATION" Strong coffee, a dish of fried potatoes, and hot griddle cakes or soda biscuit with butter, suddenly substitutes a roll and ten ounces of tea or water, the gastric glands are likely to secrete an amount of HCl and pepsin in excess of the requirements of such a slender meal and might, therefore, show a decided HCl excess which would not be apparent after his usual breakfast. Hence, while in important cases you should make one test by this accepted standard, do not depend upon it entirely. Then again it is a fact long since observed by me, and noted also by other observers, that the stomach of the same person will secrete far different amounts of gastric juice not only after meals of different size, but also at different times of the day. For example, some persons secrete but little gastric juice in the early part of the day, but more liberally of the same toward evening. On the other hand, the reverse is true of certain other persons. That is, patients have been frequently ex- amined by me who after an Ewald breakfast in the morning had a large amount of HCl in the stomach contents, whereas in the latter part of the day, owing apparently to a partial exhaustion of the nerve centers, the gastric secretion was markedly insufficient. An Objectionable Method of Getting the Stomach Con- tents. — It is still advised in some works to empty the stomach by what is called expression w-hen an analysis of its contents is to be made. That is, a medium-sized tube is passed into the stomach, and the patient, with both hands over the epigas- trium, is urged to make straining efforts. By holding the breath and active contractions of the diaphragm, the contents of the viscus are sought to be forced up through the tube. This generally succeeds in time in accomplishing the object, but in most cases only after such an amount of serious discomfort, dyspnea, retching, and often vomiting, as must disgust any patient. Indeed, this obnoxious method of getting up test meals and unskillful ways of performing lavage are largely answerable for the very general, though needless, dread of the stomach tube. TEST MEALS AND TESTING STOMACH CONTENTS 121 Extraction, however, with the Kuttner bulb already described is a very simple matter, and after the tube has been swal- lowed, requires usually a few seconds only with the patient remaining entirely passive. It is accomplished still more easily and rapidly when the latter voluntarily assists by swal- lowing movements and deep breathing. The Macroscopic Examination of the Stomach Contents. — In conformity w^itli my plan to describe methods that ac- complish as much as possible for the purposes of both diag- nosis and treatment by the simplest means with no more instrumentation than absolutely necessary, I strongly advise you to accustom yourselves to a careful study of the gross ap- pearance and other manifest characteristics of the stomach contents, whether these be vomited or extracted especially for testing. In patients who are used to the tube and not too much inconvenienced by it, it is often advisable to extract all of the stomach contents that can be obtained in this way. For reasons hitherto explained this is not advisable on the occasion of the first introduction of the tube into a patient's stomach for diagnostic purposes. But whether you bring up all the contents that can be obtained or seek only to extract enough for the usual qualitative and quantitative tests, great differences may be observed in the amounts of the contents that will readily be extracted. In exceptional patients with hyper- motility, in whom the expulsive powers of the stomach are unusually strong, or the pylorus unduly relaxed, you will frequently obtain no contents at all if you wait until the end of an hour, as is the usual rule. In these you will find it ( necessary to take up the contents at the end of thirty, forty, or forty-five minutes. In patients having a normal gastric motor power and no hyperacidity to complicate matters you may ordinarily obtain an hour after the Ewald test breakfast has been begun, from half an ounce to three or even four ounces (15 to 60 c. c.) of filtered contents. In many first attempts even with new patients under such circumstances you may obtain a much larger amount than the above maxi- 122 METHODS OF EXAMINATION mum, and in your trained patients, when you endeavor to empty their stomachs completely, you will \'ery frequently be able to obtain two to four times the normal amount. If this excessive amount consists of a thin watery fluid contain- ing no solid particles and ha^'ing no particular odor, except perhaps that of new bread, you can infer that you are prob- ably dealing with a case of HCl excess (hyperchlorhydria) and possibly gastric ulcer. This inference as to HCl excess would be confirmed if the patient should complain of a sharp acid taste when the liquid comes into the mouth and pain one to three hours after ineals. If the excessive contents obtained should consist of a foul- smelling mixture of a fluid having numerous fragments of meat or undigested bread or vegetables as well as considerable amounts of mucus floating through it, 5'ou may suspect a dilated stomach with deficient HCl (hypoacidity) and prob- ably advanced gastric catarrh. You might think then also of cancer. The inference that you were dealing with hypo- acidity and possibly gastric catarrh or cancer would be strengthened if the patient should report no particularly sharp, sour taste of the fluid passing through his mouth and only a disgusting and bitter taste with possibly a slight sour- ness, such as may be produced by an excess of organic acids and revealed to both taste and smell. The latter sort of stomach contents when allowed to stand in a conical glass usually separates into several layers, the uppermost one being frothy on account of the large content of gas from fermenta- tion. Beneath this is a layer containing much oil and still lower the heavier liquids with undigested particles of food suspended in them. Finding an excess of material in the stomach, except when there is obstruction to the outflow by a spasm of the pylorus, or from any one of numerous other possible causes, is prima facie evidence of deficient motor power in the gastric walls and often means, as was mentioned before, dilatation of the stomach (gastrectasis). In these cases several pints of decomposing contents may TEST MEALS AND TESTING STOMACH CONTENTS I2T, sometimes be obtained from the stomach. Chronic gastritis does not necessarily coexist with this condition, though it often does, and in such cases you will find mucus mixed with the stomach contents. It is proper to repeat here, however, that the finding of considerable amounts of mucus in the stomach does not of itself prove the existence of gastritis or catarrh of the organ. The catarrhal process may be situated in the nose or throat and the mucus merely swallowed. Bile, Blood, Feces, or Pus in the Stomach Contents. — = Besides considerable amounts of mucus and of undigested food, other morbid constituents usually recognizable by the naked eye may be present, such as bile and blood, or when present in large quantities, pus. Feces dependent upon obstruction in the lower bowel or upon a fistulous opening from the stom- ach into the intestines may often reveal themselves both to sight and smell. A recent hemorrhage from any part of the interior of the stomach, if considerable, may always be recog- nized macroscopically as well as microscopically. When the quantity is very small or the blood has undergone changes, it may require a chemic or microscopic test to demonstrate its presence. Blood found in the stomach contents may have come from the lungs or any of the parts above, and been swallowed, but when its origin is in the stomach itself it most frequently signifies ulcer or cancer. It may arise from cirrhosis of the liver, exceptionally as the result of so-called vicarious menstru- ation, and still more exceptionally from swallowed poisons or foreign bodies, from aneurisms or varices in the stomach walls, from severe forms of anaemia, or from certain acute infectious diseases or constitutional dyscrasise. (See Lecture LVIII.) The fluidity of the stomach contents. is more important than the quantity obtained, so far as concerns the secretory function of the viscus. When the gastric juice is normal in quantity and activity, the stomach contents should be a somewhat viscid fluid resembling rich milk in consistency. They should be of a grayish color after the Ewald breakfast and will vary in 124 METHODS OF EXAMINATION color after other meals according to the character of the food taken, being yellowish after a meal consisting largely of eggs and much darker after a meal of meat and vegetables. When the gastric juice is very strong in HCl and pepsin, the contents are likely to be thinner and more fluid than normal, flowing almost as freely as water, and rapidly filtering unless mixed with much mucus. An admixture of "mucus always delays filtration. T^he more deficient and inactive the gastric juice, as in hypochlorhydria and hypopepsia, the less perfect will be the solution of the stomach contents. Instead of perfect fluid- ity there may be a mushy condition, the chyme being so thick that it will scarcely flow through the tube, or it may contain portions of fluid mixed with but slightly changed bread crumbs or unchanged pieces of other food. Thus it may be seen that the experienced gastrologist scarcely needs to make the usual chemic and microscopic tests in order to recognize very marked departures from the normal in either direction ; but such tests are very valuable whenever it is desirable to have an accurate knowledge concerning the great majority of cases in which the stomach contents will be found to occupy a middle ground, partaking of the character of. neither extreme. A greenish-yellow tinge to the stomach contents may result from bile, or from succinic acid, and elsewhere the means of making a differential diagnosis between these is explained. Bile is always present in the small intestine, and can be recognized by Gmelin's test or by Pettenkofer's test for the bile acids. Its reflux into the stomach indicates generally a relaxed condition of the pyloric valve, but may be due to obstruction of the intestine below the entrance of the bile duct or to the straining of vomiting, etc. Much pus in the stomach contents, recognizable by the naked eye, would mean usually a serious abscess in the gastric wall or esophageal wall; but smaller amounts of pus discovered by the micro- scopic examination may have been swallowed, having their origin then in ozena, disease of the gums, or some other inflammatory condition in any of the parts above. TEST MEALS AND TESTING STOMACH CONTENTS I25 Filtering the Stomach Contents. — Having obtained a sample of the stomach contents whether by means of the instruments ah-eady described or by vomiting, and studied carefully its gross appearance macroscopically, your next step should be to measure the total quantity obtained and filter it. Chemists and other trained laboratory workers will not need instructions concerning these minor details; but for students and general practitioners, it is particularly desirable to make everything as plain as possible. Procure a good quality of filter paper and cut into squares, or better, circles, about eight inches in diameter. Fold one of these in such a manner that it will form a cone with folds radiating in every direction from the apex. Put this inside a glass funnel of three or four inches' diameter, and place the latter in any convenient wide-mouthed bottle. Empty the sample of stomach contents obtained, or a sufficient quantit}'- thereof, into this funnel and set it aside to filter. Provided there be a good quantity of it and a large amount of mucus be not present, filtration will go on rapidly, so that within fif- teen or twenty minutes you should have enough of the filtrate to enable you to make not only the indispensable simpler qual- itative tests, but also if need be, some of the quantitative tests. When the contents are very viscid you will save much time by using a filter pump or suction pump, which can be readily attached to the faucet and is not expensive. You can then insert the funnel into a rubber stopper which closes a filtering flask, the latter being connected with the filter pump by means of rubber tubing. In the absence of a water supply, an ordi- nary hand aspirator may be connected with the filter bottle, and sufficient contents filtered by compressing the bulb several times. The filter should be protected from tearing by placing a plug of absorbent cotton at the bottom of the glass funnel. A platinum cone is preferable for this purpose, but is expensive. LECTURE IX QUALITATIVE TESTS OF THE STOMACH CONTENTS The Simpler Tests for HCl. — If a strip of congo-red test- paper dipped into the extracted stomach contents or vomited matter is changed to a decided bkie or blue-black color, it means free acid of some kind and nearly always free HCl. If the change is not well marked it may mean free organic acids such as result from fermentation. Adding now a drop or two of a one-half per cent, alcoholic solution of dimethyi- amido-azo-benzol ( to be obtained of ]\Ierck, or any wholesale chemist) will produce a bright cherry-red color if the free acid should be HCl. This test may prove misleading in the rare contingency of there being present 0.2 per cent, or more of lactic acid, or in case of a very large excess of any of the organic acids, which may produce a similar color. If in doubt, vou should test also by the Giintzburg reagent, which, as modi- fied by Boas, is composed as follows : IJ Phloroglucin 2.00 Vanillin i.oo Alcohol (80 p. c.) 100.00 M. This should have been recently prepared, else it cannot be depended upon. To test for free HCl add a full drop of this to a very small drop of the stomach contents on a porcelain dish fa butter plate will answer) and heat slowly over a small flame. If free HCl be present, a brilliant carmine hue will be developed as the liquid evaporates. This is the most reliable test. The red 136 QUALITATIVE TESTS OF THE STOMACH CONTEXTS 12/ color with this test is not produced by anything except a free mineral acid, and HCl is the only free mineral acid to be found in the stomach unless taken in through the mouth.. It is desirable in many cases to make the Uilelmann test for lactic acid. If no reaction pointing to free HCl has been ob- tained, or if, with the dimethyl, etc., reagent, you have obtained a reddish color, but are uncertain as to its significance, you should always make it. The test is carried out as follows : Test for Lactic Acid. — Add lo c. c. of a 4 per cent, solution of carbolic acid to 20 c. c. of water in which a drop of the officinal solution of the chloride of iron has been dissolved. Now pour equal quantities of the blue liquid which results into each of two test tubes. To one of these add drop by drop a quantity of the stomach contents. If any notable proportion of lactic acid be present, the blue will be replaced by a peculiar greenish — or citron-yellow color. The change to an ordinary yellow color does not signify lactic acid. The presence of free HCl or of much peptone may prevent this reaction, and oxalic or citric acid, alcohol, phosphates, or dextrose might possibly mislead by giving a somewhat similar reaction, but are rarely present in sufficient cjuantity one hour after the Ewald breakfast. In any case, two of the tests just described should give conclusive results. Thus, if there be a reaction with the dimethyl, etc., and none with the Uffelmann test, there is free HCl and no important proportion of lactic acid present. If there should be a decided and unquestionable response to the Uffelmann test, with or without a reaction to the dimethyl reagent, the presence of a considerable amount of lactic acid would be shown, pointing to either cancer or advanced gastric catarrh with much stagnation and fermenta- tion. In such a case the Giintzburg and other confirmatory tests should always be made, and a thorough exploration of the stomach by an expert, both externally and internally, would be desirable. Whenever the various tests show an absence of free HCl, you should always make the foregoing test for lactic acid, since 128 METHODS OF EXAMIXATION it may be present in such cases in considerable proportion and may then mean cancer of the stomach, though it is not proof positive of that disease. A very decided response to the Uffelmann test must ahvays raise the suspicion of cancer, or tend to confirm such a suspicion when a tumor can be made out. When, from any cause, the result of the Uffelmann test is uncertain or it is desired to make the test with unusual care, you may practice the following modification of it : Place in a stoppered separating funnel 5 to lo c. c. of the filtered stomach contents and add twice the amount of pure sulphuric ether, being especially careful that it is free from alcohol. Shake this well several times during an interval of twenty minutes and then let it stand until the liquids separate into different layers. Then allow the ether to evaporate, a process which can be hastened by placing it over a hot-water bath. The residue should then be dissolved in 10 c. c. of water and the solution tested for lactic acid according to the method above given. This is more delicate than the simple Uffelmann's test without ether and gives a much more decided reaction to even minute quantities of lactic acid than does any of the substances before mentioned as liable to cause similar and misleading re- actions. A very quick and convenient method of determining roughly when lactic acid is present, is to add two drops of the officinal chloride-of-iron solution to a medium-size test tube filled with distilled water, pour one-half of this into another test tube of the same diameter, and then add to one of them several drops of the filtered stomach contents. If lactic acid be present, the liquid in the test tube to which the filtrate was added will show the same greenish-yellow color described as produced by the usual Uffelmann's test. This is the method of testing for lactic acid which I found much used in Ewald's laboratory in Berlin, and it answers well enough in cases where great exactness is not required. Tests for the Other Organic Acids. — Whenever large quan- QUALITATIVE TESTS OF THE STOMACH CONTENTS 1 29 titles of the organic acids are present in the stomach contents at the usual time after extracting any of the test meals, fer- mentation has been taking place to an abnormal extent, except, of course, when these acids have been ingested with a meal. Bu- tyric, acetic, and succinic acids may any of them be found when there is excessive fermentation, and the differentiation of them is not generally of great consequence except that it enables you to exclude from the diet, in so far as practicable, those articles which are most prone to the kind of fermentation thus shown to exist. The two former are easily recognized by the odor, acetic having the odor of vinegar, and butyric that of rancid butter. Acetic acid, after being carefully neutralized, gives a blood-red reaction on the addition of a drop or two of a solu- tion of chloride of iron. Butyric acid, on the addition of a small piece of chloride of calcium, may reveal itself in the form of small drops of oil. Succinic acid is a product of mold for- mation in the stomach, and Knapp ^ considers it indicative of a somewhat serious form of fermentation. He believes that it is oftener present than generally supposed, being mis- taken for bile on account of the greenish-yellow color with which it tinges the stomach contents. It may be recognized by producing. a dark mahogany ring when an ethereal extract of the chyrne is floated on a o. i per cent, solution of ferric chloride in water. Tests of the Salivary Digestion. — Normally the ptyalin of the saliva begins to act in the. mouth during mastication, and the action continues in the stomach before the contents of the latter become too acid, and the conversion of the starchy part of the food is carried through various stages up to the form of sugar known chemically as maltose. To test the extent to which starch digestion has thus progressed, you should put a few drops of the stomach contents on one side of a small plate, such as a butter-dish, and a short distance away from it one or two drops of Lugol's solution, which is prepared as follows: iodine, o.i ; potass, iod., 0.2; water, 200 c. c. ^ Med. Rec, September 6, 1902. 130 METHODS OF EXAMINATION Then, by tilting the dish, let the two fluids come together, and note the color changes as they mingle. A blue color would indicate either wholly unchanged starch or starch ad- vanced one stage in digestion to amylodextrin. Any shade of violet, red, or a mahogany brown, would indicate that the starch conversion had progressed to the next stage, known as erythrodextrin. If the process has progressed still further, the fluids will have the yellowish color of iodine, and the prod- uct of the starch thus far digested is known as achroodextrin. This is as far as the color reaction can help us in recognizing the degree of starch conversion, but when maltose has been formed it can be recognized by the usual tests for sugar. Normally, the starch in an Ewald test breakfast should, at the end of an hour, show either a yellowish or brownish tinge with the iodine and not a blue one. A more delicate way of carrying out this test is to put about 2 c. c. or more of the filtered contents in a test tube and pour 2— 3 drops of the Lugol's solution on the side of the inclined tube. As the two solutions mingle, a play of colors results. If in doubt as to the tint, mix the two solutions and dilute with a considerable quantity of water. The slightest tint can then be appreciated. Tests for Pepsin and the Rennet Ferment. — To test for pepsin, add to 5 c. c. of the filtered stomach contents one of the disks of albumin to be had of the dealers or small fragments of coagulated white of ^%g, and if there be no HCl present, add 2 or 3 drops of this acid and set aside. When pepsin is present in the usual amounts, the albumin should be all dissolved in the course of five to six hours, and the more rap- idly it dissolves, as a rule, the larger is the proportion of pepsin. You can prepare suitable disks of albumin, one-six- teenth inch thick and one-qukrter inch in diameter by cutting them out of the white of a hard-boiled ^%%. A supply of these should be kept on hand in 50 per cent, glycerin. Wash these disks well before using. You may test for the rennet ferment as follows : Neutralize QUALITATIVE TESTS OF THE STOMACH CONTENTS 13 1 5 c. c. of the filtered stomach contents by the addition of a solution of caustic soda until blue litmus paper is no longer reddened by it. Then add 5 c. c. of fresh pure milk, which should, if necessary, also be rendered neutral in reaction. Shake the mixture well and let it be kept at about the body tempera- ture, either in an incubator or a glass of warm v/ater (about 40° C). If rennin is present in normal proportions, a firm coagulum should form in ten to fifteen minutes. A slower reaction would indicate a deficiency of the rennet ferment, and an entire failure of coagulation, the absence of such ferment. Tests for Albumin, Propeptone, and Peptones. — The more completely any sample of stomach contents is digested the less albumin there should be present, and you may learn something therefore concerning the degree to which the digestive process has been carried by putting 4 or 5 c. c. of the filtered stomach contents into a test tube and boiling it over a Bunsen burner. Then set aside, and the amount of the deposit shows the pro- portion of albumin. Neutralize exactly by adding a weak solution of caustic soda, which precipitates the syntonin. Then filter the contents of the tube in order to get rid of the coasfu- lated albumin and the syntonin and make the test for propep- tone and peptones which will show roughly to what extent the digestion of proteids has been carried. After filtering, add to the filtrate an equal quantity of a saturated solution of sodium chloride — common salt — and shake well. If propeptone is present it will be precipitated and the more turbid the mixture becomes the larger is the amount of the propeptone. Then the addition of a few drops of commercial acetic acid will reveal flocculent masses when this is present. To test for peptones filter out any propeptone that may have been found and pro- ceed thus with the filtrate : Render the liquid decidedly alkaline by the addition of a sufficient quantity — 3 or 4 drops — of the one-tenth normal sodium hydrate solution to be referred to later under the head of Quantitative Analysis. Add also one or two drops of a i per cent, sulphate of copper solution. If then peptones are present, what is called the biuret reaction 132 METHODS OF EXAMINATION" is caused, which produces a rose red, purphsh, or strawberry tint in the hquid. EXTERNAL METHOD OF TESTING FOR GASTRIC ACIDITY A Further Development of the Benedict Effervescence Test. - — During recent years I have made a large use of Dr. A. L. Benedict's effervescence test for gastric acidity, and have found it of distinct value, especially in cases in which the stomach tube could not be introduced. It is an ingenious and very simple method.' As described by him in various com- munications, it consists essentially in administering to the patient at the height of digestion — say an hour after the Ewald breakfast — a sufficient cjuantity of sodium bicarbonate dis- solved in water, and then, with the stethoscope previously in position over the epigastrium, noting the amount of efferves- cence produced as revealed by the resulting crackling or bub- bling sounds. When a notable amount of these sounds can be heard through the stethoscope one may always infer the presence of some free acid in the stomach, and when an unusually large amount of effervescence is thus demonstrable, the amount of free acid present is manifestly correspondingly large. The objection has been made that this free acid need not necessarily be hydrochloric, but may be some one, or a com- bination, of the organic acids produced by fermentation. This is possible in rare cases, when fermentation is very exces- sive, as in cancer or aggravated catarrh ; but the skilled diagnostician can usually determine whether or not much fermentation is going on in the stomach. In such a case there is likely to be a heavily furred tongue, bad breath, poor appetite, troublesome eructations, and marked gaseous distention of the stomach, while most of tliese s^miptoms are usually absent, or present in a slight degree only, when the percentage of HCl in the stomach contents is either normal or excessive. They are "'The effervescent Test for Gastric Acidity," by Dr. A. L. Benedict, Inteniatiojial Medical Magazine, June, 1903. QUALITATIVE TESTS OF THE STOMACH CONTENTS I33 never, according to my experience, all fonncl coexisting in either of the latter conditions; and they are, on the other hand, very generally all to be noted in marked cases of organic fermentation when free HCl is absent or deficient. If the stomach be washed downward by drinking a pint of tepid water early in the morning, and an hour later an Ewald breakfast be eaten, only a very small portion of organic acid will usually form within an hour. Any notable effervescence produced by the soda at the end of an hour would thus neces- sarily come from HCl. The Percussion Note before and after Drinking a Solution of Soda. — I have developed this ingenious method a little further by briefly noting carefully before administering the soda how much resonance there is on percussion over all parts of the stomach, and then again after the patient has swallowed the soda solution and a few minutes have elapsed to permit of its chemical combination with any acid present. The difference between the percussion note before and after this little procedure is very striking whenever the percentage of the HCl preseirt is either normal or excessive. I have demonstrated this fact many times by inflating the stomach with soda solution, and then, on the following day, giving the test breakfast and analyzing some of the gastric contents in the usual way. Indeed, it is my uniform custom now in determining the size and position of the stomach to admin- ister first three-fourths to a teaspoonful of sodium bicarbonate dissolved in a goblet of water, at the height of digestion if possible, and note whether any tympany results without the further giving of an acid. If tympany is thus produced, it affords me an early evidence of the probable presence of abundant HCl, and I can proceed at once with my work of mapping out the boundaries. If no tympany, and not even a moderate increase of resonance, results, I administer addi- tionally 8 to 12 drops of strong HCl in solution (which I find preferable to tartaric acid) and proceed with my per- cussion. 134 METHODS OF EXAMINATION When the soda solution, given near the height of digestion, produces no increase in the epigastric resonance, after the region has been gently kneaded for a few moments, it is positive evidence that there is very- little or no free acid in the stomach. The above method of course lacks the definiteness and exactness of a careful chemical analysis, and is only to be recommended as a substitute when the latter is impracticable. Other Substitutes for the Chemical Tests. — Einhorn's Bead Test ^ affords another method of learning approximately as to the efficiency of the digestive glands in cases in which a tube cannot be used. It consists in attaching various food substances to a number of beads which are swallowed in a capsule. The time when, and the condition in which, these appear in the stools give useful information. Ad. Schmidt ^ has devised a method of roughly testing the gastric secretion without the use of a tube, giving lOO to 125 grams (about 4 oz.) of finely chopped, raw, smoked or superficially broiled meat (lean) and then next day exam- ining the stool microscopically for connective tissue fibers. These will be found in large numbers when gastric digestion is deficient in activity. Sahli's Desmoid Test — Sahli "^ early in 1905 reported that if a small rubber bag containing methylene blue and tied with catgut, be swallowed after a hearty meal, normal gastric digestion will be shown by the urine's being colored a bluish green within ten hours. Iodoform taken in the same way should cause the saliva within the same time to yield a violet color with starch and fuming nitric acid. If these reactions fail or are delayed, Sahli considers stomach digestion absent or deficient ; but the test is not certain, as the catgut may sometimes be dis^ested in the bowel. 'fe^ '^Jotir. A. M. A., February 2, 1907. 2 Ad. vSchmidt, Dentsch. nied. Woch., iSgg. No. 49. ^Correspondentzbl. f. Schweitzer aertze, 1905, Nos. 8. and 9. Jour. A. M. A., May 12, 1906. LECTURE X QUANTITATIVE ESTIMATIONS AND MI- CROSCOPIC EXAMINATIONS OF THE STOMACH CONTENTS The More Important Quantitative Tests of the Stomach Contents here described can be readily made by anyone pos- sessing even a minimum amount of chemical knowledge. The only additional apparatus absolutely required is a grad- uated cubic-centimeter measure and a burette, which can be obtained at a trifling cost. (See accompanying illustration.) Fig, 23. — Burette lor quantitative analysis. Premising that you have already made the Giintzburg quali- tative test for free HCl, I will now state how you may deter- mine most readily, by a series of associated tests, the quan- tities present of (i) free HCl; (2) combined chlorine (l e., the 135 I3t> METHODS OF EXAMINATION HCl loosely combined with the albuminoids of the food) ; and (3) the total acidity or sum total of all the free and combined acids, mineral and organic. This is called Topfer's method, and,; while less scientifically accurate than some of the very elaborate ones, it is reliable enough for practical clinical pur- poses in all cases in which even a trace of free hydrochloric acid is present, and also in other cases, except those in which there is at least 0.2 per cent, of lactic acid, or a large excess of the other organic acids present, as shown by the characteristic odor of vinegar or butyric acid. In chronic, painful, or flatulent indigestion, the treatment, medicinal, dietetic, and mechanical, should be very different, when there is a deficiency of HCl, from that imperatively de- manded when there is persistently a decided excess of the same, as happens in a large proportion of all such cases. The total acidity is equally important. When there is an absence of free HCl acid, even though the amount of the com- bined chlorine should not have been determined, the finding of a high total acidity — above 60 — would point to an excess of organic acids from fermentation, while a very low total acidity — 15 or below — would speak in favor of either more or less complete gastric atrophy, or a temporary paralysis of secre- tion from some one of various possible causes. For the Topfer test you will need, in addition to the burette with graduated measures, pipettes and cups or beakers holding two or three ounces, several chemical solutions, as fol- lows : one-tenth normal solution of caustic soda which should be prepared by a thoroughly trained chemist, since very much depends upon its absolute accuracy; but you can obtain usually from any reliable dealer the normal soda solution and dilute, by adding one part to nine parts of distilled water. Such a solution, when long exposed to air, becomes weak- ened by chemical changes, and it should therefore be kept in small bottles well corked and always full up to the cork. The burette must be filled with this, preferably up to the zero mark, before beginning; then, besides, the following three EXAMINATIONS OF THE STOMACH CONTENTS 13/ solutions to be used as indicators : ( i ) one-half per cent, alco- holic solution of dimethyl-amido-azo-benzol ; (2) a i per cent, watery solution of alizarin, which is known chemically as alizarin monosulphonate of sodium; (3) a i per cent, alco- holic solution of phenolpthalein. No. I does not react to combined HCl or acid salts of any kind, nor to moderate amounts of the organic acids, especially in the presence of peptones, but gives a brilliant red color with the faintest admixture of HCl in the free form. No. 2 produces a clear violet color when mixed with a solu- tion containing any of the acidities to be found in stomach contents, except that arising from the presence of combined HCl, or, as Van Valzah and Nisbett well express it, alizarin " is sensitive to all the factors of gastric acidity except the combined HCl." No. 3 only produces its characteristic dark red color in the stomach contents when all the elements of acidity, including free and combined acid of every kind, have been neutralized by the soda solution. To make the three tests, (a) measure into a beaker, or glass of any kind, 10 c. c. of the filtered stomach contents (though 5 c. c. will answer for each of the tests, when an insufficient amount of the contents has been obtained) and add to it two or three drops of the No. i — dimethyl-amido-azo-benzol. A brilliant carmine color is produced if there be the slightest proportion of free HCl present. If this results, place the beaker over a white surface and add the soda solution from the burette, drop by drop, till the bright red begins to fade to a dingy, reddish yellow. This shows that all the free HCl has been neutralized. Be careful to stop when the fading from the bright red first becomes decidedly apparent. Suppose the result of this process (called technically a titration) to show that 2.5 c. c. of the standard soda solution were necessary to neutralize 10 c. c. of the gastric contents. This would be equal to ten times 2.5, or 25 c. c. of the solution for 100 c. c. of contents, and all such calculations are made upon the basis 138 METHODS OF EXAMINATION" of 100 c. c. The amount of free HCl would, in this instance, be expressed arbitrarily by the figures 25 by some authors, while others figure out the exact equivalent percentage of free HCl by multiplying the finding 25 by the fraction .00365, which has been found to represent very nearly the amount of HCl which each c. c. of the soda solution will neutralize. Making this multiplication thus, .00365X25=. 09125, we obtain the decimal fraction .09125 as expressing the percent- age of free HCl present. (b) Next, to 10 c. c. of the stomach contents add two or three drops of the No. 2 (alizarin solution) and titrate, that is, let the soda solution flow into the mixture, drop by drop, until it changes it to a clear violet tint. Suppose 6 c. c. of the soda solution to have been used in this titration, we multiply by 10 to find the aggregate amount of the free HCl, organic acids and acid salts, but not including the combined hydro- chloric acid, i. e., the HCl combined with the albuminoids of the food. It will be remembered that alizarin reacts to all the elements of acidity in the stomach except the combined HCl. We have then obtained the figure 60 as represent- ing conveniently the amount of these combined acidities in 100 c. c. of the fluid being tested. As only a small part of this is composed of HCl in any form there is clearly no excuse in this instance for multiplying the figure 60 by the fraction ,00365 to obtain its equivalent value in terms of HCl. (c) We determine by a third titration the aggregate of all the acid elements, mineral and organic, free and combined, in the fluid under examination, to obtain what is called its total acidity. This is the procedure : To 10 c. c. of the fluid in a third vessel we add tw^o or three drops of the No. 3 (phenolphthalein) and allow the soda solu- tion to flow in as before. Soon a circle of red will surround the drops of the alkaline solution as they fall into the stomach contents, fading out again as the acids at first quickly neutral- ize it. Later the whole becomes a light rose-red, showing nearly complete saturation, but you should go on adding the EXAMINATIONS OF THE STOMACH CONTENTS 1 39 soda until each drop, as it falls in, no longer darkens percept- ibly the mixture. Then neutralization is complete. Suppose, for example, 8 c. c. to have been used in this titration, we multiply by lo and obtain 80 as the total acidity. Thus we have by these three titrations ascertained directly the percentage of free HCl, and the figure which represents the total acidity. Now, as the third titration (c) determines the sum total of all the acidities present, and the second titra- tion (b) reveals the amount of all the acidities except the com- bined HCl, it is manifest that we have only to subtract the result of (b) from that of (c) to obtain the amount of the combined HCl. Making this subtraction with the hypothetical figures above given, w^e have 80 — 60=20. In this instance, it is proper to multiply the 20 by .00365 in order to obtain the actual per- centage of combined HCl present. In the supposed case this would be 2oX.oo365=.o730. This may seem complicated, and a little puzzling at first, but when one has conveniently at hand the reagents and the few appliances required, the actual processes of titration may be easily and quickly performed, while the calculations are simple enough. The three steps may be thus briefly summarized : (a) Find how many c. c. of the soda solution are required to neutralize the measured amount of the stomach contents with No. I as an indicator, and multiply this by 10, if 10 c. c. of the contents are being tested, or by 20, if only 5 c. c. are under examination. Set down the product. (b) Find how many c. c. of the soda solution are needed to neutralize a like portion of the stomach contents with No. 2 and multipl)^ as before to obtain the result for 100 c. c. (c) Find how many c. c. of same solution are needed to neutralize an equal portion of the stomach contents with No. 3, and multiply as before. Subtract the result (b) from that of (c) and note the remainder. The result of (a) multiplied by .00365 gives the percentage of free HCl ; the remainder of I40 METHODS OP EXAMINATION (b) from (c) multiplied by the same fraction gives the per- centage of combined HCl, and the figure obtained by (c) rep- resents the total acidity. Those of you who are inexperienced in making these tests will find it helpful to ha\'e at hand control solutions as follows : A solution of HCl, a few drops to the ounce, and a drop or two of the diamethyl, etc., neutralized by a solution of caustic soda till just the proper shade of yellowish red has developed ; also a i per cent, solution of sodium carbonate containing a drop or two of the alizarin solution. Let an experienced chemist prepare these, so that they shall show exactly the right tints. Quantitative Test for Lactic Acid. — Numerous methods have been devised for determining the proportion of lactic acid present in the chyme. Most of these are rather complicated, and some of them so long and troublesome as to be quite impracticable for clinical use. Boas has devised one of the most reliable and delicate of these. It involves a very tedious series of processes, including distillation, and is never employed except for strictly scientific purposes. Boas has also made a large use of the following simpler method, which is sufficiently exact and not difficult : Add to IOC c. of the filtrate a few drops of dilute sulphuric acid, heat over the flame, which coagulates the albumin, filter and evaporate over a water bath to the*consistency of syrup, fill up to the original amount and evaporate again to a small volume. In this way the volatile fatty acids are removed and the residue contains only lactic acid. The residue must now be extracted with 200 c. c. of ether, the ether evaporated, and what remains diluted with water and titrated with phenolph- thalein and one-tenth normal soda solution. Every c. c. of the one-tenth normal soda solution employed corresponds to 1.009 per cent, of lactic acid. Quantitative Test for Fatty Acids. — The following method is employed by Leo : Determine the total acidity of the gastric contents. Then boil 10 c. c. till the vapor given off ceases to EXAMINATIONS OF THE STOMACH CONTENTS 141 show an acid reaction. Titrate the residue with one-tenth normal caustic-soda solution with phenolphthalein as an indi- cator. The decrease of acidity shows how much of the fatty / ^^^^ Fig. 24. — Yeast.— From a photograph, x about 500. The preparation was made from a culture obtained from the contents of a dilated stomach. — From Sidtiey Martin'' s " Diseases of the Stomach.'''' acids were present. Adler advises that the proportion of HCl be estimated both before and after the boiling, so that allow- ance can be made for the amount of this acid lost in the boiling. A O^ Fig. 26. — Sarcinseventriculi. A, X, 600 seen in one plane; B, X 650, diagrammatic, showing the appearance of cotton-bales. — Flus'S'e. Fig. 25. — Bacillus butyricus, x 1020. Sim- ple rods are seen at the extreme right of the figure; also swollen and spindle- shaped spore-bearing bacilli. A, a spore- germinating. — Prazinowski. Microscopic Examination of Stcmach Contents. — Valuable information can also frequently be obtained by a microscopic examination of the stomach contents. In this way the pres- ence of yeast fungi, sarcinae, various forms of mold, and numerous other micro-organisms may be detected, including especially the Boas-Oppler bacilli, which last are considered as being to some extent diagnostic of gastric carcinoma. The 142 METHODS OF EXAMINATION character of the epitheHal cehs obtained from the stomach contents and wash water after lavage are also of importance diagnostically. When such cells are nearly all of the squamous type or of the ciliated columnar form, any mucus present, even though in large quantity, may usually be set down as having been swallowed and not secreted by the stomach itself. On the other hand, numerous non-ciliated columnar or cylindric epithelial cells, especially when they show evidences of fatty degeneration and stain imperfectly, indicate an inflammatory disease of the gastric mucous membrane itself. The discovery, microscopically, of numerous groups of proliferated or degen- erated cells points to the existence of respectively a prolifera- tive or an atrophic form of chronic gastritis. Fragments obtained in the wash water in the case of sus- pected carcinoma may sometimes afford information of more or less value when examined under the microscope. Ewald, in his " Diseases of the Stomach," expresses doubt as to the possibility of recognizing in this way specific cancerous tissue, and adds, " this is certainly impossible with isolated epithelial cells." ' Riegel " thinks it probable that characteristic findings may be discovered in the wash water microscopically in the later stages of carcinoma, but Stockton, the American editor of the English translation of his work, in commenting upon the foregoing, adds the following note : " On the question of the possible early determination of the presence of carcinoma by examination of the fragments of the gastric mucosa recovered in the wash water, Hemmeter be- lieves that he has occasionally been successful in making a diagnosis by this method. Most observers regard this criterion as absolutely valueless. Einhorn, in a recent article, suggests that the diagnosis of carcinoma of the stomach may be made in this way under specially favorable conditions if a direct inva- sion of the gland-substance by epithelial cells can be observed." ' " The Diseases of the Stomach." By Dr. C. A. Ewald, New York, 1894 2 Nothnagel's Practice, " Disease of the Stomach," Philadelphia, 1903. LECTURE XI THE URINE IN GASTRO-INTESTINAL DIS EASE— URANALYSIS AN AID IN ESTI- MATING THE SECRETION OF HCl. Uranalysis Indispensable in Gastro-Intestinal Affections. — It is highly essential in the management of all chronic diseases to make thorongh analyses of the nrine from time to time. It is especially important to do this in affections of the stomach and 'intestines, since here so much useful information may be thus gained which cannot be obtained in any other way. The digestive processes which take place below the stomach cannot be investigated with any certainty or satisfaction except through examinations of the feces and urine; and examina- tions of the latter, besides being more easily made than that of the former, are in some respects even more instructive for the expert in such work. As regards the tissue changes in the processes of metabolism, uranalysis is our chief source of knowledge, though blood examinations are always important in severe or doubtful cases of impaired digestion. You may object that, besides rec[uiring such a high degree of technical training in chemistry and in the use of the micro- scope as not all general practitioners of to-day possess, thor- ough analyses of the urine and gastric contents, to say nothing of chemic and microscopic examinations of the feces and blood counts, consume a great deal more time than patients are will- ing to pay for. Better Fees Should be Paid for Analyses, etc. — It is doubt- less to an extent true that patients object to paying for such work ; but it is your duty as family physicians to assist in edu- cating the laity in such matters. Most patients of moderate means will pay, without grumbling, handsome fees for no 143 144 • METHODS OF EXAMINATION more necessary surgical operations, and they should be taught to pay adequately for exceptional time and skill devoted to indispensable, complicated, and time-consuming procedures which are performed in the laboratory. We physicians by our zeal in the cause of science and will- ingness to do certain kinds of work with little or no regard to a proper recompense cheapen our profession. Our surgical friends are right to insist upon a generous remuneration for their most valuable services; and the lawyers, too, are always far better paid than we are. When, therefore, you have trained yourselves (or been trained) to do first-class and most necessary work in the way of skilled examinations in the labor- atory and at the bedside, you should next train your patients to pay for it properly. . Boas, in his book on " Diseases of the Stomach," has summar- ized the work of numerous German investigators concerning the relations between the urine and the gastric secretion, from which it appears that it is almost possible to learn from a careful study of the former when an excess or deficiency of HCl is being secreted. Relation between Urinary Acidity and HCl Secretion These investigations show that in health the urine is most highly acid before meals and least acid, or sometimes even alkaline, after meals at the height of digestion, especially after a large meal such as dinner. When, however, a deficiency of HCl is secreted, and still more when, owing to complete atrophy of the gastric glands or to any other cause there is a stoppage of secretion (achylia gastrica), the normal falling off in the acidity of the urine during digestion is lessened or fails altogether. On the other hand, when an excess of HCl is secreted by the gastric glands the falling off in the acidity of the urine during digestion is increased and marked alkalinity is likely to appear instead. If there were no other causes than variations in the gastric secretion for fluctuations in the course of urinary acid- ity before and after meals, the matter would be very simple, THE URINE IN GASTRO-INTESTINAL DISEASE 145 and we could ascertain from uranalyses at different times of the day the state of the HCl secretion with sufficient exactness for most chnical purposes. But there are other factors in the problem which affect the result — other causes of variations in the urinary acidity which, so far, our most skilled physiologic chemists have not been able tc reckon with or allow for with sufficient exact- ness, and, therefore, up to the present time, we cannot ascertain with any approach to certainty the state of gastric secretion by uranalysis. It seems probable, though, that this problem will yet be solved, and that chemists will one day be able so tQ exclude other disturbing causes of fluctuations in the urin- ary acidity that they can determine therefrom approximately how much HCl the stomach is secreting, or at least whether the secretion is excessive or deficient. Meanwhile, in any case of suspected stomach trouble in which the introduction of a tube is impracticable, you should test the urinary acidity before breakfast and again two to three hours after dinner, and if you then find a pronounced variation from the normal decrease of acidity, and if this finding points in the same direction as the external examina- tion with the help of the Benedict effervescence test described in Lecture IX., you may infer with probable certainty that the state of the HCl secretion is as indicated by that rough test. Furthermore, in any case of unusual importance in which the stomach tube cannot be employed — whether the patient declines to swallow it, as some do, or any of the numerous con- tra-indications for its introduction are present (see Lecture VII.) — you may obtain additional confirmatory evidence as to the state of the HCl secretion by carrying out the not difficult method of determining the proportion of chlorides in the urine. Importance of Estimating the Chlorides. — While the chlo- rides in the urine are derived from the food, and their amount generally bears a direct relation to the amount ingested, gastric activity does to a great extent influence the excretion of this important urinary solid. HCl, the physiologists teach us, is 146 METHODS OF EXAMINATION formed by the parietal cells from the chlorides which the mucous membrane takes up from the blood, and the formation of acid ceases if chlorides be withheld from the food. Accord- ing to Maly, lactic acid, which is present in the stomach, splits up the sodium chloride and forms free HCl. The base set free is excreted by the urine. It is thus evident that during gastric digestion, when the formation of HCl is going on, the amount of chlorides in the urine diminishes in direct proportion to the amount of acid formed. While it is manifestly impossible to establish the exact relation without an exact knowledge as to the amount of chlorides ingested with the food, there is, nev- ertheless, a general post-prandial curve which is of diagnostic significance. During digestion, the amount of chlorides in the urine gradually diminishes, to increase again when digestion is complete and absorption commences. In hyperacidity the diminution of chlorides in the urine is marked, and is gener- ally in proportion to the degree of hyperacidity. On the other hand, in anacidity or gastric atrophy no such diminution is observed. Therefore, if you determine the chlorides in the urine voided immediately before and again one to two hours after a meal, you may obtain satisfactory information as to the probable presence of hyper- or hypo-acidity, provided, how- ever, you exclude other conditions which produce fluctuations in the excretion of chlorides, such as vomiting and the forma- tion of exudates. According to Hemmeter, if a small amount of chlorides is accompanied by an equivalent reduction in the amount of urea excreted, the indications are that the case is one of simple inanition, a benign stenosis ; but if the reduction of the chlorides is associated with a relatively large amount of urea, malignant stenosis is probably present. I may here remark that in drawing inferences as to the normal or increased excretion of chlorides, you should always take into account the urea excretion. If the increase of chlorides is due to increased digestion of food, the urea will be proportionately increased, and vice versa. The determination of chlorides is best accomplished by the THE URINE IN GASTRO-INTESTINAL DISEASE I47 very accurate method devised by Volhard. The solutions re- quired are: i. A standard silver solution prepared by dissolv- ing 29.075 grms. of silver nitrate in i liter of water. Each c. c. of this solution equals lo milligrams of sodium chloride. 2. A saturated solution of ferric alum. 3. A standard solu- tion of potassium sulphocyanid, so prepared that 25 c. c. of the solution equal 10 c. c. of the silver nitrate solution. Having prepared these solutions yourselves, or obtained them from a reliable chemist, you can make the determination with considerable ease. Method : Take 10 c. c. of the urine, add 4 c. c. of nitric acid and 15 c. c. of the silver nitrate standard solution. Dilute the whole with water to 100 c. c. Filter. Take 80 c. c. of the filtrate, add 5 c. c. of the ferric alum solu- tion and titrate with sulphocyanid solution until a permanent red color is imparted to the mixture. Divide the number of c. c. of sulphocyanid solution used by 2 and subtract the result from 15. The remainder represents the number of c. c. of silver nitrate solution required to precipitate the chloride in 10 c. c. of urine. As each c. c. of silver solution equals 10 mgms., the number of c. c. multiplied by 10 repre- sents the number of mgms. in 10 c. c. of the urine, and this again multiplied by 10 gives the amount in 100, or the per cent. For example : Suppose 6 c. c. of the sulphocyanid solution were required to bring about the end-reaction, 6-f-2=3; 15 — 3=12; 12X10=120 mgms.; 120X10=1200 mgms., or 1.2 grms. per 100 (1.2 per cent.). If you have a centrifuge the speed of which can be regulated, an electric centrifuge is best, you may use Purdy's centrifugal method, which, as described by that author, is performed as follows : Fill the graduated tube to the 10 c. c. mark with the urine, add 15 drops of nitric acid and fill to the 15 c. c. mark with a standard solution of silver nitrate ( 3 i to ji). Invert the tubes several times, replace into the centrifuge, and revolve them at the rate of 1000 revolutions per minute for three minutes. The volume of the bulk of the precipitate represents the percentage. LECTURE XII THE URINE, CONTINUED— SIGNIFICANCE OF INDICANURIA, AND TESTS FOR IT Partial Examinations of the Urine Better than None. — To examine the urin,e for albumin and sugar merely, as many do, is much better than not to examine it at all. Even to take the specific gravity and make the Heller's or the heat and nitric acid test for albumin may afford valuable information in the management of a case. But you should do a great deal more with the urine, as a rule, when the patient is chronically out of health. For a high specific gravity alone by no means proves the presence of sugar, nor a low specific gravity renal inade- quacy, and albumin, transiently present with or without casts, does not necessarily signify Bright's disease. Nor does the absence of both albumin and casts at a single examination exclude the possibility of diseased kidneys. And the urine very often presents other abnormal conditions which indicate disease in other organs than the kidneys. These are trite truths for experts in physical diagnosis, but need to be emphasized for many others. Unfortunately, the older teachings on this subject were deficient. A recent medical writer of more than ordinary prominence and ability, in very properly calling attention to the importance of more frequent analysis of the urine, names the following as the only points concerning which it is necessary in most cases to examine : " Quantity, color, clearness, odor, reaction, specific gravity, albumin, sugar, sediment." This list does not include indican, the degree of acidity, the total amount of solids excreted in twenty-four hours, or even the amount of uric acid, all of which are most important. Indicanuria, High Acidity, etc. — In my laboratory, out of 148 THE URINE IN GASTRO-INTESTINAL DISEASE I49 many hundreds of urinary analyses made during the past year, fully one-half revealed an excess of indican. This indi- canuria is most frequently a consequence of excessive putrefac- tion in the intestines, which usually indicates more or less auto-intoxication and many resulting nervous symptoms, often of a serious and distressing character. It has also been ob- served in unhealthy pleuritic exudation and in peritonitis with putrid pus (Von Jaksch), but such cases are very rare in com- parison with those resulting from putrefaction of incompletely digested proteids in the bowels. Hochsinger has found that the urine of newborn children is free from indican, and that in healthy infants it occurs only in traces. According to the latter observer, "it becomes more abundant in intestinal dis- orders, and is always most so when these are attended by diarrhea." My own experience fully confirms this last obser- vation of Hochsinger. The latter recorded also that " tuber- culosis, whether affecting the intestinal tract or not, was always accompanied by profuse indicanuria." The ether-sulphuric acid compounds generally, or aromatic sulphates, when present in the urine, have a significance similar to that of indican, and their percentage should be determined in stubborn or difficult cases, but the methods of determining them are rather complicated — scarcely practicable except in well- equipped laboratories. In a considerable pro'portion of my cases there has been also an abnormally high total acidity. Patients with overacid urine are apt to be sufferers from intestinal indigestion, constipation, rheumatism, neuralgia, headaches, or insomnia, and often several of these ailments, as well as a variety of other nervous symptoms. Not till the excessively ^cid con- dition of the urine has been relieved by improving the diges- tion; by alkaline diuretics and an appropriate diet, including an abundance of pure water, have the patients made any sub- stantial improvement in health. The falling of the total amount of solids passed by the kid- neys in twenty- four hours, below an average of looo grains 150 METHODS OF EXAMINATION (65 grms.) in a person weighing 140 pounds or upwards, indicates a depression of the renal function. If repeated tests ahvays show a markedly diminished excretion of solids, in spite of the institution of measures to increase it, there is reason to suspect beginning chronic interstitial nephritis, even though there are no decided symptoms and no albumin or casts. On the contrary, an increase in the solids when there has been no loss of weight from wasting, indicates an excessive intake of food, which you should correct. Uric acid excess is one of the most common morbid condi- tions that may be shown by a thorough examination of the urine. Without going to the length that Haig does in attrib- uting a very large proportion of chronic internal diseases to this one excrementitious product, it must be admitted that its presence in the system in unusually large amounts is always accompanied by decidedly unpleasant and often by distressing symptoms, which may be ultimately dangerous to life, but we now know that other associated metabolic products, such as the xanthin bases, are the real toxic agents. A Quick Test for Indican. — There are many tests for indican, most of which are rather complicated to be serviceable to the busy general practitioner. By the following method, however, it is easy to decide almost instantly whether there is present any notable excess of indican : Pour into a small test tube a dram (4 c. c.) of the strong- est hydrochloric acid and add about 30 drops (2 c. c.) of the urine to be tested. Shake the mixture or stir with a glass rod. If there should be a decided excess of indican, a purplish blue or violet tint will appear almost immediately. If such a reac- tion does not occur promptly, add i drop of strong fuming nitric acid. If this should not develop one of the above-men- tioned colors, there is no indicanuria ; the sooner the purple color appears, the greater is the excess of indican. Should you find an excess of indican by this simple qualita- tive test, it would be well to make a quantitative determination. This is important, not only because it furnishes information THE URINE IN GASTRO-INTESTINAL DISEASE I5I regarding the degree of indicanuria, but enables you to judge from subsequent analyses of the degree of improvement brought about by treatment. The quantitative tests for indican described in the more elaborate text-books are entirely too com- plicated for ready application, but the method devised by Dr. A. Robin is both simple and accurate. As described by him in the International Medical Magazine (December, 1900), the test is performed as follows : " Approximate Quantitative Test for Indican. — Prepare the following solutions : ( i ) Obermeyer's reagent, which is made up of strong hydrochloric acid, C. P. and 2 grms. of ferric chloride for each 1000 c. c. of the acid; (2) a 25 per cent, solution of lead acetate; (3) a solution of potassium chlorate containing i per cent, of available CI or 34.6 grms. of the salt per liter. "To 10 c. c. of the urine add i c. c. of the lead acetate solu- tion and filter through a double filter. Put 5 c. c. of the filtrate into a test tube, add 5 c. c. of Obermeyer's reagent and 2 c. c. of chloroform and invert the test tube about ten times, or until the color of the. chloroform ceases to become more intense. The latter will assume a violet or blue color, according to the amount of indican present. Now add from a dropper the potassium chlorate solution, drop by drop, shaking the mixture after each addition until the blue color of the chloroform dis- appears. The potassium chlorate liberates chlorine in the presence of a strong mineral acid and oxidizes the indigo formed by the addition of Obermeyer's reagent. If the amount of indican is normal, one or two drops will cause dis- coloration. In making your memoranda, mark down ' dis- colored by X drops of K CIO 3 solution.' This will give you exact information as to the increase or decrease of indican in a given case. " The advantages of this method over similar ones are: (i) A special oxidizer is used for converting the indican into indigo. (2) There is no danger of carrying the oxidation beyond the point of the appearance of indigo, as is the case when the 152 METHODS OF EXAMINATION chlorine solutions are used, since ferric chloride does not oxi- dize the indigo formed. ( 3 ) By employing potassium chlorate instead of the chlorides, we have a permanent solution of definite strength which is easily prepared. (4) The final oxidation of the indigo introduces a fixed point far more ac- curate than the intensity of the coloration of the chloroform upon which most of the other methods depend. (5) The determination can be made in a few minutes, only small quantities of urine being required." Test for the Total Amount of Solids. — A rough and hasty, but sufficiently accurate way of estimating the total amount of solids excreted by the kidneys in twenty-four hours is as follows : Have all the urine passed from, say 8 a. m. one day to 7 a. M. the next saved, measured, and the number of ounces noted. Then multiply the number of ounces by the last two figures that represent the specific gravity of a sample out of the entire collected urine and add to the product one-tenth of itself. For example, if 50 ounces of urine were passed in the aggregate during one day and night and the specific gravity of a sample taken out of the collection were 1020, this would be the calculation : 50X20 = 1000. Then, adding one-tenth of 1000 ^100 would make iioo, representing approximately the number of grains of solid matters excreted. This would be normal for a person weighing from 130 to 140 pounds. Those weighing less or more should excrete relatively less or more solids. After middle age the ratio of excretion is usually found some- what diminished. LECTURE XIII THE URINE, CONCLUDED — TESTS FOR URIC ACID, UREA, AND THE ACIDITIES — LABORATORY OUTFIT Tests for Uric Acid. — As to uric acid, a copious deposit of red sand in the vessel in which urine has stood for three or four hours only, points usually to excessive excretion of this substance, though a very decided acidity of the urine from other causes, such as abundant fermentation in the gastro- intestinal tract, or a marked scantiness of the urine, may lead to such a large precipitation of uric acid even when only a moderate proportion of it is being excreted. The lower powers of the microscope will also reveal a great number of uric acid crystals under the same conditions. The following method of Heintz gives fairly reliable results for clinical purposes. Take 200 c. c. of urine, and add to it 10 c. c. of strong HCl. Let it stand for twenty-four hours (better forty-eight hours) in a cool room. Collect the precipitated uric acid crystals on a previously weighed filter, and wash with cold distilled water. Dry the filter and uric acid crystals in a desiccator (or it will dry in a few hours in any warm place), and weigh. By subtracting the weight of the filter, the result will be the weight of the uric acid in 200 c. c. of urine. If albumin be present, it should first be removed and the urine should always be filtered before applying the test, otherwise subsequent filtration is very difficult. Ruheman's Method of Determining the Amount of Uric Acid by Means of the Uricometer. — An instrument has been devised by Dr. J. Ruheman of Berlin for the quantitative 154 METHODS OF EXAMINATION estimation of uric acid. It is easily manipulated by any one, and yet quite accurate. The solutions needed are as follows : A. Carbon bisulphide. >. B. Iodine Grms. 1.5 Potass, iodide " 1.5 Alcohol strong C. c. 15.0 Distilled water C. c. 185.0 The urine to be tested must be acid; if not, add acetic acid. Cloudiness is of no importance. Fill the uricometer to the mark S with the carbon bisulphide; add the solution B up to the mark J, and then add the urine to be tested up to the mark 2.45 (2.6 c. c. m.) ; close the tube and shake well. The carbon bisulphide will become dark brown. Add more urine little by little, shaking the mixture after each addition until the foam is white. The CSo will now be a light pink. Shake vigorously, and if the pink color does not disappear, add a few drops more of urine and shake vigorously again. Con- tinue this until the CSo turns a porcelain white. The pro- portion of uric acid per 1000 is read off on the right hand scale. Urea. — This is the normal end product of nitrogenous me- tabolism and in amount it should be about one-half that of the total solids. Various gastro-intestinal affections and also the diet vary its rate of excretion. The determination of urea is best accomplished by means of Doremus' modified ureometer. Ten c. c. of a saturated solution of sodium hy- drate are put in the bulb-end of the tube and i c. c. of bromine added. Care should be exercised in taking up the bromine, as it is extremely irritating and corrosive. When the reaction between the bromine and sodium hydrate is complete, as may be judged from the entire disappearance of the former, enough of water is added to fill the closed end of the tube up to a little above the bend. When the formation of gas bubbles has all subsided the apparatus is freed from the latter by inclining it. and the side tube is filled with water to the zero mark. One c. c. of urine is then carefully discharged into the hypobromite solution and the apparatus set aside until THE URINE IN GASTRO-INTESTINAL DISEASE 1 55 complete evolution of gas has occurred. The volume of gas in the closed end of the ureometer indicates the amount of urea in i c. c. of urine. Test for the Total Acidity. — Determining the degree of acidity or amount of total acidity in urine is a simple pro- cedure. It requires merely an inexpensive burette, or long glass tube graduated to tenths or fifths of a cubic centimeter, a graduated cubic centimeter measure and a small glass cup or beaker holding two to four ounces. There are required also a one-tenth normal (decinormal) solution of caustic soda and a one per cent, alcoholic solution of phenolphtha- lein. Partly fill the burette with the soda solution and note down the reading or exact figure opposite the upper limit of the solution, and for this purpose it is the rule to consider the bottom rather than the top of the curve which liquid always assumes in a tube at its upper end. Measure out and place in the glass receptacle lo c. c. of the urine and add to it one or two drops of the phenolphthalein. Then add, drop by dro]3, the soda solution from the burette until the red color thus produced no longer disappears upon shaking. A uniform pale red color will now tinge the entire lo c. c. of urine, indicating that the acidity of the latter is about neutralized. Then read the burette again and subtract the figure from that first obtained, multiply the remainder by lo, and the product is the total acidity. In the absence of a burette with its lower end so arranged as to allow the escape of the contents drop by drop, one may get on quite well by first placing a measured amount of the soda solution in any receptacle, and then taking up in an ordinary rubber-topped pipette and dropping out of this into the measured urine so much of the soda solution as is necessary to neutralize the former completely in the same manner described above. When this has been accomplished, the remaining test solution will need to be measured again and the difference between the two measurements multiplied by lo will be the figure representing the total acidity. 156 METHODS OF EXAMINATION For example, suppose that to begin with, there was in the burette or other receptacle 20.2 c. c. of the soda solution, and after the titration (as the whole process is called) there are 16. 1 c. c. left. Subtracting, it is found that 4.1 c. c. of the solution have been used. Multiplying these figures by 10 (since 10 c. c. of urine were used and all such calculations are upon the basis of 100 cubic centimeters) we have 41 as the total acidity. Important as this test is to gauge the degree of acidity of the system generally and prevent the blood from becoming too feeblv alkaline, it has been so little practiced that there is not yet by any means an agreement among different observers as to the normal acidity of the urine; but, judging by my own by no means small experience, it is safe to put it at between 20 and 30. A wide departure from these limits in either direction threatens an impairment of the health if long continued, when it does not indicate an im.pairment already established. Freund and Topfer's Test for the Urinary Acidities. — Freund and Topfer suggest the following method, which furnishes more complete data concerning the acidity of the urine: To 10 c. c. of the urine add 2 to 4 drops of a i per cent, solution of alizarin. If the resulting color is pure yellow, free acids are present; if deep violet, combined acid salts. If none of these colors appear, there are present acid salts and alkaline salts of the type of disodicphosphate. The amount of one-tenth normal HCl standard solution recpired to produce a pure yellow color represents the alkaline salts, while the amount of one-tenth normal sodium h)^drate required to cause a deep violet tint represents the acid salts. Biliary Pigments and Acids. — AMienever there is obstruc- tion to the fiow of the bile into the bowel there will be found more or less of the bile pigments and acids in the urine. It is said they may be recognized in the urine even before the ap- pearance of jaundice or the slightest change in the con- junctivae. Since disorders of the stomach and liver go hand THE URINE IN GASTRO-INTESTINAL DISEASE 1 57 in hand so very frequently, it is highly important to test the urine for such substances in all obscure or doubtful cases. The bile pigments may be revealed by the familiar Gmelin's test described in all the books, and there are many others, but one of the simplest of the good ones is Ultzmann's, which is thus carried out: Mix with lo c. c. of the urine 3 or 4 c. c. of concentrated caustic potash solution and acidify with HCl. When the bile pigments are present the urine will then turn a beautiful green color which is very striking. A very easy and sensitive test for the bile acids has been devised by Hay. It is said not to respond to any substance to be found in the urine except the bile acids. The urine should be cooled to 17° C. (about 63° F.) or less, and placed in a small glass beaker. On the surface is then sprinkled a little finely powdered sulphur. If bile acids are absent, the sulphur will not sink; if present in a proportion of 1-10,000, it will sink at once without having been shaken. If 1-40,000 is present, it will sink after gentle shaking for one minute. Ultimate sink- ing will occur if the bile acids are present in the proportion of 1-120,000. An excess of bile acids in the urine points to some important hepatic derangement. They may occur not only as a result of obstruction of the bile ducts, but also in consequence of congestion or cirrhosis of the liver and in various diseased conditions, including carcinoma or other tumors of the liver, and in severe bilious attacks. The combination of hepatic cirrhosis or congestion with constipation will often produce an excess of the bile acids in the urine. Thus something may frequently be learned by testing for these acids ; yet, ordinarily, testing for the bile pigments will determine with sufficient ac- curacy the presence of bile in the urine. Acetone and Diacetic Acid. — Not only in diabetes and in certain fevers, but also in the opposite conditions of starvation and an excessive meat diet can acetone be found in the urine. It is also frequently present in carcinoma and sometimes in other cachectic conditions such as mav arise in extensi\'e 158 METHODS OF EXAMINATION dilatation of the stomach. When, therefore, you desire to exhaust every means of reaching an approximately accurate diagnosis in a doubtful case you should test for acetone; and in order not to be misled by the possible presence of diacetic acid, which by decomposition often forms acetone, you should first test for diacetic acid by the v. Jaksch method as folloWs : Add to the urine a concentrated solution of perchloride of iron cautiously, drop by drop. If a phosphatic precipitate falls, filter this off and add a few drops of the iron solution. If now a red color appears, boil a portion of the urine, w-hich by the Avay should have been freshly voided, and to another portion add a few drops of sulphuric acid and shake with ether. If the boiled urine shows no reaction with the iron solution and the ethereal extract develops a claret-red color with that solu- tion, diacetic acid is probably present and should be removed from the sample to be tested for acetone, though most works on uranalysis make no mention of this important fact. Its removal, according to Charles F. Martin,^ is effected by render- ing the urine faintly alkaline and then shaking it carefuVy in a separator funnel with ether. The latter should be free from both alcohol and acetone. The removed ether must then be shaken with water, which takes up the acetone, and this watery solution of the purified acetone may then be tested for the latter. Lichen's Iodoform Test for Acetone is the one generally recommended, though there are numerous other substances often in the urine which produce a similar reaction, and when accuracy is desired it is best to distill the urine and test the distillate. The test is then carried out as follows : Dissolve 20 grains of potassium iodide in a dram of liquor potassse, and boil. The urine is then floated on the surface of the licjuid in a test tube. At the point of contact a precipitation of iodoform occurs. Even when a distillate of the urine is used for the test, the presence of lactic acid or ethyl alcohol in it may produce similar reactions. ^Wood's " Reference Handbook," Revised Ed. vol. i. p. 66. THE URIXE IN GASTRO-INTESTIXAL DISEASE 159 Diacetic acid is never present in urine in the absence of acetone, and its presence with the latter signifies, according to most authorities, a serious condition in the case of adults, usually portending in diabetics the approach of coma. In children it is a frequent accompaniment of fever and not neces- sarily important. Dr. Robin, in an article written at my request for the Inter- national Medical Maga:::ine, advised as follows : " For the purpose of collecting the urine and determining the amount, a graduated bottle is the only suitable vessel. The ordinary way of collecting the urine in a night-pot introduces a considerable error in the specific gravity by the constant evaporation to which the urine is subjected in an open or imperfectly closed vessel. Any ordinary bottle of a capacity of 2000 c. c. (one-half gallon) can easily be graduated by means of a long strip of paper pasted on the outside, with marks corresponding to divisions of 500 c. c. each. If the night- pot is the only container available, the patient should be in- structed to deposit a layer of vaselin on the under surface of the lid where it comes in contact with the upper edge of the pot. The amount can be measured either by means of a glass (usually of eight ounces' capacity) or a beer bottle (which contains about one pint). In the case of the busy man who is away from home during the day, he can be instructed to carry about him two flat bottles (eight ounces each) into which he urinates as occasion demands and upon reaching his house he empties them into the general container." To the foregoing valuable suggestion it should be added that the vessel in which the urine is to be collected should be care- fully scalded before used and, during the collection, a wet cloth be kept over it in order to keep it as cool as possible and prevent decomposition. The addition of preservatives cannot be advised, since most of them interfere with the chemical examination. For example, a specimen containing formalm will not react to the test for indican and chloral hydrate will give a positive reaction with Fehling's solution. LECTURE XIV THE EXAMINATION OF FECES— THE BLOOD IN GASTRO-INTESTINAL DIS- EASES A\'ere it not for the offensive odor of the feces, the examina- tion of them by the general practitioner would probably be as common as that of urine. But neither excretion is studied cis much as it should be. The data which may be obtained from an examination of feces are as important from a diagnostic standpoint as those obtained from an uranalysis. The feces represent in health the total of whatever material passes unab- sorbed through the gastro-intestinal tract. In disease, it con- tains admixtures of morbid material, the presence of which may of itself often be sufficient to establish a positive diagnosis of either some gastro-intestinal derangement or actual disease. In view of the valuable information that may be gained in this way, it would seem incumbent on the physician to over- come the natural repugnance to this malodorous excretion and resort to an examination of the feces whenever indicated by reason of obscure gastro-intestinal symptoms. Let me here remind you that the fecal odor may be successfully masked by covering the feces with a thin layer of ether. The Feces in Health. — In health the contents of the small intestines are liquid. As they reach the large intestine they are propelled with less rapidity, and in their comparatively slow course through the descending colon and sigmoid flexure lose a considerable amount of water, which is absorbed. In consequence, the feces assume a semisolid consistency and are molded. W'ithin certain limits, the consistency and form of the feces will vary even in health, the variation depending on i6o THE EXAMINATION OF FECES^ ETC. l6l the amount and character of the food and the degree of peri- stalsis. It is weh to note in this connection that the ingestion of even large amounts of water does not influence much the consistency of the fecal mass, though it does somewhat, and a deficiency of ingested fluids may be one cause of constipation. The quantity passed in twenty- four hours is about 100-200 grms. The fecal odor is due to indol and skatol, substances which are the result of bacterial action on the undigested organic matter. The color is a yellowish-brown and is pro- duced by bilirubin, which is the coloring matter derived from altered bile. The reaction is usually alkaline, but may be acid. The Macroscopic Examination. — The fecal discharges may be examined separatel}-, or the twenty-four hours' excretion collected in a closed vessel to which some formalin has been added. The formalin, of course, should be omitted when a bacteriologic investigation of the feces is intended. The feces, if semisolid, should be diluted with water and stirred into a uniform fluid mass. In this should be noted the color, reaction, and the admixture of unusual elements. The Color. — A dark pitch-like appearance is produced by the action of the gastric juice on mucus, blood, and epithelium. This appearance will sometimes characterize the feces during starvation or fasting, — always wdien there has been hemor- rhage from the stomach or upper intestine and the altered blood appears in the stools. A yellowish-gray color is due to mucus when in large quantity. The presence of a yellow- colored serum indicates a large amount of pus. A straw- colored serum occurs in cholera. A blood-like color is pro- duced by huckleberries, and sometimes by beets, while a green- ish or blackish color is due to the sulphides of mercury or bis- muth. A blackish-gray color is produced by the sulphide of iron, the sulphides of these metals being formed by the action of hydrogen sulphide present in the intestines. A yellow color is produced by rhubarb, senna, and santonin. After the admin- istration of methylene blue, a bluish-green color will appear on 1 62 METHODS OF EXAMINATION the exposure of the feces. A green color may also be pro- duced by certain chromogenic bacteria. A clay color is due to excess of fat (undigested) or absence of bilirubin. The pres- ence ^f unaltered bile-pigment is always an indication of disease. In the past few years great advance has been made in the ex- amination of the feces by Prof. Adolph Schmidt. He has de- vised a test diet which, under normal conditions, gives a prac- tically uniform stool. Schmidt's Test Diet consists of five meals per day and, as this is at variance with American customs, Roberts of New York has modified it slightly so as to conform to our habits. This modification, with the caloric value of each article, is as follows : For Breakfast calories A teacupful of well-strained oatmeal i6o A tablespoonf ul of cream 80 A teaspoonful of sugar 40 Lean meat, finely chopped, broiled rare, an amount equal to a heaping teaspoonful 60 Three slices of toast (4x4x5^ inch thick) 150 An inch cube of butter 65 A large glass of milk (8 oz.) 160 At Midday Potato puree ( i potato to 8 oz. milk) 225 A slice of toast, size as above 50 A half-inch cube of butter 30 Lean meat as above, a teacupful in amount 150 Add an inch-cube of butter , 65 One large well-baked potato 75 Add two teaspoonfuls of cream or a ^-inch cube of butter 40 Two slices of bread, size as above 100 An inch cube of butter 65 A large glass of milk 160 THE EXAMINATION OF FECES, ETC. 163 For Slipper calories A teaspoonful of rice, cooked dry 150 Add an inch cube of butter 65 Two poached eggs 140 Three shces of bread 150 An inch cube of butter 65 A large glass of milk 150 This gives a diet which consists of: proteid, 100 grams; fat, 80 grams; and carbohydrates, 300 grams. The total caloric value is about 2,400. This test diet is given until a stool is passed, which cer- tainly comes from this diet, which is usually the second or third stool after the beginning of the diet. No charcoal or carmine powder is necessary to demark the stool, as the latter is sufhciently characteristic to enable one to distinguish it without difficulty. The color is light and the consistency is uniform. At times we may find that some patients cannot take milk either because it produces. an indigestion or causes constipation. In such cases one-third of the milk may be cooked with the food, and the other may be boiled with cocoa or chocolate. As soon as the characteristic stools appear, one should be passed directly into a clean screw-topped glass jar and sent immediately to your office for examination. The examination should be made while the feces are as fresh as possible. The color, consistency, and odor should be noted. Then stir up the feces thoroughly with a horn or wooden spatula, and place a portion about the size of a walnut in a glass mortar. Grind it with the glass pestle as thoroughly as possible, adding about a teaspoonful of distilled water at a time until it is of fluid con- sistency. This is then poured out into a shallow glass ves- sel or over a black plate in a very thin film. Schmidt says : " In normal digestion there ought to appear very few brown points (smaller than pinheads), chaffy remains of the oat- meal gruel, perhaps remains of cocoa nibs, the nature of which is ultimately explained by microscopic investigation." 164 METHODS OF EXAMINATION When the patient has eaten fruit, berries, etc., before this test diet, we may find their remnants, seeds, etc., in the stool. These often grate on rubbing. Larger crystals of triple phos- phates which you so often find in the stool may also grate under the pestle. Under pathological conditions we may be able to detect with the unaided eye (1) mucus, (2) remains of the connective tissue or tendon fibers of the meat, or (3) pieces of muscle, or (4) potato, and, finally, of (5) large crystals of triple phos- phates. Small bits of mucus are easily detected by placing a little of the feces on a piece of window glass and held up against the light. It then appears as glassy transparent flakes sometimes stained yellowish by bile pigment. Large masses of mucus can scarcely be overlooked, but at times they may have mixed in with them, many epithelial cells or fat bodies, and may lose the characteristic glassy appearance so familiar to you all. Then the appearance may resemble very much a tapeworm, as mentioned in Lecture LXXX., when speaking of intestinal parasites: or the mistake may be made of thinking them to be the lining of the intestine. In case of doubt they should be submitted to the microscopic test presently to be described. The greater part of the mucus found in the stool comes from the large intestine ; that coming from the small intestine is in- timately mixed with the feces and is in very fine pieces. The more numerous the cells (leucocytes, round cells, etc.) in the mucus, the greater is the degree of inflammation. The bits of connective tissue and tendon fibers are distin- guished from the mucus by their yellowish color, greater con- sistency, and threadlike appearance. They can also be recog- nized by microscopic examination, as I shall subsequently ex- plain. They can often be found under normal conditions, but if numerous and large, they indicate a disturbance of gastric digestion, for Schmidt has demonstrated that raw connective tissue is digested only by the gastric juice. Under normal digestion with this diet there should be prac- THE EXAMINATION OF FECES, ETC. 165 tically no meat fibers visible. If seen with the naked eye, they indicate disturbances of intestinal digestion. Potato remains exist under normal digestion only as empty cells. If larger fragments are present, staining blue when a little Lugol's solution is added, derangement of starch digestion is indicated. Large crystals of ammonio-magnesium phosphate (triple phosphates) occur only in putrefying, malodorous stools. Microscopic Examination. — We usually supplement the naked-eye appearances by examining portions of the stool microscopically. In this examination, we proceed as follows : Place a drop of the fluid stool in the center of a slide and one at either end. Over one drop place a cover glass and press it down firmly, without adding anything to the feces. To a sec- ond drop add a small drop of acetic acid (30%), heat for a moment over the flame until it begins to boil, and then place over it a cover glass. To the third drop of feces add a small drop of Lugol's solution (Iodine i, KI 2, Aq. Dest. 50), and stir with a small glass rod, and finally place over it a cover glass. In the first drop (without addition) we see, under the microscope, detritus, bacteria, and other minute bodies, and also some larger bodies, which consist (i) of muscle fibers. These are yellowish in color (stained by bile) and normally show no striation. If these muscle fibers are numerous, and, further, if the striations are seen under the 1-6 inch objective, they indicate derangement of digestion in the small intestine. (2) Yellow salts of calcium and colorless soaps. (3) Isolated potato cells. (4) Chaffy remains of the oatmeal and of cocoa. In the drop treated with acetic acid, we see, after cooling, small flakes of fatty acid. If examined while hot we see drops instead of the flakes. In the third drop treated with iodine we find potato hulls which, under normal digestion, stain violet, but if starch digestion is interfered with, we see dark blue (al- most black) starch granules. Even with the test diet some fat is normally found in the stool, so that the only criterion is the amount of fat appearing. 1 66 METHODS OF EXAMINATION (i) Excessive amounts appear in deficiency of bile, in which case the subHmate test is negative, i.e. the feces are not turned red by a solution of corrosive sublimate; (2) in deficient ab- sorption of fat by a deranged small intestine; and (3) with faulty pancreatic secretion or absence of the pancreatic juice. In the latter case we find drops of neutral fat and also many large muscle fibers. Schmidt says : " Defective starch digestion has its seat in the small intestine. It depends for the most part upon a dis- turbance of the intestinal juices, and, in the absence of any other alteration in the condition of the feces, does not signify any serious disturbance." As is well known, it very often signifies merely excessive in- gestion of starch and deficient mastication, particularly in per- sons with a tendency to hyperchlorhydria. Chemical Examination. — In testing the reaction of the feces, which normally should be neutral or at least amphoteric (i.e. turn blue litmus red and red litmus blue), we place a strip of litmus paper o>i (not in) the feces, which have been rubbed up with distilled water. A very important test, according to Schmidt, is the sublimate test. To carry this out 3'ou place a small amount of the feces which have been rubbed up with water in a glass containing a saturated solution of corrosive sublimate (bichloride of mer- cury) and allow this to stand until the next day. The normal stool is colored red (indicating hydrobilirubin). Particles stained green are pathologic and consist of unchanged bile. Fermentation Tube. — Another important chem'ical test is performed by means of Strasburger's fermentation tube, which can easily be improvised by reference to Fig. 32 on engraved plate inserted at the end of this lecture. In the lower bottle is placed a portion of the feces (as it comes to you) about the size of a walnut. Add water and stir, and shove the rubber stopper in until no air bubble remains. The rubber stopper is taken from the little tube " b " and the tube filled with tap THE EXAMINATION OF FECES^ ETC. 167 water. This is then closed by putting- on the stopper with the vessel connected with it, " a " (filled) and " c " (empty) ; " c " has an opening in top. Then place the apparatus in an in- cubator (at body temperature) or in a warm place, and leave for 24 hours. If gas develops from the feces, it collects in " a " or " b," and a corresponding amount of water is driven into " c." The height of the water in " c " is noted, and the reaction of contents of " c " is taken with litmus paper and compared with the reaction of the fresh feces. Normally only a very little gas is formed, and the reaction is unchanged. If the tube " c " is more than one-third full of water at the conclusion of the test, then pathologic conditions are present. Further, if the reaction has become distinctly more acid, the fermentation is caused by carbohydrates; if, on the other hand, the reaction is distinctly more alkaline, the cause of the gas is albuminous putrefaction as pointed out by Schmidt. If carbohydrate fermentation has occurred, the gas has the odor of butyric acid (rancid butter), and the color is lighter; if albuminous putrefaction, there is putrefactive odor and the color is darker. Various Foreign Substances to be Looked For. — Even in normal feces berries, fragments of potatoes and apples, and shreds of fibrous tissue may be present. After the ingestion of oranges, the pulp and cells may be present, and the latter have been frequently mistaken for parasites, to which they bear some resemblance. In intestinal catarrh the feces may contain epithelium and cylindric shreds or membranous pieces or strings of mucous membrane. Gall stones are frequently present in the stools of patients suffering from hepatic colic. They should be looked for in every case of that affection. Intestinal parasites are frequently present, and search should he made for them in every case in which their presence is suspected. A brief description of the more important of these will be found in Lecture LXXX. 1 68 METHODS OF EXAMINATION The presence of blood indicates hemorrhage, and most fre- quently ulceration somewhere in the tract. In the feces of an individual on ordinary diet many sub- stances are often found which may be confounded with intes- tinal parasites. The general practitioner should be constantly on his guard against such mistakes, and should familiarize himself with the gross and microscopical picture of such sub- stances. The spines from raspberries have been mistaken for hookworm. In a famous case several pathologists mis- took for a parasite what Virchow demonstrated to be simply the skin of an apple. In another instance reported to me, the spiral fibers so often found in vegetables, especially bananas, caused a grave error in diagnosis. In rare instances, the eggs of flies, especially the blow fly, may have been de- posited on the food. These eggs will develop in the intestinal tract into the larvae, or maggots, and as such be passed with the stool. Crystals. — In the feces are found usually crystals of triple phosphates of coffin-lid shape, such as we so frecjuently find in decomposed urine. Besides these, there often occur the needle-formed crystals of the free fatty acids. These latter can be easily recognized by adding a drop of i per cent, al- coholic solution of Sudan III, which colors them orange to blood red. Cholesterine, which rarely occurs in the typical crystalline form, can be readily recognized by adding a drop of concentrated sulphuric acid, which gives them a red violet green and finally a blue color. Bismuth oxide crystals seen after the exhibition of bismuth subnitrate, occur in black ir- regular rhombic shape. Charcot-Leyden crystals are color- less, double diamond shaped, and always indicate some form of intestinal parasite. Vegetable parasites. It is not expected that the general practitioner will have the time, skill, or ecjuipment to make cultures from feces for the purpose of identifying the several specific micro-organisms, as the B. typhosus, B. cholerae, B. dysenterise, and others. Yet, a mere microscopic examination Fig. 27. — I. A, G, aspergillusglaucus; M, M, mucor mucedo; O, L, oidium lactis; S, C, saccharomyces cerevisise. 2. S, P, Staphylococcus pyogenes; G.gonococcus; jM, T, micrococcus tetragenes; D, P, diplococcus pneumo- niae. 3. S, P, Streptococcus pyogenes; S, F, sarcina flava; B, T, bacillus typhosus; B, A, L. bacillus acidilactici. 4. B, S. bacillus subtilis; B, C, bacillus coli communis; B, A, bacillus anthracis; B, T, bacillus tuber- culosis. 5. V, C, vibrio cholerce; B, T. bacillus tetani; B, D, bacillus diphtherise; S, S, spirillum serpens. 6. Spiroch spirochaste; Sp., spirilli from nasal mucus; A, B, actinomyces bovis; S, F, P, spirillum of Fink- ler and Prior. 170 METHODS OF EXAMINATION of stained specimens is of little value since bacteria cannot, as a rule, be identified by their morphology alone. In the accom- panying illustration are shown the more important pathogenic micro-organisms, and it may be clearly seen that while we are ; always able to distinguish by shape and form cocci from bacilli, or the latter from spirilli, we are unable to differ- FiG. 28. — a, tufts of fat needles (" arranged in tufts "). b, crystals of am- monio-magnesium phosphates (triple phosphates) on the right hand; calcium oxalate on the left; underneath, rudimentary forms, c, choles- terin-plates. d, Charcot-Leyden crystals, e^ particles of animal char- coal (given for the purpose of fixing the limits of the feces). (From " Klinik der Verdauungskrankheiten," von Prof. Dr. C. A. Ewald.) entiate the pathogenic from the saprophytic micro-organisms of the same group without further study by means of culture and even animal experiments. There is, however, one exception, the tubercle bacillus. Owing to the characteristic staining reaction of this micro- organism, its presence may be detected in the feces by mere microscopic examination of a properly stained specimen. In examining the feces for tubercle bacilli it is preferable to select particles of mucus, as they are more likely to contain the bacilli. THE EXAMINATiUN OF FECES^ ETC. 171 It has been suggested to produce constipation by the administra- tion of opiates, and then select for examination whatever sHmy particles adhere to the outside of the fecal mass. This sugges- tion is based on the assumption that the hard fecal mass, in passing through the bowels, will carry- from the tubercular ulcer whatever particles may become detached. It is to be noted that the examination for tubercle bacilli in the feces, in Fig. 29. — Stool in chronic colitis, a, triple phosphates, b, cocci and bac- teria. ^, vegetable cells (beans?), (i', Clostridium butyricum. b. /vC". j/a /ieila, ObJ. 7 J IMjr. I'i •'K- •51. Microscopic Appearaxce of Normal Test-Diet Feces. ' a Muscle-remains. d. Chaffy remains. f Detritus .: Soajr ' """' '""'• "• ^'"P'y P°t^*° «"«• '^. Cocoa re„>ai„s. •a,;. Microscopic Appearance of Pathologic Ingredie.nts in the Test- Diet Feces (Combined Picture). • ^ Fat?v a'dcU «nfr'^^.T"'';,, ''' S^^^'"'^*' '^'^^""'« "> Potato cells. Neut^raT at '^ S= Granuliferous Clostridia and hyphomycetes. tiii.diidi. y; Yeast cells. •;i(^. Fermentation Tubes (Dr. Strasburger). ( /v'ow ' • Tlir Tr,l-ni^f a, Intcsdnal Diseases ''—Schmidt and Aaron.) THE EXAMINATION OF FECES^ ETC. 1/7 drawn only to the mark 0.5 and the diluent added as before, a dilution of i to 200 is obtained. After mixing the blood in the bulb of the pipette, it is put on the glass slide containing a counting chamber. A dilu- tion of I to 200 is preferable to make an easy count and avoid crowding the blood cells in the squares. The counting chamber is ruled into 400 small squares sep- arated into groups of 16 squares by double lines. The surface of a square is i -400th of a square millimeter, and the depth of the cell being one-tenth millimeter, the space overlying each square is i -4000th of a cubic millimeter. The number of corpuscles counted in all the squares is mul- tiplied by 400, and the result by the dilution, i :ioo or i :200 depending upon the point to which the blood was drawn in the pipette, I or 0.5. This result is divided by the number of squares counted, and the final result is the number of corpuscles in a cubic millimeter of blood. In counting the zvhite blood cells a 0.5 per cent, solution of acetic acid is used, which dissolves the red cells and renders the white cells more prominent. A dilution of i :io is made by drawing the blood up in the tube to the mark i and adding the diluent to the mark 11. The leucocytes are then counted in an area of the counting chamber equal to 800 small squares, and the calculation made as before. For example, if 120 leucocytes were counted in 800 squares the result would be determined as follows: 120 X 4000 x io-r-8oo= the number of leucocytes per c. mm. To Estimate the Hemoglobin. — In estimating the percent- age of hemoglobin in a given specimen of blood we have again many instruments to select from. Talquist's hemoglobin scale is, however, the instrument most preferred. This consists of a color scale with a book of bibulous paper. The paper is touched with a drop of the blood and partly dried. The re- sulting color is then compared with those on the scale. Fur- ther detailed directions accompany the scale. 178 METHODS OF EXAMIXATIOX A capillary pipette is applied to a drop of blood and then quickly washed in one of the two compartments of the mixing chamber. Both compartments are then filled with water to the brkn, care being taken not to mix the water from one com- partment with that in the other. By moving the graduated slide a comparison of color is made and the reading taken. Another excellent apparatus for the purpose, which econo- mizes time, is that of Dare. It consists of a capillary chamber filled directly from the blood drop, a color scale, and a source of light approximately constant in character and intensity; a candle in a darkened room answers well. The readings of this apparatus are slightly higher than those from others, but allowance has been made for this. Various Diseased Conditions that may be Diagnosed by the Blood. — Lead colic has been mistaken for gastralgia, the pain of gastric ulcer or cancer, for hepatic colic, intestinal colic, and for intestinal obstruction especially. An examination of the blood should prevent such an error by revealing the basophilic granulations in the red corpuscles Avhich are nearly always present in lead-poisoning. Acute abscesses (when non-tubercular) in the appendix, or in the abdomen anywhere (or anywhere in the body, as a rule) are likely to produce a leucocytosis of 15,000 or more. Appendicitis. According to Cabot^ in acute appendicitis the development of gangrene or general peritonitis is almost invari- ably accompanied by a rise of leucocytes to upwards of 20,000. Intestinal obstruction develops within a few hours a rapid increase in the number of leucoc)i;es, which reaches usually 20,000 by the end of twenty-four hours, Avhen the obstruction is complete. When it is partial only, the leucocytosis will be in proportion, ^^^hen gangrene of an intestinal loop sets in, the leucocytes may reach 25,000 or 30,000 except when it results from an infarct of the superior mesenteric artery. Intestinal parasites, especially hookworm, usually cause a marked increase in the eosinophiles. 1 " Am. Text-Book of Surgery," Philadelphia, 1903. LECTURE XV A SYMPTOMATIC GUIDE TO DIAGNOSIS For the inexperienced practitioner especially, and at times for any physician however experienced, it should be a great convenience to have at hand a list of the various diseases or symptom-groups which the prominent symptoms encountered might signify. I have therefore carefully prepared the follow- ing tabular statement including the leading symptoms of gastro-intestinal affections with, placed opposite to each, as full a summary as possible of the diseases or other conditions which have been known to cause it. I cannot claim these lists to be exhaustive, but you will find them to contain certainly most of the possible causes of each symptom. SYMPTOMS Anorexia, or impaired ap- petite. Breath, fetor of, or foul taste in mouth. POSSIBLE CAUSES Fevers and most acute diseases ; cancer ; tu- berculosis ; anger or any powerful emotion ; worry ; anxiety ; fright; hysteria ; dyspepsia, especially the atonic form ; achylia gastrica ; hypochlorhydria,and exceptionally HCl excess; epidemic influenza ; chloro-anaemia ; diseases attended with suppuration ; alcoholism ; pro- longed insomnia ; any wasting or depressing form of disease ; neurasthenia ; gastritis ; ca- tarrhal inflammation of any mucous membrane in the gastro-intestinal tract, or of the bile ducts. Local inflammations or ulcerations of gums, tongue, tonsils, pharynx or nasopharynx ; re- tention in the mouth of decomposing food ; ca- ries of teeth ; stomatitis ; pyorrhea ; retro- pharyngeal abscess ; gastroduodenal catarrh ; jaundice ; certain foods and drugs ; certain lung diseases, as tubercular cavity, gangrene or bronchiectasis ; diabetes mellitus ; reten- tion of stomach contents from atonic dilatation 179 i8o METHODS OF EXAMINATION Bulimia, or excessive ap- petite. Constipation. of stomach, pyloric stenosis, or pylorospasm ; cancer of the stomach, esophagus, or any part of oral cavity or upper air passages ; scurvy ; necrosis of jawbone ; constipation ; acute ex- anthems ; acute infectious diseases ; anaemia; abscess of sublingual or submaxillary gland ; leucoplakia. Insufficient mastication ; obstruction of tho- racic duct ; gastric hyperacidity (hyperchlor- hydria); gastric ulcer ; acid gastritis ; diabetes; epilepsy ; various psychoses ; hysteria ; neu- rasthenia ; insanity ; idiocy ; tumor, or other affection of the brain ; Addison's disease ; tu- berculosis ; syphilis ; Basedow's disease ; preg- nancy ; disease of the uterus; chronic gastritis; chronic enteritis ; gastrectasis ; pertussis ; worms ; exceptionally carcinoma ; exophthal- mic goitre ; after starvation ; convalescence from fevers or other acute diseases. Insufficient food ; lack of coarse foods, vege- tables, or fruits ; movable kidney or the down- ward displacement of any abdominal organ ; hyperchlorhydria ; pj^lorospasm, or any ob- struction of the pylorus ; negligence as to regu- larity in time of going to stool ; insufficient mastication ; exceptionally, deficient gastric secretion ; lack of exercise ; deficiency of bile ; weakened musculature of gastric, intestinal, or abdominal walls ; excessive horseback rid- ing, as in cavalrymen ; prolonged sweating or polyuria ; chronic pancreatitis; hernia; cancer of esophagus or stomach or any portion of the intestines ; fissure or fistula in ano ; per- sistent Meckel's diverticulum ; stricture or obstruction in any part of the alimentary canal; hemorrhoids ; rectal ulcer ; prostatitis; tender or displaced uterus, or ovary ; pyosalpinx ; deranged innervation, as in nervous diseases, especially irregular or spasmodic contractions of intestinal muscles ; neurasthenia ; hysteria ; anaemia ; peritonitis ; appendicitis ; chronic portal congestion ; abuse of purgatives ; the administration of iron, lead, opium, or any astringent ; cerebral congestion; meningitis ; tumor of brain or other cerebral diseases ; adhesions of coils of intestine to each other, or to neighboring structures ; vol- A SYMPTOMATIC GUIDE TO DIAGNOSIS I8I Debility. Defecation, painful. Discolorations of the skin — jaundice or bronzing. Diarrhea. vulus, partial or complete ; intussusception, acute or chronic ; the acute stage of nearly all fevers and general infections, with the excep- tion of typhoid fever ; pelvic abscess ; preg- nancy ; tumors pressing upon the intestines. Carcinoma ; neurasthenia ; vomiting or diar- rhea ; chronic gastritis or enteritis ; under- feeding ; syphilis ; tuberculosis ; malaria ; achjdiagastrica ; confinement to bed ; depress- ing drugs, or overdosing with any drugs ; any acute illness or exhausting disease ; obstruc- tion of thoracic duct ; any severe infection. Hemorrhoids ; cancer of rectum ; rectal ulcer ; fissure or fistula in the anus ; proctitis or any disease of rectum ; disease of any of the pelvic organs accompanied by sensitiveness to pres- sure ; caries of the sacral spine ; tenderness of the sacral spine or coccyx from any cause ; prostatitis or ovaritis. Yellow fever ; gastric dilatation ; gastric ulcer; habitual constipation ; pregnancy ; cancer ; tuberculosis of abdominal viscera ; pernicious anaemia ; disease of the liver or bile ducts ; exophthalmic goiter ; acetanilid poisoning, causing a slate color ; tinea versicolor ; syphil- itic eruptions ; scleroderma ; extension of gas- troduodenitis to gall bladder and ducts ; tox- aemia; any obstruction to flow of bile, as from a neighboring tumor or displaced kidney; Addi- son's disease; mental emotion; acute infectious diseases; argyria ; acute yellow atrophy of the liver; hepatic cirrhosis or congestion ; chronic malaria ; bronze diabetes ; numerous chronic skin affections, with irregular pigmentation ; poisoning with various drugs, including silver, arsenic, and picric acid; sarcoma; alkaptonuria. Excessive action of physic ; intestinal catarrh; tumor in or near the bowel ; poisonous dose of almost any metal except lead ; ruptured pelvic abscess, appendiceal abscess or abscess open- ing into any part of the intestine ; appendici- tis ; presence of ptomaines or toxins ; perni- cious anaemia ; cholera ; typhoid fever ; Addi- son's disease ; syphilis ; influenza ; proctitis ; pneumonia ; tuberculosis ; ulceration in the bowel from any cause ; the exanthems ; fecal Stasis from prolonged constipation ; uraemic l82 METHODS OF EXAMINATION Depression, nervous. Emaciation, Eructations Excitability, iindue. Flatulency, testinal. conditions in Bright's disease ; achylia gas- trica ; the crisis of certain fevers, including es- pecially febricula and simple continued fever ; fright ; anger or other great emotion ; neuras- thenia ; exophthalmic goiter ; movable kidney ; gastroptosis ; any of the forms of cholera ; re- troflectiou of the uterus; septicaemia; diabetes ; the first stage of dysentery; intussusception; fissure in ano ; excessive ingestion of fruit or certain vegetables or any other food causing excessive fermentation ; hypochlorhydria and exceptionally hyperchlorhydria. mental or Achylia gastrica ; hypochlorhydria; excep- tionally hj'-perchlorhydria ; chronic gastritis ; chronic enteritis ; diseases of the sexual or- gans, especially ovarian disease ; anaemia or chlorosis ; obstruction of the bile duct ; chronic appendicitis ; underfeeding ; prolonged loss of sleep ; melancholia ; prolonged overstrain of brain or nervous system ; neurasthenia ; any chronic lowering disease; pregnancy. Tuberculosis ; Addison's disease ; hysterical anorexia ; starvation or underfeeding ; chronic malarial disease, and any chronic disease pro- ducing a profound dycrasia; cancer or sarcoma; chronic inflammatory diseases of the intes- tines ; chronic diarrhea ; gastric atrophy ; dil- atation of the stomach ; long-continued fevers; prolonged lactation ; marasmus ; stricture of esophagus; obstructed pylorus; obstruction in- any part of alimentary canal; very prolonged gastric ulcer ; chronic suppuration ; intestinal parasites; obstructed thoracic duct; final stages of all serious diseases ; cholera ; diabetes. Acute or chronic indigestion ; overfeeding : acute or chronic gastritis ; fermentation in the stomach or small intestines ; insufficiency of cardia ; organic affections of stomach or pan- creas ; neurasthenia or h^'steria ; nervous dys- pepsia ; aneurism of thoracic aorta ; air swal- lowing. Hyperchlorhydria; neurasthenia; uratic diathe- sis ; pregnancy; overstrain of the nervous sys- tem; prolonged eye strain ; cerebral softening; alcoholism or excessive use of nervine drugs, gastric or in- Chronic indigestion; nervous dyspepsia; neu- rasthenia or nerve exhaustion; chronic gas- A SYMPTOMATIC GUIDE TO DIAGNOSIS 183 Headache. Hemorrhage, or loss of blood or altered blood, by the mouth or rectum. tritis or enteritis ; chronic appendicitis ; hys- teria ; hyper- or hypochlorhydria ; carcinoma or sarcoma in the stomach or intestines; intes- tinal obstruction ; peritoneal adhesions. Constipation and various diseases of the digest- ive organs; angemia or sudden hemorrhage; ne- phritis ; constitutional diseases ; specific infec- tious diseases and the onset of most febrile at- tacks; intoxications, as from lead, alcohol, mer- cury, tobacco, or other drugs ; high blood pres- sure; pregnancy ; uremia ; neuroses, as in epi- lepsy, hysteria, neurasthenia ; exophthalmic goiter ; overaction of amyl nitrite or of nitro- glycerin ; blasting or other work with dynamite; inflammatory or organic diseases involving the nervous system, as in meningitis, neuritis, tu- mor, or abscess ; reflex from diseases of the ear, eye, nasopharynx, orsexual organs; physical or mental fatigue ; cerebral congestion or soften- ing ; cerebral syphilis. Gastric ulcer or erosions ; tubercular phthisis ; rupture of pulmonary vessel from aneurism (hemoptysis); hepatic cirrhosis ; gastric can- cer ; aneurism rupturing into esophagus, stom- ach, or intestines, or rupture of varicose veins into any of these ; enlarged spleen ; injuries to the mouth, nose, or throat in the case of unconscious persons, infants, and malingerers, the blood being swallowed ; injury to stomach from straining or blows ; vicarious menstrua- tion by way of the stomach ; cancer of the liver exceptionally ; corrosive poisons swal- lowed ; severe anaemias; scurvy; purpura haemorrhagica ; chronic nephritis ; certain acute infectious diseases, such as yellow fever, smallpox, and cholera ; acute yellow atrophy of liver , duodenal ulcer ; typhoid, dysenteric or other ulcers of the intestines ; hemorrhoids; cancer of the rectum ; foreign bodies ; fissures or polypi of rectum ; strangulated hernia ; in- tussusception in children ; colitis in children ; amyloid disease of the intestines ; aneurism or thrombosis of superior mesenteric artery ; portal thrombosis ; jaundice ; diarrheal attacks complicating exophthalmic goiter ; intestinal parasites ; fecal impaction ; unskilled use of instruments. 1 84 METHODS OF EXAMINATION Insomnia, or sleep. Irritability of temper, Nausea, or vomiting impaired Neurasthenia ; hyperchlorhydria ; gastric or duodenal ulcer ; constipation ; intestinal ca- tarrh ; cerebral disease ; pain anywhere in the body from cancer or other cause ; deficient food ; overloaded stomach ; indigestion, gas- tric or intestinal, from any cause ; anxiety or worry ; fear or any powerful emotion ; mental excitement of any kind. Neurasthenia ; chronic indigestion ; loss of sleep ; over-fatigue of nervous system ; hyper- chlorhydria ; the uratic diathesis ; impairment of cerebral tone from any cause ; prolonged eye strain ; pregnancy. Acute or subacute gastritis from putrefying, indigestible, or irritating food ; overloaded stomach ; chronic gastritis ; alcoholism ; anaes- thetics or opiates in full doses ; spasmodic or mechanical obstruction of the pylorus from a tumor or the cicatrix of an ulcer causing ste- nosis ; gastric cancer ; gastric or duodenal ul- cer ; dilatation of the stomach ; irritant poi- sons ; administration of emetics ; pregnancy ; locomotor ataxia ; centric or toxaemic as seen in Addison's disease ; meningitis ; cerebral tumor, abscess, or congestion ; acute infectious diseases and onset of most fevers ; reflex of obscure cerebral origin ; irritation of pharynx, larynx, or thyroid gland ; hardened ear wax ; Bright's disease ; appendicitis ; perforation of the intestines ; acute peritonitis ; acute enter- itis ; incarcerated or strangulated hernia ; in- testinal obstruction from any one of numerous causes ; acute disease of the liver ; cholecys- titis, cancer, or other disease when it causes stenosis of the bile ducts ; hepatic colic ; anae- mia ; pyelitis ; movable or floating kidney ; ptosis of any viscus ; hydronephrosis ; disease of the pancreas ; reflex from disease of the uterus, ovaries, or tubes ; reflex from diseased bladder or prostate gland ; hysteria ; neuras- thenia; intestinal parasites; obstructed ureter; subphrenic abscess ; stricture of the esophagus ; migraine ; prolonged eye strain in very sus- ceptible persons; any one of various renal affections, as calculus, tuberculosis, syphilis, cancer, or other tumor of either kidney. A SYMPTOMATIC GUIDE TO DIAGNOSIS 185 Oppression or weight in stomach. Pain referred to the right hypochondriac region or lower edge of liver. Pain, referred to the re- gion of the stomach. Pallor of the skin. Chronic gastritis; nervous dyspepsia ; neuras- thenia ; premonitory stage of gastric hemor- rhage ; atony or dilatation of the stomach ; de- ficient secretion of HCl and the ferments (hypopepsia or hypochlorhydria); achylia gas- trica ; gastric atrophy; pyrosis; gastric hy- peracidity ; any form of acute gastritis ; gastric ulcer ; gastric cancer ; dilatation of the stomach; diseases of the pancreas ; chronic gastritis. Hepatic colic ; cholecystitis; certain diseases of the liver; movable right kidney ; hydro- nephrosis ; calculus in the right kidney or its pelvis ; renal colic ; tumor of the liver, gall bladder, bile duct, pylorus, or the intestines ; ulcer of the pyloric end of the stomach or of duodenum ; rheumatism ; traumatism ; ulcer of the cecum ; right-sided pleurisy or pneu- monia ; diaphragmatic pleurisy; appendicitis. Excessive secretion of HCl (hyperchlorhydria); excessive gastric fermentation with large form- ation of organic acids and gases ; round ulcer or erosions of the stomach ; gastric cancer ; gastroptosis ; gastralgia from purely nervous causes ; atony, or dilatation of the stomach ; foreign bodies swallowed and retained in the stomach ; ulcer of the duodenum ; phlegmon- ous or simple acute gastritis ; perigastritis ; hyperaesthesia of the gastric mucous mem- brane ; acute indigestion ; morphine habit ; disease of the vertebrae ; pneumonia in chil- dren ; cancer or inflammation of the pancreas ; disease of the pleura ; especially diaphrag- matic pleurisy ; disease of the heart or pericar- dium ; affections of the intercostal nerves ; herpes zoster ; kinking of the ureter in cases of movable or floating kidney, especially on the left side ; abscess of the liver ; intes- tinal disorders; cramp of the gastric muscles from spasmodic or any obstruction of the pylorus; aneurism of the abdominal aorta; arteriosclerosis of the abdominal vessels ; rheumatism of the abdominal muscles ; pas- sage of biliary or renal calculi ; subphrenic abscess ; locomotor ataxia ; hysteria ; hypo- chondriasis ; localized peritonitis ; traumatism. Recent hemorrhage ; Bright's disease ; tuber- culosis ; malignant growths ; acute or chronic 1 86 METHODS OF EXAMINATION Ptyalism, or salivation. Regurgitation, or rumina- tion. Succussion, or splashing sounds in the abdomen. diarrhea ; chronic gastric or intestinal indiges- tion ; chronic gastric ulcer cr severe hemor- rhage in an acute one; chronic gastric catarrh ; chronic malaria ; syphilis ; gastric dilatation ; gastroptosis or enteroptesis ; morphine habit and some other drug habits ; lead poisoning ; stricture of the esophagus ; various kinds of - poisoning, both from the outside, as » from drugs, illuminating gas, etc., or from auto- toxEemia ; prison life or long confinement in any badly lighted rooms ; starvation ; deficient oxygen from poor ventilation or overcrowding, especially in cities ; chronic ill health from almost any cause ; idiopathic or pernicious anasmia; arteriosclerosis. Disease of the teeth or gums; dentition ; stom- atitis ; glossitis ; mumps ; acute tonsilitis or peritonsilitis (quinsy); nausea ; disease of the pancreas ; any one of various diseases of the stomach : intestinal worms and probably other abnormal conditions in the bowels ; tu- mor of the medulla or facial nerve ; pregnancy; facial neuralgia ; mental disease ; excessive mental emotion ; pyschic neurosis ; the ac- tion of certain drugs, especially mercury and gold in excessive doses or small doses often re- peated ; strong acids or alkalies ; jaborandi ; physostigma; muscarin; tobacco; the prepara- tions and compounds of iodine and copper and the nauseating medicaments ; various spicy food accessories, as horseradish, ginger, etc.; some obscure diseases of the brain or spinal cord, as some forms of paralj'sis ; progressive muscular atroph}^ ; rabies ; hystero-epileps}^ ; atony of the submaxillary ganglion ; irritation of cordi tympani ; irritation of cervical sympa- thetic ; early stages of variola or typhoid fever ; and the crises of fevers exceptionally. Relaxation of cardiac orifice of stomach ; neu- rosis; existence of sac or diverticulum in esoph- agus ; habit ; certain forms of indigestion ; insanity ; epilepsy ; idiocy ; neurasthenia ; hj^steria. Aton3^ or dilatation of stomach ; hydropneu- mopericardium ; gastroptosis ; enteroptosis ; when such sounds are demonstrable over ce- cum, sigmoid flexure, transverse colon, or A SYMPTOMATIC GUIDE TO DIAGNOSIS 187 Tenderness on pressure over epigastrium. Tenesmus. Tongue coated or furred. Tympany, abdominal. Vertigo. other part of the large intestine, they signify atony or dilatation of the same. Functional or organic disease in abdominal plexuses of the sympathetic nervous system ; gastric or duodenal ulcer ; acute or chronic gastritis ; hypochondriasis ; hysteria ; Addi- son's disease ; gall stones ; acute yellow atro- phy of liver ; pancreatitis ; acute pericarditis; diaphragmatic pleurisy ; irritant poisons ; peri- tonitis ; aneurism of abdominal aorta ; rheu- matism of abdominal muscles ; appendicitis exceptionally. Dysentery;, proctitis; catarrhal enteritis; diarrhea caused by irritant poisons ; overac- tion of mercury or other cathartics ; membran- ous enteritis ; irritable bladder with vesical tenesmus ; impacted faeces ; worms ; foreign body in rectum ; hemorrhoids ; polypus ; ade- noma or cancer of rectum ; intussi>sception in children ; enlarged or retroflexed uterus. The use of tobacco ; mouth-breathing ; naso- pharyngeal catarrh ; so-called bilious attacks ; the exanthems or any fever ; any systemic toxaemia ; autotox^mia ; gastritis ; gastro- duodenitis ; enteritis ; cancer anywhere in ali- mentary canal ; alcoholism ; milk diet ; neu- ralgia of second or third division of trigemi- nus ; fracture involving foramen rotundum (unilateral); hemiplegia ; rough tooth ; tonsil- itis ; thrush ; Riggs' disease ; caries of the teeth ; disease in any part of the mouth ; retropharyngeal abscess. Gastric or intestinal fermentation ; gastric or intestinal atony ; dilatation of the stomach ; gastric catarrh, cancer, or ulcer ; pyloric ste- nosis ; typhoid fever ; appendicitis ; peritoni- tis ; hysteria (pneumatosis); intestinal obstruc- tion ; sepsis ; strangulated hernia ; pressure on intestines by tumor or fluid ; defective in- nervation with either atony or spastic contrac- tion of intestinal walls ; constipation ; perforat- ing ulcer of stomach or intestines ; marked emphysema ; ascites from hepatic cirrhosis or other causes ; acute yellow atrophy of liver ; air swallowing. Neurasthenia ; lith^mia; gastric hyperacidity; chronic gastritis ; intestinal parasites ; arteri- METHODS OF EXAMINATION osclerosis ; valvular cardiac disease ; injury to vestibule of inner ear ; aneurism ; Meniere's disease ; eye strain ; epilepsy ; anaemia, es- pecially on exertion ; tumors of the brain, es- pecially of the cerebellum ; abuse of tea, cof- fee, alcohol, or tobacco ; auto-intoxication ; the chronic form of nephritis; locomotor ataxia ; disseminated sclerosis (rarely); men- tal strain or excitement in neurotic persons ; mechanical disturbance of equilibrium as in seasickness, in railway or elevator sickness ; transitory, as in looking at a rapidly rotating body ;• vertical, caused by looking down from a height ; lateral, which may occur in a person walking alongside a fence ; nocturnal, felt in act of going to sleep. PART III METHODS OF TREATMENT LECTURE XVI PROPHYLAXIS: PERSONAL HYGIENE AND FOOD REQUIREMENTS Prophylaxis^ if not exactly treatment, is better than treat- ment. To prevent disease is always much better even than to cure it when it has come. This is true from the humanitarian point of view if not according to business principles; and in these lectures I shall teach you that medicine is something more than business or a trade — that it is our duty as physicians endowed with superior knowledge upon such subjects, not only to protect in all possible ways from the dangers of disease the families and individuals intrusted to our care, but also to aid in protecting the communities wherein we dwell, by giving timely warning as to threatening unhygienic conditions and pointing out the way to remedy them. Professor R. A. F. Penrose, in lecturing upon obstetrics some thirty-five years ago, was accustomed to say that the best way to insure the birth of healthy children was to see to it that the building material was good — /. c, to make sure that the ancestors were healthy. The same may be said as to pre- venting disease of the digestive system ; the surest way to secure healthy digestive organs is to be born with them. Unfortunately, however, a very large proportion of civilized mankind are born with a strong predisposition to disease of these organs, and such persons need to be doubly careful to follow hygienic rules. By living temperately, eating the foods best adapted for easy and rapid digestion, masticating all ingesta with the greatest possible thoroughness, and avoid- ing all excesses and irregularities, not only in eating and drinking, but also in work and play, such inheritors of poor constitutions, including especially faulty digestive systems, 191 192 METHODS OF TREATMENT may often, and constantly do, greatly ontlive the most robust people whose lives are full of dissipation and reckless disre- gard of hygiene. This subject of prophylaxis will come up particularly in advising as to the care of children, their diet, exercise, baths, physical training, education, and, later, the choice of an occupation. As to all of these, you, as family physicians, will be, or should be, called upon to decide and lay down for the parents explicit directions regarding every detail. To consider all these subjects as fully as their importance demands is impracticable in this place, and you will find them exhaustivel}^ discussed in the best works on pediatrics. A few g'eneral principles, however, should govern in the hygienic management not only of delicate children, but of adults who have a predisposition to digestive disorders. These may be summarized briefly as follows : Secure for them, first of all, an abundance of pure fresh air both by day and by night. When practicable, such children or older patients should live in the country with plenty of open spaces about their houses, and the latter should be equipped with perfect systems of ventilation. Personal Hygiene. — In reality, everything pertaining to both personal and public health is in direct relation to the pre- vention of gastro-intestinal diseases, since all h3^gienic faults tend to lower the nerve tone and set up finally disease in vari- ous parts of the body, including nearly always the digestive system. The different systems are in such close sympathetic relation with each other that no one of them can be seriously injured without the others being liable and likely to become ultimately involved. Besides care of the diet, the hygienic precautions which are especially important to prevent the development of disease in the alimentary canal should include an abundance of pure, fresh air (good ventilation), a proper .development of the muscles, especially the trunk muscles (secured by outdoor ex- ercise in part), and the daily use of them in such a way as to stimulate gastric and intestinal peristalsis and insure a suffi- prophylaxis: personal hygiene 193 ciently active circulation of the blood in all of the digestive glands. This is constantly neglected by most professional persons and sedentary workers, to say nothing of the idle class. Delicate persons need also to take specially good care of the skin, by which is meant not only keeping the latter clean, since warm baths for this purpose are often greatly abused, but also a proper training of it by a daily rubbing or kneading of the entire surface of the body, which can be most efficiently done in most cases after a transient application of cold water with a sponge or wet towel. Such a daily practice is of the greatest efficacy in maintain- ing an active circulation of the blood in the skin, by means of which liability to take cold upon ordinary exposure to changes of temperature, and the danger of internal congestions, is greatly lessened. The prophylactic value of these two prac- tices — daily exercise of the trunk muscles and surface fric- tions, especially after the application of cold water— ;-can scarcely be overestimated. The teeth and gums should also receive special care. At least once daily the teeth should be brushed in such a way as to remove all remaining particles of food, and it is safest to cleanse the teeth after every meal. When such pains are taken to keep the teeth and gums always free from decomposing matter, there is infinitely less liability to the development of caries or other disease in or about the teeth ; but, in addition to these precautions, every per- son should have his mouth examined by a dentist once or twice a year to see that no disease has been set up in any of its structures that could carry infection into the parts below. There cannot be good digestion without efficient mastication, and this is impossible without good teeth. Care should be taken also to avoid the development of chronic catarrhal disease in the nose, nasopharynx, or pharynx, since the mucus swallowed from these parts is always swarming with bacteria, and liable finally to infect the stomach. 194 METHODS OF TREATMENT People who inherit a tendency to indigestion should go to the table with a quiet mind and avoid eating while seriously- fatigued. They should spend plenty of time at meals, and en- gage in no active work, either mental or physical, for half an hour after their lighter meals, or for a full hour at least after dinner. When the digestion is already much impaired the re- cumbent posture for some time after each meal will be advan- tageous. Such persons should lead as quiet, even lives as pos- sible, avoiding all excesses, every form of overstrain, mental, physical or emotional, especially sexual excesses or ir- regularities. Seven to eight hours daily of sound, refreshing sleep are also requisite to good health; but if the foregoing health rules are strictly followed, good sleep will naturally follow, except in conditions of disease, when the cause needs to be removed by having the disturbing disease cured. Hypnotic drugs rarely effect the end desired. They always do harm when long con- tinued, and fail frequently to afford even temporary relief. The taking of them should never be left to the discretion of the patient. As to clothing, the indications should be plain : Allow as lit- tle constriction of the body, especially about the chest and upper abdomen, as possible; and for those who are most of the time indoors the rule should be to wear no heavier clothes than are necessary to keep them comfortable in warm rooms, extra wraps to be put on when necessary for any unusual exposure. The Hygiene of Eating and Drinking. — The food should be simple, digestible, and thoroughly prepared for ingestion in the case of older children and adults by sufficient mastication and insalivation. The meals should be neither too near to- gether nor too far apart. For invalids numerous small feed- ings are sometimes best, but in the case of adults not ill more than three or four meals a day are inadvisable, and there should rarely be less than two. It is important, of course, that delicate persons should not fail to take enough nourishment to maintain nutrition certainly at the proper level, and more care prophylaxis: personal hygiene 195 is necessary in this respect for them than for other persons. On the other hand, it is equahy important to avoid overeating, and this danger, for most Americans at least, is greater than the other. There should be always the proper ratio between alimentation and oxygenation, as I have pointed out hitherto in various papers concerning the management of consumptives and other classes of invalids.^ In other words, the more oxy- gen one takes into one's lungs the more food one requires and can safely take, whether the oxygen be secured by abundant ventilation while resting indoors, by spending much time in the open air, even sitting on piazzas, or better, by enjoying such passive outdoor exercise as driving, automobiling, or sail- ing, by active exercise indoors with good ventilation, or best of all by active exercise in the open air. Definition of Food. — It will be in place here to define what food is, and I have tried to formulate in few words a satisfac- tory definition of it. A food is any substance which, when introduced into the system, can supply heat or force or repair tissue waste zvithout exerting any disturbing or medicinal action. Alcohol and Food Accessories. — You will observe that by no possible twisting of this definition can it be made to include alcohol or any of the so-called food accessories which are often taken with our food for the purpose of stimulating either the brain or other part of the nervous system, or the digestive apparatus. In making a clear and sharp distinction between the foods proper and the numerous substances which, by a confusion of thought, are often represented as in some sense foods, I by no means intend to condemn in toto the use of the latter sub- stances. I only insist upon clear definitions of them and clean- cut conceptions concerning them. I believe that the savory spices are sometimes useful in disease, and in their moderate use by adults often excusable in health for the reason that tempo- 1 The Ratio that Alimentation should Bear to Oxygenation in Disease of the Lungs, T/ie Med. News, September 22, 1894. 196 METHODS OF TREATMENT rarily they may perform a needed service by increasing the appetite and the enjoyment of dining. But for their injurious after-effects the same might be said of alcohohc beverages. They increase the sociabihty of festive occasions. It seems to me in the highest degree important that in the instruction of the young the exact scientific truth should be taught, and that in the management of dehcate invaHds, with irritable nervous systems and greatly enfeebled digestions, we physicians should not deceive ourselves and our patients by a confusion of defini- tions and reasoning regarding such substances. Let us call a spade a spade, and limit the word food to substances useful for nutrition, and class strictly as medicines or drugs all those articles which, being entirely without true food value, find their chief use as stimulants or irritants of tissue. The fact that alcohol can be consumed in the body to some extent with the production of heat, no more makes it a food than the fact that both it and benzine can be burned in stoves with the lib- eration of heat, constitutes these substances fuels. In both cases the process of combustion is more or less unmanageable and liable to be followed by dangerous results. In health, exercise and sufficient fresh air with the fesultant oxidation processes are the normal excitants of appetite. When we eat our meals in good company and amid as pleasant sur- roundings as possible, after a sufficient lapse of time since the previous meal, we do not, unless out of health, need any arti- ficial irritant to produce a flow either of saliva, of gastric juice, of bile, or any other of the digestive juices. Prolonged mas- tication will insure abundant insalivation at least. If we are out of health we need a physician, and sometimes, doubtless, medicine, to overcome a persistently deficient secre- tion ; but physicians do not usually find it advantageous to recommend the constant use of any one drug year after year, and so on through life. Indeed, competent observers agree that the prolonged use of any drug which at first produces stimulation will, in the end, cause overstimulation and, finally, depression of the parts stimulated. prophylaxis: personal hygiene 197 When, therefore, we reg'ularly and habitually take with our meals alcoholic beverages, tea, or coffee, or any of the spices beyond the very small amount required to give a slight flavor to the food, we should do so solely on the ground that we like them and enjoy the taste of them as well as the stimulating effect of them upon the nervous system. With this clear understanding of the matter, we shall be less likely to abuse these substances, and to force them upon the unwilling palates of children at an age when they can do most harm, and when there can scarcely exist even the possibility of benefit to be derived from them. Having thus disposed of food accessories which are not foods at all, we come now to the Classification of Foods, — The usual division is into pro- teids, carbohydrates, hydrocarbons or fats, salts, and water. The proteids are nitrog-enous elements obtained usually from the flesh of animals, from eggs, milk, the legumes (beans, peas, etc.), the grains, and other vegetable sources. They are indispensable for the repair of tissue waste, since they enter into the -composition of the cells of all the structures of the -body. They are also to some extent utilized for the production of heat and force. The carbohydrates, as the name indicates, are foods contain- ing carbon and hydrogen, along with generally other elements, but usually no nitrogen, and are obtained from a great variety of sources, including especially the grains, the legumes, and other vegetables, fruits, etc. They are practically non-existent in meats and fish. The carbohydrates are oxidized in the body with the production of heat and force. Fats, or the oily part of food, are obtained from both the animal and vegetable kingdoms, and like the carbohydrates, find their use in producing force and maintaining the heat of the body. For these purposes they are more efficient than the former, though for many persons they are decidedly less digestible. The salts include the chloride of sodium, carbonate of so- 198 METHODS OF TREATMENT dium, and phosphates and sulphates of potassium, sodium, and magnesium as well as minute amounts of iron and of certain other metals. Water constitutes a very large proportion of the body, being about two-thirds the amount of the whole by weight. It is the most universal solvent in Nature, and plays a most important role in the processes of nutrition. All of these food elements are necessary to perfect health, though one or more of them can be dispensed with for short periods. Since the proteids are in- dispensable for the repair of tissue waste and are also available to some extent for the production of heat and force, life can be maintained longer upon a proteid diet with the addition of sufficient water and salines than would be possible with a diet embracing all other varieties of food, but without proteids. When a person attempts to live for prolonged periods upon a diet containing but little proteid material, the necessary nitro- gen is taken from the muscular and other tissues of the body itself and in this way a serious form of wasting occurs. Ex- amples of the kind have been noted in poor sewing women of cities who have endeavored to live upon a diet of white bread and butter and tea, with the inevitable result of a serious loss of flesh and strength. Various estimates have been given by authors of the relative proportions of proteids, carbohydrates, etc., required to maintain nutrition. The following table gives the estimates of five prominent physiologists as to the food requirements of healthy men engaged in moderate manual labor : PROPORTIONS OF DIFFERENT FOODS IN THE NORMAL DIET ACCORDING TO VARIOUS AUTHORITIES MOLESCHOTT Ranke VOIT Foster Atwater Grms. Grms. Grms. Grms. Grms. Proteid . 130 100 118 131 125 Fats or Hydrocar- bons 40 100 56 68 125 Carbohydrates . 550 240 500 494 400 PROPHYLAXIS : PERSONAL HYGIENE 199 You should bear in mind that women require, on an average, less than men, and that a person at rest can be adequately sus- tained, without loss of weight, on somewhat more than one- half the quantities of food required for one employed at manual labor. FOOD REQUIREMENTS UNDER DIFFERENT CONDITIONS The following table of standards for American dietaries is given by Atwater Woman with light muscular exercise Woman with moderate muscular work Man without muscular work Man with light muscular work Man with moderate muscular work Man with hard muscular work 1 Proteid Fuel value Grams Calories 90 2,400 100 2,700 112 3,000 125 3,000 150 4-500 Nutritive ratio 1:5-5 1:5-6 1:5.5 1:5-8 1:6.3 That even the lowest of the figures given in the foregoing tables are excessively high has long been maintained by some writers, and especially that the amounts of proteid therein prescribed are excessive for the real needs of nutrition. Some Recent Experiments Concerning Food Requirements. — Professor R. H. Chittenden, Director of the Sheffield Scien- tific School of Yale University, in a recent very interesting and suggestive article on this subject, entitled " Physiological Economy in Nutrition,"^ wrote: "Why, now, should we assume that a daily diet of over 100 grams of proteids, with fats and carbohydrates sufficient to make up a fuel value of over 3000 large calories, is a necessary recjuisite of bodily vigor and physical and mental fitness? Mainly because of the supposition that true dietary standards may be learned by ob- Popular Science Monthly, June, 1903. 200 METHODS OF TREATMENT serving the relative amounts of nutrients actually consumed by a large number of individuals so situated that the choice of food is unrestricted. But this does not constitute very sounct evidence. It certainly is not above criticism. We may well ask ourselves whether man has yet learned wisdom with regard to himself, and whether his instincts and appetites are to be entirely trusted as safe guides to follow in the matter of his own nutrition. The experiments of Kumagawa, Siven, and other physiologists have certainly shown that men may live and thrive, for a time at least, on amounts of proteid per day equal to only one-half the amount called for in the Voit standard. Siven's experiments, in particular, certainly indi- cate that the human organism can maintain itself in nitrog- enous equilibrium with far smaller amounts of proteid in the diet than is ordinarily taught, and further, that this can be attained without unduly increasing the total calories of the food intake." In the same article from which the above is taken. Professor Chittenden describes some carefully conducted experiments upon a gentleman (Horace Fletcher) whom he refers to as having " for some five years in pursuit of a study of the subject of human nutrition, practiced a certain degree of abstinence in the taking of food and attained important economy with, as he believes, great gain in bodily and mental vigor, and with marked improvement in his general health." Omitting com- ments and details for which there is not room here, I will again cjuote Professor Chittenden's own words as to the re- sults of these experiments : " For a period of thirteen days, in January, he was under observation in the writer's laboratory, his excretions being analyzed daily with a view to ascertaining the exact amount of proteid consumed. The results showed that the average daily amount was 41.25 grams, the body weight (165 pounds) remaining practically constant." This amount of proteid, which sufficed for the needs of nutrition, was only a little more than one-third of that laid PROPHYLAXIS : PERSONAL HYGIENE 20I down by Voit as the standard requirement, or to be exact, 34.9 per cent, of Voit's figures. In a subsequent experiment the subject, Mr. Fletcher, was required to perform daily in the Yale University Gymnasium the same exercises given to the 'Varsity Crew, which, as described by the director of the gymnasium who supervised this part of the experiment, " are drastic and fatiguing and cannot be done by beginners without soreness and pain result- ing." Yet he was not in the least disturbed by them. The noteworthy points in the results of the second experi- ments as described by Professor Chittenden are that, though the subject of the experiment fully satisfied his appetite, not having been under any restrictions as to either quality or quantity of the food, and performed a large amount of violent exercise daily during the entire experiment, his consumption of proteid averaged less than 45 grams daily as compared with the 118 grams prescribed by Voit, 125 by Atwater, and 130 by Moleschott for the average proteid ration of a man at moderate labor, while his total intake of food amounted to only 1606 calories or heat units as against the 3000 to 4500 considered necessary in such a case by the same physiologists. Moreover there was no loss of weight during the experiment. Apparently nutrition was completely sustained in every respect. The subject of the experiments above referred to, Mr. Horace Fletcher, is the author of several books on topics con- nected with eating, nutrition, etc. His particular hobby is what he calls " overmastication," that is, masticating or in- salivating in some way all food whether solid, pultaceous, or Hquid, very much more completely than is usual with even the most careful of eaters. He claims that by this means one may not only maintain nutrition on greatly less than the usual food ration, but acquire a pharyngeal or buccal reflex which will unerringly indicate both when each bolus has been properly prepared for swallowing and when enough has been eaten at any meal for the needs of the body. Indeed, he maintains 202 METHODS OF TREATMENT that after practicing this method for a month or six weeks, it will be difficult for one to swallow any morsel of food until it has been sufficiently masticated and insalivated. Ifi this fast-eating age the need of more thorough mastica- tion and insalivation is a most important theme upon which to preach a new gospel and Mr. Fletcher cannot dwell upon it too long or too earnestly. However, the results of experi- ments with him as a subject will not hold good for others unless they patiently learn and practice his method of eating and chewing, and it will require a lot of missionary work to induce the rest of mankind to follow his example. Until then most people will go on eating, or bolting, twice the amount they need, washing much of it down with liquids instead of preparing it as Nature intended, and then calling upon physicians to repair the damages that must inevitably result. Moreover, experience teaches that we must sometimes tem- porarily allow patients with certain gastric or intestinal af- fections, especially catarrhal affections, a disproportionately large amount of some animal proteid — in the form preferably of meat pulp, meat juice (fresh), meat powder, or finely hashed beef — because it stimulates the gastric juice and the depressed nervous system more and is very much less liable to fermenta- tion than the carbohydrates. As a measure of prophylaxis it will be advisable, however, in all cases except in those forms of disease requiring a spe- cial modification of the diet, to keep rather closely to the rela- tive proportions of the several classes of foods given in the foregoing tables, except that recent observations have proved that the proteid element should be much less than formerly ad- vised. It is not well to advise for prolonged use any form of a one-sided diet, such as one consisting largely of meat or of milk or even exclusively of vegetables. The vegetable king- dom, including the legumes, can indeed supply all the food ele- ments required, since dried beans and peas contain an even larger percentage of proteid material than meat. For persons with a normal digestion a strict vegetable diet PROPHYLAXIS : PERSONAL HYGIENE 203 may be made to meet all the needs of nutrition, and there is much evidence to show that such persons often win in contests of physical endurance against flesh-eating competitors. Some of the peoples who subsist upon vegetables, fruit and nuts, with rarely any flesh food except occasionally a little fish, are noted for the muscular strength of their working class espe- cially ; but no such peoples have ever been distinguished for in- tellectual attainments or excelled in the mental vigor and organizing ability which have helped some of the meat-eating nations to extend their sway over a large part of the world, un- less we except the Japanese, and it is noteworthy that their re- markably rapid developmerii', both mental and physical, has been contemporaneous with an increased use of flesh foods by all of them except the poorest class. This question as to the best diet in health and disease has not yet been finally settled, and conservative thinkers are not pre- pared to accept the conclusions of the extremists on either side. Certain it is, however, that the coarser cereals, acid fruits, raw nuts, and especially uncooked starch, prove harmful to most persons who have diseased stomachs or intestines. It will be well if you can succeed in inducing your patients to keep down the proportion of flesh foods at least to that amount which, added to the proteids in the bread, cereals, and vegetables eaten, will make up the one-fifth part of their total diet held by Voit and others to be the normal requirement of this form of aliment. Even that will probably be much more than they really need. The majority of Americans of the leisure class, and many of the humbler class, eat excessively of meat in addition to large cjuantities of the rich proteid-bearing cereals and legumes, thus greatly exceeding the above-stated proteid requirements, with the result of overtaxed livers and kidneys as well as sclerotic arteries often before middle life. LECTURE XVII GENERAL CONSIDERATIONS CONCERN- ING DIET AND DIETOTHERAPY Sufficient is now known to prove beyond question that by means of appropriate diet, in connection with rest and exer- cise, much more can be accomphihed in many diseases of the digestive organs than is possible of accomphshment through the use of drugs or any other form of therapy alone. We know, for example, that certain gas^ic affections are a direct or indirect result of eating too much or too fast with insuffi- cient mastication of foods which are not themselves very in- digestible, or of eating when, on account of intense mental con- centration, recent violent exercise, or a greatly exhausted con- dition of the nervous system, an insufficient amount of blood can reach the digestive glands. A similar statement is ap- plicable to a number of intestinal troubles. RELATIVE IMPORTANCE OF DIETETICS — RESTING THE STOMACH Wegele's Estimate of Dietetics — A prominent German author some ye'ars ago wrote a work on diseases of the stomach and bowels, dividing it into two volumes.^ The first volume was devoted entirely to the dietetic treatment of such affections and included an appendix made up of culinary recipes. Of the second volume the first part, embracing nearly one-half of the book, was occupied with a consideration of the physical or mechanical methods of treatment such as lavage, i"Die diaetetische Behandlung d. Magen-Darmerkrankungen,'" and "Die physikalische und medicamentoese Behandlung d. Magen-Darm- erkrankungen," von Dr. Carl Wegele, Jena, 1893 and 1895. 204 CONSIDERATIONS CONCERNING DIET 205 irrigation of the bowels, nutrient enemas, massage, electrical applications to the stomach and intestines, baths or other ap- plications of water externally, and finally orthopedic treatment and curative gymnastics. Last of all came some chapters on the medicinal treatment of the diseases in question. Yet in this country a physician runs the risk of being considered ec- centric — in some quarters irregular even — if he does not make drug treatment his first and principal resource in the manage- ment of the digestive disorders as well as in all other dis- eases. Diseased Stomachs Need Rest — When there is acute gen- eral disease as in fever, the whole body is rested by the patient being put to bed. When an arm or leg is broken, complete rest of the affected part is secured by putting it into a splint. When the stomach is seriously damaged either by injury or disease, it also imperatively requires rest in order to regain its normal condition; but it is impossible to give it absolute rest and yet maintain life for any length of time. Hence the difficulties attendant upon the treatment of the chronically diseased digestive organs. Even though crippled, they cannot have the rest which would allow them to recover speedily. But by means of diet we can do much in the direc- tion of resting them. When the disease is found by the appro- priate tests to involve the stomach exclusively or chiefly, while the liver, pancreas, and intestinal glands are normal, we can spare the suffering part very much by prescribing food which will tax both the gastric glands and musculature as little as possible, and pass rapidly on into the duodenum, where it will meet the other digestive juices. In these cases, too, you should insist upon thorough mastication, so as to get all the help pos- sible from the saliva. When, on the other hand, the stomach is shown to be com- paratively healthy and other parts of the digestive apparatus are at fault, you may reverse the process, and give foods which can be digested mainly in the stomach. 206 METHODS OF TREATMENT When all these parts are involved, as is too often the case, we may still afford partial rest by so controlling the diet as to exclude the most fermentable articles and prevent overburden- ing- of the afflicted organs from an excess of even proper food, or by food which is either naturally tough and indigestible or made so by bad cooking. Thus it may be seen how important it is, if curative results are to be obtained, to have cases of indigestion systematically examined by the exact methods now at our command, and the diet carefully adapted to them. Nor can this adaptation be done once for all. Every case may profitably be studied and the results of the diet and treat- ment on the urine, feces, blood, body weight, nerve state, etc., closely watched. But with the earnest and conscientious co- operation of the patient and the patient's friends with the efforts of the physician, very much can be accomplished in even many of the most unproniising cases. Summary of Precautions. — To sum up, the chief points to bear in mind in advising dyspeptics regarding their eating, drinking, etc., are as follows : They should never eat a hearty meal when very tired, vexed, worried, or cold. If they have been exercising severely, they should lie down or rest in some easy position for half an hour before eating. They should eat slowly and simply, combining few things in one meal, and above all masticate thoroughly every morsel taken. They should also endeavor, so far as possible, to dine in pleasant company and to cultivate a cheerful spirit at the meal hours. It is not well for them to exercise either the mind or body actively for at least half an hour, and better an hour, after their principal meals, especially after their dinners. They must learn to use their saliva for the purpose of moistening and partly digesting their farinaceous food instead of washing it down with drinks. Let them keep their feet warm, their heads cool, their kidneys active, and their bowels open, by simple natural methods, such as exercise, drinking freely of water be- CONSIDERATIONS CONCERNING DIET 20/ tween meals, etc., avoiding drugs for these purposes except when especially ordered by their physician. Dietetic Faults the Most Frequent Causes of Gastro- intestinal Disease. — Both gastric and intestinal affections may be due to the prolonged influence of cold and dampness upon the lower extremities, or to habits of indolence which prevent a sufficient use of the muscles, and to infections of various sorts ; but it remains true that a considerable proportion of the disorders of all parts of the alimentary canal are dependent upon dietetic imprudences. The amount or quality of the food or drink, or the times or manner in which these are taken, may be unhygienic and injurious. Manifestly disease which has resulted from such faults in diet is best remedied by curing the faults upon which it depends. To attempt the cure of such disease by administering drugs, by the application of electricity or by hydriatic procedures, without correcting the dietetic error, is naturally to invite failure. A very large proportion of the various diseases which affect other parts of the human body also are directly or indirectly a consequence of dietetic faults. Therapeutic Fasting. — At different times and by different authorities, all possible forms of dietotherapeutics, from com- plete fasting to forced feeding, have been employed in the treatment of disease. Complete fasting for limited periods is of unquestionable value in certain diseased conditions, espe- cially in the early stages of fevers and acute inflammatory con- ditions ; and the thirty to forty-day fasts of numerous persons have proved that strong, well-nourished individuals may often submit even to such prolonged abstinence from food without much danger. In the acute inflammations of the gastro- intestinal tract, fasting for from one to three days is gen- erally safe and advantageous, except when the patient is greatly reduced or debilitated, especially when the case is closely watched by the physician and a trained nurse. In gastric ulcer the withholding of food by the mouth is now almost universally recommended for a period of one to tw^o 208 METHODS OF TREATMENT weeks, nutriment being meanwhile given per rectum. Ex- clusive rectal alimentation in acute appendicitis also has been strongly urged in some quarters. A^ lady physician once narrated to me that she had been cured of a stubborn and theretofore incurable fermentative dyspepsia by an involuntary fast of two weeks, necessitated by having been shipwrecked and left with the crew and several passengers for that length of time after their supply of food gave out before relief could be obtained. This physician asserted that thereafter she never suffered from dyspepsia. It seems worth considering whether in intractable cases of this kind in patients who are not much debilitated or emaciated the withholding of all food should not be tried for a short time, when they can be kept under the observation of their physician. ]\Iuch has been written lately on the subject of fasting, and many careful observations have been made, both clinically and in the laboratory, on fasting persons. Lusk's work on the " Science of Nutrition " ^ embodies elaborate reports of these. It has been sufficiently demonstrated that short fasts are safe in health and in most fairly well-nourished persons suffering from either acute or chronic ill-health except in cases of chronic wasting diseases, such as tuberculosis and diabetes, in which aggravation may result, the excretion of sugar in the latter being often thereby increased. Lusk states that " if the organism has previously been well nourished, the fasting metabolism is remarkably even, about 13 per cent, of the total energy being derived from proteid and 87 per cent, from fat." The nitrogen elimination usually decreases rather steadily, but some observers ha^•e noted that, after about the twentieth day, a rapid increase may occur, which they call the premortal rise. In the latter days of prolonged fasts, too, the excretion of acetone and ft oxybutyric acid has been found to be markedly increased, and albumen is of frequent occurrence, according to Lusk, in the starvation urine of man and animals-. ^"The Elements of the Science of Nutrition." By Graham Lusk. Phila. and London: W. B. Saunders Company. 1906. CONSIDERATIONS CONCERNING DIET 209 Evidently, therefore, prolonged fasts are not safe, especially in persons who are much below their normal weight, unless the state of their circulation and metabolism is carefully watched by a competent physician so that the administration of food can be resumed if signs of danger appear. On the other hand, under the proper conditions, an absolute fast of five to ten days, perhaps longer, in persons with unimpaired hearts and a nearly normal amount of adipose tissue, may be safely undertaken in the hope of assisting markedly the appropriate remedies to cure or, at least, greatly improve such conditions as microbic infec- tion of the stomach or intestines, gastric or duodenal u]':er and hyperchlorhydria as well as the other affections associated with an excessive functioning of any of the glands in the di- gestive tract, and, in short, for most of the results of over- eating, which are so exceedingly prevalent. The following table, from a standard authority, will serve you in selecting the proper amounts of the various articles to meet the requirements of nutrition. THE PROPORTIONS OF THE SEVERAL INGREDIENTS IN THE DIFFERENT FOOD ARTICLES Food Material Edible Portion Proteid Per cent. Fat Per cent. Carbo- hydrates Per cent. Salts Per cent. Fuel Value of one pound in calories Ribs of beef .... 15-4 35-6 0.9 1.790 Sirloin steak 18.5 20.5 I.O 1,270 Round " 20.5 10. 1 1.2 805 Veal, shoulder . 20.2 9.8 1.2 790 Mutton, shoulder 18. 1 22.4 0.9 1,280 " breast . 14.2 47-2 1.0 2,215 leg 18.3 19 0.9 1,140 Lamb, shoulder . 17-5 29.7 1.0 1,580 ^, '.', ^^S • 18 9 15-3 I.I 1,000 Chicken 24 4 2 1.4 540 Turkey- 23.9 8.7 1.2 810 Hen's egg . 14.9 10.5 0.8 720 Ham, Salted and Smoked 16.7 39-1 2.7 1,900 Shad .... 18.6 9-5 1-3 745 Whitefish . 22.1 6.5 1.6 685 vSalmon 21.6 13-4 1-4 965 Lake trout . 18.2 II. 4 1.3 820 Brook trout . 19 2.1 1.2 440 Mackerel 18.2 7.1 1-3 640 Bluefish 19 1.2 1-3 405 Butter-fish . , 17.8 II 1.2 795 Black bass . 20,4 i'7 1.2 450 210 METHODS OF TREATMENT THE PROPORTIONS OF THE SEVERAL INGREDIENTS IN THE DIFFERENT FOOD AR.'l'lCl.E?>—Contmtied Food Material Proteid Fat Carbo- Salts Fuel Value of Per Per hydrates Per Edible Portion cent. cent. Per cent. cent. one pound in calories Cod, whole 15-8 0.4 1.2 310 Halibut 18.3 5-2 I.I 560 Oysters 6.1 1.2 3-6 2 230 Clams . 6-5 0.4 4.2 2-7 215 Lobster 14.6 1-9 1-7 350 Crab . 17.8 2 3-1 415 Terrapin 21 3 5 I 540 Green turtle 18.5 0.5 1.2 305 Milk . 3-6 4 4-7 0.7 325 Butter . I 85 5 3 3.615 Cheese, full cream 28.3 35-5 I 8 4.2 2,070 " skim-milk 38.4 6.8 8 9 4.6 1,165 Potatoes 2.1 0.1 17 9 I 375 Sweet potatoes . 1-5 0.4 26 I 530 Red beets . 1-5 0.1 8 8 I.I 195 Turnips 1.2 2 8 2 I 185 Carrots i.r 0.4 8 9 I 205 Squash 0.9 0.2 10 I 0.7 215 Cabbage 2.4 0.4 5 3 1-4 155 Cauliflower . 1.6 0.8 5 0.8 155 Spinach 2.T 0.5 3 I 1-9 120 Asparagus . 1.8 0.2 3 3 0.7 105 Tomatoes . 0.8 0.4 2 5 0.3 80 Green peas . 4.4 0.5 16 I 0.9 400 String beans 2.2 0.4 9 5 0.7 235 Lima beans 7-1 0.7 22 1-7 570 Green sweet corn 2.8 I.I 14 2 0.7 300 Haricots verts I.r 0.1 2 6 I.I 70 Baked beans, canned 7-1 3.2 20 3 2.2 645 Apples 0.3 0.4 15 9 0.2 320 Grapes 1.6 I 7 21 3 0.6 500 Banana 1.4 1.4 29 S I.I 640 Pineapple . 0.4 0.3 9 7 0.3 200 Rice . 7-4 0.4 79 4 0.4 1,630 Beans, dried 23.1 2 59 2 3.1 1,615 White hominy 8-3 o.-f 77 4 0.4 1,620 Oatmeal 14-7 1.1. 68 4 2 1,845 Pearl barley 8.4 0.7 78 I I 1,635 Entire wheat II. 9 1-7 74 6 1.4 1,680 Buckwheat . 6.9 1-4 76 I I 1,605 Buckwheat farina 3-3 0.3 84 8 0.4 1,650 Wheat bread 8.8 1-7 56 3 0.9 1,280 Graham " 9-5 1-4 53 3 1.6 1,225 Rye 8.4 0.5 59 7 1.4 1,285 Soda crackers 10 3 94 70 5 1.8 1,900 Oyster crackers . II-3 4.8 77 5 2.5 1.855 Oatmeal " 10.4 i3.7 69 6 1.4 2,065 Graham " 9.8 13.6 69 7 19 2,050 Starch . 97 8 0.2 1,820 Sugar, granulated 97 3 0.2 1,820 Molasses 73 I .23 1,360 CONSIDERATIONS CONCERNING DIET 211 In ordering a diet, you would best follow pretty nearly at first the tables given in the preceding lecture, except to lessen decidedly the proportion of the proteids or albuminoid foods, having regard to the sex and occupation of the patient. Then when the latter has learned to chew all food long and thor- oughly, you might try, in well-nourished cases, whether the weight cannot be maintained upon smaller amounts so as to avoid the dangers of overfeeding. The Arrangement of Meals with Relation to Rest and Exercise. — A matter of much practical importance in relation to diet is the arrangement of the times for meals. This might have been appropriately considered in the preceding lecture under Prophylaxis, but its discussion will be ec|ually in place here. In Germany and in some other parts of Europe it is the custom to take a very light repast upon arising, and then at eleven or twelve o'clock to take what is called a second break- fast, which is a more substantial meal. Then a hearty dinner is eaten at from three to six o'clock, varying with the locality and the social position of the person. In most places a supper is taken later in the evening. In the United States the custom as to the number and character of meals varies greatly in differ- ent localities and, naturally, with different classes of people. Not a few persons eat two meals a day only, both of them usually substantial ones, at 8 to 9 a. m., and from 4 to 6 p. M., as a rule. A majority of Americans eat three meals daily, beginning with a hearty breakfast at six to eight o'clock, comprising eggs or meat and some form of carbohydrate food with coffee or one of the cereal imitations of it. The wealthier classes, in the East especially, commonly eat a luncheon more or less generous in the middle of the day, and dinner at 6 to 7 p. M. Most farmers, and working people generally, who make up a very large majority of the total population, take a hearty meal, including usually meat, in the middle of the day, and supper, ordinarily a substantial one including meat again, in the evening. A few persons, following the teaching of a Pennsylvania physician, omit breakfast alto- 212 METHODS OF TREATMENT gether, taking their first meal at from eleven to twelve o'clock, and a second one when the day's work is over, at six or some time thereafter. Advantages have been claimed for each of these methods of distributing the daily meals. The last-mentioned one possesses marked disadvantages in that the two neces- sarily rather hearty meals taken for the maintenance of the body during twenty-four hours are eaten so nearly together within a period of six to seven hours. A breakfast delayed until midday must perforce be a generous one, which might well be expected to interfere somewhat with the working power of an individual during what must be for most persons the active afternoon hours. Two meals a day will often suit sedentary persons best, but they should be eight to ten hours apart, and the luncheon or midday dinner is the meal which can be most advantageously omitted. Whether two meals, or four or five meals, will nourish the system best and with least embarrassment to the other func- tions besides those engaged in the work "of digestion, can doubtless not be settled in the same way for all. Men and women who work with their muscles usually need at least three meals, and these should be as equally divided as possible throughout the waking hours. The idle and lux- urious classes, when in good health, do not, as a rule, actually need more than three meals in the twenty-four hours, and very many of them would do better with two only. When, as usual, their time for retiring is from eleven to one o'clock at night, it is doubtless best that their largest meal — the dinner — should be taken in the early evening. If they are regularly up until midnight or later they may properly enough take a very light additional repast before retiring; but only if it be taken regularly and at the same hour every night. They will naturally, with these habits, breakfast late, rarely earlier than nine o'clock, and if they take any luncheon at all it should be a very small one at i or 2 p. m. These general statements as to customs and the food re- CONSIDERATIONS CONCERNING DIET 213 quiremeiits of persons in health having been premised, it is in place to add a few suggestions of a general character as to how patients with a stomach or bowel disease should arrange their meals. It is necessary to divide such persons into two distinct classes : First, those who, in spite of their ailment, are obliged to continue actively at work; and, second, those who can dispose of their time as is most pleasant or healthful for them. As to the latter, it may be said at once that, as a rule, •it is best for them to eat their heartiest meal in the middle of the day, so that it shall be fully digested long before the hour for retiring, which, in their case, should generally be an early one. For many of these well-to-do invalids who have weak digestive power, the best arrangement will be two to three small meals with two or more very light repasts between them, so that the digestive organs may be at no time over- burdened. Many a weak stomach will digest easily and quickly quite a small meal, while it would be embarrassed seriously by a large one. The poor dyspeptic who must remain at his desk or other work eight to ten hours daily, or the wealthy one who insists upon attending to business or devoting himself actively to any pursuit which closely occupies his time during the day, must necessarily have his meals arranged with great care. As a rule, his breakfast should be substantial, and it will often be best for him to take a plain dinner in the middle of the day, provided he can have time enough to eat it without hurrying, and a little rest after it, since his supper can then be a much lighter meal than would otherwise be necessary, and his sleep will likely be much less disturbed and more refreshing. In many instances, however, the digestion is so poor that the patient, for several hours after eating such a mixed meal as a dinner, is incapacitated for any concentrated mental effort, and in the case, therefore, of a person thus afflicted, whose occupa- tion calls for brain work during the afternoon hours, it would be much wiser to take luncheon at midday and as simple a din- ner as possible at night. It may easily be seen that the problem 214 METHODS OF TREATMENT is a somewhat intricate one, and that no hard-and-fast rule can be made which will suit all persons. Here especially the phy- sician must individualize his cases and make his dietetic direc- tions correspond to the needs of each particular case. Regularity in Times of Eating Essential. — In whatever way the times for meals may be arranged in the case of persons who have either inherited or acquired a delicacy of constitution or tendency to indigestion, the meals must be taken with the utmost possible regularity at the same hours every day. No hygienic rule is more important than this for such persons, and indeed, if they could only be made to believe it, for all persons. Horsemen know that irregularity in the times of feeding their horses will injure them and do not permit any carelessness in this regard on the part of their employees. But certain of our society people seem to consider themselves above all hygienic laws in the matter of eating and drinking, taking their last meal of the day sometimes at 6 to 7 p. m.^ but on several of the evenings each week consuming indigestible suppers at any hour, from ten to twelve, that may happen to suit best their entertainers or the character of the entertain- ment. Physicians understand well enough that this is ruin- ous to the digestion of all but the very strongest, and that even these must inevitably pay the penalty also, only a little later, and in the form of heart or kidney disease or apoplexy, if not in that of indigestion. For those who find that they can eat anything, at any time without paying the penalty as they go along, no reform, of course, is possible or at least likely ; but for the others, among whom are to be included a large proportion of the intellectual classes, the lawyers, clergy, artists, and literary people, many of whom are very social, and some of whom are among the brightest ornaments of society, it does seem as though some- thing might be done. It ought to be possible for this large and very influential class of society to assert itself in some effective way which would protect its members from the well-nigh irre- sistible temptation to transgress the laws of health — one might CONSIDERATIONS CONCERNING DIET 215 say almost the necessity of eating and drinking unhygienically, if they would not make themselves unpleasantly conspicuous — without obliging them to forego all social enjoyments. A majority of these intellectual people, who are prone to have indigestion when they transgress health rules, have a tendency to hyperchlorhydria ; their gastric glands are easily excited to oversecretion. When such persons are offered tempting viands on a festive occasion at an hour when not only their stomachs but those of all the others should be resting, they are frequently amiable enough to make a feint of eating just a little something for the sake of appearances — not to seem to frown in disapproval of what the others are doing. Perhaps they are able to find in the menu some apparently innocent thing like delicate pieces of bread and butter or bis- cuits, and they resolve just to nibble a little at one of these. The result is such a rapid pouring out of gastric juice as speed- ily constrains them to go on and eat heartily of whatever can be had, with the result often of a sleepless night and utter unfitness for the next day's duties. I have often wondered if it would not be feasible for the many agreeable people of this kind who are in society to get together, declare their independence of Dame Fashion so far as regards the late suppers, and flock by themselves at parties when the eating time comes around, or perhaps get up an occa- sional social affair of their own at which there should be nothing additional to the usual festivities except " a feast of reason and flow of soul." In the meantime, however, you will favor your dyspeptic patients most by making your prohibition of eating out of season, whether the food served be good or bad, as em- phatic as possible. The more imperative your commands the easier it will be for them to withstand the temptation placed before them. LECTURE XVIII THE DIET IN IRRITATIVE AND ATONIC CONDITIONS Classification of Diseases with Regard to Dietetic Treat- ment. — All the conditions of impaired health in which there is indigestion may, for the purpose of dietetic treatment, be divided into two great classes. One comprises the affections in which there is disease in some part of the digestive tract. This may be inflammatory or degenerative, or may merely con- sist of a persistently increased or diminished functional activ-- ity on the part of the muscular apparatus or secreting cells, or both. The other class includes affections of the nervous, circu- latory, respiratory, or genito-urinary system, accompanied by reflex or sympathetic derangements of digestion of a transient or variable character. In the latter class, the digestive organs themselves may be healthy, and the diet to be prescribed then is that appropriate to the disease existing elsewhere. If this be tuberculosis or a true neurasthenia due to overtaxed ener- gies and not to lithjemia, the diet should be generous and may be often relatively rich, or even what would usually be con- sidered indigestible, regardless of the symptoms referred to the gastro-intestinal tract. It is otherwise with the former class — the diseases involving some part of the digestive apparatus itself. Of these two sub- divisions may be made : those with increased, and those with decreased functional activity. Here you will need either to stimulate or soothe, or more frequently still, perhaps, to spare the affected organ by suitable remedies and foods. To spare an organ is to lessen its work in order that Nature may be 216 DIET IN IRRITATIVE CONDITIONS 21/ better enabled to bring about restorative changes. When you put to bed a patient with typhoid fever, or nervous prostra- tion, all the organs are spared as much of their usual work as possible. By means of diet, just as by medicines or the me- chanical methods of treatment, you can either stimulate or depress the functional activity of various structures and by the same means — a proper selection of foods — you can often do that which can seldom be done by any drug, to wit : save or spare a crippled organ, thus affording it at least relative rest, even while the other parts of the body may continue active. The Diet in Irritative Conditions. — But in all cases with irritative conditions in the digestive organs, especially in the more stubborn cases of excessive HCl secretion (hyperchlor- hydria), whether an ulcer is demonstrable or not, you may sometimes cure rapidly by carrying out the accepted treatment for gastric ulcer, which is to place the patient for a time at complete rest in bed, with at first either no food by the mouth or only small amounts of the blandest liquid nutriment in that way, supplementing this by rectal feeding. I have been much impressed by the fact that some of such cases, so long as treated for simple hyperchlorhydria with the usual drugs and diet, but allowed to go about their business or pleasures, prove exceedingly obstinate and yet respond promptly when, after the symptoms have begun to awaken the suspicion of gastric ulcer, the patients have been put to bed with only rectal feeding for a week or two, followed by a strictly liquid diet by the mouth, very gradually increased. Typical examples of the irritative disorders demanding sed- ative remedies and a sedative diet, or functional rest, are, in the stomach, round ulcer, h3^perchlorhydria, and acid gastric catarrh, and in the intestines, diarrhea, and probably also most cases of spastic constipation, as well as all the forms of enteritis and colitis. Stimulant or irritant foods and food acces- sories (or indigestible foods, which are irritating in propor- tion to their lack of digestibility), including many vegetables, especially cabbage, onions, and radishes, acid fruits, most 2l8 METHODS OF TREATMENT of the uncooked vegetables and fruits, the spices, and most of the sharper condiments, and the meats in the form usuahy eaten, are especiahy hkely to aggravate the class of gastro-intestinal diseases which are characterized or accom- panied by irritative conditions. On the other hand, the blandest and least stimulating ali- ments, such as milk and whey, as well as rice and other fari- naceous preparations, when well insalivated by thorough mas- tication, taken in small quantities at a time, and especially when the starch has been previously dextrinized by prolonged baking, conduce more to the cure of the same diseases. These starch foods should, in all cases of hyperacidity, be taken early in the meal and never at the end of it as in the form of dessert, unless the dextrinization has been very complete ; otherwise, no matter how well insalivated such food is, the high acidity of the stomach contents towards the end of the meal stops at once the process of starch coni'ersion. Meats in HCl Excess. — The meats, however, though known to stimulate secretion more than other foods, are recommended by man}^ authorities in conditions associated with excessive secretion of HCl because they combine or use up more of the surplus acid and thus often seem to lessen the discomfort after meals more than other forms of nourishment, and for the fur- ther reason that the starches are theoretically less digestible in such hyperacid conditions. These reasons for adopting a stimulating diet in a disease peculiarly characterized by irri- tation might be convincing but for the fact that such a diet tends to intensify and perpetuate the underlying morbid state of the secreting cells so that the temporary palliation of the symptoms is dearly bought. Moreover, clinical experience has shown that in these hyperchlorhydric cases starch foods taken at the beginning of small or very moderate meals and thor- oughly chewed so as to obtain the full amylolytic effect of the saliva, may generally be made to digest and agree well, espe- cially when, by means of full alkaline medication or other appropriate treatment, the irritated condition of the glands DIET IN IRRITATIVE CONDITIONS 219 is at the same time overcome as rapidly as possible. Indeed, in the hundreds of cases showing an excess of HCl which have been treated at my offices during the last few years, the gastric contents brought up for testing were nearly always in a per- fect solution, even though the analysis indicated that the proc- ess of starch conversion had not been carried so far as it normally should be in the stomach. But, as there are exceptions to all rules, so in these irritative conditions with excessive HCl secretion, you will often en- counter cases complicated with much fermentation of the starch and saccharine foods (carbohydrates) and in these it is well to let the diet at first consist largely of the blander nitrog- enous foods, such as soft-boiled eggs and the juice pressed out of beefsteak, meat powders, or finely hashed steak with sometimes plenty of fat in some palatable form (since this lessens HCl secretion), and only a minimum of the carbohy- drates. The organic acids produced by fermentation, when present in large amounts in the stomach, seem to act as an irritant in marked degree to the secretory structures, and thus in these exceptional cases may increase or even provoke a hypersecretion of HCl as surely as tough, indigestible articles, or stimulating foods, such as meats in the ordinary forms. HCl doubtless possesses important germicidal properties as against some bacteria, but yeast fungi certainly flourish in its presence, and other organisms that produce fermentation in the stomach in many cases are not inhibited by even a large excess of it to any efficient extent. Thus, w'hile certain gen- eral rules apply in the selection of a diet for any given case of gastric or intestinal disease, it is necessary constantly to indi- vidualize, to study each case by itself — indeed, on account of idiosyncrasies, it is often needful to study the response of each digestive apparatus to each special article of food which is to be depended upon as a chief part of the nourishment for any considerable time. The Diet in Atonic Conditions. — Turning now to the oppo- site class of gastro-intestinal cases, those characterized by 220 METHODS OF TREATMENT atonic conditions with symptoms of depression — deficient functional activity — as in atrophy, achylia, or hypochlorhy- dria, chronic asthenic catarrh, and carcinoma of the stomach, gastric motor insiii^ciency, dilatation of the stomach, chronic atonic constipation, etc., a somewhat different kind of diet needs to be prescribed. In the atonic cases of gastric and intestinal disease not accompanied by catarrhal inflammation, whether the atony involves chiefly the glandular or muscular structures, the diet should be first of all as digestible and nourishing as possible, and if at the same time it be stimulating, the results in bringing up nutrition will usually be all the better. Animal broths, and even the much condemned beef tea, may prove of service here as being capable of stimulating the appetite and increasing the ability of the various organs to digest more nourishing articles of food. The fermented products of milk, such as kumyss, kefir, matzoon, etc., often suit very well in these conditions ; and if the lighter alcoholic beverages, such as claret, Rhine wines, or possibly even port and sherry, are ever to be recom- mended in gastro-intestinal cases, it should be especially in these atonic forms of them. The fermented liquors, such as beer, ale, porter, brown stout, and the popular liquid malt extracts which are sometimes more carefully brewed, have also a certain tonic, or, at least, stimulant action upon the appe- tite, besides possessing some diastasic property and a very slight content of real nutriment. In small doses they can undoubt- edly be of service temporarily in such atonic cases in which there is not too great a tendency to fermentation ; possibly, also, in a limited number of similar cases in which there is considerable fermentation, dependent chiefly upon a lowered tone in the nerve centers presiding over the digestive proc- esses. In certain affections of the alimentary canal, especially in chronic asthenic catarrh of the stomach or duodenum, with good rnotor power and with normal pancreatic and hepatic secretion, you may expect favorable results from such stimu- DIET IN IRRITATIVE CONDITIONS 221 lating and yet very digestible articles of diet as broths, meat juice, meat powders, especially Mosquera's Beef ]\Ieal, and scraped or hashed lean beefsteak, and, in the less severe cases, tender lean meats in the usual forms, especially beef, mutton, lamb or poultry, roasted, broiled, or thoroughly stewed. A predominantly nitrogenous diet wdiich is'" at the same time easily digested, keeps down fermentation, and will maintain nutrition well enough for short periods — say four to six weeks, notwithstanding that it furnishes temporarily much more proteids than the normal one-tenth to one-fifth part, and much less carbohydrates than the normal, which is from four to five-sixths of the whole amount. The normal one-tenth part of fats may be supplied, and even much exceeded, with such an anticatarrhal diet, when it is found to agree, but sometimes this proportion of fats will increase fermentation so much as to retard the cure. With this diet, a small amount — three, four, or five slices daily — of moderately stale bread and butter can usually be allowed, and in those cases without HCl excess it need not be toasted or in the form of zwieback, the particles of which are too hard and gritty for easy solution in the stom- ach, in consequence of which there often result from such food increased flatulence and constipation. Most hard biscuits (crackers) are open to the same objection, beside the danger of having been kept too long. A free use of water, preferably taken rather hot, is an almost indispensable accompaniment of such a nitrogenous anticatarrhal regimen in order to maintain an efficient elimina- tion through all the emunctories, as well as to cleanse away the accumulations of mucus from the affected membranes. When, however, in these or in any other cases, the gastric motility is much impaired as a result of other causes than hyperacidity, the fluids of all kinds must be strictly limited ; gastric lavage and flushing of the colon, more ef^cient methods when pru- dently managed, must then take the place of the copious water- drinking. A milk diet is the favorite resource of many routine practi- 222 METHODS OF TREATMENT tioners in all catarrhal or suspected catarrhal cases, for under the still prevalent guessing methods the diagnosis is very ©ften wrongly made. It suits sometimes admirably, but quite as often fails or aggravates, especially when there is excessive lactic fermentation and in the cases with deficient motor power in the stomach. Eskay's Food or peptonized milk may succeed when plain milk fails, and Plasmon can often be added to the latter with advantage, making a more nourishing but still easily digestible and non-irritating food. Some such restricted diet is usually advisable in the worst catarrhal inflammations of the alimentary canal, and greatly promotes a cure, though care must be taken that the patient is properly and sufficiently nourished. To persevere long with a very one-sided or deficient diet is to risk impairing nutrition to a serious extent. The patient should be weighed from time to time to see that there is no undue loss of weight, and above all you should keep a close watch upon the urine. Until you have learned to judge from this excretion the state of the metabolism — whether or not the nutrition is being maintained at the proper level — you should not feel yourselves entirely competent to manage complicated cases of gastro-intestinal disease. The Diet in Diarrhea and Constipation. — This is not the place to discuss at length the diet appropriate to either diarrhea or constipation, and they are fully considered in subsequent lectures ; but it may be said in brief here that, while in diarrhea the diet should be as non-irritating, digestible, and nutritious as possible — preferably also usually in rather concentrated form — in constipation, even in the atonic variety, it will not always answer to have it too bulky or irritating. The fruits and cruder vegetables are decidedly contra-indicated in the former; they usually favor more normal evacuations in the latter, and are' to be tried hopefully in every uncomplicated case ; but when constipation is a result of, or complicated with, a catarrhal process in any portion of the tract, such a coarse, irritating diet will nearly always disagree. It will then DIET IN IRRITATIVE CONDITIONS 223 usually either increase the constipation or proVoke frequent loose stools with much pain and flatulence — a condition worse than the original disease. One way in which an irritating diet will sometimes aggravate is by provoking an excessive HCl secretion (hyperchlorhydria), which conduces powerfully to the production of constipation. This is most likely to result from an excess of acid fruits in the dietary, especially in nervous, excitable persons with hyperassthetic mucous mem- branes. Spastic constipation has not yet been sufficiently studied to speak too positively about it. In this form of the trouble, which yields best to the bromides and other sedative remedies, an irritant diet would a priori be expected to dis- agree, and yet some prominent observers have reported that it often seems to yield to a diet containing much cellulose, as is found particularly in the vegetables and fruits. Regarding the remaining gastro-intestinal diseases, the ptoses or downward displacements, which are exceedingly prevalent, and the malignant growths in, or adjacent to, the digestive tube, which are comparatively infrequent, the diet should be adapted to whatever associated motor or secretory derange- ment is predominant, though it must always be as little irritat- ing .and as digestible as practicable, and also as nutritious as can be digested, even with the aid of digestants when required. In the case of tumors there is generally in the stomach deficient motility, with greatly decreased secretion of gastric juice and the development of catarrhal inflammation; in the intestines, when these are encroached upon, a lowered motility and secre- tion of the normal juices, with usually constipation at first, but later most frequently an excessive mucous secretion with diarrhea, or sometimes constipation alternating with diarrhea. Diet can do little for the exceedingly prevalent displace- ments of the abdominal organs, but must be suited carefully to the resulting visceral diseases. Proper Cooking and Thorough Mastication. — In all gastro- intestinal affections, except in uncomplicated atonic constipa- tion, the food is likely to agree best if easily digestible and not 224 METHODS OF TREATMENT too fermentable ; also if finely divided and properly cooked, which means, in the case of eggs, to a very slight extent only, in that of meat, until the tougher parts are softened, but never tyi they are dried up, and in the case of starch foods as thoroughly as possible, until the hard shell of cellulose which surrounds each particle of starch has burst, so that the starch itself can be acted upon. A point of the greatest importance, too, is that starch food, particularly, should not only be cooked long and thoroughly, but after that be masticated as completely as possible. This is indispensable for many reasons : which, though they have been referred to at some length in a previous lecture, cannot be emphasized too strongly and therefore are here briefly sum- marized: (i) It tends to prevent overeating; (2) it insures a more perfect comminution of the food ; ( 3 ) it greatly increases the secretion of saliva, which at the same time converts the starch into soluble forms (dextrine, dextrose, etc.), and then dissolves it — /. e., it digests it — and it cannot otherwise be digested before reaching the duodenum; (4) both the act of chewing and the alkaline saliva, thus supplied in larger amount to the stomach, increase the secretion of the gastric juice; and (5) the prolonged movements of mastication probably also assist reflexly in stimulating the secretion of the pancreas and intestinal glands as well as the peristaltic movements of the gastric and intestinal muscles. Dangers in Overrestriction of the Diet. — One more general rule should be insisted upon in regard to the dietetic treatment of indigestion cases : Do not restrict the diet in pure nervous dyspepsia when there is no considerable derangement of either secretion or motility in the digestive organs ; and even when these are demonstrably involved do not restrict the diet too severely or in too sweeping a manner unless for serious reasons and for a short time. While a scientifically arranged diet in a case under the immediate observation of an expert physician can often almost alone work wonders and sometimes cure magically cases that had resisted other treatment, it is DIET IN IRRITATIVE CONDITIONS 225 better to let the a\'erage invalid " eat everything " even, than to send him away to be beyond the reach of his physician for weeks or months at a time, with a very narrow, meager dietary, containing mostly articles which he does not like and cannot eat with any relish. For in such cases the patient, in spite of our science, will often go hungry and grow thin and weak. IMoreover, hyperchlorhydria under such conditions will sometimes change suddenly into hypochlorhydria, and the regimen which suited perfectly at first may end by produc- ing a dangerous aggravation. Diet in the Uratic Diathesis. — Closely related to disorders of the gastro-intestinal tract is the so-called uric acid or uratic diathesis, and in the treatment of this, diet is all-important. Without attempting here to go into this large and much- mooted subject fully, I may be permitted briefly to express a very positive conviction, based upon a considerable experience, that to cure the condition, besides insuring plenty of exercise, active or passive, and complete elimination through all the emunctories, it is necessary greatly to lessen the habitual ingestion of flesh foods, and to prohibit altogether the eating of the glandular portions of animals, such as liver, sweet- breads, calves' brains, kidneys, etc. In the worst cases, forbid also the use of meat soups or meat extracts, as well as coffee and tea, since the former contain a very large proportion of the objectionable uratic products, and the latter contain alka- loids almost identical with the xanthin bases, which are now believed by most of the authorities to be the chief offending substance among those of the uric acid series. Sugar also often has to be restricted in such cases, for the reason that it is not only very fermentable, but so much more readily oxidizable than the proteids, that when much of it is taken with the latter, the oxygenation is insufficient; a portion of the proteid matter ingested is left unoxidized with a resulting increase of the injurious products of suboxidation — to wit : the xanthin or purin bases, together with other injurious substances, both known and unknown. LECTURE XIX SUGAR, SPICES, ETC., IN GASTRO-INTES- TINAL CASES The Most Difficult Point in a Difficult Subject. — The place of sugar in the diet of gastro-intestinal cases calls for special consideration. It is one of the most difficult points in the whole subject of dietetics, which itself comprises perhaps the most difficult, complicated, and, as yet, unsettled part of practical medicine. Sugar is essential to nutrition. The carbohydrate element in a natural dietary needs to comprise about three- fifths of all the nutriment taken, and must be converted into dextrose, a form of sugar, before being capable of assimilation in the body. Its oxidation produces most of the heat and force which are essential to the vital processes. Yet when eaten daily with the heartier meals it disagrees with most dyspeptics. In conditions in which HCl is seci'feted excessively by the gastric glands, sugar has been demonstrated to have the property of lessening the excessive secretion. JMoreover, in these hyperchlorhydric cases the amylolytic or starch-convert- ing action of the saliva is usually much interfered with by the too rapid acidification of the gastric contents, so that in such cases, especially, I have often observed a peculiar sugar hunger, indicating that the system is not getting as much of this food element as it requires. In so far, therefore, sugar should prove useful in the forms of indigestion accompanied by an excess of HCl. Another point of importance also is the fact that solutions of sugar are among the few things that can be absorbed rapidly from the stomach itself without first pass- ing through the pylorus into the intestines, thus furnishing 226 SPICES IN GASTRO-INTESTINAL CASES 227 with unusual promptness energy to the tired or debihtated body. Yet, when acting- upon the suggestions of some recent writers, I have attempted to feed sugar freely to hyperchlorhydric patients they, while usually reporting an improved feeling of well-being during the first few days of the diet, later have almost uniformly shown serious embarrassment as the result of hepatic derangement, increased flatulence with consequent insomnia, and sometimes embarrassed cardiac action. How, then, can we solve the difficulty and furnish more sugar to these h3^perchlorhydric, and to other even more debilitated, patients who are in need of this valuable nutriment? It has been suggested by some writers that the sugar of milk or fruit sugar (levulose) might advantageously be substituted for the ordinary cane sugar in the case of such patients as are here referred to. These are doubtless somewhat less fermentable than the ordinary commercial sugar, but are very expensive and, therefore, not very practicable for use as foods. Besides, even though less fermentable than other sugar, they are still enough so to produce often serious distress when eaten at all freely, in the usual way, along with other food. An Experiment worth Trying. — I have experimented some- what in this line with results which are at least interesting and suggestive, if not yet conclusive. I have noticed that the first meal or two in which sugar has been largely given may agree perfectly well, especially if no strong proteid food, such as meat or eggs or indigestible vegetables, have been taken at the same meal. For example, a patient, who had found previously that to top off a dinner with ice cream, cake, or pudding would invariably produce aggravated flatulency, has reported that when an occasional light luncheon or supper has been eaten consisting of such a carbohydrate combination as cake and ice cream and a few chocolate caramels, which are usually additionally indigestible for most dyspeptics because of the large proportion of oil in the chocolate, no increased flat- ulence or other unpleasant results have followed. If these experiments should be confirmed by a more extended trial of 228 METHODS OF TREATMENT such a method of feeding, it may be possible to let certain of our dyspeptic patients have, say twice or thrice a week, one light meal of the kind described — that is, made up chiefly of ^ sugar combined with thoroughly cooked starch in a form capable of being chewed, as in cake, or with cream or milk as in ice cream, junket, or other palatable combination of these food articles or, possibly, in the milder cases, some of the nourishing sweet confections compounded of sugar and nuts, though these last would be much more risky. Such a grateful and valuable addition to the diet of many dyspeptics, even at long intervals, would greatly lessen the sense of deprivation of which they complain when denied sweets altogether and at the same time help much to increase their weight and nutrition. Moreover, if the experiment should fail, the disagreement of the sweet combination taken by itself would convince the patient that such foods must be avoided altogether. Why the Sweets often Disagree after a Dinner. — The reason why sugar may sometimes be made to agree when taken in the manner above indicated, even though it markedly dis- agrees when ingested as a part of one or more large meals every day, is not far to seek. ( i ) The usual sweet dessert taken after dinner is nearly always simply so much surplusage; that is, it is additional food taken because of its palate-tickling qualities after a sufficiency of other food had already been taken, and often after the stomach had been greatly overloaded with the substantial of the meal. (2) Most persons, in cities especially, do not take enough physical exercise to insure the complete oxidation of all the food eaten by them, and it is a well-known fact that sugar, being much more easily oxidizable than meat and vegetables, will,, when taken with the latter, be oxidized first, thus leaving the more difficultly oxidized proteids to remain in the system in suboxidized forms, including especially the various xanthin or purin bases ; and these, when in excess, exert a markedly toxic action upon various im- portant structures of the body. (3) The liver and other organs which perform the function of converting sugar into SPICES IN GASTRO-INTESTINAL CASES 229 giycogen, storing it up and again distributing it to the system as required, are readily overtaxed in many hyperchlorhydrics, so that a moderate meal including considerable sugar might be well tolerated when taken two or three times a week, and the patient gain largely thereby; while sugar, taken once or twice a day, as is the custom of many Americans, might seri- ously derange the metabolism. It ought, however, to be borne in mind that such a trial of sweets in any marked case of dypepsia, particularly when the liver is at the same time much diseased or even functionally impaired, needs to be made with great caution. The patient in every instance should be given to understand clearly that it is only an experiment which may fail with the result of tem- porarily aggravating the malady; and that if it succeeds, any attempt to repeat the experiment daily, especially to vary it by taking the sweets along with hearty meals, would be likely to prove disastrous. The patients who should respond best to this method of feeding sugar are those who usually are most in need of it, to wit, those suffering from a large excess of HCl in the gastric juice ; but it will not agree with all of even these. THE SPICES, CONDIMENTS, AND BEVERAGES The Spices, etc.. Drugs, not Foods. — Under the head of " Prophylaxis, Food Requirements, etc.," I have considered these classes of articles with Sufficient fullness in so far as regards their use in health. I told you that they are drugs, and not foods in any sense of the latter word ; yet like other drugs they are sometimes of use temporarily in disease. The results of experiments have been contradictory as to their effect upon secretion at first, but all agree that in the end they lower it. Lately it has been shown that some of the spices by their primary action stimulate the motor function of the stomach, but finally depress it, just as depression ultimately results after all forms of stimulation. Temporarily, there- fore, the spices may be useful as an addition to the diets of 230 . METHODS OF TREATMENT dyspeptics having a poor gastric motility, provided they are employed merely as a palliative while more efficient measures are being carried out with a view to a definite cure of the fault, and are withdrawn after this object has been achieved. But there is no reason to believe that any harm can follow such a slight seasoning of foods as may be necessary to impart to them for unspoiled palates an agreeable flavor, and salt being a necessary constituent of the body, the taste for it is natural — one to be satisfied. The subject of the choice of a suitable beverage to drink with or after meals, in cases of gastro-intestinal disease, re- quires consideration. The alcoholic liquors have effects which make them un- desirable in most such diseases — their prolonged use in all of them. Small amounts of dilute solutions of spirits are per- haps the safest when a stimulant is needed, but even they are contra-indicated in cases of excessive secretion, while the livers of dyspeptics, in which a cirrhotic process, according to Boix,^ has already begun, are endangered by their use for long periods, tO' say nothing of their cumulative injurious effect upon hearts and arteries in which degenerative processes have been initiated. The wines and fermented liquors have injurious properties of their own dependent upon the irritant influence of the acids which they always contain, in addition to those of the alcohol. Concerning the effect of the latter in the more severe gastric affections many leading gastrologists even in Germany (where the drinking of beer is almost universal among all classes) advise against them as a general rule. Boas, e. g., says :^ " When there is much mucus in the stomach patients must renounce alcohol and tobacco." Professor Riegel of Giessen, after summarizing the rather ■> " The Liver of Dyspeptics," by Dr. E. Boix, G. P. Putnam's Sons, New York, 1887. ^ " Diagnostik u. Therapie d. Magenkrankheiten," II Theil, Leipzig, 1895, p. 27. SPICES IN GASTRO-INTESTINAL CASES 23 1 contradictory results of investigators in this field, is ecjually emphatic, saying:^ "In general, therefore, we may say that in diseases of the stomach we can get along very well without alcohol. In all conditions in which the stomach is irritable, as in ulcer, acute and chronic diseases of the stomach with increased secretion of gastric juice, alcohol is to be con- demned." Then, after admitting that there are atonic condi- tions in which a glass of wine may seem to do good, Riegel goes on to say as to the national drink : " Beer is hardly to be recommended in diseases of the stomach. The relatively large quantity of fluid taken distends the stomach and dilutes the gastric juice, so that, for this reason alone, beer is not a proper article of diet for many stomach cases." Then after referring to the fermentation- exciting action of beer as another objection to it, he concedes its harmlessness in small doses for certain classes of cases, in- stancing here " simple hyperacidity," which the sour American beers usually aggravate decidedly, and sums up the matter thus : " Beer is contra-indicated in all cases afflicted with atony of the stomach with ectasia, with ulcer, and with hypersecretion. All strong spirituous liquors,- particularly drinks prepared with spices, are to be forbidden in stomach diseases. Champagne, too, must be considered a beverage that is in general unsuited for diseases of the stomach. It ivill he seen from all that has been said, that in general alcohol should be stricken from the diet list of a sufferer from any disease of the stomach; only III very rare cases zvill its administration be advantageous." Coffee and tea in this country, where alcoholic stimulants are not largely used at meals, are the most universal table beverages. Though very much less has been written and spoken against these popular accompaniments of our food, quite as little can be said in their favor on scientific grounds ; they are capable of doing nearly as much harm in gastro- ^ Nothnagel's " Practice, Diseases of the Stomach," Philadelphia, Saun- ders & Co., 1903, p. 219. 232 METHODS OF TREATMENT intestinal affections when used at all freely, and especially if taken strong. Riegel ^ considers tea safer than coft'ee for dyspeptics, yet my earliest recollections of medical practice include experi- ences with indigestion cases in Dr. R. G. Curtin's dispensary service at the University Hospital in Philadelphia, when that clever clinician was accustomed often to make an offhand diagnosis of " tea dyspepsia " in servant girls the moment they entered the room, from a certain peculiar, anxious, drawn ex- pression of the face. Schultz, in a series of experiments reported ni the Zeifschrift fur physiologische Chemie a number of years ago," found : 1. Under the conditions of the experiment 94 per cent, of albuminous digestion when neither tea nor coffee was added to the digesting mixture. 2. On the addition of tea the amount of digestion was only 66 per cent. 3. When coffee was added the amount of digestion was 66 per cent. In the stomach, acting through the nervous system, coffee and, to a less extent, tea, probably stimulate primarily, but sec- ondarily lower the digestion, acting like all stimulants by ex- hausting the gastric glands prematurely. Stimulants are no more nor less than drugs in spite of the fondness of many of us for word-juggling concerning them, and drugs, however useful now and then for short periods under medical direction, are not advisable as constant and per- petual additions to the diet of any sick persons, even though they may be tolerated for considerable periods by well persons. Water, Milk, etc — Water is the basis of all beverages and constitutes 90 to 95 per cent, of most of them. If it must be flavored let it be with something as little medicinal as possible, such as the burnt grains of some one of the cereals or in certain cases a very small amount of lemon juice, or good fresh milk. ^ Ibid., p. 221. 2 "Eating and Drinking," by Albert H. Hoy, M. D., p. 193. SPICES IN GASTRO-INTESTINAL CASES 233 Milk itself, however, does not by any means suit all dyspep- tics, being very liable to ferment in some stomachs and intes- tines with the production of irritating organic acids, gases, etc., besides having a tendency to constipate most persons. Moreover milk is a decidedly nourishing food which, when ingested, needs to be taken slowly, so that it can be digested, and not poured down hastily as beverages are likely to be. Every adult man needs five to six pints of fluid daily to do the solvent work of the system, and the more pure and dilute the form in which most of it is taken, the better. The required amount of fluid can be somewhat less in the case of a person who is prevented by illness from actively ex- ercising: and for gastro-intestinal cases it will make much dif- ference how and when you direct it to be taken. In marked hyperchlorhydria it may be drunk rather freely during and after meals to dilute the overacid gastric juice, and this prac- tice will then facilitate, not delay, the emptying of the stomach. It is then best taken rather cool or cold, but not ice cold. In constipation a liberal drinking of water between meals, including a glass of cold water upon arising, will assist in se- curing regular evacuations of the bowels. In atonic forms of stomach trouble there should be little drinking at or near meals. Most of the fluid required should then be taken between meals, and much less in the aggregate tl an the usual amount should be taken. In aggravated or ex- tensive gastric dilatation most of the needed fluid, as well as some, or even all, of the food and medicine, for a time may need to be given per rectum to avoid overdistending the stomach. In nervous forms of indigestion not dependent upon any gas- tric or intestinal disease the patient's inclinations regarding water-drinking may be allowed to guide, except that excessive ice-water-drinking should be forbidden. LECTURE XX THE AUTHOR'S AND OTHER PROGRES- SIVE SERIES OF DIETS For the very prevalent cases of impaired digestion, espe- cially from catarrhal disease, persistently excessive or deficient secretion, weak motor power, gastric ulcer, etc., there is often much advantage in having at hand a progressive series of diets to be modified as each case may require. I offer the following, v/hich may be useful to you if not prescribed in a routine way without discrimination : Diet No. i. — Take every two hours from a wineglassful to a gobletful of peptonized milk, matzoon, or whey, or milk prepared with Eskay's Food according to directions ; or a teacupful of clam broth, chicken broth, beef tea, or any meat broth slightly seasoned and with the fat all skimmed off; or the same quantity of rice water, barley water, toast water, gum-arabic water or egg water may be given as an alternative nutriment. When there is obstinate vomiting, a tablespoonful of any of the above may be given every fifteen minutes till the stomach has been settled ; or withhold all food by the mouth and feed by enemas till the vomiting has been controlled. Diet No. 2. — Take every two to three hours the juice from a quarter to a half-pound of lightly broiled lean beef expressed by a meat press or lemon squeezer ; or the meat may be chewed by the patient and the juice swallowed while the fiber is rejected. Two tablespoonfuls of Bovinine or an equivalent amount of any good beef extract may be added to a glass in 234 PROGRESSIVE SERIES OF DIETS 235 which the whites of one or two eggs have been beaten up, mixed with two to four ounces of water and flavored to suit the taste. This may be taken every two to three hours instead of the beef juice part of the time, as an ahernative food, in some low conditions ; but no beef extract equals fresh beef juice in nutritive value. Diet No. 3. — Take every two hours one to two goblets of good fresh milk, with a tablespoonful of limewater or a pinch of salt in it, or prepared with Eskay's Food according to direc- tions. It should be sipped slowly and may be preceded by the thorough mastication of half a slice of stale white wheaten bread, preferably well toasted, or the same quantity of un- sweetened zwieback, but neither of these should be very hard; or by two or three Bent & Co.'s water crackers, or Educator crackers may be taken with the milk; provided great care be taken to see that the crackers are fresh. Thin rice or barley gruel may in certain cases be mixed with the milk in the proportion of one-third gruel to two-thirds milk. No other food as a rule should be taken while on this diet. Diet No. 4. — At any of the three usual meals a few of the following foods may be selected : Broiled lean beefsteak, lamb, or mutton chop, — any of these scraped so as to obtain the pulp and juice, avoiding the fiber and fat; finely chopped lean beef made into little cakes after the removal of all the fat and gristle and then broiled over the coals; eggs soft-boiled or poached; stale wheaten bread (the best home-made bread is preferable), which may be lightly toasted, and a very little butter may be eaten on it; good fresh gluten wafers ; zwieback, unsweetened ; a little finely ground spinach or string beans well cooked, baked or mashed white potatoes, or finely ground boiled spinach. At the end of each meal a cup of hot water, an infusion of cocoa shells, or of any good cereal preparation intended to imitate the flavor of coffee. 236 METHODS OF TREATMENT If hungry at 1 1 a. m. or at 4 p. m., take one or two raw eggs well beaten and mixed with water, with the addition of beef extract if desired ; or instead, stale bread and butter or toast or zwieback may be taken with a glass of hot water flavored, in any way preferred. Except in the cases in which the proper tests have shown weak motor power in the stomach walls, the patient may drink freely, though not more than a single gobletful at a time, of Poland Spring, Bethesda, Clysmic, Buffalo Lithia or Apollinaris water, or any good pure water as little impregnated with mineral ingredients as possible, but not any of the stronger alkaline waters unless especially prescribed by the physician. Rain water or any pure soft water will answer the purpose well, if boiled to destroy all germs and afterward cooled down and recharged with air to give it life by shaking it a few minutes in a bottle which is not entirely filled. Foods and Drinks to be Avoided while on Diet No. 4. — All articles not especially mentioned as permissible, and particularly all foods made or served with sugar, shellfish, fried things, mufiins, fresh or hot rolls, soda biscuits, flannel cakes, etc. ; bread not at least one day old ; fruits ; vegetables except as above mentioned ; nuts, raisins, candies, pastries, ices, cakes, puddings, twice-cooked or warmed-over meats, cheese as a rule to which there are exceptions, sausages and scrapple as well as pickles and other very sour things, and all hot or sharp condiments, spices, etc., and alcoholic beverages except as specially permitted. Vichy and the other strong alkaline waters should be avoided, except when prescribed for hyperacidity as shown by a chemical analysis of the stomach contents. Diet No. 5. — Selection may be made from any articles in the previous lists and from any in this table. None of these foods should be made or served with sugar with the special exceptions mentioned. Soups. — Any plain, simple soup not too rich or greasy. PROGRESSIVE SERIES OF DIETS 2.';i^'J Fish. — Raw oysters in their season, but no other shellfish; any other kind of edible fish properly cooked except eel, salmon, herring, and salted mackerel, which are exceptionally oily ; and shad should be eaten sparingly if at all. Meats. — Very tender, broiled, lean beefsteak, lamb chop, venison, antelope meat, hare or rabbit, chicken, scjuab, cjuail or any edible bird except duck or goose ; also in moderation, ham well boiled and afterward baked; broiled or stewed sweet- breads, except in case of lith^emics ; any of the following roasts, if the fat and gristle are carefully rejected : beef, lamb, mutton, chicken, and sparingly of turkey, but not the dressing of any roast fowl or meat. Eggs. — In all forms except fried; omelets, if baked and not fried; eggs in baked custards and light puddings, if not pre- pared with sugar. Farinaceous. — Wheaten bread at least one day old, and better two days old; toast or unsweetened zwieback; gluten wafers, plain water crackers, or saltines, or Bent & Co.'s, or Educator crackers, or Uneeda Biscuits. These forms of bakery products are very liable to become stale before sold, and then may produce much flatulence. Good bread a day or two old often agrees better; corn bread made without sugar and with only the smallest amount of shortening, best in the form of the Southern hoe-cake or pone. Any of these breads may be lightly buttered. All the mushes (which are usually swallowed without chewing or admixture of the saliva) are purposely omitted from this list; but small portions of the thoroughly dextrinized breakfast foods, such as Force, Grape Nuts, and Shredded Wheat Biscuits, may agree well when eaten dry and even when taken with milk (less certainly with cream) are much better tolerated by dyspeptics than oatmeal, cracked wheat, etc. Boiled rice also is one of the most di- gestible of the cereals. Rice biscuits are still better. Vegetables. — White potatoes, baked in their skins or boiled and mashed with milk instead of butter; baked scjuash, stewed celery ; finely ground spinach ; boiled and finely mashed car- 238 METHODS OF TREATMENT rots or parsnips, but not cooked with butter; string beans; young and very tender peas; and, merely as a relish, a leaf or ^ two of lettuce or small piece of uncooked celery, -served with salt, but no vinegar. Also any vegetable puree. Dessert. — A sweet orange, a baked sweet apple, or a few white grapes, and occasionally, when found to agree, after cautious trial, a fully ripe peach or pear; also sparingly of stewed fruits, if but slightly sweetened; after a luncheon or very light dinner, one tgg made into a baked custard with milk, but without sugar. If flavored with vanilla, lemon, or sherry, this makes a delicious dessert. Also curds and whey without sugar; very sparingly of Iceland moss jelly or of guava or other fruit jelly; a small portion of malted milk or of Hor- lick's or Mellin's Food served with fresh cream; but these jellies and malted foods are all too sweet to agree with many doubtful stomachs, especially at the end of a hearty meal. Drinks. — Any of those mentioned in No. 4, or a glass of Apollinaris, Poland, Bethesda, Clysmic, or Buffalo Lithia water may be taken at the end of the meal; and also one cup of chocolate or cocoa if taken without sugar, or very slightly sweetened. Water may be drunk freely between meals, except in the cases of dilated stomachs, or of those in which the motility or propulsive power has been found deficient. Avoid while on Diet No. 5. — All foods or drinks not allowed on the above or previous lists. Nuts, raisins, candies, shellfish, pastry, tarts, rich cakes or puddings, or other des- serts, except those above named as permissible, raw fruit and vegetables, except as above allowed, twice-cooked or warmed- over meats, cheese, sausage, and scrapple, vinegar, sharp or hot sauces and condiments, alcoholic drinks, strong tea or coffee, and sweetened chocolate or cocoa, as a rule, to which there may be exceptions. . Diet No. 6. — May take in addition to the articles mentioned -in the previous lists: PROGRESSIVE SERIES OF DIETS 239 Soups. — Small quantity of any kind not too rich or greasy. Fish. — Oysters in their season in any form except fried; no other shellfish, but any of the other edible kinds not fried. Meats. — Any kind of cooked meats other than those fried except corned beef, salt pork, very young veal, and " high " game. Duck, goose, and turkey should be eaten spar- ingly, if at all, by persons whose digestion is doubtful, and the dressing should be avoided by them entirely. Boiled meats are far less digestible than those roasted or broiled, as well as less nutritious. Eggs. — In any form except fried hard or combined with sugar in rich desserts. Grains or Cereal Foods. — The drier forms, such as stale bread, toast, and crackers, which require tO' be chewed, are always best ; also corn bread, rye bread, brown wheaten bread, and rolls ; but a moderate amount of the mushes may be taken by patients whose intestinal digestion has been restored nearly to the normal. The best of them are Force, Grape Nuts, Shredded Wheat Biscuits, Wheatena, rice flakes, maize flakes, thoroughly boiled rice, the finest grades of cracked wheat, if cooked overnight in a double kettle, and the finest well-bolted kinds of oatmeal cooked in the same way. They should be eaten with a small amount of fresh cream or milk and mixed well with the saliva. Butter may be taken with the bread, except at dinner, when it is better omitted. Vegetables. — Any of the following, well cooked : aspara- gus, beets, Brussels sprouts, beans in puree, or very thoroughly boiled and afterward baked till brown; cauliflower, carrots, celery, dandelion, egg-plant, mushrooms, onions, parsnips, ten- der young peas, parsley, potatoes, not fried unless in the form of Saratoga chips shaved very thin, pumpkins, spinach, string beans, summer squash, sweet corn (if young and very tender), tomatoes, turnips, turnip tops, and vegetable oysters. The following uncooked vegetables may be partaken of spar- ingly, merely as a relish, since they are difficult of digestion 240 METHODS OF TREATMENT for many persons, and have small food value: lettuce, olives, raw celery, and cole slaw. Dessert. — Oranges, baked apples, ripe peaches, pears, grapes. Bananas, melons, light simple puddings, custards, sparingly of jellies, and very sparingly indeed of nuts. Ice cream and water ice are borne fairly well by many not robust stomachs, if taken as part of a light lunch, yet often disagree when taken at the end of a dinner. If eaten after dinner, it should be very slowly and in small amounts. Drinks. — Cocoa or chocolate; very moderately of coffee or tea not too strong, though one is better without these in the long run. The lighter wines may be taken by those accus- tomed :o them, except where there is a tendency to hyperacidity. The malt liquors are better avoided as beverages by even con- valescents from gastro-intestinal diseases. In subacidity, when there are indications for a stimulant with a diastasic- prepara- tion, a good liquid malt extract in wineglassful doses may be allowed ; but not as a rule the beers, ales, etc., in the usual amounts. In cases where a stimulant is really indicated, a very small portion of whisky in water is often safer. Avoid while on Diet No. 6. — Very rich, very sweet or complicated dishes ; articles fried in fat ; soda biscuits and all hot or even fresh breads as a general rule ; most kinds of shell- fish, except oysters in their season ; pastries, ices after a full meal ; sausage, scrapple, and warmed-over meats ; very strong coft'ee or tea, and large cjuantities of any coffee or tea ; alco- holic beverages, except under the conditions and restrictions above mentioned. The sharper condiments, such as pepper, mustard, and the hot sauces should be either avoided or taken very sparingly. Classes of Cases for which the Foregoing Diet Lists are Indicated. — Nos. i and 2 are suited to acute and subacute gas- tritis or cases of irritable stomach from whatever cause. Aided by appropriate medicines and other accessory measures, such a regimen should be speedily effectual, and not need, as a rule, to be continued beyond a few days. PROGRESSIVE SERIES OF DIETS 241 The articles prescribed in No. 3 usually agree well with cases of subacute gastric catarrh and with certain forms of chronic gastric catarrh ; also, with acute nephritis and any of the other conditions for which a milk diet may be indicated. It answers for the severest cases of hyperchlorhydria and for gastric ulcer after a preliminary period of rectal feeding. Out of the first three tables can be formed a good regimen for advanced cases of gastric cancer, but for many such cases some of the things in No. 4 would need to be added. No. 4 is adapted to a large proportion of the cases of chronic catarrh of the stomach (gastritis chronica) of pronounced type in the stage in which they are usually first seen by the specialist, as well as to many cases of chronic intestinal catarrh. No. 5 is intended especially for the same classes of diseases when somewhat further advanced toward a cure. Nos. 4 and 5 may be suited to the treatment of numerous chronic affections in which a simple and easily digestible and yet highly nutritious diet is' required. No. 6 is too liberal to be entirely safe for most dyspeptics even when convalescent, but it serves the very useful purpose of encouraging them to look forward to it as comparatively a feast of good things to which they may hope to attain later on, and at all events it is a simpler and safer diet than that to which most of them are accustomed, and than that to which they would promptly return upon being pronounced convales- cent, unless peremptorily limited to a less hamiful one by their physician. It can easily be cut down to the exact needs of any particular case. It can be modified also by simply striking out unsuitable articles so as to answer for diabetes, obesity, lith?emia, and numerous other diseases. For catarrhal inflammations involving both the stomach and intestines, the lists i to 4 may be employed, the more restricted ones for acute or severe cases, and No. 4, or even No. 5, for the chronic ones and those progressing toward recovery. When the catarrhal inflammation is confined wholly or mainly 242 METHODS OF TREATMENT to the intestinal mucous membrane, the gastric juice being active and the stomach in good condition, the dietetic treatment by lean meat and hot water with the addition of stale bread or toast and a few relishes, often suits remarkably well if not persisted in too long. Such a plan of diet can easily be adapted from No. 4 or No. 5 by striking off the vegetables and other articles not recjuired. Aberrations from the normal in the amount or character of the gastric juice — whether they con- stitute hyperchlorhydria or hypochlorhydria, hyperpepsia or hypopepsia — demand special dietetic treatment which can be readily met by modifications or combinations of these tables. Special diet directions for gastric ulcer, hyperchlorhydria and other important diseases axe given further on under their respective heads. DIET DIRECTIONS OF LEUBE AND PENZOLDT It should be of interest to you to know how leading German clinicians and specialists in digestive diseases direct their patients as to diet. Leube instituted a series of experiments upon persons with impaired -digestion, to determine the length of time that the principal food substances and preparations re- quired to digest and pass out of the stomach in such cases. He constructed diet tables for gastric ulcer and other serious diseases of the stomach based upon such experiments, and so arranged as to progress from a list of the simplest and most easily digested articles up to one containing numerous decid- edly strong and nourishing foods which require more time and digestive power.^ I append here, in the form summarized by Riegel, LEUBE'S DIET SCHEME Diet I. — If the digestion is very much reduced, the follow- ing articles of food are most easily digested ; bouillon, meat solutions, milk, raw or soft-boiled or poached eggs. Diet II. — Less digestible than Diet I are the following ' Nothnagel's " Practice, Dis. of the Stomach," by Franz Riegel, Pro- fessor, etc., Philadelphia, 1903. PROGRESSIVE SERIES OF DIETS 243 articles of food: boiled calves' brain, boiled thymus, l^oiled chicken and pigeon. These different kinds of meat are enumerated in the order of their digestibility. Other articles of food that are permissible are gruels, and in the evening milk mushes made with tapioca and white of egg. The majority of patients can assimilate boiled calves' feet in addition to the articles of meat mentioned. Diet III. — If Diet II can be digested, Diet III follows. The increase consists in adding cooked or raw beef to the above diet list. Leube mentions the following method of preparing beefsteak, and claims that beef cooked in this way is very easily digestible. The meat should be allowed to lie for some time and scraped with a dull spoon ; in this way a meat-pulp is obtained consisting only of the delicate parts of the muscle, and containing none of the tough, hard, and sinewy portions. These meat-scrapings are roasted in fresh butter. Raw ham is also permissible in this stage. In addition to meat, a little mashed potato may be given, some white bread that is not too fresh, and possibly small cjuantities of coffee or tea v/ith milk. Diet IV. — Roast chicken, roast pigeon, venison, partridge, roast beef, medium to raw (particularly cold), veal (from the leg), pickerel, boiled shad (even young ones are hard to di- gest), macaroni, bouillon with rice. Small quantities of wine to be taken one to two hours before eating; gravies are contra-indicated. Young and finely chopped spinach is the best vegetable ; other vegetables, as asparagus, may be tried, al- though Leube considers this a risky procedure. The patients are allowed to take a more liberal diet after this fourth diet, but the increase should be very gradual. They should refrain from eating vegetables, salads, and preserves, and fruits for a long time. The first of these articles that they may eat is a baked apple. Penzoldt afterward repeated Leube's experiments upon healthy persons and improved upon the latter's diet tables, con- siderably enlarging and extending them. He constructed a 244 METHODS OF TREATMENT series of four diet lists founded upon similar data, including the time each kind of food remained in the normal stomach, and added directions as to how each article should be cooked and ^aten, as well as the cjuantity to be taken at a time. Penzoldt's four lists are designed to train the weakened digestive ap- paratus gradually and progressively up to the full performance of its work. Numerous authors have republished Penzoldt's diet tables, and they are generally accepted as constituting a reliable basis upon which to arrange dietaries for the more serious cases of gastro-intestinal disease, though of course every case requires special study and its own appropriate diet directions. I reproduce here in full the Penzoldt scheme : PENZOLDT'S DIET TABLES FOR GRADUAL TRAINING OF THE DIGESTIVE CAPACITY First Diet (about Ten Days) Largest Foods or Drinks Quantity at One Time Preparation Character How to be Taken Bouillon . . 250 gm. X liter. From beef. Lean, very little salted or not at all. Slowly. Cow's milk. . 250 gm. Well boiled, or Pure milk, or If preferred, % liter. s t er i 1 iz e d ]4, lime-water with a little (Soxhlet's ap- and % milk. tea. paratus). Eggs. . . . One or Very soft, just Fresh. If raw, should t w 0. warmed or raw. be stirred in- to the warm, not boiling bouillon. Meat solution — 30-40 gm. Should have Teaspoon f u 1 (Leube-Ros- only a faint doses stirred enthal's) . odor of bouil- lon. into bouillon. Cakes (Albert Six. Without sugar. Not softened, biscuits). . but should be well masti- cated and in- salivated. Water . . . % liter. Ordinary or natural car- bonated, con- t a i n i n g a sma 11 pe r- centage of carbonic acid (Selters). Not too cold. PROGRESSIVE SERIES OF DIETS Second Diet (about Ten Days) 245 Largest Foods or Drinks Quantity at One Time Preparation Character How to be Taken Calf's brain . 100 gm. Boiled. Freed from all membran e s and fiber. Preferably in bouillon. Sweetbreads, 100 gm. Boiled. As the above. Best in bouil- (thymus Should be lon. gland) peeled out carefully. Pigeons . . . One. Boiled. Only if young, without skin, tendons, and the like. Same as above. Chickens . . One, the ^ize of a pigeon. Boiled. As above (no fatten e d chickens). Same as above. Raw beef . . 100 gm. Finely chopped From the fillet To be eaten or scraped,' (tenderloin). with bis- with a little cuits. salt. Raw-beef sau- 100 gm. Without addi- Smoked a little. As above. sage . . . tions. Tapioca . . . 30 gm. Boiled to a gruel with milk. Third Diet (about Eight Days) Largest Foods or Drinks Quantity at One Time Preparation Character How to be Taken Pigeon . . . One To be broiled with a little fresh butter. Only young birds without skin, etc. Without sauce Chicken . . One As above. As above. As above. Beefsteak . . 100 gm. With fresh but- ter, quite rare (English). From the ten- derloin, well beaten. As above. Ham .... 100 gm. Raw, scraped Smoked a little With white fine. without the bread. bones. Milk bread, 50 gm. Baked crisp. Stale rolls, etc. To be well toast, or Frei- chewed and berg pretzels. insalivated. Potatoes . . 50 gm. Mashed, or forced through a strainer. Boiled in salt water and mashed. The potatoes should be m e a 1 y , crumbling on crushing. Cauliflower . 50 gm. Boiled in salt water as veg- Only the flow- ers to be used. etables. 24^ METHODS OF TREATMENT Fourth Diet (about Eight to Fourteen Days). Largest Foods or Drinks Quantity at One Time Preparation Character How to be Taken Venison . . ZOO gm. Roast. From the back, hung for a time, but not gamy; with- out high fla- vor. Partridge . . One. Roast without bacon. Young birds, without skin, tendons, feet, etc., after having hung for a time. Roast beef. . loo gm. Medium to rare From well-fat- ted cattle ; pounded. Warm or cold. Fillet . . . ICO gm. Same as above. Same as above. Same as above. Veal .... loo gm. Roasted. Back or leg. Warm or cold. Pike Boiled in salt Perch-pike Carp I ■ Trout J water with- The bones to be In the fish lOO gm. out any addi- removed. gravy. tions. Caviar . . . 50 gm. Raw. Russian caviar, slightly salt- ed. Soft, without Asparagus . , 50 gm. Boiled. With a little the hard por- melted butter tions. Rice .... 50 gm. Mashed and forced thro ugh a strainer. Soft boiled rice. Likewise. Poached eggs. Two eggs. With a little fresh butter and salt. O m e 1 e t t e Two With about 20 Must have risen To be eaten at souffle . . eggs. gm. sugar. well . once. Stewed fruit . 50 gm. From fresh boiled fruit, forced through a sieve. To be free of skins and seeds. Red wine . . 100 gm Light, pure Bordeaux, or similar red wine. Slightly warmed. It is noteworthy that Penzoldt allows no alcoholic stimulant until after the expiration of twenty-eight days of treatment and then only about three ounces of a light red wine. The calves' brain and sweetbread which he includes in his second PROGRESSIVE SERIES OF DIETS 247 dietary are digestible enough, but in the hght of recent knowl- edge unsnited to the many dyspeptics who are also lithsemic, on account of the large content of the alloxuric bases which all such glandular parts of animals contain. His prescription of raw sausage at the same early stage of the treatment of a serious stomach case would be open to criticism also from the point of view of most American authorities upon dietetics, and the raw meat liberally allowed in two of the lists would not readily be taken by many American patients, even if their physicians cared to let them risk the dangers of trichinae, the bacilH of tuberculosis, etc. The very liberal allowance of meat, including, in the form of bouillon, much of the meat ex- tractives which contain its most soluble and toxic ingredients, would not suit well in the very numerous cases of indigestion in elderly persons, complicated, as so very many of them are, with disease of the kidneys, heart, and arteries. Nevertheless the dietaries will afford you valuable sugges- tions for your guidance in many difficult cases. LECTURE XXI FEEDING BY OTHER ROUTES THAN THE MOUTH It happens in many cases that for considerable periods either no food or insufficient quantities of it can be taken by the mouth. In round ulcer of the stomach, recent hemorrhage from the stomach or esophagus, whatever the cause may have been, and in corrosive poisoning in the upper part of the alimentary canal anywhere, most authorities now advise giving the stomach complete rest till the acute condition has been relieved; in gastric ulcer from one to three weeks. Food is given by the bowel meanwhile, and after such a period the usual method of taking nourishment per os is gradually re- sumed. In severer grades of gastrectasis it is also generally agreed that rectal feeding greatly assists the cure. In the worst case of this kind which I have ever seen, the patient hav- ing been reduced almost to a skeleton by the prolonged attempt to nourish exclusively by the mouth when there was frequent vomiting and very little absorption. I had not only all food, but also the medicines, administered per rectum, while the stomach was washed out daily and the viscus afterward treated by the induced current (faradic electricity), intragastrically. This patient made a good recovery and is now in fairly robust health eight years afterward. In cancer of the esophagus or of the cardia, or obstruction of either of these from any cause, the patient should be fed by nutrient enemas until the operation of gastrostomy can be performed. The Technique of Rectal Alimentation. — Formerly it was considered necessary to have all proteid food introduced into the bowel previously peptonized, but Ewald first demonstrated that 248 FEEDING BY OTHER ROUTES THAN THE MOUTH 249 the rectum and colon when healthy can absorb eggs, glucose, starch, etc., in such a form as to be assimilated and furnish nutriment to the system. Evvald's directions for the prepara- tion of such an enema are as follows : Beat up thoroughly 2 or 3 eggs with a tablespoonful of water. Have ready beforehand a 20 per cent, solution of glucose boiled with a pinch of the best flour and add a wineglassful of claret. When this solu- tion has cooled enough not to coagulate the eggs, the two are gradually stirred together and should not make in all more than half a pint. In hospital practice 3 to 5 eggs are beaten up and mixed with about 5 ounces of a 1 5 or 20 per cent, solu- tion of glucose for the same purpose. The addition of 15 grains of table salt for each egg has been found by him and other observers to increase markedly the absorbability of such enemas. The latter are introduced with a soft rubber rectal tube several times a day, after a preliminary washing out of the bowel with a warm salt solution, and, it is said, can be continued for a long time in most cases without being rejected. My own experience has been that usually, by the end of a month, the rectum is likely to become irritable and then no longer to retain the injection. Ewald has found it necessary in some cases to add a little starch in order to make the solution more viscid and to overcome irritability of the bowel; also sometimes a few drops of tincture of opium. He adds some further directions that are worth your particular attention, since care as to such important details makes often all the difference between success and failure. He has the patient lie in the dorsal or left lateral position during the introduction of the enema, though I have had better success with the patients lying at first on the left side and then after half an hour or so having them turn and lie on the right side with the hips somewhat raised upon a cushion. This, I fancy, helps to carry the enema by gravity over intO' the ascending colon and cecum, where it does not provoke efforts at expulsion, and where also there should be more rapid absorption than from the lower end of the large bowel. Ewald further advises 250 METHODS OF TREATMENT that the vessel holding the liquid be placed about two feet above the anal orifice of the patient and the enema be allowed to pass in very slowdy. Time enough should be given after the cleans- , ing injection to let all the fluid return before the nutrient enema is introduced, otherwise there would be danger of its coming away again immediately. Most authorities advise having the cleansing injections administered an hour before the nutritive enema ; also that the quantity of the latter should not exceed half a pint. It is further important that the patient should rest recumbent for an hour after each nutritive enema. Boas' Formula for a Nutrient Enema. — Riegel bears per- sonal testimony to the eft'ectiveness of the follow^ing prescrip- tion of Boas : Half a pint of milk, yolks of 2 eggs, a small quantity of salt, a tablespoonful of red wine and a tablespoon- ful of " Kraftmehl," instead of which special brand of flour probably any good wheat flour would answer as well. In view of the fact that albumin is especially recjuired by the system and that the whites of eggs are quite as easily absorbed as the yolks, I usually order for an enema 2 raw egg's well beaten up and added to about half a pint of milk, a saltspoonful of salt, and when there is any need of stimulation, a tablespoonful of whisky or brandy. Sometimes sugar or glucose is also added. But, notwithstanding that undigested food may be fed per rectum for weeks at a time, there are cases in which the nour- ishment needs to be continued in this way for much longer periods and then the method recommended by Leube has much to be said in its favor. It consists of chopped meat and fat mixed with pancreas in the following proportions : Chopped beef, 150 to 300 grms. ; finely chopped and fat-free pancreas (from hog or cow), 50 to 100 grms. When fat is desired to be a part of the feeding, 25 to 50 grms. of this may be added. Riegel reports that in several of his cases he was enabled to keep patients alive for months by feeding in this w^ay, and one patient with stricture of the esophagus was nourished for ten months by this means exclusively. Any method of rectal feed- ing which will accomplish such results should be considered FEEDING BY OTHER ROUTES THAN THE MOUTH 2^1 invaluable and resorted to in serious emergencies, regardless of the trouble involved in carrying it out. Rectal alimentation should be employed as an auxiliary to other feeding much more largely than it now is. You will find it useful as such an auxiliary in any case in which, on account of disease in the stomach which prevents a complete and satisfactory nourishment of the patient by the mouth, the nutrition is suffering. Besides the desperate classes of disease above mentioned in which this method is resorted to for the purpose of saving life, it will prove helpful in hyperchlorhydria of severe type with low peptonizing power in spite of excessive HCl; also in numerous cases of hypochlorhydria, and still more in achylia gastrica when the digestive power of the stom- ach does not speedily come up under the treatment carried out, you might wisely administer nutrient enemas in addition to such an amount of food by the mouth as the patient can be made to take and digest. In such conditions this sort of sup- plemental feeding promises more than a dependence upon forced feeding by the mouth exclusively, especially if at the same time by the help of stimulating soups or broths, as well as by the administration of the appropriate stomachic medi- cines, the digestive power and the amount of food ingested have been increased as much as possible. Forced feeding is likely often merely to overburden an unwilling, because weak, stomach, while moderate feeding in such cases, supplemented by nutrient enemas, should bring up nutrition faster. The Injection of Food Subcutaneously. — Emergencies have arisen which compelled a resort to other methods of feeding than either those by the mouth or rectum. When any of the conditions exist that preclude the taking of nourishment by the mouth and the rectum, or any part of the colon is the seat of disease acute enough to prevent the retention of enemas, some other means of feeding must be found if life is to be maintained. Under such circumstances subcutaneous feeding has been practiced for short periods with the result, apparently, of affording some sustenance. Numerous experiments on ani- 252 METHODS OF TREATMENT mals have been done to determine how snch subcutaneous injections of certain foods could be borne and the results upon , nutrition, and it was found that oil especially could be used in this way to some advantage. Other substances, as diluted milk, solutions of sugar, albumin, etc., have been injected in this way, and it has been demonstrated that these were ab- sorbed without any local or general reaction. In the compara- tively few attempts, however, in which subcutaneous feeding has been practiced upon human beings, olive oil or other bland fats have been employed, and while they seemed to be pretty well tolerated, exact experiments are wanting to show to what extent the food thus introduced has been utilized for the purposes of the economy. Thomas B. Keyes ^ of Chicago believes he has proved that subcutaneous injections of oil increase the cell activity of the body, and thus prove a valuable stimulant to nutrition, espe- cially in tuberculosis, when fats taken by the mouth are not well digested and assimilated. Patients who were in danger of perishing for want of nour- ishment have also been placed in baths of warm milk with some apparent gain to their nutrition. However, the fact that a person in fair health may live for several weeks without any food at all makes it a little uncertain whether, in some or all of such cases, the patients were not really being sustained by the oxidation of their own tissues. ^Canadian Jour, of Med. and Surg., May, 1906. LECTURE XXII METHODS OF TREATMENT IN GASTRO- INTESTINAL DISEASES When you are called to a case and have made the diagnosis, the most important thing of all is to decide, when possible, the origin or cause of the disease. In probably four-fifths of all gastric affections, as in most other disturbances of health, Nature would gradually effect a restoration to the normal con- dition, provided all causes of abnormal functioning could be radically and permanently removed. This point cannot be impressed and emphasized too strongly. Most of our failures are due to our inability either to discover the exact cause of the disease or to remove it when found. Manifestly, when the cause is in large part a bad inheritance, it cannot be removed ; but fortunately, bad inheritance alone is rarely responsible wholly for the derangements of health which we are called upon to treat. It is merely a predisposing cause, and when in spite of it the patient can be induced to live in strict accordance with hygienic requirements, he may enjoy a good measure of health notwithstanding. Many failures in treatment occur in cases in which the physician has made a correct diagnosis, but places too little stress in his directions to the patient upon the importance of changing radically the faulty modes of living which produced the disease, and too much upon our remedies, especially drugs. Unless we stop the leak, however, which is draining away the energies of the patient, we shall make little permanent progress in curing him, whether we rely chiefly upon hydrotherapy, massage, or other manual treatments, elec- tricity, vibratory stimulation, climatotherapy, or merely upon the most skillfully concocted combinations of medicine. For 254 METHODS OF TREATMENT example, if the patient habitually overtasks his brain or other part of his nervous system, he will be only temporarily relieved, not cured, by strychnine, phosphorus, etc., and would gain equally little permanent benefit from any of the above men- tioned mechanical modes of treatment. The society woman who squeezes and drags her abdominal viscera out of place by tight corsets and heav}^ skirts suspended from the lower abdo- men and spends most of her evenings up to a late hour in the polluted atmosphere of crowded assembly rooms, ending with an indigestible supper at midnight, will never be cured of her neurasthenia, nervous dyspepsia, or gastroptosis until her habits in these respects have all been brought into conformity with the common-sense rules of hygiene. Incidentally it may be said here, too, that the uterine displacements of such women can never be successfully overcome and their pelvic organs main- tained in their normal place until the malpositions of the ab- dominal viscera above have been corrected and the causes of them have been removed by the patient's abandonment of the irrational modes of dress, as well as the development by suit- able exercises of their abdominal muscles. Again, the student and professional man who attempt to achieve impossible tasks b^^ cutting short their allowance of sleep, and whipping up their exhausted energies to enable them to follow so reckless a method of work, by drinking strong coffee or other stimulant, can manifestly not hope to regain a normal tone in their nervous and digestive systems until they can be induced to apportion their hours of work, recreation, and sleep more wisely. It should be still more manifest that the sedentary clerk or gluttonous man of leisure, who regularly eats twice as much food as the amount of exercise taken by him enables him to oxidize, cannot possibly recover health and stay well by the consumption of any quantity of stomach bitters or artificial digestants. He might find more temporary benefit from mas- sage or hydrotherapy, since these procedures increase oxidiza- tion, but the gain would last only so long as the treatment TREATMENT IN GASTRO-INTESTINAL DISEASES 255 should be continued. Equally impossible is it to cure and keep well a patient who bolts his food without mastication and insal- ivation, and, regardless of Nature's requirements, takes daily into his stomach twice as much proteid matter as he does carbo- hydrates and fats, instead of letting them form about one-tenth of the total, as is the normal proportion. If, therefore, you would make permanent cures, insist as strenuously as possible that your patients shall reform their un- hygienic modes of living — not only their eating and drinking, but also their neglect to take exercise — and that they shall breathe an abundance of fresh outdoor air as little contam- inated by the poisonous products of our civilization as their means and opportunities will permit. There are ways enough in which the health is damaged, including many vices and unhygienic practices, into the details of which it is unnecessary to enter here. Suffice it to say that all departures from the normal in the way of living must be cured — reformed alto- gether — if the results achieved by our treatment are to be satis- factory and permanent. Therapeutic Methods. — Coming now to the various thera- peutic methods in vogue, I must ask the indulgence of strait- laced critics, if there still remain any who are in sympathy with the authorities satirized by Moliere, and represented by him as having exacted of candidates for the degree of Doctor of ^ledicine an oath never to alter the practice of physic. For myself, I have always gloried especially in the fact that the adherents of regular medicine are broad and catholic, being fettered by no creed limitations, but free to make use of any remedy or therapeutic measure which experience has shown, or can show, to have value. This is in marked contrast with the creeds of the many sects and pathies which build pretentious therapeutic structures upon the slender foundation of a single dogma or some one narrow idea. Hence, in these lectures I do not hesitate to sanction the use of any remedy or therapeutic measure, whether, like cod-liver oil, its value was originally 'liscovered by ignorant fishwn'ves, or expectancy and minute 256 METHODS OF TREATMENT doses of drugs, the frequent effectiveness of which we have learned from the homeopaths ; electricity and water locally ap- plied, the usefulness of which we learned from former electro- , paths and hydropaths so-called, or other forms of mechanical, manual and vibratory stimulation, some of which are nowadays becoming popular. According to my understanding of the doctrine held by us as regular scientific physicians, it is our duty to prove all things and hold fast to that which is good, quite regardless of its source or of alleged faults in those who first employed it. It is a hopeful feature of our present-day therapeutics that more direct and manageable modes of influencing disease than the administration of drug remedies are increasingly employed. We are learning that stimulation or sedation of a diseased organ can often be more quickly, certainly, and safely effected through the application of heat or cold by water or otherwise, or through some one of the numerous other mechanical forms of treatment, gymnastic exercises, etc. These methods can be so used as either to affect the whole system or to limit the action to some one or more parts without disturbing to any considerable extent the remainder of the body. It is much more convenient and often more economical for the patients to depend upon medicines, except in so far as a skillfully arranged diet may promote the cure, and in many diseases, as, for example, the least stubborn cases of hyperchlor- hydria, chronic inflammation of joints, eczema, etc., active medication with alkalies, nerve sedatives, or salicylates, iodides, purgatives, etc., will often do the work quite effectually; but rarely without exerting an injurious effect upon other structures including some of the nerve centers, with a considerable depres- sion of the vital force which most chronic invalids can ill afford to sustain. Certain of the forms of electricity, etc., on the other hand, can now be so used as frequently to cure these chronic conditions rapidly, not only without injury to any other parts or any lowering of the general system, but, on the contrar}'-, with the advantage of actually improving the general TREATMENT IN GASTRO-INTESTINAL DISEASES 25/ nerve tone. It is exactly analogous to the modern treatment of fevers by cold baths, which act by strengthening the nerve centers, instead of antipyretic drugs or the older-fashioned bleeding and tartar emetic, which, indeed, lowered the fever, but at the same time lowered the patient. Yet medicines are often indispensable to the cure of certain diseases and in very many cases, when used with the skill and precision which are possible only after making an exact diag- nosis, may prove most valuable auxiliaries to the more directly acting mechanical forms of treatment. But whether you administer medicines or apply other modes' of therapy, or both combined, you will need to be careful that in your zeal to cure the patient you do not overdose or overdo in any way. Overdosing and Overdoing in Therapeutics. — There can be no fixed dose of an active medicine any more than a uniform size for a drink of whisky. With regard to the latter, some persons would be intoxicated by a tablespoonful, while for others a half-pint tumblerful would merely steady their nerves. It is the same with cathartic medicine ; we have all seen patients whom a teaspoonful of castor oil would purge, and when such persons get the usual drug-store dose of an ounce, harm must necessarily be done. So with all the energetic remedies of the Pharmacopeia. The same dose of any of them is likely to act very differently upon different persons, and what would be a suitable stimulating dose for those of robust constitution might seriously overstimulate weaker ones. The only safe rule, therefore, in prescribing for a new patient, is to begin with a dose somewhat under the minimum, and gradually increase it as found necessary to produce the desired effect. Such a pre- caution is scarcely less necessary in prescribing a new remedy for any patient. The so-called dosimetric method of admin- istering minimum doses of the active principles of drugs, and repeating them at short intervals until the required effect has been obtained, has thus a real advantage in addition to the claim of its advocates that there is greater cer- 258 METHODS OF TREATMENT tainty in the results to be accomplished by the alkaloids as com- pared with the Galenic preparations of numerous remedies. It is safer than ordering a maximum dose at once in a threatening ■^ase with directions to repeat the same at definite intervals, regardless of effects. What is true of medicines is equally true of other thera- peutic measures. Even diet cures are often sadly overdone, to the great injury of the patient. The same is true of exercise, massage, electricity, etc. Patients differ most widely in their response to every sort of remedial agency, mechanical as well as medicinal, and what is sauce for the goose is decidedly not always sauce for the gander. You will find it wisest to begin with much less than the usual dose of any such agency and study its effect upon each individual patient. Young physicians, especially, need to be reminded that Na- ture unaided makes innumerable cures, and that a very little assistance at just the right time and place may be all-sufficient; also, that our drugs sometimes harm more than they help. Even the Christian Scientists, faith curists, etc., occasionally produce astonishing results merely by stopping medicines which we had pushed too long or too vigorously. While, when we know our therapeutics and have studied our cases well, we .should not be too timid and may often gain much by boldness in applying needed remedies, yet the German motto, '' Nur nicht schaden " — " Only don't do any harm " — sometimes embodies the safest rule. LECTURE XXIII THE REMEDIAL VALUE OF ACTIVE EX- ERCISE, INCLUDING OUTDOOR GAMES, GYMNASTICS, ETC. Exercise Indispensable. — A good muscular development and a daily use of the muscles, especially of the trunk muscles, are of the utmost advantage as aids to digestion. Body workers need give no thought to this subject, but those engaged in sedentary occupations must perforce do so if they would con- tinue in even fair health. Sedentary workers with impaired digestions will find attention to this matter of physical exercise an important requirement. Most of them, by rising half an hour earlier in the morning, can go through a few gymnastic movements for the trunk muscles followed by a cold sponge bath, with great advantage, and when their day's work is done, unless unduly exhausted, should take as long a walk or as much other exercise in the open air as is practicable for them. But when the nerve force has from any cause been largely lowered and a condition of marked neurasthenia been set up, you would err gravely in advising them to increase the exhaustion which their daily labor itself produces by going through any gym- nastic or other exercise in addition. Such patients often recover soonest with the help of a complete rest cure and in any case should, if possible, take a short vacation from work, devoting it largely to rest in the recumbent position, with an abundance of nourishing but digestible food. Failing this, they should at least so arrange their work as to secure the longest possible hours for sleep and fritter away none of their nervous energy by useless dissipations in the evenings. This is a most important practical point which cannot be impressed too 259 26o METHODS OF TREATMENT strongly upon all physicians who have the management of those complicated cases of indigestion which are mainly dependent upon neurasthenia or overtaxed energies. It is highly probable that a proper attention to diet and exer- cise would prevent the development of nearly all the cases of gastro-intestinal disease not dependent upon traumatism or some other outside agency. The forms of exercise most valu- able in the treatment of these affections are such as increase the tonicity of the abdominal muscles and the different muscular layers of the viscera, including the muscular walls of the stom- ach and intestines particularly. Various Kinds of Exercise. — Rowing is doubtless the best outdoor exercise to effect this purpose, and among those prac- ticable in gymnasiums or indoors elsewhere are the various turning movements, the rowing machines, exercises with pul- leys, and the various other exercises designed especially for the trunk muscles, such as raising the upper half of the body from a horizontal nearly to a sitting position repeatedly. The swinging of Indian clubs and dumbbells, and many of the resisted movements which bring into action especially the abdominal muscles, are also useful. In addition to the special advantages to be derived from the exercise of the muscles above mentioned, a neglect of which is answerable for so much dyspepsia and constipation among professional men and women and others leading a sedentary life, it cannot be too strongly emphasized or too often repeated that exercise of the muscles generally is not only helpful in all such cases, but essential to the health of every animal. Our bodies are so constituted that without frecjuent movements of numerous groups of muscles the vital processes languish and very slug- gishly and imperfectlv perform their functions. Muscular movements increase all the oxidation processes and facilitate the circulation not onh^ in the veins, arteries, and arterioles, but also in the lymph vessels. Therefore, after a proper regulation of the diet, the first step in the treatment of a dyspeptic, pro- vided he or she be not profoundly neurasthenic and in need of REMEDIAL VALUE OF ACTIVE EXERCISE 261 a prolonged period of rest with passive exercises (massage), electricity, and nutritious feeding, should be to see to it that enough exercise is taken to insure a perfect combustion, through oxidation, and a proper assimilation, of the food eaten. In selecting the kind of exercise to be prescribed, regard must be had, of course, to the physical condition as well as the social position, occupation, and tastes of the patient. Horseback rid- ing would be the best suited to a large proportion of the patients who have the means and leisure to indulge in it, par- ticularly since it offers a maximum of movement to most of the structures of the body, with a minimum of fatiguing effort ; and, moreover, takes the patient usually into the country, where the air is pure and the surroundings enlivening. But we cannot pre- scribe this form of exercise for the wife of the workingman, who is borne down by the anxieties and cares of a large family ; nor, as a rule, for the bookkeeper or stenographer, who must spend ten hours daily in the counting-room. The poor tired-out mother usually needs most a season of rest from her monoto- nous round of duties, a remedy rarely practicable for her; but all these victims of closely confining occupations would profit greatly by a daily walk, even though it should be only in the city streets or open scjuares, and would also gain much by sponging their bodies every morning with cold witer, followed by vigorous friction with a coarse towel, and then devoting ten minutes to light gymnastic exercises desig-ned to strengthen the abdominal muscles. At the very least they could several times daily take breathing exercises in front of an open window, and this would fill up their lungs with fresh air and lend additional vigor to the oxidation processes. Instead of such rational means of improving their physical condition, many sedentary indoor workers spend a large share of their evenings in crowded theaters or other assembly rooms, where their systems are still further poisoned by an atmosphere contaminated by illuminating gas and the emanations and exhalations from thousands of other human beings packed in nearly always imperfectly ventilated halls. 262 METHODS OF TREATMENT Special Forms of Gymnastics Recommended.— It may be as well to describe here a few of the more useful of the special gymnastic exercises which may be carried out in any well- jVentilated room as well as in a regular gymnasium, or best of all, when practicable, in the open air, as upon the roof of a house so constructed as to permit of a roof garden upon it, or on any porch or piazza. These include the special room gymnastics which I have long been teaching my patients. It is, of course, impossible to go fully into this large subject here with the small space at my com- mand ; but those of you who are interested in physical culture, as all of you should be, will naturally procure special books concerning it. You should instruct the patient always to begin by raising one or more of the windows in even the coldest weather, as there is comparatively little gain to be derived from filling up the lungs with exhausted and polluted air. Premis- ing, then, that the windows are open and the patient's body clothed as lightly and loosely as practicable, let him begin by taking two breathing exercises, which are carried out as follows : 1. Stand erect, facing the open window and only a short distance back from it, with the hands at the sides, palms inward, the body kept perfectly erect. Raise the arms directly outward and upward until they are both horizontal with the palms still downward, meanwhile inflating the lungs through the nose slowly and continuously. Then let the arms fall rap- idly to the sides, meanwhile exhaling as forcibly as possible so as to completely empty the air cells in order to permit of the entrance of a new supply of pure air. Repeat this mjDve- ment three or four times and then, 2. Standing with the hands in the same position as before, raise the arms again to the horizontal, and then turning the palms forward carry the arms around nearly in the same hori- zontal plane until the hands meet in front. Continue the infla- tion of the lungs during the whole of this movement. Then, as before, let the hands suddenlv fall to the sides while the lungs REMEDIAL VALUE OF ACTIVE EXERCISE 263 are forcibly emptied. This movement can also be repeated three or four, or even more, times with advantage. 3. Begin now the gymnastic movements proper by support- ing the body with the hands on the front of an ordinary chair Fig. 32. — Chair exercise for arm and trunk muscles. on either side, while the body is extended so that it is sup- ported wholly upon the toes and upon the hands resting upon the chair. While in this position bend the arms at the elbows and swing the middle part of the body as far down as possible and then bring it back .to the original position. This exercise Fig. 33. — Second position of tlie same. need not be done more than once during the first two or three periods of practice, and after that it may be repeated oftener up to three, four, or even five times in persons who have a fair degree of strength in their abdominal and back muscles. (See Figs. 32 and 33.)^ 4. Stand erect, with the feet eight to ten inches apart, and ^ These illustrations have been taken from " Hygiene in the Treatment of Dyspepsia," published by The Brunswick Pharmacal Cq. of New Bruns- wick, N. J. 264 METHODS OF TREATMENT without flexing the knees, bend the body forward, with the arms extended until the fingers approach as near to the floor -, as the patient can get them, while the knees are kept extended. In following this movement, the bend should be largely at the- hip joints, but also in part at all the joints of the spinal column. Not many persons can reach the floor at first, but the majority '\d^^\' 1 Fig. 34, — Forward and backward body-bending. can after a little practice. This exercise, like the preceding one, should not be repeated more than once or twice at the earlier attempts, but with increased practice may finally be done half a dozen times during each exercise period. (See Fig. 34.) 5. Immediately after finishing Exercise No. 4, the patient should revolve the upper half of the body upon the hips as a pivot, bending first far forward, then to the right, then back- ward, then to the left and finally forward again and so on around. This last movement is not difficult and can be done five or ten times at once. It is very useful in stimulating the peristaltic action in the intestines and in strengthening the abdominal muscles. 6. Let the patient sit on a low stool and revolve as in the REMEDIAL VALUE OF ACTIVE EXERCISE 265 preceding exercise. By reason of the flexed position of the thighs this produces even a greater stimulation to the peri- staltic apparatus. (See Fig. 35.) 7. Let the patient lie down upon the back on a firm level surface, such as a rug upon the floor or on a straight couch. Fig. 35. ^Rotary movement of the trunk while sitting. Then, while the lower half of the body remains horizontal, slowly raise the head and thorax to the perpendicular. Then as gradually return to the horizontal position, not letting the upper half of the body fall back quickly. After raising the tipper half of the body in this manner, allow that part to remain horizontal while the legs are slowly raised as nearly to the perpendicular as possible and then as slowly returned to their former position. Repeat these movements each two or three times in the beginning, but later they may be gradually in- creased to twenty or thirty times at each exercise period, but never until fatigued. 8. Stand erect with the feet eight to ten inches apart and bend the knees as much as possible until the buttocks approach 266 METHODS OF TREATMENT closely to the heels in the squatting position, the body resting wholly upon the toes. Then slowly raise the body again to the original position. Repeat this two or three times at first and later five to ten times. 9. A very useful form of exercise which can be practiced while standing or sitting in a room, or even when walking out Fig. 36. — Pulley exercise for arm and trunk muscles. of doors, is the alternate contraction and relaxation of the diaphragm and abdominal muscles, producing movements resembling those which constitute one of the Oriental dances first introduced into this country at the time of the Chicago Fair. 10. Exercises with pulleys or elastic cords as shown in the accompanying illustrations, Figures 36 and 37. The apparatus for pulleys with weights are cumbrous and somewhat expen- sive, but the elastic cords with pulley attachments are quite inexpensive and can be obtained of any dealer in athletic goods. These cords can be so used as to strengthen greatly the ab- dominal muscles. Ijut the above-described exercises, 3 to 9, will effectithe same results. There are manv other exercises which might be described here, but the above will suffice if carried out properly and REMEDIAL VALUE OF ACTIVE EXERCISE 267 sufficiently often. They are those best adapted to the develop- ment of the abdominal and trunk muscles generally, whose functional activity is indispensable to a normal performance of the digestive functions. They should not be depended upon entirely, since other exercises for the development of the arms, Fig. 37. — Same with low attachment of the pulleys. the thoracic muscles or other trunk muscles, etc., are almost equally important ; and no person ought to be content with the performance of indoor exercise exclusively, however good or often repeated. Exercise in the open air is very necessary to the restoration and maintenance of perfect health, and those dyspeptics who possess the requisite means and leisure should row, ride horseback, walk, or play at some not too violent out- door game such as golf or croquet for an hour or two on at least every pleasant day the year round. The stronger patients may safely indulge in the more active games including tennis, basket-ball, bicycling, etc. LECTURE XXIV PASSIVE EXERCISES, INCLUDING MAS- SAGE—THE REST TREATMENT There are numerous methods of modifying the nutrition of the body which are properly classed under the head of passive exercise. Chief among these are massage and unresisted Swedish movements. Similar movements resisted by the patients are really active exercise for both patient and operator. Riding in any kind of conveyance involves a constant vibration which is more or less stimulating — a passive form of exercise unless the patient drives a spirited team, when it ma}^ become decidedly active. Riding in trolley or steam cars affords thus a kind of passive exercise of which persons resident in the sub- urbs of cities necessarily take a certain amount daily. Some observant patients who travel ten to twenty miles every day in this way have reported to me that they find it stimulat- ing or tonic, while weaker persons experience overstimulation and fatigue from the same cause. The kind of vibration now produced by special machines, driven usually by electric motors and employed for the local stimulation of various parts of the body, comes under the same category, as indeed does the so-called manual therapy as well in fact as the various electric modalities. But these are discussed elsewhere in this series of lectures, under their respective heads. Massage and the Swedish movements alone, to sav nothing of the other kinds of passive exercise, constitute a very large subject, well worthy of your study — one concerning which many books have been written without exhausting it. Mas- sage and the kindred passive movements afTord a most valu- 268 PASSIVE EXERCISES^ INCLUDING MASSAGE 269 able means of influencing the circulation and nutrition of all the bodily structures. It is often most clumsily done by in- competent manipulators and without a proper and intelligent supervision by the physician. In gastric and intestinal disease it is an efficient stimulant to both the secretory and motor functions in any part of the tract when properly given ; but it may be even skillfully applied with the result of producing harm instead of good, as in cases of excessive secretion of HCl and in spastic constipation, in the latter of wdiich there are spasmodic contractions of the circular muscles of the intestines with the result of retarding the onward passage of feces. Vigorous massage increases the previously existing hypersecre- tion of the gastric juice and also the spasmodic contractions above mentioned. Alassage is sometimes too vigorously ap- plied also over sensitive regions in the spine which would be benefited by very slight stimulation, but aggravated by the repeated and strong irritation of daily or tri-weekly forcible kneadings. In kneading the abdomen, too, much harm can easily be done when there is a displaced and tender, congested kidney, as well as in various acute or subacute inflammations. In brief, if all physicians were better acquainted with the extreme value of properly given massage in suitable cases and with the possible injuries which may result from it when improperly applied, this method of treatment would be much more widely and advantageously used than it now is. Mas- sage can only be taught by practical demonstrations, and it would therefore be quite useless to give here any extended account of the various manipulations and the technique of applying them. Some time ago I observed carefully a series of cases in w^hich abdominal massage was either the only or chief form of treatment. These vv^ere mostly cases of neurasthenia with the stomach more or less involved. In a larger number of cases under treatment by massage together with other therapeutic measures, the functional work of the gastric glands was greatly enhanced ; but the difficulty in many of these is to determine to what part of the treatment the result was due. 270 METHODS OF TREATMENT HCl Increased by Massage. — In the following cases abdom- inal massage was the main dependence in the way of treatment ; no drugs were given beyond a laxative, as required. The diet was a mixed one, from which sweet things, hot or fresh bread, shellfish and other highly fermentable articles were excluded: Case I. — Chronic gastric catarrh with slight intestinal catarrh in a professional man, aged forty-nine. There had formerly been an excess of HCl, but under treatment this had been reduced and for several months the percentage of that acid had ranged between .040 and .050. After three weeks of abdominal massage, twice a day — morning and night — following the drinking of a glass of water, the HCl had increased to .114. No drugs had been given meanwhile, except small laxative doses of extract of cas- cara at bedtime. Case 11. — Neurasthenia with ansemia and chronic gastritis. On March 13, 1897, the proportion of free HCl, by the Mintz method, was found to be .065 ; total acidity, 54. With no active treatment except abdominal massage, meanwhile, a test on April 15, one month later, showed free HCl .091 ; total acidity, 59. A large number of cases have occurred in my practice in which a total absence of HCl, pepsin, and the rennet-ferment persisted in spite of both massage and the administration of HCl along with various other roborant measures, showing the existence probably of gastric atrophy ; but in other cases of chronic gastric catarrh the amount of free HCl was finally restored under an energetic treatment by means of massage and galvanism together with the administration of both HCl and pepsin persevered with for long periods — in one instance for most of the time during a period of five or six months, with lavage employed in addition during a part of the time. Since the welfare of the patient has always seemed to me greatly more important than even the establishment of a possible truth in medical science, I have never depended upon massage alone in any case of anacidity or achylia gastrica, but as the indications for supplying the deficient pepsin and acid PASSIVE EXERCISES^ INCLUDING MASSAGE 2/1 seemed so positive, and practical advantages derivable there- from have often been so immediate and decided, I have generally administered these remedies as the first step, and proceeded afterward to add to the treatment, massage, electric- it v, exercise, and all other practicable building-up measures. The result has usually been favorable. When the gastric glands failed to respond, the internal remedies mentioned and all attempts to re-establish digestion in the stomach were aban- doned, but a perseverance with massage and the other physical or mechanical measures have almost uniformly so improved the intestinal digestion that the patients have recovered finally a fair degree of health. The following cases indicate that massage in certain very sensitive patients is capable not only of aggravating, but even of producing hyperchlorhydria. Hyperchlorhydria Produced by Massage. — Case IIL — Neurasthenia with chronic catarrh and constipation in a literary man, aged fifty, who would not give up his occupation, and often overworked. ■ He had been under treatment at times during the past three years. Tests, after the Ewald breakfast, had shown a small excess of HCl. After long having had a virtually normal gastric juice, for some time during the past autumn there had been a deficiency of HCl coinciding with increased fermentation in both the stomach and intestines and an unusual debility. An hour after the Ewald breakfast on December ist, there was found to be a total absence of free HCl. He was ordered massage and also dilute HCl in lo-drop doses three times a day, an hour after each meal. The dose was to be added to half a glass of water and taken by sips dur- ing the hour following. He did not report again until at the end of three weeks, when his medicine was discontinued, though the massage was not. A day or two later the Ewald test Ijreakfast was given him, and the result showed the highest degree of acidity ever found in his stomach contents — total acidity 82, and free HCl .167. It was afterward learned that he had been given an unusually vigorous general and abdom- inal massage treatment at nine o'clock the night before, and then having awakened very early on the morning of the test, he had tried the experiment of actively massering his own 272 METHODS OF TREATAIENT Stomach in the hope of obtaining another hour's nap. An hour afterward he took the test breakfast. During the day following this test he was required to eat and drink exactly -, the same as on the preceding day, and to pursue the same routine in all respects except to have no massage treatment. The result was; total acidity 46; free HCl .087 — only a little more than half the amounts respectively shown by the test of the day before after the unusual stimulation of the abdominal viscera by a second massage treatment within about seven hours. Hyperchlorhydria Aggravated by Massage. — Case IV. — Marked neurasthenia in a gentleman, aged sixty, with a history of very excessive hyperchlorhydria and frequently recurring attacks of gastralgia for several years. He came under ob- servation early in November. In this case there is a strong suspicion of gastric or duodenal ulcer. Various kinds of treat- ment had been tried in New York and elsewhere, with tem- porary relief of the pain, but never with any notable effect upon the excessive secretion of HCl, which was said to have been on one occasion four times the normal amount. My first test showed a total acidity of 112, and free HCl .124. He was placed upon a diet as bland as possible to be obtained in a hotel and ordered a combination of alkalies to be taken in moderately full doses two hours after each meal. Massage was also prescribed to be given daily over the whole body except the stomach, though the masseur was directed to knead over the course of the colon very gently. At the end of eight days, a second test-meal showed the total acidity to be 104, and the free HCl .219. Close inquiry elicited the fact that the masseur had misunderstood my directions and been giving full and rather vigorous massage over the entire abdomen, including the stomach. This doubtless accounted in the main for the aggravation, though his food had included too much meat and had been more highly seasoned than was desirable, which must have contributed to the result. He was now removed to a private room in a hospital, placed upon a most careful diet, and no treatment of the abdomen permitted except the lightest effleurage over the bowels. Under these better conditions the proportion of acid was speedily reduced to the normal, though so long as the case remained under treatment it showed a strong tendencv to rise again, requiring a continued use of alkaline remedies once or twice a day to hold it down. There was never a free hemorrhage from the stomach or bowels, and PASSIVE EXERCISES^ INCLUDING MASSAGE 2/3 no local tender points could be found either in front or at the back, but there was vomiting as well as much pain after taking food, and the existence of ulcer was quite possible. The inference from the last tw^o cases is obvious. Consider- ing the serious and often disastrous results to health that may come from hyperchlorhydria with its train of intestinal and nervous symptoms, and the readiness with which it can be greatly increased by massage of the abdomen, this powerful remedy should be prescribed with great carefulness and with more exact dosage than is now customary; and it needs to be remembered that in many neurasthenic patients with a tendency to excessive secretion of the gastric glands, even very moderate massage over the abdomen can set up this troublesome condi- tion with a resulting aggravation of the constipation, as well as of the insomnia and all the nervous symptoms. Indications for Massage of Abdomen. — It may be well here to summarize in tabular form the conditions under which mas- sage of the abdomen has been found in my experience par- ticularly useful : 1. Chronic gastritis in all its forms excepting those ac- companied by hyperchlorhydria. 2. Anacidity or subacidity, except when dependent upon acute gastritis, carcinoma, or, though this does not often co- exist, ulcer. 3. Gastrectasis, not dependent on, or associated with cancer or ulcer. 4. Atonic conditions of the stomach walls, whether progressed to the stage of dilatation or not. 5. Displacements of the various abdominal organs, including a: Gastroptosis. h: Nephroptosis, except in cases in which the displaced kidney has become excessively tender on pressure, and always with care to avoid manipulating the movable kidney. c: Enteroptosis. d: Hepatoptosis. 2/4 METHODS OF TREATMENT 6. Chronic intestinal catarrh, not compHcated by deep ulcer- tion. 7. Dilatation of the intestines. 8. Chronic catarrhal appendicitis. 9. Constipation from unknown causes with the exception that deep or vigorous kneading may aggravate the spastic forms and those resulting from stricture or other serious obstruction. In many cases massage alone cures. 10. In a group of symptoms which comprise especially ten- derness, over a region three or four inches in diameter includ- ing the umbilicus as its center, and a marked pulsation of the abdominal aorta in the entire epigastric region. These symp- toms have been assumed, with how much of truth I am not prepared to say, to denote congestion or irritation of the solar plexus or of one or more of the other plexuses of the abdominal sympathetic. They are often met with in practice and may be the result of auto-infection from the gastro-intestinal tract. My experience shows that these symptoms are usually benefited by gentle kneading of the abdomen in connection with careful attention to diet. The following are the principal Contra-Indications for Massage of the Abdomen: 1. Ulceration in any part of the stomach or intestines. 2. Cancer of any of the abdominal organs. 3. Acute inflammation of any abdominal or pelvic organ. 4. Hyperchlorhydria, or acid gastritis, or, indeed, any of the forms of excessive secretion of the gastric juice. 5. Prolapsed kidneys which are sensitive to palpation. 6. Aneurism of any of the abdominal or thoracic arteries. 7. During the menstrual period, when the flow is excessive or when there is a tendency to menorrhagia. 8. In fatty degeneration or marked dilatation of the heart and advanced phthisis, especially with a tendency to hemop- tysis, abdominal massage should be practiced — if at all — with much care and gentleness. In addition to the foregoing, Boas, on the authority of Dr. PASSIVE EXERCISES,, INCLUDING MASSAGE 2/5 Zabluclowski (a well-known masseur and writer on massage in Berlin) mentions, as another contra-indication, a tense condi- tion or kind of tetanic contraction of the recti muscles, which is so often seen in cases of neurasthenia. In such cases, Zablu- dowski advises "hands off." Zabludowski's method (as I happen to know from personal experience of it, when, in Berlin in 1895) is one in which tapotement and a peculiar mixture of violent slapping and vigorous kneading predominate. These procedures would be harmful, of course, under the conditions above referred to, but the gentle stroking and kneading which are given to such patients, under my personal direction, have been found uniformly helpful and curative to the underlying disease, and at the same time soothing to the overtense muscles. Boas would also permit massage in cases of gastric ulcer, except Avhere adhesive inflammation has attached the stomach to adjacent organs, and very properly advises caution in mas- sering the stomach or intestines when overfilled with contents or even with gases. It seems to me, however, wiser to avoid massage of the abdomen altogether in the cases in which there are positive signs or symptoms of ulcer, and especially when these (as nearly always happens) include hyperchlorhydria. Most of the foregoing contra-indications are self-evident, and need only to be mentioned. In cases of chronic gastric catarrh, it is well to have massage of the abdomen given in the morning (fasting), the patient having first taken one or two glasses of water which may be medicated with some alkali or an antiseptic when advisable. This is much less efficient in cleansing the gastric walls of the adherent viscid mucus than lavage, but may help in patients for whom the latter is impracticable. The value of massage of the abdomen in cases of malnutri- tion associated with indigestion of atonic type and with deficient secretion of the various glands involved, can hardly be overestimated. In suitable cases and when properly given under the physician's personal supervision it accomplishes very 2/6 METHODS OF TREATMENT much more than drugs, stimulating, as it does, every gland, muscle, and other tissue within reach of the operator's fingers. In this way the metabolic processes are all quickened. More food is transmuted into blood which in turn is better purified by a more active elimination of the toxic products of tissue metamorphosis, and a larger amount of richer, purer blood, is continually brought into contact with all the structures acted upon. In this way, what was a vicious circle is broken up and the conditions are so changed that the processes- can proceed with more activity toward a perfect restoration of health. The Rest Treatment, — The institution of this method of treating numerous cases of debilitated persons by Dr. S. Weir Mitchell, some thirty years ago, marked a great advance in therapeutics. It has been applied chiefly in markedly neurotic or hysteric patients, but is well suited to certain classes of dyspeptics, especially those whose cases are complicated with neurasthenia. In commenting on this method in a recent editorial ^ I used the following language : " By this method such patients are not only given the absolute rest in bed which is grateful to many of them, and helpful to nearly all of them, but, what is far more important, are thereby removed at once from numer- ous actual or possible disturbing causes— from mental strain, overexcitement or overexertion of any kind, nagging cares and worries, the temptation to dietetic indiscretions as to food or drink, late hours with insufficient sleep and dissipation of whatever form, w^hether downright vicious and under the ban, or fashionable and approved by society, no matter how un- hygienic. All such dangers, know^n and unknown, are cut off at one blow by the rest treatment, and many of them are particularly efficient causes of hyperchlorhydria." I might have added with equal truth that the method is help- ful in the cases of most women who are at once dyspeptic and neurasthenic, whatever the form oi the gastric derangement 1 Inf. Med. Mag., June, 1903. PASSIVE EXERCISES, INCLUDING MASSAGE 2// may chance to be; but with this quaHfication that when the analysis of the stomach contents shows an excessive secretion of HCl, stimulation of the gastric glands by vigorous massage, as has already been explained, is unsuitable and likely to aggravate ; and whenever the tests of the gastric motility in such cases show marked atony of the stomach walls, especially if there be fully developed gastrectasis, the large dependence upon a milk diet which is the usual routine in. the rest cure, would need to be replaced by a less bulky and more solid diet. A form of rest treatment is particularly well adapted to, and has proved in large numbers of cases brilliantly success- ful in, gastric ulcer, in which disease it is supplemented most effectually by rectal feeding at first and later by a liquid diet, chiefly milk. LECTURE XXV ELECTRICITY: GALVANIC, FARADIC, AND STATIC— HIGH-FREQUENCY AND POLY- PHASE CURRENTS ^ Electricity. — We are probably just beginning to learn the methods by which the various forms of electricity may be applied with advantage in the treatment of diseases of the stomach and intestines. In addition to the galvanic and faradic currents, which have been increasingly used for many years by leading clinicians in these lines, the static spark, static breeze, and more recently the secondary (electrostatic) currents obtained from the static machine, for which we are indebted to Dr. W. J. Morton, as well as the so-called cur- rents of high potential and high frequency, are finding a by no means uniniportant place in the therapy of these cases. With a few exceptions, even the more recent works on the diseases of the digestive system do not devote sufficient atten- tion to the method of applying these various forms of elec- tricity. Continuous Current, or Galvanism. — Central galvanization, i. e., the continuous current passed through the cerebral and spinal centers, as first described by Beard, is usually effective in nervous dyspepsia and the numerous nervous complications of the indigestions when at the same time proper attention is given to the diet, and a suitable apportionment of rest and exercise; but some of the electrostatic currents, and probably mechanical vibration, can now do as much or more, in skilled hands. Applied intragastrically, or in sufficiently large doses, 20 ma. or more, externally through the gastric region, galvanism is often effective in gastralgia and all the sensory derangements 278 ELECTRICITY : GALVANIC, FARADIC, AND STATIC 279 of the stomach, especially when dependent, as so many of them probably are, upon faults in the great nerve plexuses of the sympathetic system in the abdomen. Central galvanization is described and illustrated by Rockwell,^ and the accompany- ing cut, taken from the latest edition of his work, gives a good Fig. 38. — Central galvanization. idea of the procedure. Moderately strong currents of 10 to 30 ma. (and Doumer employs even 100 ma. wnth electrodes 6 cm. in diameter), applied directly over and to the sides of the abdomen, have been highly recommended by recent French writ- ers in the treatment of chronic intestinal catarrh, and ought to exert a curative influence upon chronic catarrhal appendicitis in its earlier stages. In doses of i to 5 ma. galvanism has been ' " Medical and Surgical Electricity," by A. D. Rockwell, A. M., M. D., New York, E. B. Treat & Co., 1903. 280 METHODS OF TREATMENT applied beneficially within the rectum for chronic proctitis, hemorrhoids, etc., though great caution is recjuired in its appli- cation here, since damage can easily be inflicted by using a dose * relatively too large for the sensitiveness of the part or the stage of the disease. Small doses are safest in this region. Besides its value in relieving pain in the stomach, the gal- vanic current, applied intragastrically, has also proved effica- cious in certain cases of chronic gastritis. Strictures in accessible parts of the alimentary tube, as par- ticularly in the esophagus and in the rectum or its vicinity, are, to some extent, amenable to treatment by a constant current in the form of either a very gentle electrolysis or dilatation with metallic bougies connected with the negative pole of a galvanic battery, a mild current of 3 to 5, and never more than 10 ma., being applied. Robert Newman^ claims to have used this method in the urethra for thirty-six years and cured thereby 2500 cases of stricture in that tube without a failure or relapse. Many surgeons claim to have tried the same method and failed, but Newman was certainly successful with it. ' The Induced Current, or Faradic Electricity. — This form of electricity may afford the greatest assistance in the treatment of certain gastro-intestinal diseases. Like central galvanization, what is known as general faradization, alone or in connection with the former, proves often very helpful in the treat- ment of all forms of neurasthenia, including especially those associated with dyspeptic derangements. The technique of these and of the various other methods of electric treatment is fully described in Rockwell's work already cited. The faradic cur- rent has been found effective in restoring tone to the debilitated abdominal muscles as well as the muscles of the viscera even when applied externally, and has proved particularly effective in the latter direction, when brought directly in contact with the internal lining of the cavity to be affected. This statement is unquestionably true, however the effect of the electricity maybe explained, and quite regardless of the contention upon this sub- "^ Jour, of Advanced Therapeutics, September, 1903, p. 554. electricity: galvanic, faradic, and static 281 ject as to the possibility of producing contractions by electric stimulation of the muscles through the mucous membrane from within or through the abdominal parietes from without. It matters little in what way the curative results obtained by elec- tricity in the stomach are produced. Personally, however, I believe that such stimulation does produce contractions of the muscles in cjuestion, since the contractions can often be dis- tinctly noted in the human being. I was the first to publish the observation that faradic electricity, applied intragastrically, tends to lessen the secretion of the HCl in the gastric juice, slowly after a primary stimulation during the earlier treat- ments when coils having coarse short wires are used, and much sooner when coils with long fine wires and very rapid, smoothly acting interruption are employed. These last forms of battery constitute the so-called high ten- sion faradic apparatus. But I shall have more to say of this when I come to the subject of intragastric methods. Static electricity until very recently has not been employed in treating diseases of the stomach and intestines. Even now its employment is confined to a small proportion of physicians who do electric work, and few specialists in the treatment of diseases of the nervous and digestive systems are using it to any large extent. It affords, however, a most valuable addition to our resources in these affections. Nervous dyspepsia and the various gastric and intestinal neuroses are particularly suscept- ible to cure through its agency. Sparks, the static bath or breeze, the localized brush discharge, frictional applications, the static wave current, and the static induced current can any of them afford marked assistance in the treatment of certain gastro-intestinal troubles and particularly in the nervous de- rangements associated with or dependent upon them, as well as in certain forms of renal diseases which result from them.^ The long percussive sparks are applied to the spine as a means ' The Effects of the Secondary Static Currents in Removing Albttmin and Casts from the Urine, with Reports of Cases. By Boardman Reed. A»!. Mcdicme, November 28, 1903. 282 ■ • METHODS OF TREATMENT of general tonic treatment, or to the liver, stomach, and lower abdomen over the intestines when these are to be aroused to more energetic functioning, especially the musculature of the latter. The static bath is a milder general tonic applicable to cases which cannot easily bear the slight pain of the sparks, while the breeze and local brush discharge are suitable for the Pig. 3g._The static electric machine. stimulation of regions winch are n.tolerant of the stronger spark applications. The static wave current apphed oh entire spine, acts again as a remarkable general tome and v.al stimulant, and by means of this current a profound stmtulafon electricity: galvanic, faradic, and static 283 of the nutrition can be effected in any organ lying near the sur- face of the body. The static induced current can do whatever can be done with the ordinary faradic induced current, being especially similar to the high-tension form of the latter, but in consequence of its greater voltage and rapidity of interruptions, the effect is greater. Physicians unfamiliar w^ith the uses of static electricity and totally ignorant upon the whole subject have sometimes ex- pressed the opinion that the results obtained thereby are psychic and due wholly to suggestion. At one time I leaned to this view myself ; but after being cured by static sparks of a very stubborn neuritis for which other therapeutic measures had failed to accomplish anything, I changed my mind. Moreover, in numerous recent cases of autotoxic nephritis resulting apparently from chronic indigestion, I have seen the albumin and casts rapidly removed by the static wave current and static induced current ; and in one large series of cases analyses of the urine made shortly before and after the ap- plication of such currents showed an increase of the urea at the second examination in every case with a single exception. Such clinical results and experimental data must suffice to cure the skepticism of any physician who is open to conviction. High-Frequency Currents, — High-frequency currents are among the newest developments in the way of electricity. They are alternating currents in which the alternations are prodigiously rapid. The effects are in many cases extraor- dinary in the direction of improvement in the nutrition. They produce almost no sensation in the part to which they are applied except a merely agreeable warmth and feeling of vibration, and yet in suitable cases the results are highly favorable. Their action is similar to that of the static wave current, especially except that they produce less sensation and therefore can be applied within the cavities of the body quite painlessly and generally wnth benefit whenever the parts to which they are applied are in an atonic condition resulting from imperfect nutrition. They have already been employed 284 METHODS OF TREATMENT largely in France and England and to a less extent in this country in the treatment of atonic dyspepsia, gastric dilatation, constipation, etc., and Herschell of London claims to have Fig. 40. — Herschell-Dean triphase apparatus. found them, when applied within the stomach, even more efficient in hyperchlorhydria than the high-tension faradic current, which he has used extensively with the help of my modification of the Einhorn intragastric electrode '^ and con- firmed the fact first observed and reported by me that this latter current is effective in lessening hypersecretion. 1" Manual of Intragastric Technique," by Geo. Herschell, M. D., Lou- don, 1903, p. 147- electricity: galvanic, faradic, and static 285 Polyphase currents are the very latest form of electric stimulation to be applied in the treatment of disease. They have been used for several years in France, and Herschell of London has very lately published a small monograph upon the subject, besides having devised a number of instruments and apparatus for the application of them/ He employs the tri- phase current especially, and claims for it the power of raising the blood pressure in the numerous cases of neurasthenia which are characterized by a low arterial tension. He finds it very useful also in nervous dyspepsia, hyperaesthesia of the gastric mucous membrane, muscular atony of the stomach, constipation, and various other gastro-intestinal affections. Indeed, he gives it the preference over all other forms of treat- ment for " restoring the tone to the muscular substance of the gastro-intestinal tract." \ 1" Polyphase Currents in Electrotherapy," by Geo. Herschell, M. D., London, H. J. Glaisher, 1903. In many cases of hyperchlorhydria in which the derangement does not depend upon ulcer or upon adhesions of the stomach wall to any of the adjacent viscera and especially when the musculature of the stomach is atonic, the current from a high-tension faradic coil applied directly to the interior of the organ, is more effective than any other remedy as a de- pressant to the excessive secretion ; but the above-mentioned complica- tionscontra-indicate all intragastric applications of electricity. Great care, therefore, to determine the absence of such complications before resort- ing to these methods should be taken in every case, and whenever the high-tension faradic current applied intragastrically fails speedily to relieve hyperchlorhydria, the existence of some such contra-indicating 1 complication should be suspected and another form of treatment be adopted. The ordinary faradic current with coarse short coil was at one time .nuch employed within the rectum for the relief of constipation, but used , n this way it sometimes irritated sensitive rectums and vibration applied a the same way has proved both a safer and a more effective remedy. LECTURE XXVI VARIOUS FORMS OF ELECTRIC AND HY- DRO-ELECTRIC CURRENTS APPLIED DIRECTLY WITHIN THE BOWEL The induced current (faradism) has long been applied within the rectum for constipation with good results, this method often relieving the condition and sometimes curing it by stimulating the sacral plexus as well as the muscles directly- involved in defecation. Three to fifteen ma. of the continuous current can be used in the same way. The negative pole is usually applied within the bowel. More recently the electro- static currents discovered by Morton, the static wave and static induced currents, have been used successfully in the rectum for the cure of the same disease, as well as for chronic prostatitis and other affections not coming within the scope of these lectures. The very similar high-frequency currents of D'Arsonval are employed in like manner to effect the- same ends. Dr. S. Cohn of New York, in a paper published in the New York Medical Journal of September 6, 1902, described an effective way of employing the static currents in the treatment of constipation, as follows : " I use static electricity either in the form of the wave current or of the static induced current ; the first in the milder forms of constipation, the latter in the very obstinate cases of long standing. The polarity is of importance, as the positive pole has a stronger effect on the tissues it is in contact with than the negative pole. " In using the static wave current the patient is in contact with one pole only, while the other one may be grounded or not. ELECTRIC AND HYDRO-ELECTRIC CURRENTS 287 If we use a current without grounding, the current is a very mild one. By grounding we make the current considerably stronger. The contact is made either by the rectum (the pa- tient sitting on the upright rectal electrode) or by the abdom- inal walls (tinfoil plate, 8 by lo). The current strength is regulated by the spark gap between the sliding poles. " The static induced current enables us to use very powerful means without causing the patient any pain. The static induced current is, in reality, a current of high tension and high frequency. While the static wave current distributes its strength over the whole body, the static induced current con- centrates its W'hole strength between two points of the body. The patient is connected with the outer surface of the Leydeu jars, while the inner surfaces are connected with the poles of the machine. One electrode is generally on the abdomen, the other one either in the rectum (direct) or on th& back (percu- taneous). The current strength is also regulated by the spark gap. As the patient need not be insulated, we can also use the labile method. " The powerful action of this current, as well as that of the wave current, may be enhanced by a mode of administration called the undulating or swelling current. By this we under- stand a current that, starting from zero, gradually swells to a maximum of strength and returns in the same way to zero. By alternately increasing and decreasing this current, we produce in the muscles alternations of wavelike contractions and relaxations. The efTect of this mode of administration of'the current is a tonic exercise of the muscles, and, in using it, we do not risk the danger of overworking and exhausting the muscles, as their maximum contractions are only of short \ duration. The circulation of the blood and lymph will cer- tainly be accelerated by this milking-like process, and we can readily understand how the atonic condition of the tissues is improved. On the static machine we get the swelling current by slowly removing one pole from and then approaching it to the other." 255 METHODS OF TREATMENT Hydro-electric Applications within the Bowel. — Bondet, of Paris, originated the method of applying the continuous cur- rent to the mucous membrane of the rectum and entire colon with that best of all electrodes, water, as the internal means of contact with the parts to be influenced, and large flat elec- trodes of any convenient material for the external one. It is an excellent means of treating chronic intestinal catarrh especially, as well as other intestinal disorders. I found this method in use in Ewald's Clinic in 1895, and a serviceable apparatus was employed there for the purpose. Dr. Margaret Cleaves has also devised a good form of apparatus for conveying both the water and the electric current into the bowel, and an illus- tration of it is shown on page 289. From a paper contributed by Dr. Cleaves to the Interna- tional Medical Magazine,'^ I reproduce the following extracts describing the technique of applying this hydro-electric treat- ment : "A normal or physiologic saline solution of six-tenths of i per cent., at a temperature of 100° F., is used, and as it flows into the intestine becomes the electrolyte conveying the current to every part of the mucous membrane with which it comes in contact. The indifferent contact is made by means of a large (at least forty-five square inches in area), well-wetted electrode to the hepatic area and abdominal wall, or to the lumbar cord and lumbo-sacral plexus, according to the indications in each individual case. If a direct stimulation to the origin of the nerve supply is paramount to the stimulation of atonic and relaxed abdominal walls, the latter should be used, otherwise the former ; and the writer often uses a two-way contact, i. c., by means of a bifurcated cord attached to both the spinal and abdominal electrodes. In this event the greatest expenditure of energy will be between the intestinal and spinal contact, because by reason of the pressure from the recumbent position as well as by the absence of fat, characteristic of the average abdominal wall, a better contact is secured and resistance di- ' In/. Med. Mag., October, 1902, p. 603. ELECTRIC AND HYDRO-ELECTRIC CURRENTS 289 minished. There will also be an expenditure between the intestinal and abdominal contacts, but not so great, by reason of increased resistance, as in the former instance. The indica- tions for the placing of contacts in each individual case must be governed by the pathology of that particular case. As hepatic torpor, associated with congestion of the liver and congestion, even catarrhal inflammation of the gall-duct and bladder, exist very commonly in the class of intestinal condi- tions under consideration, the hepatic and abdominal contact is imperative. " A long curved electrode of hard rubber may be used or one of soft rubber, as is used in the administration of a high enema. Fig. 41. — Dr, Cleaves' long curved electrode for hydro-electric applica- tions within the bowel. In the event of disease at the sigmoid flexure a localized action can be obtained at that point by the use of a double current or irrigating electrode. " By the use of the long electrode, at least eight inches, the fluid is carried beyond the reflexes governing defecation, there- by modifying the desire to empty the bowel during treatment, and permitting a sufficient expenditure of energy to secure the desired result. With the patient in position and the body contacts carefully adjusted, connection is made between the electrode, the hose of the irrigating jar, and with the conduct- ing cord from the terminal of the battery indicated in the par- ticular case. The water is then turned on to permit of the expulsion of air from the electrode and also to allow the water which has cooled to pass out of the hose. This done, and a little vaselin placed at the anus tO' facilitate the entrance of the electrode, it is introduced in the same manner as in an ordinary irrigation of the intestinal tract. In the introduction of the 290 METHODS OF TREATMENT electrode great care should be taken to avoid pain. No forcible pressure should be used, but it should be allowed to glide easily into position. This can readily be accomplished if it is allowed "* to follow the curves of the bowel, i. e., toward the umbilicus for the first one and one-half inches, then toward the hollow of the sacrum. In the average case there is no pain or dis- comfort from its introduction, save just as the bulb passes the sphincter ani muscle. If difficulty is experienced the water may be turned on in order to distend the rectum, thus facilitat- ing the introduction, \\lien this is accomplished and the water flows freely, the current is gradually turned on. Only such a pressure or E. ]M. F. should be used as is necessary to over- come the resistance of the conducting circuit, for here a de- structive action is not desired, but rather such an expenditure of energy^ as will tend to establish nutritive processes. This extensive water electrode, affording as it does a large square inch area of surface, makes it possible to secure by the use of a low E. M. E. a large current strength, and therefore great electric energ}^ without pain or discomfort. A rate of flow, however, of from i to 20 or 30 ma.'s may be used according to the pathologic conditions and the patient's tolerance of the cur- rent. Under no circumstances should the application be carried to the point of pain, other than the griping induced b}- the peri- staltic action resulting from its use. There are varying degrees of tolerance in different patients, according both to the pathol- ogy and personal idiosyncrasies. " If there are adhesive bands due to an old peritoneal inflam- mation, they are put upon the stretch by the distention of the bowel with water and pain results. Care must be taken not to permit the flow of sufficient water to cause pain and subsequent soreness. Gradually the amount can be increased, thereby securing greater current distril:)Ution, but no sudden violence should be done, nor should the bowel be so distended at any time as to perpetuate a paretic state. In cases of colitis, espe- cially if the condition approaches a subacute type, a minimum expenditure of energv must be made, and in many instances ELECTRIC AND HYDRO-ELECTRIC CURRENTS 29 1 an amperage of from i to 5 milliamperes is not only suffi- cient, but all that can be tolerated, while in the average case 10 to 20 ma.'s suffice. Nothing is to be gained by carrying the application to the point of pain, which is an indication of too great and hurtful expenditure of energy. In the event of an increase of current, as the resistance is overcome, causing pain or discomfort to the patient, it should be turned off until it is again brought to the point of the patient's tolerance. " The time limit in these applications must be governed by the patient's ability to retain the water. Patients differ in this regard. In some cases a pint is with difficulty retained and an application of only from three to five minutes is possible. These are the cases where the lower bowel is more or less filled with hardened fecal matter, which not only prevents the elec- trode slipping into place, but obstructs the opening of the bulb, preventing, in the first place, the free ingress of water and in the second its passage be3'ond the reflexes governing defeca- tion. Because of this it is good practice to direct the patient to take a small rectal enema before coming for treatment. Sub- sequent applications can be more successfully made. From one to three quarts of water may be used for from five to ten min- utes before the desire to empty the bowel becomes urgent. In pathologic conditions characterized by extreme atony of the intestinal tract, a considerable cjuantity of water will be toler- ated on account of the loss of power in the intestinal coats. As normal contractility is established a gradually lessening quan- tity can be retained. In all cases less water should be used in successive administrations. As nutritive changes are estab- lished in the intestinal tract with a tendency to recurrence of normal peristaltic movement, the desire to empty the bowel comes much more promptly than in the earlier applications. Measures to Combat Possible Collapse from Sudden Emp- tying of the Bowel. — '" From the very complete emptying of the bowel, which almost always follows the first treatment, a condition of more or less profound collapse may arise. This should be combated by the administration of from one-half to 292 METHODS OF TREATMENT one pint of hot water per os and rest in the recumbent position. This rarely occurs after the first treatment, and seldom then. " The current may be reversed in order to secure a more stimulating effect, or interrupted. Sometimes an application of the combined continuous and induced currents may be made, but the writer uses, as a rule, a subsequent application of the sinusoidal current or a general application of the franklinic current. In the large undulatory or wavelike contraction of the sinusoidal current of low frequency, a slow-moving stimu- lus, fully applicable to the excitation of slow-moving processes, is obtained. One of three things will promptly follow an intes- tinal hydro-electric treatment ; first, a free and complete evacu- ation of the bowel, followed by a sense of great relief, accom- panied in some cases by more or less severe collapse ; second, a certain amount of fecal matter may be expelled, with gas ; or, third, discolored water may be passed, with or without gas. In the latter condition the treatment should be repeated in at least twenty-four hours, and in intestinal occlusion in from seven to eight hours. In the latter condition at least three applications may be made within the twenty-four hours. In the chronic catarrhal conditions associated with constipation, treatment should be given at first every other day. The fre- quency of the seances must be governed by the patient's re- sponse. As soon as a tendency to normal peristalsis is estab- lished, less frequent applications should be made. The average length of time during which treatment must continue depends upon the nature, degree, and standing of pathologic change, as well as the individual recuperative power. In the writer's experience from one to three months has sufficed. Upon the establishment of nutritive changes with a return to normal peristalsis, the intestinal treatment should be discontinued, and the further management of the case made a matter of hygienic and dietetic detail, regular habits, and healthful dress. " In the average case the active, i. e., intestinal contact, should be attached to the negative terminal, on account of the ELECTRIC AND HYDRO-ELECTRIC CURRENTS 293 characteristic polar action. In catarrhal conditions associated with diarrhea, a silver or a copper wire may replace the plat- inum wire in the electrode and the intestinal contact attached to the positive terminal. In this way a mild application of either the silver or the copper salt may be made to the intestinal mucous membrane, and also driven in cataphorically, as well as the stimulating and regenerating influence of the current utilized. Or, if preferred, the water may be suitably medicated and used at the positive pole. The Hydro-electric Method in Muco-membranous Enteritis. — " In the treatment of muco-membranous enteritis, the intes- tinal tract benefits by irrigation with a physiologic saline solu- tion at its normal temperature, which frees the mucous membrane of mucous shreds, pus cells even, as well as retained fecal matter, while by the well-known chemical action of the current, nutritive changes are established in the glandular structure, nerve centers stimulated, circulation quickened, and absorptive activity increased. Of a considerable number of such cases treated, all had run a persistently chronic course, were characterized by irregular exacerbations, lack of marked febrile excitement, with derangement of the intestinal canal, muco-membranous discharges, mental depression, greatly im- paired health, also by more or less gastric disturbance, impaired appetite, repugnance to food, furred tongue, and foul breath. All were of some years' standing and had resisted the remedial agents administered from time to time when the subject of medical attention. At the time they passed from observation, several months after the discontinuance of treatment, they had normal appetites, relief from gastro-intestinal distress, regular l)o\vels, absence of muco-membranous casts, and greatly im- proved general health. The tongue, which was improved from the first treatment, lost its coating and the red, irritable con- dition of the sides and tips after the second treatment. " From six to eight applications were made in these cases, with from lo to 30 ma.'s of current, the quantity of water varying according to individual tolerance from one pmt 294 METHODS OF TREATMENT to three quarts. The average seance was ten minutes in length." Prerequisites for, and Limitations of, the Hydro-electric Method. — The method described by Dr. Cleaves above requires a good electric outfit, including a milliamperemeter, and, be- sides, the physician's office where it is to be carried out must be in close proximity to a toilet room ; but given all these prerequi- sites and the necessary technical skill on the part of the physi- cian, the mode of treatment yields often very gratifying results. In a number of obstinate cases dependent upon chronic colitis, I have found the hydro-electric method very effective, ^^M though exceptionally troublesome. When patients can com- mand the services of a thoroughly expert masseur, and can have in addition full doses of the continuous electric current passed through the abdomen from side to side, equally good results can usually be obtained. In all cases, however, great stress must be laid upon the diet. No method of treatment will succeed in effecting permanent cures in such cases unless the patient can be induced to change his habits of living and follow the rules of hygiene strictly in all respects. Provided the diet is sufficiently laxative and enough exercise of the body, muscles is taken daily, almost any of the forms of electricity ap- plied externally are usually effective in overcoming constipation, particularly with the help of good massage, except when the constipation is due to a spastic condition or some mechanical obstruction. There is one objection to the long-continued use of water or any watery solution in the bowel, whether accom- panied by electricity or not. This is that thereby the peristaltic apparatus is accustomed to a preternaturally strong stimulus, and there is thus danger that afterward the mere stimulus of the presence in the intestines of feces, which should normally | be sufficient to produce evacuations, may fail to excite them. ' The introduction of water or of hydro-electric currents into the colon should therefore be strictly limited to cases in which there is a chronic catarrhal inflammation, which there is hope ELECTRIC AND HYDRO-ELECTRIC CURRENTS 295 of curing by such means within a few weeks, and then with the intestinal mucosa left in a normal state, it is often possible to bring" about natural evacuations by simple hygienic means, including at first a specially laxative diet and an unusual amount of exercise of the abdominal muscles. LECTURE XXVII OTHER DIRECT METHODS OF TREATIN' THE INTESTINES Those of you who have had most experience in practice can- not fail to have noticed that medicines, especially when givei by the mouth, usually fail to accomplish much in the treatmeni of chronic intestinal diseases, whether they take the form of constipation simply or of chronic enteritis with frequent alter- nations of constipation and diarrhea, and in either case a! plentiful array of nervous symptoms which yield to no kind of therapy until the underlying cause has been removed. You should not be surprised, therefore, at the number of unusual methods which have been devised to remedy these complicated and always stubborn conditions. I am acquainting you with the technique of the more effective of such methods, most of which seem to have proved remarkably successful in the hands of those who devised and have become expert in the use of them, though other clinicians, who are not so expert with them, have often been less fortunate in getting good results. Carbon Dioxide in Diseases of the Rectum and Colon. — Dr. A. Rose ^ of New York strongly recommends the use of injec- tions of carbonic acid gas into the rectum for ulcers, fissures, and catarrhal affections of the rectum as well as for ulceration or catarrh of the colon. Rose thus describes his method of disengaging and administering the gas : " I have tried and have suggested carbonic acid gas infla- tion of the rectum in enteritis membranacea, and in the few cases I have thus far treated in this manner the results have been gratifying, but I am not prepared to publish my observa- ^ Int. Med. Mag., October, 1902, p. 617. 296 METHODS OF TREATING THE INTESTINES 297 tions, because none of these cases could be diagnosticated as pure enteritis membranacea. One was complicated with gen- eral neurosis, spasm of the pylorus and morphinismus ; in an- other there existed well-pronounced splanchnoptosis ; and in none of these cases was the treatment confined to the applica- tion of carbonic acid gas alone. However, from theoretic reasons, we are justified in giving the carbonic acid inflation a trial in enteritis membranacea. " In the course of time I have experimented with different kinds of apparatus, and afterwards I have fallen back upon the one I first made use of, because it has the advantage over the others that it can be easily improvised, as a rule, with the aid of a nearby druggist. It consists of a bottle holding a pint or a little less, with a wide neck and a rubber stopper perforated Fig. 42. — Rose's apparatus for generating carbonic dioxide. so as to admit a tube, with a nozzle, as the case may be, for nose, rectum, or vagina. (See illustration.) A solution of about six drams of bicarbonate of soda in about six or eight ounces of cold water is introduced into the bottle, and four drams of crystallized tartaric acid (if pulverized acid is used the development of the gas goes on too rapidly) are added. The larger these crystals are the better. Instead of the tartaric acid crystals, disks of acid sulphate of soda may be used. The bottle is then closed, and the carbonic acid developing in the water rises through the tube, the nozzle of which has been placed in position. The form of gas generated serves quite well to apply the gas to the 298 METHODS OF TREATMENT nasal cavities, to inflate the rectum, and in some instances it can be used to g'ive vaginal gas douches. Gas develops during about ten to twelve minutes. Its disadvantage is that the cur- rent of gas can neither be regulated nor interrupted, but in case this should be desirable, we may attach a reservoir in the shape of a rubber bag in which the gas is made to enter and from which the flow can be regulated at will. " A few seconds after the gas enters the rectum there is produced a sensation of warmth, then a slight desire to evacuate the bowel, which immediately passes away. In pa- tients who avoid pressure and control the levator there is no voiding of gas, the muscular closure sufficing to retain it, except after the intestine has taken up to its full capacity. The abdomen gradually becomes expanded and, when the patient begins to complain of tension, the administration is discon- tinued, or the patient is at liberty to void the gas. After the gas, or a certain amount of it, has been voided, the inflation may be resumed. As a rule, I continue inflation with or with- out interruption for about five minutes ; patients accustomed to the procedure may endure it for a somewhat longer time. Car- bonic acid gas may be employed then with perfect impunity. When the inflation is carried out ad maximwn the lower part of the abdomen becomes expanded, the abdominal walls are under great tension, but, notwithstanding, the liver is not at all, or only very slightly, pushed upward; on percussion over this organ the dullness remains about as before ; there is no raising of the diaphragm, consequently no retraction of the' lungs ; no dyspnoea is observed ; no^ cyanosis. Persons experi- mented on may complain of disagreeable tension of the abdom- inal walls, but even this unpleasantness disappears more and more as the patient becomes accustomed to inflation." Turck's Colonic Treatment. — Professor Fenton B. Turck of Chicago advocates the use of what he denominates " pneu- matic massage " for the colon as well as for the stomach. He describes the procedure as follows : " In one of the experiments quoted above of Me3'-er and METHODS OF TREATING THE INTESTINES 299 Prebriam, attention was called to the effect npon the heart and circulation by distention of the stomach with air. If the disten- tion continues, a fall in blood pressure occurs, and collapse may ensue, but I have found that after distending the stomach or colon, if the air is allowed immediately to escape through the tube, the blood pressure will not only return to normal, but there results a marked improvement in the circulation. This Fig. 43. — Turck's apparatus for pneumatic gymnastics. improvement is not confined to the walls of the stomach or colon, but influences all the abdominal vessels. I therefore adopted the use of air instead of water, as a form of exercise for the stomach and colon, to which I gave the name ' Pneu- matic Gymnastics,' and ' Gymnastic Massage.' ^ " The method is very simple. The air is forced into the stomach or colon through the introduced double or single soft rubber tube, preferably the double tube. Either an atomizing ^ Turck, Methods of Diagnosis and Therapeutics, Jour. Amer. Med. Assoc, June 22, 1895 ; ibid.. Am. Med. and Surg. Bull., July i, 1895 ; Modern Methods of Treatment of Diseases of the Intestines, TV. Y, Med. four., March 13 and 20, 1897 ; Pneumatic Gymnastics, Brit. Med. Jour., October 28, 1895, p. 1328. 300 METHODS OF TREATMENT bulb or the air from a compressed air tank is used. As I previously stated {Jour. A. M. A., June 22, 1895) 'the in- troduction of the air distends the stomach and contraction forces the air out through the other tube, so that we have a pneumatic massage.' I have called attention, not only to this method of treatment of the stomach, but also of the colon as follows {Airier. Med. and Surg. Bull., July i, 1895) : ' By the introduction of air through one tube and its exit through the other tube, it acts as a " pneumatic massage " and does not stretch or overdistend the alread}^ weakened .organ. The effect of the treatment is also immediate, and two weeks will often show a marked improvement. It may be used in the stomach or colon, and the nebulized cloud can be forced into the in- testines ; and when hydrogen gas is used, the whole intestinal tract can be treated.' " The method of using heated air, moist or dry, and medi- cated when desired, I have repeatedly shown is an additional advantage in this method of pneumatic gymnastics of the stomach or colon. Steam or vapor introduced at a temperature of 55° C. is a vaso-motor stimulant. Gas and air have been previously used in the stomach and intestines, principally for diagnostic purposes. Von Ziemssen was among the first to advocate the use of COo for distending the stomach and colon to facilitate examination. Senn used hydrogen gas for the purpose of locating intestinal perforations. CO2 introduced into the stomach has also been used for its therapeutic effect, and HjS forced into the intestine was supposed to possess medical properties. The intestines have been inflated for therapeutic purposes to overcome obstruction. " But the pneumatic gymnastics which I have advocated is an entirely different procedure, and depends upon a different principle. The pneumatic gymnastics of the colon may be combined with abdominal massage (when not contra-indi- cated), which helps to force out the air. This improves the circulation at once. It is especially indicated in atony as- sociated with constipation." METHODS OF TREATING THE INTESTINES 30I Turck's Method of Doing Lavage of the Colon. — Turck is also a strong advocate of the injection alternately of hot and cold water into the colon for the purpose of stimulating the circulation in the whole splanchnic area and has in many cases undoubtedly produced excellent results in this way. To obviate the irritation which water and most medicated solu- tions are liable to produce in the bowel he employs an infusion of slippery elm, which is not only soothing, but has been found by him to be a poor culture medium for germs. The same infusion he recommends for lavage of the stomach also. Flushing of the Colon. — The practice of washing out the colon by the injection every day or every other day of large quantities of warm water, several quarts or even gallons in some cases, while a valuable resource sometimes for emer- gencies, is most injurious in its effects when long continued or regularly depended upon for the evacuation of the bowels in chronic constipation. I cannot warn you too strongly against this fad, which was introduced into use in this country many years ago by a layman, and for a time vaunted as an extraordinary means of promoting health and longevity. I know of no more certain means of causing an obstinate form of constipation with finally dilatation of the colon. It is, how- ever, an effective method of unloading quickly the bowels when these have long been neglected — i. e., as a preliminary to more rational methods of treatment. In chronic colitis, too, a moderate flushing of the colon, with medicated solutions for a limited time, will often prove effective in modifying the catarrhal process. I have seen good results from the use of the following prescription for two or three weeks at a time, together with abdominal massage and other appropriate treat- ment : ^ Acid, carbol 3 iss Glycerin , § iii Listerin q. s. ad | vi M. S. Two tablespoonfuls in two quarts of cool or tepid water by enema every other night. 2,02 METHODS OF TREATMENT Dr. Deardorff ^ of San Francisco, who first suggested the above prescription, advises that such an enema be employed every akernate evening for a few weeks and that the bowels be evacuated by means of an enema of the normal salt solution on the other evenings. A better way is to rely upon the injection of two to six ounces of olive or cottonseed oil to secure evacu- ations on the nights when the medicated enema is not used. Indeed, since I have learned the great value of even quite small doses per rectum of any one of the bland vegetable oils in overcoming constipation when persevered with for weeks or months, if necessary, and carried out in connection with a suitable diet, gymnastic movements and some mechanical measures for the stimulation of the nerve centers and muscular apparatus concerned in defecation, I find that these are generally all-sufficient for the cure of the milder cases of constipation, especially in patients who are not very old, with very little medicine introduced at either end of the alimentary tube. Technique of Administering Oil Enemas — This method, which comes to us from Germany, has a very large weight of authority in its favor and is as harmless as it is effectual in not only relieving both atonic and spastic constipation, often un- aided, but in finally curing it, when the patient will eat, drink, exercise, and live in all ways hygienically, though in stubborn cases other measures are valuable auxiliaries. Let the patient have ready prepared before rmdressing at bedtime two to eight ounces of some bland oil warmed to the body temperature. This can be best introduced by means of a glass or metal reservoir and an ordinary short semiflexible rectal tube con- nected by rubber tubing. It will be safer to begin with the smaller dose and gradually increase till the dose is reached which produces a sufficiently full evacuation. The reservoir containing the oil should not be hung at a height of more than two or three feet above the patient. Then, when fully ready to retire, let him lie down on the left side with a pillow !/«/. Aled. Mag., May, 1899, p. 354. METHODS OF TREATING THE INTESTINES 3O3 under the hips and slowly inject the oil, being careful to lie quietly in the same position till all desire to evacuate the oil has ceased. After lying on the left side for a few minutes, he should turn, and thereafter during the night lie mostly on the right side. At first it may be desirable to keep a folded towel against the anus during the night to prevent the bed's being- soiled, but persons having a normally tight sphincter will not find this necessary. When there is a persistent pressure to have the enema expelled it may be because of impacted feces in the rectum, which should be removed by one or two thorough colon flushings in the beginning of the treatment. If, in spite of this precaution, the oil will not remain in the bowel during the night, it may be advisable exceptionally to employ a long soft rubber rectal tube with which to introduce the oil, and have skilled assistance in passing it well up into the colon where, with care to see that the patient lies for some time on the right side after retiring, it will, as a rule, give no further trouble till it comes away in the morning with a soft or normal evacuation of feces — often a copious one. You should care- fully direct the patient to let the injection of the oil be the very last thing done before getting into bed, since, when he is obliged to get up and go about the room afterward, the oil may not be retained. In cases of pronounced colitis it is often better still to mix with the oil just before injecting it from half to one teaspoonful of the subcarbonate of bismuth. This in- creases the soothinsf and healing effects of the oil. LECTURE XXVIII VIBRATION, MANUAL THERAPY, AND OTHER :\IECHANICAL FORMS OF TREAT- MENT jMechanical vibration is an old method of general and local stimulation which has been much employed in the larger in- stitutions such as that of the government in Baden Baden, in the numerous Zander institutes of Europe and America, and in some of the principal sanitariums of this country. Lately ingenious forms of apparatus have been devised and put upon the market for the purpose of more conveniently regulating the application of vibration to the spine, joints, and other regions and cavities of the body, including the rectum, vagina, etc. There is so far less literature upon this subject than could be desired, but I believe that in the future the method will be more thoroughly studied and found, for application in certain localities of the body, superior to stimulation by means of electricity. The late Dr. ]\Iaurice F. Pilgrim of X'ew York, a former vice president of the American Electro-Therapeutic Associa- tion, and therefore, presumably an expert in the therapeutic uses of electricity, recently wrote a book on " Alechanical Vibratory Stimulation." ^ He was a very enthusiastic advo- cate of the method, giving it the preference over electricity in many cases for which local or general stimulation is indicated. The recent investigations of physiologists demonstrating that vaso-constrictor and vaso-dilator nerve fibers pass out from the spine with the various spinal nerves and go finally to control the caliber of the smaller arteries and arterioles in ' " Mechanical Vibrator}^ Stimulation," b}' ]\Iaurice F. Pilgrim, M. D.. New York, The Lawrence Press, no Fifth Avenue. 304 MECHANICAL FORMS OF TREATMENT 305 the periphery and the viscera, have afforded an apparent scientific basis for all the forms of local stimulation, especially over the regions on either side of the spine, which before rested merely upon empiricism. Hence the greatly increased activity and zeal displa3^ecl now in the propagation of such methods. I have been the more willing to put to the test the claims made in behalf of vibratory stimulation from the fact that it is almost identical in principle with the vibratory movement in hand massage, only capable of more delicate and varied as well as more vigorous and sustained application, and very similar to the stimulation produced by electricity which I have been applying to the spine, as well as to the other parts, for over thirty years with excellent results. I studied the effects of mechanical massage, including vibration as formerly employed in a cruder way in Baden Baden, in 1885, and in the Battle Creek Sanitarium in 1893, and then received a favorable im- pression as to its value. It possesses some real advantages over other forms of mechanical treatment now that apparatus for applying it has been so perfected that it can be conveniently and effectively employed in any office which is in connection with an electric light plant. By means of some of the im- proved instruments for applying vibration, treatments varying in force, as well as in the length of the vibratory movement, can be given conveniently and effectively to any external part of the body and to several of the accessible cavities. Dr. Pilgrim gives the following summary of the advantages claimed for mechanical vibration : " Treatment by mechanical vibratory stimulation has been found by practical experiment to be capable of : " (1) Increasing the volume of the blood and lymph flow to a given area or organ ; " (2) Increasing nutrition ; " (3) Improving the respiratory process and functions; ■ " (4) Stimulating secretion; " (5) Improving muscular and general metabolism, and increasing the production of animal heat; 3o6 METHODS OF TREATMENT " (6) Stimulating the excretory organs and assisting the functions of ehmination ; " (7) Softening and reheving muscular contractures; " (8) Relieving engorgement and congestion; Fig. 44. — A vibrator. " (9) Facilitating the removal through the natural channels of the lymphatics, of tumors, exudates, and other products of ■inflammation; relieving varicosities and dissipating eruptions; " (10) Inhibiting and relieving pain." The method is especially applicable in atony of the stomach and intestines both secretory and motor, and the stimulation can be advantageously r.pplied either directly in front over MECHANICAL FORMS OF TREATMENT 307 the abdomen or to the corresponding" areas on either side of the spine over the nerves which supply the parts involved. Various forms of manual therapy have come into vogue within recent times, including osteopathy, mechano-neural therapy, chiropraxis, naturopathy, etc. These have agreed in condemning all methods of treatment except their own, claim- ing that medicines are entirely useless and harmful in every case, and that by means of various kinds of manipulations many of them similar to those of the familiar Swedish move- ments and massage, all the curable diseases, both acute and chronic, can be cured. The osteopaths, more rational appar- ently than the other sectarians named, have virtually abandoned these extravagant claims, and in many of their schools materia medica as well as pathology, bacteriology, and the other funda- mental branches indispensable to an educated and competent physician, are now being taught. They devote particular at- tention to the deviations of the vertebrae and other faults in the spine which are too often neglected by physicians generally (except by the regular orthopedic surgeons), and seem to ac- complish good results in some cases of chronic ill-health due to such faults afflicting especially persons engaged in sedentary oc- cupations from long sitting or working in cramped positions. Indeed, these practitioners have become largely spine special- ists, but, according to my observations, fail generally, as do, in fact, the majority of practitioners of all the so-called schools, to recognize and correct the enormously frequent and very im- portant displacements of the abdominal viscera. If anything of value in the osteopathic or other exclusive methods has not hitherto been practiced by our masseurs, masseuses, nurses, and bath-attendants, it should be, and assuredly will be, hereafter taught them, so that, under the supervision of broadly and properly trained physicians, any needed mechanical treatments can be given. (See pp. 83 and 255.) Certain it is that neither the naturopathists nor any other of the sects can prop- erly claim a monopoly of our natural forces, sunlight, water, exercise, diet, etc. We all use them. 308 METHODS OF TREATMENT Numerous writers have in late years discussed the anatomic and physiologic foundations for the treatment of the different organs through the spinal nerves at their origins. One claim made by Arnold/ as well as by Pilgrim in the book previously cited, is that in many neurasthenics as well as in numerous other patients affected with disease in some of the thoracic or abdominal organs, a peculiar change can be recognized by the touch in the muscles alongside the spinal vertebrae correspond- ing to the origin of the nerves supplying the affected part. By allowing the patient to lie down upon one side, while you feel along the upper side of the spine gently with the tips of the fingers, you may detect frequently instead of the normal soft mass of muscular fiber running parallel to the spine on either side, a cord-like structure which feels hard and tense under the fingers. Whenever such a cord-like band can be felt there is said by Pilgrim to be a contracted or possibly atrophic state of the tissues beneath, and usually the patient finds palpa- tion over such a place more or less painful. Frecjuent treatment of these morbidly affected parts by mild electric applications, or by mechanical vibratory stimulation (probably also by man- ual treatment), will often remove the abnormal condition and at the same time the unusual sensitiveness to pressure with simultaneous improvement in the condition of the organs or parts supplied by the nerves arising from the adjacent parts of the spinal cord. Counter-irritants. — The actual cautery, blisters, rubefaci- ents, wet and dry cupping, etc., have been in use since the earliest times as means to modify the blood supply of parts di- rectly underneath or adjacent to the site of application. The fact that they occasionally influence the circulation- in more distant parts has been frequently observed, as when hyper^emia of the brain or pelvic organs has been lessened by immersing the feet in hot mustard water. Such effects have doubtless been due in part to a reflex stimulation of the vaso-motor centers and in part only to a direct derivation of an excess of '^Interti. Med. Mag., for May, July, and August, 1903. MECHANICAL FORMS OF TREATMENT 309 blood from the part to which the appHcation is made. Coun- ter-irritants can be made highly useful as palliatives, partic- ularly in various gastro-intestinal affections; and the remedy which can only palliate in stubborn chronic conditions can often cure the same when of recent origin. Heat and Cold. — These agents act in much the same way as the foregoing, and are of even wider applicability. The great value of ice packs to the abdomen in peritonitis and appen- dicitis need not be dwelt upon here. Hot wet packs applied over the epigastrium or lower abdomen also exercise a power- ful sedative influence upon the circulation in the viscera under- neath. These agents might have been more appropriately in- cluded under the head of hydrotherapy, except that they are not always applied in the form of water or ict or the vapor of water. Dry heat in the form of hot air, hot bottles, and hot bricks is often used for the same purpose, but usually is not nearly as efficacious as the hydriatic methods of applying it. Hydriatic Procedures. — Numerous volumes have been writ- ten upon the various forms of hydrotherapy, and it will be im- possible to go deeply into so large a subject in this connection. Suffice it to say that we have few more powerful means of influencing the circulation and nutrition in any part of the body, including of course the digestive organs, than by a skill- ful use of water and the various hydriatic applications. I shall have more to say to you about this under the head of the dif- ferent diseases to be discussed in subsecjuent lectures, and an abundance of literature is accessible upon the subject, including especially the works of Dr. Simon Baruch ^ and Dr. J. H. Kellogg- in this country. Phototherapy, or the Finsen Light Treatment, has also been proved useful by numerous observers in gastro-intestinal af- fections. Exposure of the body to the sun's rays has been found tonic and restorative in adynamic conditions generally; and there is apparently no good reason why the sun's rays ■•"Uses of Water in Modern Medicine," Detroit, Geo. S. Davis, 1892. ^" Rational Hydrotherapy," J. H. Kellogg, F. A. Davis Co., Phila., 1901. 3IO METHODS OF TREATMENT should not be concentrated and reflected into the rectum for the treatment of hemorrhoids and rectal ulcers as well as for ulceration in the larynx or disease of the cervix uteri. Similarity of the Effects of the Different Mechanical Methods. — Most of the mechanical modes of treatment tend to produce like effects. Electricity, hydriatic procedures, exercise in the form of special gymnastic movements and mas- sage both manual and mechanical, the former including all the forms of manipulation and pressure over the spinal nerve origins and over the lymphatic as well as other glands, and the latter, especially vibratory stimulation over the same important regions, are different means of exciting to more vigorous, or at least more healthful, action ( i ) the great lymphatic system with its vitally important eliminative function, which is often sluggish in its work in sedentary persons, or congested and blocked by an excess of detritus from neighboring abscesses, inflammatory exudates or, more exceptionally, malignant growths undergoing resolution as a result of x-ray treatment ; (2) the vaso-motor system of nerves and the intimately as- sociated sympathetic chain of ganglia which dominate the blood supply and secretory and excretory work of all the vis- cera, including especially the digestive organs as well as the blood supply of all other parts of the body; (3) the secretory glands of the abdominal organs through the stimulation (or inhibition in certain cases) by mechanical vibration, manipula- tion, or electric applications along the spine, of secretion in the different viscera by means of which, in the case of the liver and intestines, with the help of stimulation also of the peristaltic apparatus, more thorough evacuations of the bowels can be effected and constipation often be cured; (4) the muscular system generally by direct local excitation as well as through the nerves supplying the muscles, thus increasing the develop- ment of the latter and augmenting their vastly important work in metabolism, heat production, etc.; (5) the skin, the activity of the circulation and sweat glands of which is es- sential to the healthy functioning of the digestive organs; and I MECHANICAL FORMS OF TREATMENT 3II (6) the kidneys, the chief emunctories of the body, any inter- ference with whose action not only seriously embarrasses di- gestion, but also endangers life itself. Abundant physical exercise alone in the hardy laborer, whose work is out of doors, accomplishes all these results without care or forethought. Massage can also go far toward maintaining all the functions in a healthy state, or restoring them when disturbed by minor derangements. Hydrotherapy can often keep the skin active and healthy and invigorate the circulatory and nervous systems, when none of the organs are seriously diseased, but though usually helpful in nervous dyspepsia, generally fails when de- pended on alone to remedy structural disease in the gastro- intestinal tract. The various forms of electricity and the newer developments in vibratory stimulation I have already seen accomplish excellent results which make me hopeful of the future. Treatments Through the Spine. — As to treatment through the spine, I have had some experience in that direction with electricity, vibration, hydriatic methods, and counter-irritants, all of which have been found to help much at times in disease of the digestive organs. Dr. Albert Abrams of San Francisco, a distinguished regular physician of large experience, and the author of numerous books, has just borne emphatic testimony to the good results which can be accomplished by these as well as by more novel methods of influencing the viscera through their nerve supply. He has published a new work, which is the most scientific and at the same time the most practical which has yet appeared on this subject.^ He treats it in a broad and comprehensive way, giving particular directions for acting upon the lungs, heart, and arteries, and the abdominal viscera through the spine by means of either electricity or concussion of the vertebras with plexors. Yet, unlike most other ad- vocates of similar treatments, he does not ignore the great value of the appropriate medicinal remedies in many cases. ^ Spondylotherapy ; Spinal Concussion and the Application of other Methods to the Spine in the Treatment of Disease. By Albert Abrams, M. D., (Univ. of Heidelberg). San Francisco: The Philopolis Press. 1910. LECTURE XXIX INTRAGASTRIC METHODS OF TREAT- MENT— LAVAGE, INTRAGASTRIC SPRAY, ETC. When and How to Wash Out the Stomach. — The " when " involves these questions: (i) in what cases, (2) how often, and (3) at what time of the day. The first is the most diffi- cult to answer. Lavage helps many cases in a most striking manner. In others, apparently similar, it fails and may do harm. Sidney Martin, while bearing testimony to its great benefit in certain conditions, says : " The method of treatment has been much abused and must be applied with circumspec- tion." Ewald hit the nail on the head in his paper before the British Medical Association when he cautioned against the " too long continuance and too frequent employment of wash- ing out the stomach," adding that " when it does good, it does so very soon." The tube is far more valuable for diagnosis than for treat- ment. In all your cases of indigestion and often in neuras- thenia, constipation, insomnia, and especially in stubborn head- aches, you would do well to ascertain, by means of an analysis of the stomach contents under varying conditions, exactly what sort of work the organ is doing as to its secretory func- tion, and also gain full information about its even more im- portant motor function. When such tests show a large amount of mucus, you may suspect gastric catarrh, and in most cases of chronic catarrhal inflammation of the stomach itself, lavage will do good ; in many of them it is almost indispensable. More often the mucus comes from the parts above, having 312 INTRAGASTRIC METHODS OF TREATMENT 313 been swallowed, and the diagnosis of chronic gastric catarrh, which many physicians attempt to make offhand, frequently presents difficulties, even with the help of chemical and micro- scopic examinations of the stomach contents. But this sub- ject will be considered in a subsequent lecture. The most imperative indication for lavage is gastrectasis, or dilatation of the stomach, whether resulting from narrowing of the pyloric orifice (cancer or other tumors, or the cicatrix of an ulcer), from a kink of the small intestines (which may follow displacement of the stomach, colon, or right kidney), or from atony of the muscular walls of the organ. Whatever the cause, dilatation, when neglected, tends to become a serious condition, and lavage judiciously done is an aid to the cure in the atonic cases, while it is a most valuable pallia- tive in the desperate ones, until operative relief can be obtained. In bad cases of gastric catarrh and in patients not too reduced in strength, provided all the results are encouraging, it will be proper to wash out every day at first, until the amount of mucus is markedly lessened. This will be the more advisable if the microscope shows the presence of numerous yeast fungi or sarcinse in the wash water. As the conditions improve, or sooner if the patient should fall off in flesh, tone, or appetite, prolong the intervals, until by the end of a month, once a week may be often enough. When the treatment has been begun early and is properly carried out, you will often succeed in removing all the symptoms and signs of gastritis in one or two months; but 1 in very advanced or debilitated cases you will need to be guided by the effects, and sometimes in such cases, with dila- tation dependent upon a mechanical obstruction of the outlet, a radical cure is not practicable. The best that can be accomplished then, under ordinary conditions, without oper- ative interference is palliation, and for this you may find it useful to cleanse away the accumulated mucus and bacteria, at least once a week during the remainder of life. 314 METHODS OF TREATMENT Best Time for Lavage. — In nearly all cases the best time for lavage is before breakfast. At this time remains of digested food are very rarely found in the stomach to be washed away and lost to the system, except in the worst cases of dilatation. It is a most inconvenient hour for the physician, but it is usually practicable to have nurses trained so as to do the work with all necessary skill. A good nurse can report intelligently as to the macroscopic appearance of the wash water, and in all important cases she should from time to time save samples of it for microscopic examination — a little of the first brought up for examination as to the amount of mucus and presence of bacteria, and some of the last to be tested as to the presence of degenerated epithelium from the gastric mucous membrane. My own custom is to employ the electric centrifuge to obtain a concentrated sedi- ment for this purpose. Many good authorities advise that lavage be done at bed- time when fermenting food in the stomach prevents sleep. This may exceptionally be useful, especially in cases of gas- tralgia, but diseased stomachs are rarely empty at bedtime and experience teaches that, as a continuous practice, washing away half-digested food is disastrous. When severe fermen- tation cannot be otherwise controlled, it would be better to feed less b}^ the stomach and help out by nutritive enemas. How to wash out: The way to introduce the tube is fully described in Lecture VII. Don't procure any of the complicated apparatus for lavage you will see described in the books. They are all troublesome and unsatisfactory. Lavage, according to my experience, is best carried out with a simple soft rubber stomach tube, in size about No. 32 of the French scale. It should be provided with an opening directly in the end and with one large opening about half an inch above. It is also advisable to have a number of openings about pin-head size near the end so as to produce a sprinkler effect upon the walls of the stomach when the fluid is poured in and also to insure a continuous return flow in spite of the INTRAGASTRIC METHODS OF TREATMENT 31$ possible blocking of the larger openings by pieces of food. The tube should be about four and a half feet long and have fitted into its upper end a large glass funnel, when to be used for the purpose of lavage, and a bulb in the course of it helps to keep it clear. It is also desirable to cut off about one foot of the upper end and insert a piece of glass tube four inches long to serve as a fenestra, so that you may observe when the water is flowing in or out without interruption. The tube should be made of highly polished rubber and should be dis- carded whenever cracks have occurred in it, since these are liable to irritate some portion of the mucous membrane. After use the tube should be thoroughly cleansed with hot water and afterward allowed to stand for some time in a 5 per cent, solution of formalin in order thoroughly to disin- fect it. If you have not analyzed the stomach contents and do not know, whether hydrochloric acid is deficient or in excess, it will be safer for you to use tepid or warm (not hot) water which has been sterilized by boiling, with bicarbonate of sodium dissolved in it to the extent of one or two teaspoon- fuls to the Cjuart. If the treatment should be continued longer than a month, and you remain in ignorance as to the gastric secretion, it will be best to omit even the soda after that time and wash out with boiled water only. If an analysis has shown that you are dealing with an acid gastric catarrh (in which the glands secrete an excess of HCl and the ferments as well as of mucus) you can dissolve a tablespoonful of soda to the quart of water and go on with this for a long time, pro- vider! the hyperacidity persists and the patient is improving in nerve tone. But don't mistake the familiar sour stomach of fermenting carbohydrates for hyperacidity from an excess of HCl. In the former condition the prolonged use of alka- lies is very hurtful. When there is a marked deficiency of HCl, the water may Ije hotter and table salt, from a teaspoonful to a tablespoonful, may 1je added to each quart. Exceptionally, stronger anti septics or astringents may be used. The most serviceable I 3i6 METHODS OF TREATMENT have found to be alum, one-half teaspoonful, and nitrate of silver, one or two grains, to the quart. Strong HCl, a half Fig. 45. — Lavage of the stomach. Inserting the tube. teaspoonful to the quart, will often answer well, when there is a marked deficiency of gastric juice. Many other drugs, including boric acid, salicylic acid, tannic acid, resorcin, and alumnol are employed in this way, but all of them, and especially the stronger ones, are liable to have an injurious action when continued long. It is a safe rule, and one which I try to follow, never to use for lavage more than four times as much of any drug as could be safely left INTRAGASTRIC METHODS OF TREATMENT Z^7 to absorb, since one-fourth will often pass into the bowel and be absorbed. The tube with the funnel inserted in it having been intro- duced, the solution, previously prepared and placed in a pitcher Fig. 46. — Lavage of the stomach. Pouring the solution into the funnel. at hand, is poured in, a pint or quart at a time. Just before the last of the water has disappeared from the funnel the latter should be carried quickly down toward the floor and held in the upright position over a pail. By siphonage the liquid now flows back into the funnel, where it may be inspected 3i8 METHODS OF TREATMENT before emptying. One quart of water is quite as much as most patients will care to have used at the first washing or , two, but later you should gradually increase the cpantity, until finally several cjuarts, or enough to cleanse away all the mucus, may be introduced, but not more than one quart at a time, and in some very weak stomachs a pint at a time will be more advisable. Be careful always to get out again all the water you put into the stomach, especially when medicated, or at least as much of it as has not passed on into the duodenum. A practical wa-inkle, which I have found to lessen consider- ably the time recjuired to loosen and detach all the mucus in old gastric catarrhs, is to have the patient drink a tumbler or two of warm water before taking the tube, and then, lying down on the back, make voluntary contractions of the ab- dominal muscles so as to splash the water around in the stomach for three to five minutes. When this is done, scarcely one-half the usual quantity of water is required in the washing out which follows directly afterward. Delicate patients should be allowed to rest in the recumbent position half an hour at least after lavage, and in no case should a meal be eaten within that time after the pro- cedure. The Intragastric Douche and Spray. — Various devices are in use, both in Europe and in this country, as substitutes for Fig. 47. — Turck's stomach sprinkling tube. lavage. These include what are virtually stomach tubes with numerous small openings at the end, through which water or any medicated fluid can be forced in fine jets so as to cleanse the walls of the viscus and either stimulate or, in suitable cases, soothe and medicate them. Turck employs for this INTRAGASTRIC METHODS OF TREATMENT 319 purpose what he calls the sprinkling tube or needle douche, an illustration of which is here given. It consists of a double tube, the shorter of. which has its lower end perforated with numerous small holes. When water is forced in through this tube, either by elevating the reservoir some twelve feet high or employing a force pump, the mucous membrane of the stomach should be effectually cleansed by t?ie numerous fine jets impinging upon it. Turck claims that when hot and cold water are used alternately — 115° to 45° F. — the action is that of a powerful vaso-motor stimulant. The longer tube serves for the outflow, keeping the stomach empty. This is a useful apparatus. Einhorn has invented a special apparatus for spraying the inner walls of the stomach with medicated solutions, claiming Fig. 48. — Einhorn's intragastric spray apparatus. that, on account of the very much smaller dose of any toxic agent thus required to medicate the whole mucous membrane, the risk of a poisonous effect is avoided. He employs the ordinary spray apparatus, except that Ijetween the bottle and terminal spraying nozzle a sufficient length of a small soft tube is inserted to extend from a con- venient point outside the mouth to the interior of the stomach. Air is then forced through the apparatus in the usual way by 320 METHODS OF TREATMENT compression of a rubber bulb with the hand. This has a less cleansing effect than either lavage or Turck's needle douche, but affords a very useful means of disinfecting or 'otherwise medicating the mucous membrane of the viscus. The spraying is only effective when the stomach is empty, and, if necessary to secure this condition, lavage should precede it. 1 LECTURE XXX INTRAGASTRIC METHODS, CONTINUED— INTRAGASTRIC ELECTRICITY The most strikingly favorable results I have observed from any form of instrumental treatment in the stomach have been from the use of faradism with an electrode inside the viscus. The direct application of electricity to the stomach from within is entirely practicable with the instruments now obtainable, and it may surprise some of you to learn that it is an even simpler procedure than lavage. Notwithstanding some state- ments to the contrary, during the past fifteen years there has accumulated a large array of evidence, both experimental and clinical, in this country and elsewhere, to the fact that direct electrization of the stomach through an electrode within the viscus, the current being completed by the application of the other pole either to the back or the epigastric region, can cause contractions of its walls and a diminution of its size. There is clinical testimony also from a number of observers to the fact that the innervation and secretory function of the stomach can be powerfully influenced in the same way. As Simple as Lavage. — Lest it be inferred that the method must be complicated and difficult, one, therefore, which could have only a remote interest for general practitioners, let me say to you, and emphasize it as strongly as possible, that intra- gastric electric treatment is at least as simple as lavage, pro- ducing even less strain upon a weak or nervous patient, and for persons accustomed to the tube, unless in a case of gastric ulcer or cancer for which it is wholly unsuited, is by no means so dangerous in its possible consequences, when wrongly used, as are drugs recklessly and unskillfully prescribed. 321 3^2 AIETHODS OF TREATMENT This is so true that, with the instrument and method now employed for this purpose in my practice, I not only advise family physicians how to overcome atonic conditions and dilatations of the stomach by this means, but also instruct nurses, and in exceptional cases even the relatives or friends of patients, so that they can administer the treatment safely under my general supervision. This means, of course, that the method has been much simplified since the earlier experiments with it. Dr. Charles G. Stockton of Buffalo was the first in America to employ electricity in this manner, having begun using it in 1887. He devised a very ingenious electrode, which he has continued to use up to the present time with excellent resuls. It was fully described in a paper by him in 1891.^ He has seen markedly curative effects in cases of stomachs with weakened or apparently absent motility, in gastric dilata- tion, catarrh, atrophy and in " some in which the hydrochloric acid existed in excess." Intragastric Electrodes. — For several years the intragastric electrode devised by Einhorn was employed to some extent in my practice and occasionally with strikingly good results, especially in a few cases of very marked dilatation without pyloric stenosis. Some difficulty, however, was experienced in introducing it into the stomach of occasional patients on account of the considerable diameter of the terminal bulb con- taining the electrode and the absence of any stiffness in the cord or rheophore. Ewald obviated this in part by covering the very flexible cord with a medium-sized rubber tube fitted neatly to the bulb. Thus a very slight degree of stiffness was produced, sufficient to permit of the electrode's being gently pushed down in patients who could not otherwise swallow it. I found this modification in use in Ewald's clinic in Berlin in 1895, and brought one home with me. It rendered good service for a time till it wore out. Then recourse was had to • The Use of the Gastric Electrode in Diminished Peristalsis, by Charles G. Stockton, M. D., Medical Times a7id Register, November 7, 1891. INTRAGASTRIC METHODS OF TREATMENT 323 the original Einhorn instrument, and upon extending its em- ployment to a large number of cases, including some with very nervous throats, several difficulties were encountered. The instrument resembles a large capsule with a flexible cord attached, and a few patients who were accustomed to the stomach-tube and able to take the largest-sized capsule by itself, insisted that they could not swallow one with a string- to it. There was at times still more trouble in getting the electrode up again. The bulb would catch in the narrowest part of the esophagus and fail to pass through, even with the aid of deglutition-movements. Then the patient in such a contingency would sometimes grasp the cord and give it a hard tug, with the result of breaking the very fine wires inside. In these cases it was sometimes necessary to insert the fore- finger down behind the larynx, disengage the electrode and draw it out. An illustration of the original electrode invented by Pro- fessor Einhorn, and largely used in all parts of the United States, is herewith shown. I have had this instrument modified so as to render it easier both to introduce and to withdraw, and now rarely have any difficulty in admin- istering electricity directly within the stomach. Great credit is due Professor Einhorn for originating his very serviceable electrode, and I do not claim any for so modi- fying it as to make it better suit my needs ; but the fact that the modified instrument is in some respects an improvement on the original would appear evident from the description of the original just given with that of the modification which fol- lows, as well as from the accompanying illustrations of both. Reed's Modification of the Einhorn Electrode. — In the Fig. 49. — Einhorn's intragastric electrode. 324 METHODS OF TREATMENT modification the bulb or capsule covering the bit of metal which constitutes the electrode proper is much narrower, as well as longer and more sloping at both ends, than that of the Einhorn and Ewald instruments, so that it is easier both to introduce it into the stomach and to get it out again, which is equally important. The cord is composed of spiral wire cov- ered thinly with rubber, and has, like the Ewald electrode, enough firmness to enable it to be gently pushed through a spasmodi- cally contracted esophagus, and yet is so small as not to provoke usually any marked flow of saliva. It does not prevent talking or drinking, or otherwise annoy the majority of pa- tients during the five to eight minutes that each treatment must last. These are all extremely practical points in carrying out the method • in nervous or fussy patients. Turck's gyromele is capable of being used as an electrode, but I have not employed it for that purpose. Boas, in his work on the stomach ^ describes and pictures an intragastric electrode which should be effective, but in- volves the same inconvenience usually experienced in washing out the stomach, owing to the prolonged contact of a tube of considerable size with the throat and mouth. I have never used the Stockton electrode, but it must have distinct advantages for cases requiring a preliminary lavage. Effect of Intragastric Electricity upon Secretion. — My ex- perience with electricity applied within the stomach has been somewhat striking as to the effects on secretion. Besides finding it helpful in certain cases of gastralgia, and in some cases of obscure gastric pain of unknown origin, using here the positive pole of the galvanic current with a strength of 5 to lo ma., I have found the ordinary faradic current in ' " Diagnostik u. Therapie der Magenkrankheiten," I Theil, S. 298. Fig. 50. — Reed's electrode. INTRAGASTRIC METHODS OF TREATMENT 32$ virtually all cases of muscular atony, or atonic dilatation, decidedly beneficial and sometimes rapidly curative. The slowly interrupted current of any faradic coil with a strength just sufficient to produce contractions in the stomach, and the currents obtainable from the familiar faradic batteries in general use having coils of short, coarse wire and not of a very high power, I have found not only to improve the motility and gradually to contract the stomach, when it was enlarged, but also, as a rule, to stimulate primarily the gasiric glands and increase the percentage of hydrochloric acid, in those cases at least in which the latter was below the normal without atrophy having developed. Except in a single case reported below, I have never em- ployed this form of faradic battery in hyperchlorhydria, con- sidering its effect as generally tonic and stimulating. I be- lieve that it always tends to stimulate at first and that, just as very large doses of drugs can overstimulate and depress, and moderate doses frecjuently repeated often do the same, so a very powerful faradic current for a short time, or even a mild :one daily applied for a long time (as in Case I), can and does produce depression of the glandular function. Doubtless there is no possible dose of faradism which could rapidly de- press the motor function also, since the primary effect of even the strongest current is to produce a tetanic cramp of the muscle.' There is the probable danger, however, that a too long continuance of moderate currents, directly applied to the stomach-walls, would in the end by over-stimulation lower the motor function. With a good high-tension coil it is possible to apply a much stronger current painlessly than with the ordinary coil, and too strong a current may at first cause increased secretion as I is the case with the ordinary faradic current. My experience teaches that such a coil with a long fine wire and rapid interruptions applied with one pole in the stomach and the other in the form of a large flat sponge, felt, or clay electrode, over the epigastrium, will generally, with a 326 METHODS OF TREATMENT proper strength of current lessen the percentage of the hydro- chloric acid in the gastric juice, whether it was previously normal or in excess. In only a few exceptional cases has it failed to do this, and then the treatment was not kept up with sufficient regularity, nor were the patients under the requisite hygienic conditions. Having early learned of its markedly depressing effect upon the glands, I have never em- ployed the high-tension coil in a case of deficient gastric secretion, but have resorted to it often in stubborn cases of the opposite class, in which there is excessive secretion — hyper- chlorhydria. Action of Faradic Currents on Secretion Discovered Ac- cidentally. — My discovery of this power in faradic currents of high intensity was accidental. While in general practice I had come to make considerable use of such currents in ovarian pain and other conditions accompanied by obscure pain or dis- comfort in the pelvis. For this purpose I had obtained one of Kidder's best high-tension faradic batteries and, after replac- ing its troublesome chy cells b}-^ an efficient Grenet cell, found it a most useful machine. When I began to make a large use of electricity in the stomach, this particular battery proved to be the most convenient and reliable one in my outfit, and so was most frecjuenth^ employed. I was soon surprised to observe a rapid diminution in the proportion of hydrochloric acid in the stomach-contents of cases thus treated. REPORTS OF TWO ILLUSTRATIVE CASES. You may be interested in the reports of two cases which illustrate strongly the depressing influence of the high-tension faradic currents upon the gastric secretion. Very many other similar cases are recorded in my notebooks, though at present I do not employ the method so often as formerly for the reason that, with a more skillful use of antacid and sedative remedies, the dernier ressorf, intragastric electricity,, is less frequently necessary. Numerous cases which involved motor INTRAGASTRIC METHODS OF TREATMENT 32/ onditions with or without dilatation have been reported by me [n previous papers/ The first case which was treated by me with the help of Intragastric electricity has been referred to briefly in a previous )aper,' but shows so strikingly the great value of this method n even a ver}^ desperate condition, that a fuller account of it s now given you: Case I. Lady, aged twenty-two years, unmarried, was sent jo me from a town in Northern New York in the year 1896, vhile I was in general practice in Atlantic City. She had been I'or years out of health in various ways. When she came under ;ny care she had dilatation of the stomach with some gas- ■ roptosis, very movable right kidney, and catarrh of the whole i ^astro-intestinal tract, with extreme emaciation, prostration, (ind anaemia. There was excess of the gastric secretion, the r'ree HCl being .182, and the total acidity 90. The lower 30undary of the stomach was three inches below the umbilicus. The upper boundary was only one inch above the lowest rib in ;he left parasternal line. She was barely able to walk and was daily growing weaker as well as thinner. There was also a rise of temperature to ioo°" or higher, every afternoon. I put 'ler to bed, ordered lavage and a very restricted diet w^th some rectal feeding, after irrigation of the colon. Tonic medicines were also administered per rectum. In spite of all this the improvement w-as slight, and after a time a moderate faradic current from an ordinary cheap coarse coil was applied every day with one electrode in the stomach and the other over the epigastrium. To avoid fatiguing the patient too much, the electricity was administered not directly after washing out the stomach, but at another time of the day. These various meas- ures, except the rest in bed, were continued more or less per- sistently during a period of three months, after which the appli- cations of electricity were made every second day. By the end of tlie three months the stomach had decidedly retracted in size, 'Dilatation of the Stomach, with Reports of Cases Treated by Diet, Massage, and Intragastric Electricity, y^z^rwa/ American Medical Asso- ciation, July 30, 1898 ; and Displacements and Dilatations of the Adomi- nal Organs ; their Relation to Faulty Modes of Dress, and Their Treat- ment, Therapeutic Gazette, September, 1899. ^ " International Clinics," vol. i. , Seventh Series. 328 METHODS OF TREATMENT ■*! the lower border being then found one inch above the umbihcus. The patient had gained many pounds in weight, was much stronger, and the proportion of HCl had steadily lessened. An examination of the stomach-contents made about ten weeks later showed an absence of free HCl and a total acidity of only 35 ; her improvement continued. Two years after my treat- ment began, though she had meanwhile returned home and re- ported to. me at long intervals only, I found her with a good color, plump and strong. Her digestion was reasonably good with moderate care of her diet. The former loose kidney could no longer be felt, and her stomach had not only retracted within the noniial limits, but had returned to its normal posi- tion. The foregoing having been the first case in which I ap- plied any form of the electric current within the stomach, I was inexperienced, and thought only of the very serious con- dition of dilatation and stagnation, with the resulting alarm- ing failure of nutrition. I had then had a limited experience only with hyperchlorhydria, and did not realize that this con- dition, by producing a spasmodic closure of the pylorus, had doubtless been the chief cause of the dilatation. In making the direct electric applications to the. stomach, I looked upon them as an extreme measure for combating the dangerous motor condition and did not consider the effect upon secre- tion. Therefore, frequent tests of the stomach-contents were not made as is my present custom in all such cases, else the percentage of HCl would not have been allowed to be lowered so far. But with the administration of hydrochloric acid and pepsin as medicines, and later tonics by the mouth, the gastric juice soon regained its normal strength. The patient above referred to brought an invalid mother to consult me in August, 1903, and was herself then in good health, ceven years after the treatment described, having gained fully forty pounds in weight. Case H. Widow, aged thirty-five, long neurasthenic and dyspeptic. Right kidney very movable. Stomach somewhat dilated ; constipation and some intestinal catarrh. Percentage INTRAGASTRIC METHODS OF TREATMENT 329 of HCl in gastric juice excessive when patient first came under my care in 1897. The hyperchlorhydria was then soon controlled by the usual remedies, and with it most of her com- plaints disappeared. But there have been recurrences since, due probably to reflex irritation from the floating kidney. In ]\Iarch, 1899, she returned with the HCl in greater excess than ever before, and this time persistent treatment by diet, alkalies, belladonna, etc., failed to control it. Finally the high-tension faradic current was applied through my intragastric electrode six times at inters-als of two to three days, with the result that the percentage of HCl came down to .051. It had been as high as .196 after the Ewald test-breakfast. I urged opera- tion, which the patient declined. In September last she re- turned with marked hyperchlorhydria again, and besides, whene^'er we tested her stomach-contents, bile was always found present, showing probably pressure by the kidney on the duodenum below the point of entrance of the common bile- duct. She had lost much flesh and her color was very sallow. Again I tried to relieve her by means of diet and full doses of the usual remedies and, again failing, applied the high-tension current within the stomach in addition to the administration of the remedies internally. Again there was a prompt diminu- tion of the HCl secretion to the normal. The Technique of Applying Electricity Intragastrically. — A few words more as to the technique of this method of ad- ministering electricity. My patients after a light, early break- fast come for this treatment not earlier than 11 a. m., and those with very sensitive stomachs and poor motility, preferably at 12 or later. One or two glasses of water, according to the capacity of the stomach, are then taken and a large flat elec- trode, well-wetted, applied over the epigastrium. In some cases, when, as often happens in these cases, the lower four or I five dorsal vertebrae are sensitive, the flat electrode is applied I over them. Then the battery being ready, the patient, while I sitting on the side of a lounge or couch, swallows the intra- gastric electrode with a little guidance and gentle pushing, if ^' necessary, on the part of the physician, and afterwards lies idown. The current is turned on gently at first and the strength gradually increased to that which the patient 330 METHODS OF TREATMENT can distinctly feel, not all that he can possibly bear, since the maximum current which can be borne is very much stronger with a high-tension coil than with an ordinary faradic battery. Five minutes of such a current every other day, I have found enough as a laile, though in stubborn cases it is given for seven or eight minutes at each sitting. More has some- times produced harmful depression with loss of appetite, and after twelve or fifteen such treatments, if the desired result has not been sooner accomplished, it is best to in- termit them for a week or two. It needs to be strongly em- phasized, however, that in all cases in which electricity is applied within the stomach, especially in those in which there is hydrochloric acid excess for which a high-tension current is being used, there should be a quantitative test of the stomach- contents about every week, or, at the longest, every two weeks, to prevent the risk of injurious overaction. A very few patients will be seen in whom no kind of intra- gastric instrument can be used without a harmful amount of disturbance. But the electrode employed by me is more easily introduced than the ordinary stomach tube and, once in posi- tion, rarely occasions any considerable annoyance. The ex- ceptions are comprised by a small proportion of cases in which nausea is experienced when the current strength is increased beyond a certain moderate limit. In these a milder current needs to be used, and a longer course of treatment is therefore required to effect the desired result. A longer experience with this form of treatment has resulted in more failures than at first, but I am now convinced that these were generally due to the presence of a latent ulcer in either the stomach or duodenum. Later reports from the surgeons con- cerning the findings at operations have shown frequently ulcers in the duodenum especially, with no symptoms other than those of hyperchlorhydria. LECTURE XXXI THE MEDICINAL THERAPY OF DISEASES OF THE STOMACH AND INTESTINES In placing this form of therapy last, I do not intend to con- vey to you the impression that it is of slight importance, but rather that in the treatment of the chronic affections of the stomach and intestines as well as of most chronic diseases, — it is less frecjuently of permanent advantage tO' the patient than the hygienic, dietetic, and mechanical methods already described. In many forms of gastro-intestinal diseases, particularly in gastric ulcer, and all the derangements associated with marked hypersecretion of the HCl of the gas- tric juice, diarrhea, intestinal colic, etc., certain drugs can prove extremely efficacious, especially in the beginning of the treatment. I shall not attempt here to specify all the drugs which may be useful in treating gastro-intestinal diseases, but rather to refer to the various classes of remedies, specifying particularly such of them as I have found in my own experi- ence to possess marked remedial value. For the purposes of this discussion, drugs may be classified into acids and alkalies, (ligestants, astringents, antiseptics, stimulants and sedatives, nerve tonics, chalybeates, certain bland oils and drugs of the bismuth type which, in addition to their general systemic effects, produce mechanically, by their local sedative action, a remedial influence ; and laxatives or purgatives. The Administrations of Acids. — HCl is virtually the only acid which I have found it necessary to prescribe as an acid in real gastric or intestinal cases, though in nervous dyspepsia from neurasthenia dilute phosphoric acid is often an efficient substitute. Salicylic, carbolic, and hydrocyanic acids are also 332 METHODS OF TREATMENT occasionally useful, but none of these act as acids, being prescribed on account of other properties in them. Nitric and nitrohydrochloric acids are often given in gastric and hepatic cases and the latter I formerly employed largely myself, but we possess very much less definite knowledge of their effects, and I doubt whether either is so well suited to atonic gastric conditions as the dilute hydrochloric acid. Letting the latter, therefore, stand for the whole class of acids, when such a remedy is needed in the varieties of disease under discussion, I cannot do better than to reproduce here in full the following paper by myself, which was presented to the Section of Materia Medica and Therapeutics of the American Medical Association in June, 1898. The paper was as follows: " The Place of Hydrochloric Acid in the Treatment of Diseases of the Stomach. — The time has come for a definite and precise statement of what hydrochloric acid can do in the treatment of stomach diseases — when and how it is useful, as well as when and how it can be harmful. " Riegel in his recent work ^ very pertinently remarks : ' While formerly HCl was prescribed in nearly all dyspeptic conditions, its employment has of late been essentially limited, since it has been recognized that it is by no means true, as was once assumed, that in almost every form of dyspepsia a lack of HCl exists.' There is much other testimony to the effect that even among the aggravated stomach conditions for which the advice of a specialist is sought, an excess of this acid is very often found in the gastric juice. Could all cases of gastric derangement, including the earlier stages of catarrhal affections, be brought to the test of a chemical analysis of the stomach contents, it is probable that those with either a normal or excessive secretion would be largely in the majority. And none of these require the administration of HCl as a medicine. Indeed, it is capable of doing pronounced harm in all such cases. We should expect, a priori, that to introduce this active drug artificially into stomachs which already secrete it in too 1 " Die Erkrankungen des Magens," Vienna, 1896. MEDICINAL THERAPY OF DISEASES OF STOMACH 333 large quantities, would intensify the depressing and painful- symptoms of hyperchlorhydria. Experience has abundantly shown that this result usually follows in such cases when the jdrug is administered in considerable doses. j " The well-known antiseptic power of HCl might tempt one to give it in the numerous cases in which, despite the presence pf a normal percentage of this acid in the gastric juice, the [patients suffer from eructations of gas as a result of fermenta- !:ion in the stomach, and (as still more frequently happens in :ases with a normal or overabundant secretion of gastric nice) are plagued with a large amount of intestinal flatulency, [ndeed, this remedy is administered every day by excellent i physicians in these conditions, not after having actually earned, through a gastric analysis, that a full proportion of :\1CI is not secreted, but upon a venture, assuming that there rnay be a deficiency, and if not, that in any case the drug is , Imtiseptic and must do some good. Just here is where the nistake is made. Hydrochloric Acid is an Injurious Remedy in Certain ;)ases. — " To administer HCl in cases in which it is not defi- ient, is not only to do no possible good, but generally to do ;iarm, and for these reasons : This drug, as has been pointed out ,y the writer in previous papers,^ acts even in small doses as a ecided stimulant to the gastric glands, and when long con- linued rarely fails to increase largely their activity, except in astric atrophy or cancer. This property, which renders it so seful as a remedy when the gastric juice is insufficiently ;creted, becomes a cause of injury in the opposite condition. fherefore, HCl taken into a stomach already fully supplied '■ith it, and the stomach contents after meals being thus as :id as nature intended them to be, must not only produce at le time an excessive degree of acidity, with all the harmful 'Diet in the Chronic Catarrhs of the Gastro-Intestinal TvRct, Jotrr. »ier. Med. Assoc, February 19, 1898 ; and Important Indications and intra-Indications for Massage of the Abdomen, Inter. Med. Ma^.,]an-a- y, 1898. 334 METHODS OF TREATMENT results especially to digestion in the small intestine which this implies, hut, if administered often enough, may easily set up a more or less permanent hyperchlorhydria. Hydrochloric Acid does not Prevent Fermentation. — " But it may be urged that we might risk some overacidifying of the gastric juice and the resulting impairment of intestinal diges- tion if by this means we can lessen fermentation in the stomach. Unfortunately, however, in the cases in which there is no deficiency of HCl, very little, if any, antiseptic action can be demonstrated as a result of its administration. In the acid gastritis described by various authors in Germany and France, and especially in recent treatises by Hemm^ter ^ and by Van Valzah and Xisbet ■ in this country, a condition which my own experience has shown to be very common, and the one most often present when a normal or excessive proportion of HCl is found associated with much fermentation, the gas-forming bacteria seem to acquire a tolerance for the HCl and to thrive in spite of it. At all events, the fact that even a very great excess of HCl in the human stomach does not prevent fer- mentation has been made familiar to the writer by a large number of observations. Riegel has lately called attention to it without attempting to account for it. In his work already referred to he says : " ' That the presence of free HCl in the stomach contents is no hindrance to the de\'elopment of an abundant gaseous fermenta- tion is a long since established clinical fact, which, through the researches of Kuhn and Strauss, has been given a further support. It has been proved that the HCl of the gastric juice under the existing conditions has absolutely not the disinfecting properties against the yeast fungi which have been established for it in a pure solution of the drug or in artificially prepared gastric juice, but, on the contrary, the view always maintained 1 " Diseases of the Stomach," by Dr. John C. Hemmeter, Philadelphia, 2 " Diseases of the Stomach," by Dr. W. W. Van Valzah and Dr. J. B. Nisbet, Philadelphia, 1898. MEDICINAL THERAPY OF DISEASES OF STOMACH 335 by US has been confirmed — that when stagnation exists the preferred soil for the gaseous fermentation is afforded by just those cases which show a normal or overlarge amount of * HCl.' " Some experiments recently reported to the Hospital ]\Iedi- cal Society by Toinot and Brouardel, and published in the I British Medical Journal, show- that the bacillus coli can be I made to acquire a tolerance for arsenious acid even in strong ! solutions. They succeeded in training this bacillus to grow well in bouillon containing three grams to the liter of arsenious jj acid. " Then, why may it not be that bacteria in the stomach grad- ually become accustomed to the presence of HCl until finally even a large excess of it does not affect them? At all events the gas-forming micro-organisms are found to flourish in the I stomach even when there is present a very large excess of HCl ; and in these cases when they have become ciironic, it is [i the rule to have grievous complaints of flatulency, both gastric ' and intestinal, with an endless train of nervous symptoms, ' including, especially, mental depression and insomnia, along with, usually, constipation. |, Valuable Effects of Hydrochloric Acid. — " AVhat has already I been said as to the contra-indications for HCl tells, in a meas- ure, where and how it can be helpful in the treatment of gastric I affections. There are a few prominent gastro-enterologists who ;: seem to place little reliance upon this drug in any case, but the i writer has found it of exceeding value not only as a palliative in cases of atonic dyspepsia, but also as a reconstructive tonic in cases of chronic gastric catarrh, which have not yet pro- gressed to entire atrophy of the glands. In fact, the results which have followed its administration in my practice (usually in combination with pepsin) fully warrant me in assigning to it in the therapeutics of all the stomach diseases characterized by hypoi^epsia (except cancer and atrophy) a place second only to diet and the mechanical treatments, including especially abdominal massage. 33^ METHODS OF TREATMENT ' " My notebooks contain the histories of a large number of cases in which the administration of HCl for from one to four months, more or less continuously, has been followed by a most notable and apparently permanent increase in the secre- tion of the gastric glands. In the majority of my cases mas- sage and the use of pulleys or other suitable exercise for the strengthening of the trunk muscles were also employed as a regular part of the treatment, and the results in these cannot, of course, be cited as proving the efficacy of any one of the curative measures relied upon. The cure of the patient having been naturally the first consideration, the treatment has not been limited to any one agency, no matter how valuable. A large amount of evidence has thus been accumulated which, it must be admitted, is inconclusive in so far as concerns the relative value of the various remedies used. " But, fortunately for the purposes of this paper, some of my hypopeptic patients found it impracticable to have massage, and, at the same time, were unable, for various reasons, to carry out with any regularity the directions as to methodical exercise, and the marked gain in digestive power acquired by these must be credited mainly to the medicine taken. " AA'egele^ and Hemmeter- among recent authors bear wit- ness to the powers of HCl as a stomachic or stimulant to the peptic glands. Hemmeter also quotes Riegel, Reichmann, -and ]\lintz as having reported cases of achylia gastrica in which the restoration of the secretion of HCl was efifected by a more or less prolonged dosage with the same acid. Hemmeter gives twenty drops of the diluted HCl in appropriate cases in two ounces of water every half hour, beginning fifteen minutes before meals and continuing it till half an hour after the meal. He has frequently seen excellent results from this method, and Ijelieves that the motor function of the stomach is favorably influenced as well as the glands, a view which my own experi- ■■ " Therapie der Verdauungskrankheiten," von Dr. Carl Wegele, Janu- ary, 1895. « Loc. cit. MEDICINAL THERAPY OF DISEASES OF STOMACH 337 ence confirms. My practice has been to give much smaller doses, I direct the patient usually to begin with a dose of four or five drops of the dilute HCl given after each meal in this way: The amount prescribed, which is gradually increased if necessary up to ten, or exceptionally even to twenty drops, is added to half a goblet of water which the patient is directed to take in small sips at frequent intervals during an hour or an hour and a half. In cases of complete or nearly complete anacidity the sipping of the diluted acid is begun immediately after the meal, but in other cases not till the meal has been over for half an hour. In this way the amylaceous portions of the food are given time for the action of the saliva. I was led to adopt this gradual method of administering the acid through having observed a number of cases with absence of free HCl in which the patients complained of a marked burning in their stomachs after taking quite small doses of the remedy. This apparent intolerance of the drug was overcome entirely by having it taken gradually in small sips, and the results eventu- ally were quite as gratifying as in other cases in which no such disagreement had occurred. " Except in those cases where, in spite of deficient or absent HCl secretion, there had been demonstrated a normal propor- tion of pepsin or of pepsinogen, I have usually combined with HCl a moderate amount of a good preparation of pepsin in the form of a glycerole. When, owing to the exigencies of a busy practice, the quantitative tests have included the total acidity and the amount of free HCl only, pepsin has generally been added to the mixture, and in a very large proportion of such cases the digestive power has decidedly increased, insomuch that the patients after a time were able to do without stomach remedies. " Reports of Cases. — In the cases, reports of which are given below, no very severe restrictions of the diet were imposed, though hot or fresh bread, fried articles, sugar, nuts, vinegar, the sourer fruits, especially uncooked, and shellfish, except oysters in their season, were excluded, and the patients were 33S METHODS OF TREATMENT enjoined to eat slowly, using their saliva to moisten all starch foods and to drink either nothing or very sparingly aP meals. " Case I. — Lady, aged 36, resident in New York, while on a visit in Philadelphia, came under my care on account of chronic indigestion, with much fermentation, constipation, anaemia, irregular menses, impaired sleep, and cardiac palpi- tation. She gave a history of having suffered in a similar manner for several years, and of having had more or less, trouble with her stomach for twelve years. Had formerly had much pain after meals, and for this had been directed to take, freely and continuously, tablets made up mostly of sodium bicarbonate, about five grains in each. She began by taking one every hour, or sixteen a day, but finally reduced them to eight daily. These were continued with little or no medical oversight for three years, until they markedly disagreed by causing nausea. External examination, when this patient came under my care in December, 1896, showed the right kidney to be loose and very movable and the stomach dilated, extending from the normal limit above to several inches below the level of the umbilicus, with tardy expulsion of the contents. The liver area was somewhat smaller than normal, but the other organs presented nothing abnormal. " Analysis of the stomach contents after a test breakfast showed a total acidity of only 24 and an entire absence of free HCl. Rennet test, no result in twelve hours. Indican in excess in urine. My first prescription contained in each fluid dram in x of dilute HCl with 111 xv of glycerole of pepsin, m i^ of Tr. Nuc. vom. and 111 ^ of carbolic acid. A tea- spoonful was added to half a glass of water and, beginning half an hour after meals, the patient sipped the entire solution during the hour following. " Shortly after l^eginning treatment she was attacked with a severe diarrhea, which necessitated a different line of medica- tion for a week or more. Then a new digestive mixture was given, with the dose of HCl reduced one-half, and the other ingredients, except pepsin, omitted. " February 25, 1897, the patient came on from New York and reported improvement in nearly all ways. She had con- tinued her last mixture. The stomach analysis now showed T. A. 40 and free HCl .0146. Less fermentation and better MEDICINAL THERAPY OF DISEASES OF STOMACH 339 sleep. No excess of inclican in urine. The pepsin was now left out of the HCl mixture and a few drops of carbolic acid were again added to it. Massage of the abdomen was tried, but proved too exciting to the menstrual function, the first- treatment having brought on the flow, out of time and in excess. " Since the above date, the patient has seen me at long inter- vals only. October 7, 1897, she came on to Philadelphia and reported that she had continued the HCl mixture until six weeks previously and considered herself then practically well. She had gained twelve pounds in weight, presented a good color and clean tongue, and had lost most of her symptoms except the constipation. " She afterward fell ill with grippe in New York, and came under the care of Dr. Lockwood of that city 011 account of this disease and its complications. She was confined to her bed or her room there a large part of the winter, but at the end of it all her physician wrote me, under date of March 28, 1898, that a gastric analysis showed total acidity 50; free HCl 22 (equal to .080) and combined HCl 22. " She reported herself to me again April 4, 1898, and looked well, considering her recent long illness. There was improved gastric motility, but her stomach was still greatly enlarged, she having declined intragastric electricity and abdominal massage, the two surest remedies for that condition. " Case H. — Lady, aged 40, wife of a physician in a neigh- boring city, consulted me March 22, 1897, on account of paroxysmal attacks of indigestion, from which she had suf- fered for twenty-six years. They were characterized by vio- lent eructations of gas and seemed to be caused by some un- usual emotion or excitement. Formerly they occurred once in several months and were not followed by any specially unpleas- ant consequences, except nausea and some feeling of oppres- sion. But within the last two years there have been three serious attacks of the kind, which were followed by colicky pains and jaundice, with pruritus, lasting a week. These attacks also followed some marked nervous shock or emotional excitement. One occurred just after her father's death. Be- tween times she is said to have had usually fair digestion, with no ])ain or discomfort after meals and very little eructation. Her bowels have l^een fairlv regular as a rule, but she is very constipated ahvays at the time of the attacks. The latter, of 340 METHODS OF TREATMENT late, have sometimes recurred every day for several weeks, accompanied by severe colicky pains and vomiting. Ingesta, taken two or three days before, have occasionally been vomited. Color pale, and looks dejected. Physical examination : Lungs and heart normal. Liver enlarged. Stomach, slight displace- ment downward along with atonic dilatation ; the upper bound- ary was one to one and a half inches too low, and the lower boundary between two and three inches below the level of the umbilicus. The kidneys not palpable. No tumor. Gastric analysis after test breakfast : T. A. 12 ; free HCl entirely want- ing. Small amount of mucus. Diagnosis : Chronic catarrh of the stomach and duodenum. Prescribed :- 3 Tr. Nuc. vomic, f 3ij; Ac. hydrochlor. dil, q. s. ad f Sj ; Sig. 10 to 15 drops in half a glass of water after meals. Diet to be as unfer- mentable as possible. " Two months later patient reported improvement. No fur- ther attacks. " August 6th of same year her husband reported that she had been obliged to continue the mixture regularly. Every attempt to omit it was followed by a return of indigestion. October 14th; patient recovered a few days ago from one of her severe attacks, which lasted two weeks, with eructations, pain, and constipation. "Gastric analysis: T. A. 18; free HCl, none; mucus, very small amount. Prescribed: IJ Ac. hydrochlor. dil., f 3 vj ; gly- cerol pepsin, q. s. ad fjij ; Sig. Ten drops in half a glass of water, half an hour after meals, by sips. Every other week to take the following: 1^ Argent, nitrat., gr. x; Ext. tar- axaci, 3 j ; M. et. ft. pil No. LX. ; Sig. One after each meal. "April 21, 1898. Has taken both medicines, as above ordered, the HCl mixture continuously. and the silver half the time. She now has a good color and is very much stronger. No further attacks. Gastric analysis : T. A. 40; free HCl .041 (nearly normal) ; mucus, a small amount. The lower border of the stomach was found to be near the level of the umbili- icus. " Case HI. — Lady, a teacher, aged 23, referred by Dr. Samuel Bolton of Philadelphia, October 6, 1897. Her chief complaint was headaches and vomiting every few days with much nausea, and occasionally vomiting, especially evenings between the attacks. There was also stubborn constipation MEDICINAL THERAPY OF DISEASES OF STOMACH 34 1 and feeling of load in her stomach after meals. Organs gen- erally found healthy except stomach, which was moderately dilated, extending down to half an inch below the umbilicus with delayed emptying. The gastric analysis showed only a very small amount of free HCl — .014, though the total acidity was 66, representing largely fermentation products. There was much mucus in the stomach. I advised lavage and the combination of HCl and pepsin as the main treatment. On account of marked starch indigestion, she also took Taka-dias- tase for a time, and Roncegno water was taken for some weeks to bring up the cjuality of the blood. " On April 9, 1898, I found the stomach much retracted in size, the lower border being one and a half inches above the umbilicus, and the gastric analysis showed T. A. 56 ; free HCl .075 (that is a normal secretion) ; mucus a very small amount. She had had no severe headache with vomiting for three months and had regained a normal color, though her gastric catarrh is not yet entirely well. " Case IV. — Gentleman, aged 66, consulted me July 21, 1897, ^^ Atlantic City, on account of chronic indigestion, from which he claimed to have suffered nearly all his life. Painful accumulations of gas and obstinate constipation were prom- inent features. The external physical examination revealed nothing abnormal. Gastric analysis: T. A. 16; free HCl wanting. Starch digestion good. Mucus very small amount. He was placed upon H^Cl and pepsin in the usual way. He has since seen me several times on account of his wife, but reported that he himself was doing so well on the di- gestive mixture as not to require any further medical assist- ance. " December i6th, he was seen, and was then feeling well. On April 22, 1898, his wife called to consult me for herself and reported that her husband had been continuing his HCl and pepsin, though less regularly, having virtually recovered his health. He had taken no other medicine except a little nux vomica during the first few weeks, and a laxative at night. He had not had massage, except such kneading over the abdomen as he had been able to give himself. " In this case no opportunity has been offered of testing the stomach contents again, but it is highly probable, from the decided improvement in the patient's digestion, as well as in his 342 METHODS OF TREATMENT general health, that the gastric glands are now doing much better work. " Reports of a number of other cases might be added, in which, under a treatment consisting either entirely or mainly of the administration of HCl and pepsin, conditions of apepsia or hypopepsia improved more or less markedly, the gastric secretion having returned to the normal. AA'ithout claiming that such fragments of clinical experience can be accepted as denionstrating beyond question that HCl stimulates the gastric glands, it must be admitted that a strong presumption is thus established as to the existence of such an action." Later Experience with HCl. — During the twelve years which have elapsed since the foregoing article was written, not only my own further observations in a large number of cases, but the clinical experience of a majority of other writers upon the subject have confirmed the views and results therein recorded. Pawlow,^ in some experiments on dogs, failed to obtain evidence that HCl has a directly stimulating effect upon the gastric secretion, but this failure by no means disproves the significance of the numerous positive findings above reported, and the results of recent carefully conducted experiments by myself.' HCl does not exert an}" sudden stimulant effect which could be demonstrable at once, but rather a gradual tonic influence which only after some days or weeks, and sometimes not until after months, of use in small doses, makes itself mani- fest in the form of an increased secretion. As to the methods of administering the dihite HCl, the paper above reproduced in full describes that which has proved most effective in my hands, and I quote also the following from a paper by myself, read by invitation before the Alabama State Medical Society, April 15, 1902, and entitled "The Place of Drugs in the Treatment of Stomach Troubles."^ ■• " The Work of the Digestive Glands," Philadelphia, igo2. 2 The Place of Drugs in the Treatment of Stomach Troubles, Inf. Med. Mag., June, 1902. 2 Loc. cit. MEDICINAL THERAPY OF DISEASES OF STOMACH 343 " 111 the condition of deficient secretion of the gastric juice, especially of the HCl — such as obtains generally in old cases of chronic gastric catarrh of the atonic type, and even also in some cases of chronic nen-e exhaustion of long standing — an entirely opposite line of treatment is necessary. In many of these cases nothing effects such prompt beneficial results as the administra- tion of the officinal dilute HCl in doses of from 5 to 30 drops, combined usually with pepsin. Rarely have I found it advan- tageous to increase the dose beyond the latter amount, even when the deficiency in the secretion of HCl has been very great, notwithstanding the recommendations of some high foreign authorities in favor of colossal doses of the acid. These rec- ommendations are based upon theoretic grounds, especially the fact that it would require several drams of the dilute HCl to meet the requirements of the stomach in the digestion of a large mixed meal. The truth is that the usefulness of the HCl as a remed}^ consists mainly in its stimulating action upon the secreting cells of the stomach, and probably not to any consid- erable extent upon jts power of supplying the place of the absent or deficient gastric juice. This point I have fully con- sidered in several previous communications, and will not enlarge upon here. Let it suffice that my own experience, which is amply supported by that of numerous other careful observers, proves beyond cjuestion that HCl does, in many cases, gradually bring ud the secretion of the normal acid of the stomach to its proper level when deficient or even almost absent previously. " Experience demonstrates also that very large doses, and even in fact moderate doses, sometimes markedly disagree with stomachs v/hich careful tests show to be greatly in need of the remedy. A burning pain is often produced by it in such over- sensitive stomachs, and it is necessary, therefore, in these cases, to administer it a little at a time. The appropriate dose should be added to a half tumbler of water and taken in sips every few minutes during the hour following each meal. I am accus- tomed to prescribe the remedy in this way in all cases where 344 METHODS OF TREATMENT such a prescription is indicated, and my patients frequently allude to it familiarly as ' the sips.' In these cases character- ised by deficient secretion, benefit may also be obtained often from the administration of the bitter tonics, especially nux vomica, quassia, columbo, etc., and Ewald, among other Ger- man writers, strongly recommends condurango bark for the same condition."' Useful as is HCl as a remedy when deficient, it can do so much harm when administered in unsuitable cases that the practice of prescribing it without any tests having been made, on the mere suspicion that the dyspepsia complained of is due to a lack of this element in the gastric juice, cannot be too strongly condemned. I have seen numerous cases in which serious results followed its administration even for a short time, when it was not needed. LECTURE XXXII DIGESTANTS, ALKALIES, AND NATURAL SPRING WATERS The Digestants. — Theoretically, pepsin or some other prep- aration capable of digesting proteids in the stomach with the. aid of HCl — such as papoid, caroid, pineapple juice, etc. — and also for other classes of cases the rennet ferment, the various extracts of pancreas, etc., should be valuable helps in many cases of indigestion, but, as a matter of fact, it is probable that few, if any, remedies are frequently prescribed with such dis- appointing results. The chief reason for this is, doubtless, that they are not given to the right cases, or else not at the right times or in sufficient -amounts. My own observations, con- firmed by those of Einhorn and of other very busy internists, would indicate that in some places, if not in civilized countries generally, a majority of dyspeptics have too much HCl, and probably also of the ferments, in their gastric juice, and, therefore, need in the earlier stages of their malady, alkalies, bismuth, and sedatives, rather than digestants of any kind. Again, though exceptionally, the gastric juice in certain cases does not contain sufficient pepsin, while HCl is yet pres- ent in normal amount ; more frequently when one is deficient both are, and in such cases to order pepsin or any proteolytic ferment witliout including HCl in the prescription, is to ac- complish no good result and possibly to do harm. A series of experiments carried out in my laboratory in 1901 showed that in four out of six cases the addition of pepsin without HCl to samples of chyme in test tubes taken up during the height of digestion produced a slight retardation of the digestion of cubes of albumin placed in the tubes at the same 345 34^ METHODS OF TREATMENT time. These four samples of chyme contained free HCl. though in somewhat deficient amount. There were numerous ?)ther experiments and they tended to prove that the adminis- tration of pepsin alone, even when HCl seems to be present in normal proportion, is ineffective, neither improving the digest- ive work at the time nor producing any such beneficial after effect as results from the administration of HCl. It is likel)^, however, that there are occasional exceptional cases having along with a full supply of HCl a deficiency of pepsin, and that in such cases the administration of some proteolytic ferment like pepsin might prove efficacious. The same series of experiments showed that while the ad- ministration of scale pepsin in 5-grain doses for periods of five to seventeen days did not effect any improvement in the work of the peptic glands, dilute HCl in lo-drop doses given three times a day for five to six days markedly increased the subsequent secretion of the same acid. Moreover, as an ad- ditional experiment, six specimens of chyme extracted from the same five subjects one hour after a test breakfast were sub- jected to the following tests : " Small cubes of coagulated egg albumin of the same size were prepared and one of these introduced into each of four test tubes with 3 c. c. of the filtered stomach contents taken up one hour after an Ewald breakfast. Nothing further was put into tube i ; to tube 2 two grains of scale pepsin were added ; to tube 3 one drop of dilute HCl, and to tube 4 both pepsin and HCl were added." The tubes were kept in an incubator at a temperature of approximately 38 C. Of the tubes to which HCl alone had been added four out of the six showed a more rapid digestion than in the control tube. In the same proportion of the tubes to which pepsin alone had been added there was a slower digestion than in the control — a positive retardation ; but in all of the six tubes to which both HCl and pepsin had been added the process of solution was more rapid. Confirmatory Clinical Evidence. — A limited number of such DIGESTANTS^ ALKALIES, NATURAL SPRING WATERS 347 experiments, no matter how carefully conducted, cannot be accepted as conclusive, but when they confirm abundant clinical experience the results should certainly have weight. Having begun earlier in my practice as a somewhat routine plan the administration of HCl and pepsin combined in smaller doses of the fonner, too, than are commonly advised in cases of deficient secretion of the same, and having found that my cases almost uniformly improved under it, the percentage of HCl secreted gradually increasing, I have continued to follow such a method. Its value has been confirmed by my own experiments as well as the observations of other clinicians, not- withstanding the disbelief in the value of pepsin expressed by some authors. By itself the latter is doubtless generally value- less, but combined with HCl it is highly effective, wherever the tests show the latter to be deficient. The objectors urge that in most such instances pepsin or pepsinogen is present in the gas- tric juice. Doubtless ; and it is still more certainly true that the rennet ferment is almost never absent from the gastric juice, except in atrophy, yet the Russian experimenters have demonstrated that in atonic dyspepsias generally no digestant or combination of them acts with the magical efficacy of the natural gastric juice taken from a living dog, which contains along with the HCl not only pepsin and rennin, but probably also other ferments or active elements which chemists have not yet been able to discover by their analyses. Useless Pepsin Compounds. — But let me warn you to place no faith in the pharmaceutic monstrosities which are said to contain pepsin combined with pancreatin, with which it is positively incompatible, nor those in which it is combined with wines or any preparation of alcohol which, except in the weakest dilutions, interfere with its action. Nature under- stands better how to combine it so as to have its work done ef- fectually. Pancreatic Preparations, — Pancreatin not only cannot be combined in the same mixture with pepsin, since they mutually destroy each other, but it cannot be prescribed with any benefit 348 METHODS OF TREATMENT SO long as pepsin and HCl are being secreted by the stomach, though in cases of deficient secretion of the latter it may often be used helpfully to peptonize artificially milk, porridges, etc., before these are ingested. It may also render effective aid when administered with a small amount of soda to patients with gastric atrophy — when there is no longer any gastric juice. But while the various extracts of pancreas act best in an alkaline or feebly acid medium, you should bear in mind that much soda in these atrophic cases, according to recent experiments, is likely to diminish the secretion of the pancreas itself, which is normally promoted by the presence of some free HCl in the duodenum. This observed fact w^ould lead one to infer that since, in gastric atrophy, dependence for digestion must be placed mainly upon the pancreatic juice, it should be best even in these cases to administer HCl (without pepsin), but clinical experience has shown this to be commonly ineffective under such conditions. Alkalies in Gastro-intestinal Disease. — The alkalies form a most important class of remedies in certain diseases of the stomach and intestines. In deficient gastric secretion the mineral acids (HCl being the best of them) have proved themselves highly advantageous with real curative virtues ; yet they can be dispensed with. One can get on without them and yet hope for fairly satisfactory results. If the patients do not progress so surely toward a favorable result, they at least do not suffer for w^ant of them. In the gastric derangements, however, accompanied by a large excess of HCl with severe acute pain or other urgent , symptoms consequent upon the excessive secretion, we have no efifective medicinal substitute for full doses of some alkali and such a remedy is imperatively required. Some general suggestions as to the dosage and modes of administering alkalies in such cases were contained in the paper above cited and they are here reproduced.^ " The administration of alkalies is generally necessary in ^ The Place o£ Drugs in the Treatment of Stomach Troubles, Int. Med. Mag., June, 1902. DIGESTANTS, ALKALIES, NATURAL SPRING WATERS 349 excessive secretion of the HCl of the gastric juice, whether it be in the form of an excess of the same during the digestive periods only, as is most common, and known as hyperchlor- hydria, or a persistent flow during aU the twenty-four hours of every day, as in Reichmann's disease, or a paroxysmal flov/ with very large excess for a few days at a time, as in gas- troxynsis. This treatment is necessary whether the HCl excess is a merely functional derangement, or is associated with either an acid gastric catarrh or with round ulcer of the stomach. The selection of the alkali in such cases is not a matter of indifference. When the bowels are not in need of a laxative, sodium bicarbonate in doses of from 15 to 60 grains, given two hours after each meal, and in the worst cases com- bined for a week or two at first, with small or moderate doses of either belladonna or atropin, will be usually most useful. Sometimes it is better to administer, at the same periods, a combination of sodium bicarbonate 15 grains, bismuth subni- trate or subcarbonate 1.5 grains, and calcined magnesia 10 to 20 grains, according to the condition of the intestines, the dose of the magnesia being adjusted so as not to allow constipation to result from the bismuth. In many such cases magnesia, having a far greater alkalinity, acts better than soda, since large doses of soda are required when the latter is given alone. " In the constipated cases a similar combination, with a sufficient increase of the magnesia to insure regular evacua- tions, usually suits well, and the belladonna here affords valuable assistance in bringing about a freer opening of the bowels. The HCl excess often depends upon reflex irritation from a movable kidney, and then drugs will do little good till the latter can be held in its normal place. When the hyper- chlorhydria has already developed into gastric ulcer, the op- portunity is afforded for some of the most brilliant results obtainable in the therapeutics of any chronic disease." But the special method of treating gastric ulcer is fully discussed in a separate lecture under that head. , The alkaline mineral waters deserve special mention here. 35° METHODS OF TREATMENT They include particularly the Vichy, Selters, Carlsbad and other spring waters of Europe as well as the Saratoga Vichy, Saratoga Kissingen, and Bedford Spring waters of this country. Perhaps mention ought to be made also in this connection of numerous very slightly alkaline waters, such as those from the Poland Spring in Maine, and those from several springs in the vicinity of Waukesha, Wisconsin, besides the many much advertised lithia waters, the latter of which when natural, however, contain as a rule only the minutest quantities of lithia. Few of these contain a sufficient proportion of any alkali to exert a noteworthy antacid action, but many of them seem to produce a beneficial influence upon nutrition quite out of proportion to their mineral contents. A large part of this is doubtless due to the diuretic action of the water itself, which the patients would not drink so freely if it were not supposed to possess some medicinal properties ; but I am in- clined to believe that the minute amounts of silica and other saline ingredients, even in the very small proportions present, increase the efficiency of the water. Natural spring waters as a rule do often effect results which cannot be obtained by the administration of equivalent doses of their principal mineral constituents in artificial solutions, and when patients are able to bear the increased expense of such medication you may sometimes find it preferable to prescribe the French Vichy waters instead of sodium bicarbonate, or Bedford water when you desire a slight laxative action in addition to an antacid one. There are many other American alkaline spring waters which no doubt possess valuable reme- dial properties, but sufficient experience with them has not yet been accumulated to warrant dependence upon them. The Saratoga Vichy water is said to answer well in hyperchlor- hydria, but it happens that my experience has been greater with the imported Vichy, and in urgent cases I have preferred full doses of soda or magnesia or a combination of these with bismuth, as directed in my lecture on that affection. The Effect of Alkalies before and after Meals. — Upon one DIGESTANTS^ ALKALIES, NATURAL SPRING WATERS 351 point concerning which there seem to be very divergent opinions held by authors, I desire to advise you strongly and emphatically : it is as to the effect of alkalies and the alkaline waters upon gastric secretion. Certain writers have asserted that an alkali given before eating always increases the secre- tion of HCl, and given after meals lessens it. This is not true. This piece of misinformation has been handed down from the time of Sidney Ringer at least, and from how much more re- mote a period I do not know. The facts are that a relatively small dose of any alkali, or alkaline waters in which the alkaline element predominates over the saline constituents, will tend to stimulate secretion whether taken before or after meals, (though doubtless rather more certainly when taken upon an empty stomach), and that in a relatively large dose it will tend to lessen secfetion. I have repeatedly confirmed this in practice, and often to my great regret as well as to the sorrow of some of my worst hyperchlorhydric patients, when, in trying to restrain the very excessive execretion of HCl, I prescribed too small a dose of some alkali, as, e. g., 15 to 20 grains of sodium bicarbonate to be taken an hour or two after eating, since the result was an aggravation of the trouble. How small the dose must be to stimulate and how large to depress, depend upon the susceptibility of each patient's gastric glands. The Saline or Chloride Waters. — There is a marked dif- ference in the effects of those natural spring waters which contain predominantly the alkaline carbonates combined generally with some of the sulphates of sodium, etc., as in the Carlsbad waters, and on the other hand such waters as those of Homburg and Kissingen which contain chiefly the chlo- rides. The former in the usual doses lessen hyperchlorhydria, and depurate generally, being, therefore, particularly well suited to plethoric persons who' regularly overeat and under- exercise. The chloride waters, on the contrary, in the case of patients with deficient HCl usually stimulate the appetite and gastric secretion and tend to correct catarrhal tendencies in the gastro-intestinal tract without weakening or depressing. The 352 METHODS OF TREATMENT persons — mostly neurasthenics — who are benefited by these saHne chloride of sodium waters, would be nearly always iiTJured by a course at Carlsbad, and in some instances at least the converse is true. Some day, it is to be hoped, our numer- ous American spring waters will have been sufficiently studied, so that we may obtain from them a like variety of effects and prescribe them in the same way to meet definite indica- tions. Since the foregoing was put in type, I have had the pleasure of going over the ]MS. of Professor von Noorden's monograph concerning the " Effects of Saline Waters on ^Metabolism " (which at the time of this writing is going through the press of Messrs. E. B. Treat & Co., of Xew York), and find that a series of very carefully conducted experiments and clinical observations, carried out by himself and his assistants, some- what modifies the views hitherto generally held in regard to the action of these spring waters. He has satisfactorily established, I think, that as used in the ordinary dosage in connection with an appropriate diet, both the Homburg and Kissingen waters may influence favorably, not only most cases of chronic gastric catarrh associated with hypochlorhydria, but also a certain proportion of cases of acid gastric catarrh, and perhaps also, some cases of hyperchlorhy- dria dependent upon reflex or other causes. The good effects in the latter class of derangements are doubtless due in large part to the influence of such waters in overcoming constipa- tion, and relieving the catarrhal condition in both stomach and intestines, thereby improving the nutrition generally. I quote here the exact language used by von Noorden in his summing up regarcHng the effects of the waters in ques- tion^ : " In numerous cases of gastric disorder, particularh^ in gas- tric catarrh, the use of saline mineral waters leads to an ac- 1 " Concerning the Effects of Saline "Waters (Kissingen, Homburg) on Metabolism;" by Prof. Carl von Noorden (Frankfort) and Dr. Carl Dapper Bad Kissingen). E. B. Treat & Co., New York, 1904. DIGEST ANTS, ALKALIES, NATURAL SPRING WATERS 353 tive and permanent increase in the production of hydrochloric acid. '' In numerous cases of gastric disorder accompanied by hyperacidity (particularly in nervous dyspepsia) the moderate use of saline mineral waters leads to a decrease in the hydro- chloric acid production, and a decrease of the subjective symptoms."' LECTURE XXXIII TONICS, STIMULANTS, AND SEDATIVES The Nerve Tonics. — In true cases of gastro-intestinal neurasthenia — nervous dyspepsia — good results can often be obtained from the giving of nerve tonics in suitable doses, pro- vided no one drug, and still less a combination of them, be administered long enough to overstimulate. The most useful drugs for this purpose I have found to include the hypophos- phites, the glycerophosphates, iron, arsenic, gold, silver, qui- nine, the valerianates, and small doses of the bromides combined with some roborant remedy. The bromide of sodium in doses of 5 to lo grains, after meals, in a mixture with tincture of the chloride of iron well diluted and pleasantly flavored, will often prove effective, when not permitted to constipate. In no class of cases, however, does the experience and personal skill of the physician count for so much as in the manifold complications of neurasthenia and anaemia with more or less well-defined disease of the gastro-intestinal tract or vague derangements of digestion and nutrition. Inexperienced physicians usually make the mistake of prescribing too much medicine — especially too many and too strong nerve tonics in these as in other troublesome cases. Your safest rule will be to give the nerve tonics — which, with the exception of iron, act chiefly as " spurs to a tired horse " in most cases — as cautiously and sparingly as possible, beginning with small doses increased as necessary, and not to continue with any one of them — except iron for anaemic patients — veiy long, rarely over two to four weeks, and only so long if it has agreed perfectly well. Belladonna and hyoscyamus or their alkaloids are useful sometimes in hyperchlorhydria and in bowel obstruction, but 354 TONICS, STIMULANTS, AND SEDATIVES 355 they are remedies for emergencies and their prolonged use can do much mischief. Alcohol Rarely Necessary. — As to alcohohc stimulants on the one hand and the more powerful sedatives or narcotics on the other, with increasing experience I find myself prescribing both classes of remedies less and less. When patients are tired or exhausted, the manifest indication is for rest rather than for a stimulant of any kind, unless there is a persistent lack of energy in some organ when the appropriate tonic drug (pro- vided no hygienic or mechanical measure will effect the object) would seem generally more suitable than the very temporary stimulation of alcohol, followed speedily by its inevitable reac- tion with then increased debility. HCl, e. g., is the best stimulant for the gastric glands; electricity, massage, or other mechanical excitant for the gastric or intestinal musculature (though these, in suitable dose, are powerful stimulants of secretion also), with strychnine or some medicinal purgative as a less desirable substitute ; the Nauheim baths and exercises are the best cure for a weakened heart muscle with various medicinal heart tonics as substitutes, which are superior at least to alcoholic stimulants because their effects are longer lasting, even though at the best not very long. See Lecture LXXXII. The bromides are of real value because they steady an un- stable nervous system, and in small doses, not exceeding 5 to 10 grains, two or three times a day for short periods, act as tonics rather than as depressants, though, when long admin- istered, they lower the strength both mental and physical as well as most of the bodily functions. The Relief of Pain and Insomnia Produced by Disease of the Stomach or Bowels. — Opiates and other narcotic remedies are exceptionally recjuired to quiet pain which cannot be other- wise controlled, though I do not now prescribe them once where twenty years ago I would probably have found them necessary fifty times. Alkalies or an unloading of the bowels will relieve most pains in the stomach or bowels, with the help 35^ METHODS OF TREATMENT sometimes of a hot wet pack or an active counter-irritant locally. ' Hypnotics are, I trust, less abused than they were when sulphonal first came into vogue and, like all such remedies upon their original introduction, was hailed as a boon to in- somniacs — an agent which was said to soothe mildly and harm- lessly, without the possibility of danger. I have seen at least one patient made insane by sulphonal and two or three die from the prolonged use of it and trional, so that I am less easily convinced now that any such remedies are desirable unless for desperate emergencies. When your dyspeptic patients do not sleep, in the absence of brain disease or of any clearly recogniz- able painful condition, it will usually be because of a seriously lowered nerve tone which calls for building-up, not lowering, agents, such as all the hypnotics and narcotics are in full seda- tive doses ; but perhaps the most frequent exciting cause of wakefulness will be found to be indigestion with accumulations of gas in the stomach or bowels. The surest remedy in these last cases will be that which will stop the fermentation, if at the same time measures are carried out designed to fortify the strength and raise the nerve tone of the patient. Iron and its Principal Preparations. — It is probable that iron is not sufficiently often given in the affections of the stomach and intestines. The fact that its astringent preparations frequently increase constipation and, at least in full doses and when not properly combined, may disturb the digestion, has led to a distrust and neglect of this grand remedy in a class of cases for which at times it is able to do very much. Chronic indigestion in most of its forms goes hand in hand with anaemia. A vicious circle is soon formed; the indigestion pro- duces a lowered nutrition with impoverished blood and these in turn increase the indigestion. Iron in many cases can speedily break such a chain of sequences and supply the addi- tional energy which is necessary to restore the digestive power. Rven the fermentation can often be restrained by 5 to 10 drops of the good old-fashioned tincture of the chloride of iron taken TONICS^ STIMULANTS, AND SEDATIVES 357 after meals and guarded, as previously suggested in speaking of nerve tonics, by the same number of grains of sodium bromide freely diluted, especially if there be added to the treatment either HCl or an alkali, accordingly as the gastric secretion is deficient or excessive. Such a combination is at once tonic, nervine, and antiseptic, and I have found it to effect much good in anjemic, debilitated dyspeptics when the stomach was not irritable. In these cases constipation nearly always exists anyway, and if you follow the methods of cure I shall lay down for you in a subsecjuent lecture, this symptom will usually respond to your treatment satisfactorily in due time, in spite of the iron — sometimes all the sooner because of the im- proved digestive power and increased nerve and muscle tone which iron gives. For many cases, however, blander preparations, such as the reduced iron, the carbonate, the pyrophosphate or especially Blaud's pills are better borne and effect the desired result more certainly because of the combination with an alkali which per- mits the giving of very large doses safely. Another most efficient preparation for anaemic nervous patients with deficient gastric secretion is the modern substitute for the old Parrish's Chemical Food — Syr. ferri phosphatis — though it contains proportionately a good deal less iron than the others, along with much dilute phosphoric acid. The expensive preparations with which the market is just now flooded are no better ; most of them are not so good as those above named. The so-called organic iron compounds are less efficient and only slightly, if at all better borne than the blander official preparations, so that there is rarely an excuse for resorting to them. However, Pepto-Mangan has been very largely employed with good results, and this as well as Ovofer- rin and other similar organic compounds of iron may be tried in cases in which the stronger iron salts disagree. The Ferruginous Mineral Waters. — Ever since learning personally from Professor Ewald, in 1895, that it was a remarkably effective remedy, I have prescribed largely the Ron- 35^ METHODS OF TREATMENT cegno Water, which seems to be Httle known in this country, and have almost uniformly been pleased with the results. It (3omes from the South Tyrol, and is so strong both in iron and arsenic that a tablespoonful of it with a glass of any pure water makes a fairly full dose, while one to two teaspoonfuls after each meal (always with plenty of water) prove sufficient for many cases. Small doses of these two metals usually agree best with dyspeptics, and any considerable dose of this strong water might disagree in decided inflammatory conditions or in cases having any tendency to vomiting or diarrhea. Ewald often prescribes also the Levico iron and arsenic water from another spring in the South Tyrol, especially for the gastric neu- roses. There are many other famous springs of iron water, includ- ing, especially in Europe, those of Franzenbad and Elster. which are practically recommended by Boas because in their waters the iron is combined with large amounts of alkaline and saline ingredients, and he considers iron by itself, not thus combined, to be badly borne in well-marked dyspeptic cases. It is certainly true that iron preparations are always likely to agree best in even cases of nervous dyspepsia, and still more so in serious -gastric or intestinal disorders, when combined with one or more alkalies and salines, especially mild laxatives largely diluted, as occurs in many popular iron waters. The list of the mineral springs in the United States contain- ing iron in notable quantities is a very long one, but unfor- tunately most of them are yet undeveloped, their virtues known to a few only, and their valuable medicinal waters scarcely ob- tainable anywhere away from the localities of the springs them- selves. The springs at Saratoga and Ballston Spa, New York, are alkaline, saline, and laxative, with a small content of iron, while the Putnam Spring of Saratoga has over 7 grains of iron to the gallon. The water from the Londonderry Litha Springs of New Hampshire contains 1.85 grains of iron carbonate and 7.29 grains of lithia carbonate to the gallon along with about the same proportion of carbonate of magnesium, and also a TONICS^ STIMULANTS,, AND SEDATIVES 359 very much larger proportion of lime salts, which are less desir- able for many cases. The "Round" Spring at Aurora Springs, Missouri, contains about 7 grains of iron tO' the gallon, and among other iron springs of some note are the Bath Alum and Rock Enon Springs, Vii'ginia; the Topeka Mineral Wells, Kansas; Brown's Wells, ^Mississippi; and the Adirondack ^Mineral Spring and Oak Orchard Acid Spring, New York. At Hammonton, Xew Jersey, half-way between Philadelphia and Atlantic City, there is a spring the water of which contains 13.63 grains of iron to the gallon, a much larger proportion than any of those above named (so far as their analyses are known) except the very strong arsenic iron waters of the South Tyrol. The Bismuth Preparations, and Cerium Oxalate. — The salts of bismuth are of prime importance in the treatment of many digestive disorders, and in the same class may well be placed the oxalate of cerium, which is equally insoluble and has a very similar sedative action upon the mucous membranes. The latter drug, however, " while it seems to exert less antiseptic and astringent action than the bismuth salts, goes beyond these in influencing apparently the pneumogastric center either directly or reflexly, insomuch that it often helps to control reflex nausea as well as coughs. The bismuth preparations are nearly identical in their action, except that, as previously explained, the subcarbonate is some- what more alkaline, and the salicylate rather more antiseptic. I have never been able to observe any superior virtues of any kind in the subgallate, and indeed, whether prescribing for astringent, antiseptic, or local sedative effects, have usually found the subnitrate about as good as any other of the salts. The possibilities of bismuth for good are often not fully realized, because it is given upon a full stomach instead of an empty one and in far too small doses. As a sedative and astringent in gastric ulcer, for instance, doses of 20 to 60 grains are rec|uired. In such doses on an empty stomach it proves exceedingly effective. 360 METHODS OF TREATMENT The Bland Oils. — Olive oil and cottonseed oil (and probably also linseed oil, thoug'h I have had less experience with this internally) seem to exert nO' real dynamic action, but for that very reason are most valuable as mechanical remedies — cures — in constipation. Probably the most highly refined petroleum oils may be equally free from medicinal influence, but cosmo- line, vaselin, and albolene, all of which I have made full trials of, dO' in time depress weak hearts a little. They act even better than the bland vegetable oils in overcoming constipation, when taken by the mouth, since they make no call whatever upon the digestive juices, nO' attempt seeming to be made by the latter to act upon them, and no disorder of the digestion results — rather, on the contrary, an improvement of it in conse- quence, doubtless, of their help in keeping the lower bowels unloaded. Dr. A. L. Benedict has discovered a firm which is said to purify the coal oil so thoroughly that no toxic product remains in the oil. The latter is called Purpetrol. My ex- perience with this preparation has not been large, but it has proved efficient in a number of cases. It exerts very little, if any, depressing effect on the heart. In my experience during the- past year, the cotton-seed oil injected *nto the bowel at bedtime in doses of 2 to 6 ounces, and allowed to remain till morning, has succeeded in a large minority, if not a majority, of all patients suffering from chronic constipation, in curing the disease when the patients would persevere with it and follow out at the same time a proper regimen, including gymnastic exercises, a suitable laxa- tive diet, and in the worst cases a course of massage and electricity. The effect of all these bland oils seems to be to soften the feces and lubricate the mucous membrane ; and, besides, they act locally as sedatives, soothing an irritated mucous mem- brane. LECTURE XXXIV ANTISEPTICS, ASTRINGENTS, AND LAXA- TIVES—MINUTE DOSES OF CERTAIN DRUGS Antiseptic remedies are usually disappointing. They sometimes seem efficient in the milder cases of fermentation or putrefaction — cases in which a more careful diet with more exercise and attention to the bowels are nearly always suffi- cient of themselves to cure ; but when there is serious and per- sistent gas formation, as in catarrhal affections and in cases with decidedly weakened motor power of the stomach or intestines, antiseptics as well as other remedies fail until the cause can be removed.- Stomach washing, laxatives, or colon douches — measures which rapidly remove the fermenting remains of food or feces from the weak-walled viscera — are, in such cases, often the only really effective palliatives even, while appropriate mechanical modes of treatment are nearly always required to cure. Carbolic acid, which is often given and helps somewhat to restrain moderate fermentation in the stomach, is only safe or pemiissible when the gastric secretion is low, since it rap- idly stimulates it, often aggravating or causing hyperchlorhy- dria even when ingested per rectum. The sulphocarbolates are inefficient except in the largest doses, and then probably act as carbolic acid upon the glands. The salicylates restrain fer- mentation to some extent; but, like the former remedies, only more so, weaken the heart if long administered. Bismuth in full doses is mildly antiseptic, but constipates. Probably the safest antiseptics, when otherwise indicated, are nitrate of silver and tincture of the chloride of iron, since 361 362 METHODS OF TREATMENT both are tonics; the former exerts a good effect in doses of one-twelfth to one-quarter grain in catarrhal cases (combined Vith bismuth subnitrate), especially in chronic acid gastritis; and the latter, in 5- to lo-drop doses, well diluted, combined frequently with 5-grain doses of sodium bromide three times a da}^, agrees better in atonic cases accompanied by excessive fermentation. The iron I have seen markedly and quickly im- prove the motor function of some stomachs. Resorcin, thymol, menthol, spirits of chloroform, and numerous other drugs credited with antiseptic powers, may prove useful auxiliaries to more curative treatment for short periods, but none of them can be safely continued long, and all of them will be likely to fail you at times in cases in which they seem most needed. Sodium benzoate, and ammonium benzo- ate act efficiently in some mild cases, and salol has decided antiseptic power; but these have the same limitations and ob- jections as the drugs previously mentioned. Astringents are not abused as much as laxatives, merely because diarrhea is not as frequent as constipation, but a wrong use of them is responsible for much suffering and numerous deaths, especially in children. I recall with sorrow the ill success that I had in treating such cases in my earlier years of practice while a zealous believer in the efficacy of combinations of astringents with opium. These combinations are often temporarily effective, but the flux generally returns in aggravated form after being checked for a time with any of the stronger astringents, even in spite of a persistence with them in the largest allowable doses; this is almost invariably so in chronic forms of diarrhea, and especially so in dys- entery. Bismuth, which possesses only feeble astringent powers, is niost useful in catarrhal affections of the alimentary canal, and this chiefly because of its locally emollient virtues as well as probably its slight antiseptic influence. Its various salts have all toxic properties and can do harm in the colossal doses given for x-ray work. (P. 88.) The subcarbonate, being ANTISEPTICS, ASTRINGENTS, AND LAXATIVES 363 the most alkaline, probably has some advantages in hyper- chlorhydria, and the salicylate is somewhat more antiseptic than its other salts. Laxatives and purgatives constitute a very important class of remedies, though perhaps none are more frequently abused. The need of regular and complete alvine evacuations is impera- tive ; no case of indigestion can be even improved when this function is imperfectly performed, but, on the other hand, one might add with truth that the digestion is never really sound so long as laxatives have to be regularly administered to secure bowel movements. Laxatives and purgatives, then, are very necessary for emer- gencies, sometimes helpful in overcoming obstruction, and useful almost as a routine measure in the beginning of the treatment for diarrhea, but harmful usually when depended upon as a prolonged means of treatment in chronic constipa- tion ; yet, in the more intractable forms of the trouble, when a cure is out of the question, a judicious alternation of some of the milder laxatives may be necesary as a choice of evils — safer, usually, than a constant dependence upon enemas of water or any aqueous solutions. If, however, we may be allowed to include among laxatives such bland vegetable oils as olive, cottonseed, and linseed oil, the two former of which in particular scarcely possess any real medicinal properties, it cannot be said that all remedies of this class are useless as a means of curing constipation, though most of them certainly are. When given by enema in doses of two to six ounces at bedtime, together with a suitable diet and sufficient exercise, they do not often fail to cure, acting mechanically as solvents of the feces and lubricants of the intestinal mucous membrane. In catarrhal dysentery the saline laxatives constitute the best form of treatment — full aperient doses at first and smaller doses at three- or four-hour intervals later. Castor oil and calomel in moderate purgative doses are still the best remedies to clear out the alimentary canal in beginning the treatment of 364 METHODS OF TREATMENT diarrhea; very small doses of the same, from one-hundredth to one-tenth of the purgative dose, are often the most efficient means of treating the same disease later, after a complete emp- tying of the bowels. Similar minute doses of podophyllin are also very effective, especially in painless watery forms of diarrhea either in afebrile conditions or in typhoid fever. The following case, previously reported by me,^ shows in a striking way what very small doses of podophyllin and again similar doses of Fowler's solution of arsenic can occasionally do in desperate forms of diarrhea, after opium and astringents have failed : " Early in August, 1886, before the underground sewerage had been generally introduced into the hotels of Atlantic City, a girl of thirteen developed a violent attack of typhoid fever. Before the end of the first week the child lay in a stupor, with bowels moving involuntarily a dozen or more times a day. Dr. Julius Kaemmerer, lately of Philadel- phia, a physician of great experience and ability, was associ- ated with me in the case. The outlook for the child having become very bad, a distinguished consultant was called from Philadelphia. The usual astringents, bismuth, opium, and even lead, were given persistently without effect. Another consultant from the same city, a gentleman of the highest eminence and of world-wide reputation, was now sent for to see the girl. Other astringents were tried in the hope of checking the exceedingly profuse diarrhea, which was fast exhausting her, but all to no avail. Our consultants made but one visit each, returning afterward to Philadelphia, and so had little opportunity to display their undoubted skill and fertility of resource. The case was now desperate in the extreme, and we had scarcely a hope that death could be averted. At this juncture the writer recalled some fortunate experiences with comparatively small doses of podophyllin in severe diarrhea. It was remembered that podophyllin specially affects the small intestine, the part in which the most characteristic pathologic changes are found in enteric fever, and since Dr. Anstie's experiments, quoted by Professor Ringer, showed that the ■• The Primary and Secondary Action of Drugs, Lotidon Practitioner, April and May, 1888. ANTISEPTICS^ ASTRINGENTS, AND LAXATIVES 365 drug in large doses caused intense congestion and even ulcera- tion of the small intestines, it was believed that a suitable dose should exert an opposite or restorative action upon the same part. Dr. Kaemmerer, though not acquainted with such a use of the drug, willingly consented to the trial, since we had pretty well exhausted all the usual measures, and, indeed, the patient's stomach had become irritable, so that she could retain but little of anything. Then, stopping all other medi- cines, we administered i-i20th of a grain of podophyllin with a little sugar every third hour. After the third dose a marked improvement set in. The discharge from the bowels was rap- idly checked, until within twenty-four hours the stools almost entirely ceased, and my colleague even expressed the appre- hension that the medicine might prove too astringent. " The effect upon the temperature, which had been ranging between 103° and 104° to 104.5° F., was quite extraordi- nary. Quinine had been used at an earlier stage with little effect, and fairly full doses of antipyrin produced absolutely no favorable impression, though we had neither of us seen it fail before. But coincidently with the correction of the diar- rhea after beginning podophyllin, there was a marked decline in the temperature, amounting at first tO' about two degrees in twenty-four hours. The subsequent treatment was mainly of a supporting character with occasional remedies for a pul- monary complication, which at times gave trouble, and the im- provement, with the exception of such complication, thence- forth went on steadily till the temperature reached the normal. " After the temperature had remained normal for a week, there occurred on the 15th of September a relapse, the tempera- ture rising on the i6th to 105.4°, higher than at any time before. There were again frequent involuntary stools, with yet more profound adynamia, as well as delirium and stupor. Podophyllin was again tried in the same doses, and now failed. We then resorted to Fowler's solution in doses of one-eighth of a drop every two hours. Since arsenic, in full doses, pro- duces a violent choleraic condition, probably by paralysis of the vaso-motor nerve supplying the stomach and intestinal tract, it was reasoned that small doses should exert an opposite, i. e., a tonic or restorative action upon the same tract. The effect was as prompt and satisfactory as had been that of the podo- phyllin in the former attack. The bowels were speedily checked, the temperature rapidly fell, touching the normal 366 METHODS OF TREATMENT again by September 23. Thenceforward convalescence was uninterrupted, very little other medicine being given." I could instance numerous other cases in my experience in which one-hundredth of grain doses of podophyllin proved promptly efficient in controlling similar severe forms of diar- rhea, both acute and chronic. The Usefulness of Certain Drugs in Minute Doses — Cup- rum Arsenite. — It was John Wesley, I think, who objected to letting the devil have all the good tunes, and whatever wicked- ness may still be imputed to the homeopaths, I never could see the wisdom of letting them monopolize any really efficient remedies. In this connection it is worthy of note that it was in my practice in Atlantic City some twenty or more years ago that minute doses of arsenite of copper were first given a sys- tematic trial by any physician of the regular school. I related my experience with it in colic and diarrhea to Dr. John Aulde of Philadelphia, and in consequence of his enthusiastic pub- lished reports concerning its efficacy, it rapidly attained such popularity that for many years past most of the manufacturing pharmacists have included it in their lists of tablet triturates. It has since been so greatly abused by administering it in cases for which it was unsuitable, and in too large doses, that its popu- larity has of late been waning; but it remains true that in doses of one-thousandth to one-five hundredth of a grain repeated every fifteen to thirty minutes, arsenite of copper will often control severe intestinal colics dependent upon spasmodic con- tractions of the circular muscular fibers of the intestines, whether the accompanying condition be one of spastic constipa- tion or colicky diarrhea. But it will not cure appendicitis or peritonitis, nor will it remove any obstruction of the intes- tines not dependent upon spasm, and it is useless and danger- ous usually to push its administration beyond a few hours, at the most, since it ordinarily proves effective in that time if it ever will, and even such small doses can produce toxic effects if continued long. ANTISEPTICS, ASTRINGENTS, AND LAXATIVES 3^7 If any of you should be interested in the modus operandi of medicines in such minute doses, you will find the subject fully discussed in my London Practitioner paper above cited. I therein explained it in strict accordance with the scientific law that overstimulation always produces secondary depression, and that in the case of certain drugs, including most of the purgatives especially, we have been accustomed to avail our- selves only or chiefly of the large-dose, secondary, and often toxic, action, while the homeopaths limit themselves exclusively (whenever they adhere closely to their principles) to the oppo- site primary small-dose action, which is always stimulant to the nerve centers or other parts affected, though if this chance to be an inhibitory nervT, the result of its stimulation must be a' lessening of function in the structure supplied by it. Thus the action is really antipathic, not homeopathic at all, since nearly all disease signifies weakness and depression in the diseased structure itself, in its regulating center, or in the ner^'es or vessels supplying it. But we of the regular school also habitually administer many remedies for their primaiy small-dose effect only, avoiding strictly the large doses which would produce their physio- logic or toxic action. Among such remedies may be men- tioned arsenic, most of the metallic salts, hydrocyanic acid, alcohol, and ether and chloroform internally. Other drugs we administer in both small and large doses for totally dif- ferent and often opposite effects. These include tartar emetic and ipecac, which in quite small doses act as expectorants, and the latter at least, as an anti-emetic, with no depression, while in large doses they produce vomiting and depression — when pushed, marked prostration. Calomel is largely used by pedi- atrists in small doses to control diarrhea in children, and the bichloride has been lauded as a tonic blood-maker in certain cases, while the purgative, depressing, and tissue-destroying influence of mercury, in its larger range of dosage, is well known. Certain other drugs, such as the drastic cathartics, the vermifuges, and the astringents, we regularly administer 368 METHODS OF TREATMENT for one of their secondary or physiologic effects only. It would seem that our therapeutics might gain much if the materia medica were to be studied anew, and a clear state- ment made regarding each drug as to its powers in each of its ranges of dose. The bugaboO', homeopathy, ought no longer to stand in the way of progress in this direction. PART IV THE GASTRO-TNTESTINAL CLINIC LECTURE XXXV INTRODUCTORY— THE CLASSIFICATION OF DISEASES In Part I, have been rehearsed briefly certain elementary and basic facts, anatomic, physiologic, etc., which should assist you somewhat in. the study of our subject. In Part II, have been discussed the various methods of examining patients in whom there is reason to suspect the existence of disease of the stomach or intestines. And in Part III you have had pre- sented to you rather full descriptions of the methods in general by means of which such disease can be best remedied. Now we come to the still more important part of our task, the consid- eration individually of the diseases in question. At the threshold of this study arises the question of classifi- cation — nosology. Various plans have been followed by others. Most authors have admitted the desirability of basing their classifications so far as possible uj)on anatomic and patho- logic grounds, but all have been obliged to admit also that many clinical pictures must be recognized and treated as distinct enti- ties for which no well-defined pathologic basis yet exists. They differ, however, widely in their methods of drawing the lines. Several eminent authors, for example, refuse to consider as a distinct disease such a conspicuous anatomic and pathologic con- dition as gastric dilatation, and insist upon considering it under a term having reference to'the atony or insufficiency of the gas- tric muscles upon which it usually depends. Then, nervous dys- pepsia and the gastric neuroses generally are terms restricted by some to a comparatively few obscure affections not other- wise explicable, while others expand them widely, including under them all the derangements of secretion as well as the 371 372 THE GASTRO-INTESTINAL CLINIC motor and sensory disturbances. I shall try to take a middle and conservative ground in this respect. Without disputing that both excessive and deficient secretion of HCl are often attributable merely to nervous causes, I shall describe these very frequent and important affections to you under titles that do not imply any special theory as to causation. They consti- tute symptom groups calling for special forms of treatment additional to, and very different from, that required for the original nervous or other affections to v^hich they are second- ary; and, moreover, they may result also from inflammations of the gastric mucous membrane as well as from other causes, including, acording to my own observations, besides those of other writers, movable kidney — perhaps also the displacements of other abdominal organs — gall-stones, renal calculi, etc. There are abundant reasons, then, for considering these affec- tions under separate names. I am inclined to agree rather with Leube than with some of the more recent writers in limiting the term Nervous Dyspep- sia to those gastric or intestinal derangements of apparent nervous origin for which no anatomic or pathologic basis has yet been discovered. For example, whether or not hyperchlor- hydria can cause gastric ulcer and proliferative gastritis, these latter affections are now believed to be capable of producing hyperchlorhydria, so that not all cases of the latter at least can be properly classed as neuroses. In like manner, certain obscure gastric pains which are now usually called neurotic, or at least neuralgic — gastralgic — are likely to result really from perigastric adhesions or other undetermined, but none the less actual, anatomic lesions. The truth is that the nervous system is intimately involved with every derangement of the health in whatsoever part or organ it shows itself, regardless of whether such part or organ is itself structurally diseased or not; but the opinion is growing that the difference between what are called functional diseases and those known to be organic is less than was formerly supposed. It is difficult to conceive of the possibility of any consider- THE CLASSIFICATION OF DISEASES 373 able or prolonged disturbance of function that does not involve at least a slight change of structure, however transient in dura- tion. And the longer such a so-called functional disease lasts, the greater is likely to be the structural change accompanying it. For example, whenever on account of the reflex irritation from a movable kidney, an overtaxed brain, or merely over- eating, the gastric glands are stimulated into excessive secre- tion and we have the familiar picture of hyperchlorhydria set up, it is inconceivable that the glands remain the same as under normal conditions. They are necessarily swollen, congested, and the blood supply to them is unduly increased. This hyper- remia might properly enough be spoken of as functional when it is transient and the glands return within a few hours or even days to the normal again; but when it persists for weeks or months, pathologists find that certain structural changes have taken place in the cells, changes which are not necessarily per- manent or irremediable, but none the less pathologic in char- acter. If by functional diseases were meant those which are usually curable and temporary, and by organic diseases those which are incurable and, therefore, permanent, there would be more reason for such a classification; but no such significance ran now be attached to these terms, since it has been well established that resolution can occur in inflamed tissues and that degenerated cells sometimes undergo regeneration. In other words, organic diseases are sometimes curable; and, on the other hand, certain affections which have been generally classed among the functional disorders are comparatively sel- dom completely cured. There does not seem, thus, to be any good reason for retain- ing longer the time-honored division of diseases into functional and organic. It is confusing, misleading, and serves no good purpose. A better classification for the so-called functional disorders would be under the title, Diseases Having No Known Anatomic Basis. Then, in placing certain gastro-intestinal derangements under the head of neuroses, as must be done for the present, 374 THE GASTRO-INTESTINAL CLINIC we should clearly explain that by such a classification we merely express our ignorance of their actual causes or of the lesions upon which they really depend, though some of them are known to be manifestation of actual disease in the nervous system. I agree in the main with Riegel who, in this connec- tion, says ■} " Are we justified in separating all functional disorders of the stomach, all forms of dyspepsia, into those diseases that are based on some tangible anatomic lesions of the organ and those that are purely functional in character? Is it correct to desig- nate the latter class as neuroses? I believe that a division of this character goes altogether too far; however desirable it may be to have an anatomic basis for every disturbance of function, we cannot say that we possess such a basis for the present in a large number of functional diseases of the stom- ach ; at the same time it does not appear to me that we are justi- fied in designating the latter class of disturbances neuroses, because we have not so far discovered the lesions of the stom- ach that cause them. " We are hardly justified in calling a disease a nervous dis- order because pathologic-anatomic changes are absent, or, better, because we cannot find them ; more is needed, we should be able to demonstrate and to prove that these functional disor- ders are really caused by hyperstimulation or inhibition." Riegel, it will be observed, while still finding it convenient to designate as functional the lighter or more obscure affections for which we cannot demonstrate an anatomic cause or lesion, plainly considers that some such lesion exists even though we cannot find it. I would, therefore, paraphrase one of the sentences quoted above from Riegel to read thus : " We are hardly justified in calling a disease a functional disorder because pathologic-anatomic changes are absent, or better, because we cannot find them." But, while tliere probably are no diseases which involve ex- ■• " Diseases of the Stomach," by Franz Riegel, Philadelphia, etc., W. B. Saunders & Co., 1903, p. 291. THE* CLASSIFICATION OF DISEASES 375 clusively functions and not at all the organs by which the func- tions are performed — that is none that may properly be called functional disease only — there are doubtless many affections of the gastro-intestinal tract which may with strict propriety be called nervous, because they are either symptoms of disease in the nerve centers or elsewhere in the nervous system or else they are reflected from morbid conditions in some other part and only show themselves in the regions mentioned because of the heightened reflexes which a diseased nervous system produces. This is especially likely to occur in hysteria or neurasthenia. Another difficulty in arriving at a satisfactory classification of the diseases under consideration is the fact that inherited or acquired weakness of the nervous system is constantly ob- served as a complication of the familiar diseases of undoubted organic character such as ulcer, cancer, etc. In consequence we rarely encounter a clinical picture that is not more or less complicated with nervous features. An inherited neurasthenic tendency predisposes to displacements and constipation, while these help to develop nervous trouble or increase an already existing neurasthenia and thus things tend to go on from bad to worse in a vicious circle. Again certain persons have been endowed from birth with a neurotic tendency to overeat and to eat too fast for adequate mastication. Naturally they easily fall victims to one or more of a whole series of affections such as hyperchlorhydria, acid gastric catarrh, ulcer, constipa- tion, diarrhea, dilatation or displacement of the stomach, etc., some of which are usually classed among the neuroses, some among functional disorders, and others among the organic diseases, and yet types of each class may often coexist in such a case. Frequently it is the nervous complications of the dis- eases causing real tissue changes which determine the symp- toms. I have seen a number of cases in which a pronounced chronic gastritis has existed for years without producing any discomfort, because there did not happen to be any nervous complications, and the patients, but for a persistently furred n^ THE GASTRO-INTESTINAL CLINIC tongue, or some eruption on the skin, considered themselves well. *A11 that can be done, then, is to designate with appropriate names the principal groups of symptoms or pathologic condi- tions and describe these to you as clearly as possible, cautioning you at the same .time that you must not expect often to find them simple and uncomplicated, but most frequentl}^ inex- tricably mingled with symptoms of a weakened or otherwise diseased nervous system and at times with morbid states in other parts. Furthermore you should bear in mind that while some of the diseases which, for want of fuller knowledge, are classed among the neuroses, are really nervous affections, others are either reflexes from diseases elsewhere in the body or dependent upon lesions not discoverable, or at least not yet discovered. Diseases of the Stomach and Intestines not always Separa- ble. — In another respect I have found it convenient to depart from the conventional rule of authors to consider the diseases of the stomach exclusively in one part of their works, and diseases of the intestines exclusively in another — often in a separate volume. Nature has not separated the affections of these different segments of the alimentary tube by any such marked differences as to render this necessaiy, and it has seemed to me more natural and logical to discuss ulcer of the duode- num in the lecture directly following that in which ulcer of the stomach is considered, since the peptic ulcer constitutes practi- cally the same disease whether it occurs in the stomach or in the duodenum. Then, having taken up the consideration of the subject of ulceration, it is more convenient and natural to continue with the same subject and proceed with the discussion of other ulcers of the intestines in the succeeding lectures, than it would be to postpone this to a later part of the book. Then, again, it has been more convenient to consider together in one lecture the subject of syphilis of the stomach and intestines and in another separate one the subject of tuberculous ulcera- tions of the stomach and intestines, in a book covering so much THE CLASSIFICATION OF DISEASES . 377 ground within so small a space as this one essays to do. I regret that it has not been practicable also, without doing violence otherwise to the most natural sequence of the chapters, to consider the catarrhal inflammations of the duodenum and small intestine generally directly after the discussion of such inflammations of the stomach, since they are closely allied and catarrh of the stomach probably rarely exists without the co- existence of a similar process in the duodenum. LECTURE XXXVI GASTRIC ATONY, OR MYASTHENIA GAS- TRICA (MOTOR INSUFFICIENCY, ME- CHANICAL INSUFFICIENCY) Under the head of Gastric Atony I shall describe to you that condition "in which the muscular layers of the stomach walls have become abnormally weakened and unable on this account to empty the viscus within the usual time. Many names have been suggested for the condition, some of which seem to me quite inappropriate, and the multiplication of names for it still goes on with much resulting confusion for students of the subject. Names for pathologic conditions or groups of symptoms which are frequently met with, even though devoid of a known pathologic basis, first of all should designate the condition as accurately as possible and, with this requirement fulfilled, the simpler and more familiar the term the better. The old term gastric atony or atony of the stomach expressed a very definite idea, that of a flabby weakened condi- tion of the motor apparatus of the stomach, which prevented its being emptied as quickly as normally it should be. It is closely allied to the conception of gastric dilatation or gastrectasis because in both the stomach walls are weak and flabby, with usually a marked splashing sound to be elicited at almost any time during the day. The chief difference between these two conditions is the fact that in simple atony the stomach is merely weak but not enlarged, v^^hereas in dilatation it is weak and enlarged both. But there is an entirely different condition in which the stomach is unable to empty itself within the normal time for the reason that there exists an obstruction at its out- let. There is in these cases often for a long time no weakness 378 GASTRIC ATONY 379 of any kind in the stomach, but, on the contrary, at first just the opposite as a rule, the muscular walls developing an exceptional degree of thickness and strength in the effort to overcome the obstruction. The only things in common between these two opposite conditions are the circumstances that in both the stomach is abnormally long in emptying itself and the hyper- trophy which usually results primarily from a persistent ob- struction of the pylorus eventually passes over into atony and then finally into an overstretching of the stomach walls. Both gastric atony from nervous or other constitutional cause and pyloric obstruction thus tend at last to develop into dilatation — gastrectasis. Several recent authors, including Boas, Riegel, and others, insist that these two opposite conditions of gastric weakness and excessive gastric strength should be considered together under a single name and hence the suggestion of various new terms such as Muscular Insufficiency, Mechanical Insufficiency, etc., having regard to the inability of the stomach in both to get rid of its contents in the usual time. It seems to me, however, simpler, less confusing, and better every way to adhere to the old name Gastric Atony for the very definite condition of motor weakness in the stomach, and designate the condition of excessive strength of the stomach walls developed in the effort of the viscus to overcome an obstruction, by a different name which should be based upon its aetiology and pathology. Thus, if we call the latter condi- tion Pyloric Obstruction, we have a name which does not need to be explained or defended and at the same time one which accurately defines it. The chief symptoms of Gastric Atony and of Pyloric Obstruction in its earlier stage before the thick wall weakens or dilatation occurs, are not the same, but very unlike, and the methods of treatment must be different. Why then confuse by our nomenclature such different entities ? Relative Importance of Atony, Dilatation, etc. — By giving Gastric Atony and the allied conditions, Gastric Dilatation and the displacements of the abdominal organs, the first place in 380 THE GASTRO-INTESTINAL CLINIC those of these lectures which are devoted to the consideration of the diagnosis and treatment of the various diseases of the ■stomach and intestines, I desire to impress upon you particu- larly their great relative importance. Too often physicians fancy that the main thing in regard to a doubtful stomach is to ascertain how much HCl it secretes, which cannot be surely determined without the introduction of a tube, and certain chemical processes which involve some sort of a laboratory and chemical training, while the results, though very important in many cases, are much less so as a rule than the determination of the motor power of the stomach, which it has already been shown, in Lecture VI., can be done in nearly all cases within a few minutes by an external examination, with- out having to introduce any kind of instrument into the stomach. Many patients continue to enjoy fair health in spite of hav- ing a moderate excess of HCl constantly secreted and others, with a marked deficiency, or even a total lack of the same, often manage to get on without serious indisposition so long as they live very carefully ; but the person wdiose stomach can- not get rid of a hearty dinner within seven hours, by passing it on into the duodenum, is always more or less of an invalid, and when his stomach does not habitually empty itself within each twenty-four hours, he is a sick man who urgently requires help, either medical or surgical, if he is to be prevented from more or less rapidly succumbing to his malady, and this quite regardless of whether his stomach secretes an excess or a defi- ciency of gastric juice. Various Degrees o£ Atony. — There may be various degrees of gastric atony, and it is not necessary to limit the term arbi- trarily to the state of weakness which prevents the viscus from emptying itself within seven hours after a dinner, as Leube and others do. The constant inability to accomplish this implies a decided grade of atony — a sufficient impairment of the motor power to injure the health quite materially, though less, of course, than that degree of atony which shows regularly GASTRIC ATONY 38 1 some remains of food in the stomach in the morning before breakfast has been taken. Indeed, whenever there is regularly experienced a feeling of weight or heaviness in the stomach after a full meal, and a splashing sound is obtainable at almost any time during the day by tapping over the stomach, you will be safe in diagnosing some degree of muscular atony, though these in any given case may possibly be symptoms of the graver condition of dilatation into which the atony has already devel-' oped. In the latter case, however, enlargement, as well as weakness of the stomach, can be made out by a suitable exam- ination, even a merely external one. Etiology. — Atony of the stomach is one of the most frequent results of our modern high-pressure mode of living. All the prevalent faults of hygiene, such as immoderate eating, ex- cesses i)i vino and in venery, overwork, especially mental over- work, deficient sleep, and a lack of pure air and of exercise out of doors, predispose to this condition. Whatever tends to cause neurasthenia will be equally efficient in producing gastric atony, which, indeed^ is a very frequent accompaniment of neurasthenia. Typhoid or malarial fever and tuberculosis markedly favor its development, as do also the severer cases of gastric catarrh, even in the asthenic form. Sthenic, or acid gastric catarrh, as well as a severe hyperchlorhydria, often causes spasm of the pylorus, with a resulting obstruction of the outlet, which, as in the case of cancer or other tumor in the pylorus or duodenum, or a mechanical obstruction of any kind in the same region, after a primary strengthening or hypertro- phy of the stomach walls, in nearly all such cases finally super- induces a very marked degree of gastric atony and dilatation, but it is probable that in most of these cases there is first an enlargement of the stomach, due to muscular overaction, and that then atony and dilatation both result secondarily. This subject will be considered when I take up dilatation of the stomach. In women the corset, by putting the abdomen in splints and preventing any efficient exercise of the abdominal muscles, 382 THE GASTRO-INTESTINAL CLINIC powerfully conduces to gastric atony. It produces a most flabby condition of the abdominal muscles, thus lessening mark- edly the external supports of all the abdominal viscera. Sag- ging of many of these (splanchnoptosis) naturally follows, and is further favored by the constriction of the waistband and corset above, especially the old-fashioned short corset, less by the long straight-front kind, as well as by the weight of the skirts. The latter are supported only by the prominence over the belly, which the corsets and waistbands have helped to form by forcing the viscera downward and forward. This pro- tuberance, therefore, is made up generally of the displaced stomach and intestines, including, in some cases, one or both kidneys as well. The displaced stomach is nearly always an atonic one, probably as a result of its disturbed innervation, and, indeed, the same forces just described often directly dilate it by dragging down the greater curvature, while the other parts of it remain fixed. The tendency to atony, with its secjuel dilatation, and also to displacement of the stomach, is often inherited from one or both parents. Symptomatology. — The symptoms of gastric atony are those usually attributed to dyspepsia. Indeed, when dyspepsia is not the result of an increased or lessened gastric secretion, or of catarrh, ulcer, or cancer of the stomach, it very generally means impaired motility or gastric atony — or the more serious condition of dilatation. Symptoms in these cases may be wholly wanting, but there may be a furred tongue, bad breath, belching of much gas (or possibly flatulence in the bowels), weight or heaviness after meals, though rarely a real pain, constipation, -headache, disturbed sleep. Sometimes, though as a rule only after the development of dilatation and stagnation of the food, and also after the intestines have become secondarily involved by a catarrhal process, there may be more severe phenomena, such as anaemia, nervous and mental de- pression, complete loss of appetite, much physical prostration, emaciation, etc. Generally, however, so long as the disease is limited to a moderate atony of the stomach, the patient, though GASTRIC ATONY 383 complaining much, will eat and sleep fairly well, continue to attend to usual duties, and present the appearance of good, if not robust, health. Diagnosis. — In Lecture VI., under the general head of Meth- ods of Examination, I have described a convenient method of deciding whether gastric atony be present or not, as well as the degree of it. It is a more satisfactory one than any other that does not require the introduction of a tube. The same subject was gone over fully in an article entitled Atony, Dilatation, and Displacements of the Stomach, which I contributed to the International Medical Annual for 1900. The following extract from that article will make clear several of the more practicable methods of diagnosticating gastric atony: " Simple Tests of Gastric Motility. — If the patient be made to uncover the abdomen and assume the supine position with the legs slightly flexed, a few taps with the tips of the fingers over the stomach will generally reveal a marked muscular atony, when present, by the splashing sound which is pro- duced. Sometimes,' in consequence of extreme tension of the abdominal muscles, this splashing sound cannot be obtained even when the stomach contains much fluid and its walls are quite weak. In such a case, if, while the examiner presses his fingers against the lower part of the stomach, the patient be induced to contract voluntarily and repeatedly his diaphragm and abdominal muscles, as is done by the Oriental muscle dancers, the splash can usually be produced, or at least any fluid present can be felt, when there is much motor insuffi- ciency. " In the perfectly normal stomach with properly strong and resilient muscles and not prolapsed, the splash cannot be evoked by any method, even directly after drinking. The louder the splash, the larger the area over which it can be developed, and the longer after a meal, or after drinking a definite quantity of fluid, it can be recognized, the greater the motor insuffi- ciency. When it can be heard over a much larger area than the stomach normally covers, the atony has become a dilata- 384 THE GASTRO-INTESTINAL CLINIC tion ; when heard lower than normal, there may be only a downward displacement. " The writer of this has lately described a more accurate practical method by which any physician reasonably well skilled in percussion can first determine the boundaries of the stomach by percussion over it when empty, and again after drinking one or two glasses of water with the patient in differ- ent positions, especially recumbent and standing; and then, having ascertained the size and position of the viscus, he may easily determine its relative muscular power or motility by the time recjuired to empty itself after test meals. Examinations of the abdomen by both the splash and percussion in the two different positions, and by the method above mentioned, will readily show when the stomach has become empty by the dis- appearance of the splash previously obtained, and of the zone of dullness heard over the lowest part of the stomach on per- cussion with the patient .standing. In determining the bound- aries, the results are more positive if the stomach be first inflated, either by pumping air in through a tube or by having the patient take a small teaspoonful of sodium bicarbonate dis- solved in a glass of water, followed by 30 drops of dilute HCl in half a glass of water. " In the case of patients accustomed to the tube, it is easier, for the physician at least, to introduce that instrument at dif- ferent periods after meals, and thus learn how long it takes the stomach to propel its contents into the duodenum. This is Leube's method of testing the motor function." Ewald's salol test was formerly much used to determine the motility of stomachs, but has been less depended upon of late, because with it there are possible sources of error; yet it will usually yield approximately correct results. It is described in Lecture VI. Treatment. — To cure simple atony of the stomach it is necessary, first of all, to remove the cause. If the patient has eaten or drunk immoderately, he must stop and follow rational dietetic rules. Faulty modes of dress must be abandoned. Any GASTRIC ATONY 385 Other palpable transgressions of the laws of health must then be corrected. If a condition of general neurasthenia exist, there must be a resort to the usual methods of overcoming it by rest in a degree suitable to the needs of the case, regulated exercise and nutritious feeding, with massage and electricity generally as well as locally to the region of the stomach. Direct faradization of the stomach with the intragastric elec- trode, as described in the lecture on the Treatment of Chronic Sthenic Gastritis (Lecture L.), will be the most rapid and efficient means usually of restoring tone to the weakened gas- tric muscle. Abdominal massage is next in efhcacy, except when hyperchlorhydria complicates. When there is any excess of HCl in the gastric juice, massage of the abdomen needs to be avoided, and the condition must be vigorously combated by diet and by administering- alkalies in full and frequent doses at first, with smaller ones or less frequent ones later to main- tain the effect; and in such a case, which does not yield soon to medicines, the high-tension faradic current may be admin- istered intragastrically for five to eight minutes every other day. This will often succeed in stubborn cases which are not dependent upon ulcer or the scar of one. To neglect hyper- chlorhydria is not only to risk the development of gastric ulcer and other serious complications, but also spasm of the pylorus, with a resulting dilatation of the stomach. Fuller details of the treatment applicable both to the severer cases of gastric atony and to dilatation resulting from either atony or hyper- acidity, are given in Lecture XXXIX. LECTURE XXXVII DILATATION OF THE STOMACH— (DILA- TATIO VENTRICULI, GASTRECTASIS) Several distinguished authors decHne to give a place in their nomenclature for this very common and well-defined anatomic disease. They do not deny that there are such dis- eases as dilatation of the heart, dilatation of the esophagus, dilatation of the intestines, and probably dilatation of most of the other hollow organs, but when the stomach is affected in the same way, they prefer to disregard the anatomic condition and classify the malady according to one of its causes, such as obstruction of the pylorus or \veakness of the stomach walls (myasthenia gastrica, motor or mechanical insufficiency), or according to its most important symptom, stagnation — ischo- chymia. I freely concede that there is some force in their con- tentions, but nearly every innovator in this respect has coined a new name for the affection, and the result, besides being con- trary to the analogy of similar lesions elsewhere, is complicat- ing and confusing. Dilatation of the stomach is easily under- stood as that condition in which the viscus is both weaker in expulsive power, and larger than the average normal stomach, with a tendency to grow worse in both respects. The accuracy of this definition is in no way lessened by the fact that robust persons who eat or drink excessively may acquire stomachs of extra-large capacity, going on to enormous size in some in- stances, without at first showing any impairment of their motor powder or other functions. Such enlarged stomachs during their stage of hypertrophy have been described by Ewald as cases of megastria, and by Boas as megalogastria. As such persons are usually not long-lived, it is quite possible 386 DILATATION OF THE STOMACH 387 that most of them may die before the stage of dilatation develops. Acute Gastrectasis. — By the term gastrectasis, or dilatation of the stomach, is usually signified a chronic or persistent form, which is rarely fatal except by gradually undermining the health and vigor after months or years. Recently, however, many cases of what are called usually acute dilatation of the stomach have been reported. Little or nothing is to be found in most text-books and treatises upon the stomach concerning this form of disease. Yet it is doubtless much more frequent than has been supposed, and as most of the cases so far reported have proved fatal, it is important to bestow some attention upon the subject in this connection. Until very recently, the diagnosis was rarely made before death, it having remained for the autopsy to demonstrate the cause. A variety of hypotheses has been put forward to account for the sudden supervention of such a dangerous con- dition. It has occurred most frequently as either a sequel of operations upon the stomach or other viscera, or as a complica- tion of pneumonia, or of one of the acute infectious fevers. Some writers have supposed that the gastric muscles had be- come suddenly paralyzed, others that there was a spasm of the pylorus as a result of hyperacidity. It is noteworthy that numer- ous cases carefully studied by stomach specialists, including two by Friedenwald of Baltimore,^ had an enormous secretion of hyperacid fluid. Still others hold that there must have been a mechanical obstruction of some kind either at the pylorus, or, which seems more plausible, since the duodenum is often found to have shared in the dilatation, at some point in the intestines below. It is very probable that each of these causes may be occasion- ally efficient in producing a sudden and dangerous dilatation, especially under the conditions named above, when the vital powers have been seriously weakened by infectious disease or the shock of an operation ; also that in dyspeptic or debilitated '' A7H. Med., August 10, igoi. 388 THE GASTRO-INTESTINAL CLINIC persons overloading the stomach might cause it. Those of you ,who have followed this series of lectures attentively should not have much difficulty in making promptly the diagnosis of acute dilatation of the stomach, especially after the further consider- ation of the subject of gastric dilatation in general, given in this and the subsequent lectures. The same rules apply con- cerning both the diagnosis and treatment of the acute form as in the case of the chronic form, except that the symptoms, espe- cially the prostration and later the vomiting, are more urgent, the pain, distention, and tympany usually much greater than in any chronic case, however marked or severe, and the necessity for frequent and thorough evacuation of the dilated viscus by lavage, more imperative. An early recognition of the con- dition, and energetic treatment of it in such a manner, would probably have saved a majority of the fatal cases hitherto reported, though, in those in which the infection and prostra- tion were extreme, it is possible enough that even our more efficient modern methods of combating such accidents might have failed. It seems scarcely necessary to remind you not to permit food, drink, or medicines to be taken by the mouth in acute dilatation. Least of all should soups or other excitants to the gastric glands be ingested in these cases, since there is likely to be in them a hypersecretion of the gastric juice, amounting sometimes, as in Friedenwald's cases, to a gastrosuccorrhea. CHRONIC DILATATION OF THE STOMACH. The .Etiology. — Since these lectures are designed tO' be prac- tical lessons on, rather than exhaustive expositions of, the sub- jects discussed, I shall teach you, regardless of the endless va- riety of classifications and definitions found in the books, that setiologically there are two -main kinds of chronic dilatation of the stomach — ( i ) the atonic, and (2) the obstructive. The lat- ter may be subdivided again into (a) those in which the obstruc- tion is spasmodic, which probably include a large majority, and (b) those in which it is mechanical. The mechanical obstruc- DILATATION OF THE STOMACH 389 tion may result from any of the following conditions, which are named as nearly as possible in the order of their frequency : ( I ) Round peptic ulcer, or the cicatrix of one, in the pylorus or duodenum; (2) the stenosing form of chronic gastritis, involv- ing especially the pylorus; (3) cancer of the pylorus or duo- denum; (4) kinks, or sharp flexures, in the pyloric end of the stomach or in the duodenum, produced by a displacement of the stomach, or by adhesions gluing the pylorus or duodenum to adjacent structures; (5) very rarely other tumors or a dis- placed right kidney occluding the outlet of the stomach, or les- sening the lumen of the pylorus or of the gut below by pressure from without. The strictl}^ atonic dilatations, in which neither hyperacidity with spasmodic closure of the pylorus, nor mechanical obstruc- tion plays any part in the aetiology, are probably less both in frequency and in extent, as a rule, than those depending upon obstruction, though you will see numerous cases in women in whom the corset and dragging skirts have had much to do with the causation as described in the preceding lecture on Gastric Atony. I have found dilatations dependent upon an excessive secretion of HCl (hyperchlorhydria and acid gastric catarrh), exceedingly common, and in a few cases the dilatation has seemed to result from an excessive organic acidity due to fermentation. It is possible that a certain proportion of the cases in which the findings are dilatation of the stomach with absence of free HCl, stagnation of the contents, much organic acidity from fermentation, and no mechanical obstruction discoverable, may have been due to excessive eating and drinking, which first pro- duced a hypertrophy of the organ, followed later by a weaken- ing of the muscular fibers and dilatation. Other powerfully predisposing causes of atonic stomach walls, and thus indi- rectly of dilatation, are tuberculosis, cancer, gastroptosis, and diseases of the heart, catarrh of the stomach, especially in the acid form, and intestinal catarrh, disease of the liver, anaemia, .or any vice of nutrition which lowers the nerve and muscle 390 THE GASTRO-IXTESTIXAL CLIXIC tone generally. You should not forget that inheritance also plays an important role in the tendency to gastrectasis. The children of parents thus afflicted do not often escape it, accord- ing to my experience. Symptomatology. — The symptoms differ much in the vari- ous types. In the mildest atonic form in which there are motor insufficiency and overdistention after eating, \Yith little enlarge- ment demonstrable when the organ is empty, the only symp- toms may be a coated tongue, bad taste in the mouth, a feeling of weight in the epigastrium, and an uncomfortable fullness after meals, with usually considerable flatulence (especially shown by belching), a lessened appetite (though exceptionally the appetite continues good), and often constipation, headache, poor sleep, and some vague impairment of the general health. When the cardiac orifice contracts more tightly than the pyloric there may be no belching, but only a gradual accumulation of gas in the bowels. In such cases both the stomach and bowels are markedly distended and tympanitic for many hours after each meal. The bowels in such a case are often uncomfortably distended till after the next stool. In the hyperacid form of dilatation there may be spasm of the pylorus only, with the cardia not tightly closed, when there will be active contractions of the stomach, accompanied usually by pain, which is relieved by belching of gas or by copious vom- iting. When in this form of dilatation both orifices of the stomach remain long spasmodically closed, the violent and ineffectual contractions produce severe crampy pains, which are often not relieved until a large dose of some alkali or a decided sedative has been given or until emesis has been pro- duced. The same conditions cause rapid exhaustion and overstretching of the muscular coats of the stomach, resulting finally, when not relieved, in considerable dilatation' with some- times stagnation. In marked dilatation, fermentation is always excessive, the intestines are secondarily irritated and often infected. Constipation may then become obstinate, with all its in- DILATATION OF THE STOMACH 39I jurious consequences, but may alternate with diarrhea; and aniEmia and the other symptoms of auto-intoxication, in- ckiding mental and nervous depression, headache, insomnia, weakness, emaciation, etc., are likely to develop. The same cause, pyloric spasm due to hyperchlorhydria or acid gastric catarrh, may in time produce what is called dilatation with retention, a term applied to those cases, usually severe, in which remains of food are found in the stomach in the morn- ing before breakfast, that is, ten to twelve hours after the last meal. You may occasionally encounter such a retention, even in cases of rather moderate dilatation, especially when the pa- tient has eaten a heartier or more complicated meal than usual, or eaten the last meal of the day when exceptionally tired or worried. When the stage of retention has been reached, the vomiting becomes characteristic, occurring every two or three days, and bringing up often several pints of very sour and most offensive fermenting masses of partly digested food. Emacia- tion and a variable degree of physical weakness usually show themselves by this time, and go on from bad to worse in cases not under proper treatment, but in these hyper- acid cases a vigorous and persistent treatment of the underly- ing condition may arrest the process at almost any stage, and start the patient on a long and toilsome road, which will finally lead, if persevered in, to a restoration of health. When dilatation has resulted from any mechanical obstruc- tion of the stomach outlet, except the swallowing of a foreign body, there are not likely to result such violent spasmodic pains as may follow the sudden closure of both orifices from the irri- tation of hyperacid gastric contents. The stenosis of the pylorus may develop more gradually, and thus the element of spasm be absent from the clinical picture. In other respects the symptoms, except when the obstruction is caused by a malignant growth, are much the same, and develop as in the form already described, though the course is usually more steadily downward and not amenable to non-surgical treat- ment, as it is in the hyperacid cases. 39- THE GASTRO-INTESTINAL CLINIC In the malignant cases, there is the added constitutional Infection which hastens the downward course and begets its ^own peculiar cachexia, usually some time before the dilatation has progressed far enough to produce a serious auto-intoxica- tion from the stagnation and retention. In all the severer forms of dilatation which are accompanied by great delay in emptying the stomach, and especially by copi- ous vomiting, the system is insufficiently supplied with fluid, and, in consequence, there is scanty urine, with thirst and a dry skin. You should always bear in mind in doubtful afebrile cases, accompanied by pronounced scantiness of the urine, that you may be dealing with dilatation of the stomach, and proceed to make a very careful examination of the abdomen. Among the objective symptoms, or physical signs of gastric dilatation, are the splashing sound which is nearly always to be obtained in such cases by a light tapping with the fingers over the stomach, or by succussion, not only during the usual digestive period of two or three hours after a light meal, such as the continental breakfast, or six to seven hours after the usual mixed meal, such as a dinner, but even for a much longer period after eating. In a marked case of dilatation you can usually obtain the splash at any time after breakfast during the entire .day and evening, though, unless there is retention, no such signs of fluid remaining in the stomach should be discov- erable before any food or drink has been taken in the morning. When there is only slight dilatation of the stomach with strong or spasmodically contracted abdominal muscles, the splash may be elicited only by causing the patient to make sudden volun- tary contractions of the diaphragm and recti muscles. The signs of dilatation, as well as of displacements of the stomach, which are afforded by percussion in various positions of the body and auscultatory percussion and auscultatory friction, were fully described and discussed in Lecture V. Some fur- ther account of them was also given in Lecture XXXVI., on Gastric Atony. By the administration of a teaspoonful of sodium bicar- DILATATION OP THE STOMACH 393 bonate well dissolved in water, follow^ed by 30 to 40 drops of dilute HCl, or a large half-teaspoonful of tartaric acid dis- solved in half a glass of water, you will be able to inflate thoroughly any except the very largest dilated stomach, and with these it is safe to repeat the above doses within a few minutes. Having thus produced a marked tympany over the entire stomach, no great delicacy in percussion is required to map out the boundaries, except in very obese persons, and these are pretty sure not to have seriously dilated stomachs, though the latter are often simply enlarged — hypertrophied. To clinch the matter you should always note carefully the area limits of tympany on percussion, with the patient recumbent. Then, give two glasses of water and percuss the patient while in the standing position. If a zone of positive dullness or flat- ness now appears across the middle or even lower abdomen where before there was tympany, and you can elicit a splash there where there was none before, the lower line of the dullness marks the lower border of the stomach, especially if the lowest limits of the splash coincide. If the colon should be full and the result, therefore, seem in doubt, empty it by a copious enema, or by physic, and test in the same way again. Some of the chemical tests of gastric motility, such as Ewald's salol test, or Klemperer's oil test, may be employed to confirm the results of percussion, but are not very cer- tain, and not necessary. Reliable means of deciding in very doubtful cases as to the position of the boundaries are the instrumental methods, such as palpating with one hand over the bared abdomen, the tip of a sound introduced into the stomach ; or, better yet, palpating in the same way Turck's revolving sound — the gyromele. By means of the latter, especially, one w^ith a little practice can easily and very certainly outline the stomach. There remain the examination "f the organ by m«ans of the Roentgen rays — practicable with the aid of an unusually powerful apparatus only — after causing the patient to swallow half an ounce of bismuth in emulsion, on each of several days in succession, and the use of the electric 394 THE GASTRO-INTESTINAL CLINIC lamp within the stomach, which is feasible enough when further confirmation of the simpler methods is necessary. Bismuth has been proved to be unsafe in enormous doses too frequently repeated, and wdien used in this w^ay, care should be taken to secure thorough bowel movements every day. See page 88. COMPLICATIONS AND CONSEQUENCES OF GASTRIC DILATATION It would be a well-nigh endless task to enumerate all the possible complications and consequences of gastrectasis, espe- cially if one were to include in the list all the consequences of the diseased conditions upon which dilatation of the stomach may depend. Hyperchlorhydria, in any of its forms, including acid gastritis, pyloric ulcer, pyloric cancer, and other obstruct- ive disease of the pylorus, as well as diabetes and various acute infective diseases which can cause gastrectasis, all tend to produce at the same time other derangements of the health, and all of these that occur might be considered in a sense com- plications of the dilatation. Among the most serious of the complications which can result from a neglected gastrectasis, through the fermentation and putrefaction of the long-retained gastric contents, is tetany, a brief account of which will be found below. Autotoxic nephritis, a weakening of the entire muscular sys- tem, including the heart, insomnia, neurasthenia, and nervous prostration are other possible complications or consequences of the autotoxsemia which may be superinduced by a prolonged and incurable or badly treated curable form of dilatation of the stomach. Tetany. — In many and various forms of gastro-intestinal disease associated with neurasthenia and anaemia, you will find a hyperexcitability of the reflexes. In a good many of them the patients will complain of being awakened out of sleep by involuntary twitchings or contractions of the extremities — especially the legs. Very exceptionally, indeed, in extreme dilatation of the stomach with hyperchlorhydria or stenosis of DILATATION OF THE STOMACH 395 the pylorus, there occurs what is called tetany. This affection is characterized by convulsive attacks in which there are spas- modic contractions of the flexor muscles of the arms and legs, especially the calves. The abdominal and other muscles may also be involved, and there is often during the attack a peculiar fixed grimace due to a spasm of the facial muscles. Generally, consciousness is not lost, but there is frequently some disturbance of the speech, and occasionally complete un- consciousness. The cases thus affected are difficult to diagnos- ticate from true epilepsy. The attacks may be so severe in rare cases as to closely resemble tetanus itself. It is now generally admitted that gastric tetany is the result of an auto-intoxication. The decomposing stagnant material in the stomach poisons the blood and nerves, so that the slight- est exciting cause may provoke, an attack. In not a few in- stances attacks of the kind have been provoked by lavage of the stomach, but it is highly probable that these were neglected and aggravated cases that could not have recovered under any circumstances, and also that if the lavage had been begun early enough and carried out intelligently at the proper time with the aid of such other treatment, medical, mechan- ical, or surgical, as was required for the dilatation, there would have been no tetany, and that in many of these cases a cure might have resulted. The therapy of gastric tetany is consid- ered at the end of Lecture XXXIX., in the Treatment of Dila- tation of the Stomach. LECTURE XXXVIII THE DIAGNOSIS OF DILATATION OF THE STOMACH When a stomach has once become decidedly dilated, from whatever cause, its most conspicuous local features will be (i) an enlargement of the organ beyond the usual limits of the nor- mal stomach; (2) slowness and often incompleteness in pass- ing its contents on into the duodenum; (3) a flabbiness or re- laxed condition of the stomach walls, as shown by the splashing sound over the viscus, elicited in various ways as previously described, and by the lack of resistance felt on palpating deeply the same part of the abdomen. Incidentally, also, there will be increased fermentation of the ingesta with much gas, which may show itself by eructations or, passing downward, produce an uncomfortable distention of the intestines. In case both orifices of the organ are spasmod- ically contracted, the stomach itself undergoes marked and more or less painful distention, sometimes so much so that it stands out prominentl}^, and its size and location can then be determined upon simple inspection. In such cases, too, there are often powerful and painful contractions of the stomach walls, which may be visible externally. In dilatation which is at all marked, the percussion note over the stomach is nearly always tympanitic, so that it is not usually difficult to map out its boundaries, even without artificial inflation, by the spe- cial method described in Lecture VI. When this is not the case, you can usually succeed in inflating it sufficiently by the method described in the preceding lecture. Many authors advise inflating by pumping air in through a tube which is first introduced in the usual way, and this is a 396 DIAGNOSIS OF DILATATION OF STOMACH , 397 very good method ; but, remembering that these lectures are ad- dressed to general practitioners, I am trying to teach the sim- plest methods which can be depended on to effect the desired result. The tube is indispensable in determining the functional work of the stomach and diagnosticating the diseases of its glands, as well as in the treatment of some of its affections. No intragastric instrument, however, is necessary, except in unusual instances, to make out the size and location of the stomach with sufficient exactness for most clinical purposes, and this should always be done at the very first consultation with a dyspeptic, when to insist upon introducing a tube immediately would often prevent any subsequent consulta- tions and thus result in a loss to both patient and physician. As much as possible should be learned first without the tube, and the importance of the knowledge thus acquired, especially if gastric dilatation be demonstrated or a displacement of the stomach, intestines, liver, or kidneys be found, assists greatly in reconciling the patient to less agreeable procedures afterward ; and one or more of these faults you will find, as a rule, in fully one-third to one-half of your chronically ailing women patients. To establish the diagnosis, then, of dilatation of the stom- ach you must (i) demonstrate an enlargement of it, and (2) abnormal weakness in its walls. The normal stomach extends from the diaphragm above, at the left, where it is in appo- sition with the heart, to a point in the middle line midway between the ensiform process of the sternum and the umbilicus or at the lowest one inch above the latter, and from the anterior axillary line, at the left, one and one-half to two inches to the right of the middle line. But considerable variations in the size of the stomach may occur normally. In Germany, stom- achs seem to average larger than elsewhere, and a number of German writers hold that one not extending below the level of the umbilicus is not abnormally large ; but a preponderance of other trustworthy evidence is in favor of the dimensions above given. The accompanying illustrations represent side by side a 398 THE GASTRO-IXTESTINAL CLINIC normal and a moderately dilated stomach. Figure 51 is an exact reproduction of one in Fleiner's Krankhcitcn dev Ver- FiG. 51. — Stomach of normal size. The stomach, normal in size and position, is shown by the dashed line, the liver to the right and partly covering it. The shaded part is that in contact with the abdominal wall. dauuiigsovganc, and Figure 52 is the same with the stomach enlarged downward and laterally, as it most commonly is in gastrectasis of a not very high grade. In the cases of pyloric DIAGNOSIS OF DILATATION OF STOMACH 399 tumors, and in certain atonic cases, a much more extensive dilatation may result. Figure 51 shows the outlines of a stomach in the normal posi- FiG. 52.— The stomach dilated, but not displaced, is shown by the dashed line. tion and of the average size, as it is usually found in a perfectly healthy young person; and it is noteworthy that in middle or advanced age, especially in persons who have in- 400 THE GASTRO-INTESTINAL CLINIC diilged excessively in either food or drink, the stomach is usually larger than. during the first half of life. The shaded area in the same illustration shows that part of the stomach usually in contact with the anterior abdominal wall and there- fore easily percussed; a relatively small area, you will notice. But not many stomachs of normal size and position will be met with among dyspeptics. The lower border in most cases will be found at or below the navel. When the organ has been fully inflated, except possibly in very fat persons, the lesser curvature and entire fundus can be made out by careful percussion, in spite of the overlying structures. If percussion should fail, as it almost never does in skilled hands, the best of the instrumental aids tO' a correct diagnosis are Turck's gyromele or revolving sound, and some one of the forms of apparatus by means of which the interior of the stom- ach is dimly illuminated by a tiny electric light on the end of a sound. The gyromele affords the most accurate results, since it does not distend the organ any, nor otherwise mislead. Its distal end can easily be palpated, as it wabbles around the outer limits of the viscus. But it must be employed cautiously, and never when an ulcer or cancer is likely to be present. Pa- tients like it even less than they do the tube. Though I have in my office a number of such ingenious intragastric instruments and am familiar with their technique, I rarely employ them, having never yet failed to learn by percussion and the splash, with sufficient exactness for all practical purposes, the size and position of the stomach after inflating it, even in obese patients. In the more doubtful cases, the aid of auscultatory percus- sion and auscultatory friction may be necessary ; and it may be as well to repeat here that in any case of decided dilatation when liquid is present in the viscus, a splashing sound can be obtained usually by succussion, or by clapotage (abrupt tapping over it, with the fingers held perpendicularly to the abdomen). By auscultating with the help of a binaural stethoscope to as- certain over how large a region the splash is heard, the lower and right borders of the stomach can be approximately deter- DIAGNOSIS OF DILATATION OF STOMACH 401 mined, though sometimes the splash cannot be heard within an inch or two of the lower border and the full size is then not revealed. Percussion, however, corrects this finding. To determine the second indispensable factor in gastric dila- tation, to wit, deficient motility or a lack of propulsive power Fig. 53. — Area of tympany in case of gastrectasis with gastroptosis. in the stomach, the surest method is to withdraw the contents with the help of a tube at sufficient intervals after eating — about three hours after a light carbohydrate meal, and six to seven hours after a large mixed meal, such as a dinner. If then the stomach be found empty, there is no^ serious lack of motor power, but if much liquid or remains of food are then brought up, the propulsive power is poor, except, of course, when there is obstruction at the pylorus. But when there is enlargement with an easily obtained splashing sound, dilatation is present, either atonic or obstructive. A foamy, yeasty appearance of the contents with a very sour or rancid odor would be also confirmatory evidence of dilatation with stagnation. If food remnants, or even digested chyme, should be found in the 402 THE GASTRO-INTESTINAL CLINIC stomach before breakfast, it would show dilatation with reten- tion. The salol test will give you results usually which approx- imate correctness ; and by a further development of the external method of determining the boundaries, I have learned to decide with much exactness when a stomach has emptied itself. After having once fixed the location of the greater curvature, it is only necessary to tap for the splash with the patient recumbent, and percuss with him first recumbent and then standing (espe- cially if the colon has been previously cleared), to decide positively whether or not the. stomach is substantially empty. By testing thus at the proper intervals after meals, the motor power can be judged. (See Lecture VI.) Differential Diagnosis. — Having thus settled the two main points as above described, if there is enlargement with mark- edly weakened motor power, dilatation exists ; but there might possibly be present also gastroplegia, or paralysis of the stomach, a very rare condition, which you may never encoun- ter. The latter comes on suddenly and usually after some severe shock, mental, moral, or physical, especially after an operation. The suddenness of the onset and the completeness of the retention of all food with a swelling in the epigastrium would be diagnostic. Megastria, or simple hypertrophy of the stomach, should never mislead you, since in this disease, though the stomach is enlarged, it is strong, able to empty itself in the proper time, and no marked splashing sound is obtain- able even shortly after eating or drinking. Gastroptosis alone, or downward displacement of the stom- ach simply, would be distinguished by the fact that the fundus of the stomach and the lesser as well as the greater curvature, would be found too low, as shown by moderately strong per- cussion after full inflation, or the use of the instrumental meth- ods of exploration previously described. The tympanitic note could not then be heard up to the region of cardiac dullness as normally it should be, except that in the cases of displaced pyloric end, there would be no change in the percussion note over the fundus. Furthermore, unless dilatation should com- I DIAGNOSIS OF DILATATION OF STOMACH 403 plicate the displacement, as it usually does sooner or later, the signs of insufficient propulsive power would be wanting. The condition most likely to cause confusion is that form of displacement known as vertical stomach, in which the supports of the pyloric end having become much relaxed and elongated, it drops downward and swings around toward the left until the organ is almost perpendicular in the abdominal cavity. Before such a displaced stomach has secondarily dilated, it could not, of course, show the motor insufficiency of true gas- trectasis, and even after such a development you should be able to easily distinguish it by a careful percussion laterally after full inflation. The narrowness of the perpendicular strip of tympany extending down into the pelvis often, with a splash generally obtainable over the same peculiar space only, is quite striking. I lately saw three such cases in new patients during a single week. Reichmann's disease, in which there is a continual flow of gastric juice, might be mistaken foi dilatation if occurring in an abnormally large stomach, since fluid could in such a case be found in the organ at times when it should be empty. But if you wash out such a stomach and then withhold all food and drink from the patient for half a day, fluid would be found present at the end of that time in Reichmann's disease, but not in dilatation. Moreover, in the latter disease, the fluid to be obtained from the fasting stomach or before breakfast is likely to be a very strong gastric juice with little or no food remains and odorless, while in dilatation the contents are malodorous, sour-smelling, and full of partly digested food along with abundant fermentation products. Hypertrophic enlargement of the stomach without dilatation might also deceive you, if at the same time there should be such an excessive secretion of HCl (hyperchlorhydria) as to produce spasm of the pylorus with temporary retention of the gastric contents ; or the same kind of a stomach with such a deficiency of gastric juice (hypochlorhydria, hypopepsia) as to prevent the digestion of the gastric contents, might mislead, 404 THE GASTRO-INTESTINAL CLINIC since in this case the contents might exceptionally be retained beyond the usual time, especially if meat imperfectly masti- eated had formed part of the food taken. In both these cases, however, emptying the stomach with a tube, and a chemical examination of the contents (in the case of marked hypochlor- hydria even simple inspection should suffice), would reveal the true cause of the delayed expulsion. Moreover, in the condi- tions supposed, there would be an absence of the splashing sound, even with the organ partly filled, and this alone would be incompatible with much muscular atony — still more with marked dilatation. Ewald teaches that we should also differentiate gastric dila- tation from an overdistended colon, ovarian cysts, sacculated ascites, hydronephrosis, and echinococcus cysts, but anyone who has learned to percuss out the boundaries of the stomach after inflation could scarcely be misled by any of the above- mentioned diseases. If, however, you should have serious doubt as to the possible presence of any of them, the use of the gyromele in the stomach would enable you to reach a positive decision. In all doubtful cases the examination should be begun with the stomach and colon both empty. You can then afterward introduce fluid into the stomach as required. LECTURE XXXIX TREATMENT OF DILATATION OF THE STOMACH Prognosis. — Gastrectasis, resulting from a mechanical ob- struction of the pylorus, has, naturally, the same prognosis as its cause. When this is the cicatrix of a healed ulcer, a benign tumor in or near the outlet, the pressure of a displaced right kidney, inflammatory adhesions between the stomach and any adjacent organ, or a kinking of the duodenum from a down- ward displacement of the stomach, prompt surgical interven- tion may often effect a restoration to health ; but in cases due to the last-named cause, or to a marked displacement of the right kidney, a resort to the knife is rarely necessary, non- surgical measures usually sufficing, if skillfully carried out and for a sufficient length of time. When the obstruction is due to a malignant growth, a very early diagnosis, followed at once by a removal of the neoplasm, may rescue the patient ; but under present prevalent conditions this rarely happens, because the diagnosis is nearly always made too late. The cases dependent upon hyperchlorhydria and the atonic cases are amenable to treatment by dietetic, medicinal, and mechanical means when taken in time, but unfortunately are rarely recog- nized until they have progressed to an advanced stage and the patient's health has been so badly undermined that the recovery is tedious and difficult. Treatment. — It is unnecessary to mention here the indica- tions for the surgical operations when a cancer or other tumor obstructs the pylorus, producing gastrectasis and threatening a speedy fatal result, since these are more appropriately discussed in Lecture LXXXIL, on the Surgery of the Stomach and Intes- 405 406 THE GASTRO-INTESTINAL CLINIC tines. The other mechanical obstructions calhng for surgical intervention are also referred to briefly in the same place ; besides -sthey are all fully described in the works on surgery, and the general practitioners who are prepared to open the abdominal cavity in an emergency (as all of you should be) will neces- sarily have such works at hand. But I need scarcely add that except in a grave emergency admitting of no delay, you should summon the most expert laparotomist obtainable to perform such delicate operations. It is my purpose to indicate here how you may treat hope- fully by non-operative measures the cases of dilatation amenable to such treatment. These measures comprise diet, lavage, abdominal massage, electricity, gymnastics of the trunk muscles, a few medicinal remedies, and all the means by which the health and strength of the patient can be built up, includ- ing, in addition to those just mentioned, hydrotherapy, climato- therapy, a judicious alternation of rest and outdoor exercise, etc. Dilatation from Pyloric Spasm. — Let us consider first a most important class of what may be called the non-surgical dilatations of the stomach — to wit, those dependent upon spasm of the pylorus following severe and generally old neglected cases of hyperchlorhydria or acid gastric catarrh. These are likely to be stubborn, because nearly always accompanied either as cause or consequence by chronic intestinal indigestion and often by intestinal catarrh with neurasthenia and greatly lowered nutrition. The diet, which is most important in all cases of dilatation, is especially so in this form of it and is different from that required for simple atonic dilatation. The articles which usually agree best are milk, cream and butter, eggs, stale bread, toasted (but not too hard, and not the coarsest kinds of bread, which are too irritating), and the partly dex- trinized grain foods such as Shredded Wheat Biscuits, Force, Grape Nuts, Malta Vita, etc., taken dry or slightly moistened with milk or water, purees of the blander vegetables, Plasmon (a valuable new proteid made from milk), olive oil and other TREATMENT OF DILATATION OF STOMACH 40/ fats, beef juice, and often finely chopped beef, but either no meats in the ordinary form, or small portions of them, as well as of fish and oysters ; no other shellfish. Nothing irritating or very stimulating to the gastric glands should be allowed, and this rules out entirely the condiments, acids and acid fruits, in- cluding tomatoes, and renders generally undesirable the coarser kinds of breads, of cereals and of vegetables, coffee and tea, and the alcoholic beverages without exception. Recent experi- ments have shown that the fats and sugar are especially efficacious in lessening the secretion of the gastric juice, though they are often contra-indicated by the intestinal complication. The starch foods, except when partly dextrinized, are difficult of digestion in such cases and must be very thoroughly in- salivated, as can best be done with the dryer forms long masticated, and all these should be taken very early in a meal — never at the end of it. Even then, in bad cases it is well to give Taka Diastase or some other good diastatic preparation with such foods, or just before meals to assist in converting the starch. In this, as in all the forms O'f gastric dilatation, very large meals and any overloading of the stomach with either food or drink must be absolutely prohibited. Whether only two or three moderate meals or a greater number of smaller ones at shorter intervals are to be taken daily is a cjuestion to be de- termined in each case by itself, since no general rule will apply to all. Sometimes frec[uent small feedings agree well, but less time is then left for the debilitated organ to rest and recuperate between, so that, as a rule, you will probably find the best curative results to follow the plan of giving two or three times a day a moderate amount of bland, digestible food as concentrated in form as possible, so as not to distend unduly, and then, if necessary in bad cases to keep the nutrition up to the proper level, you may have additional nourishment ad- ministered by enema once, twice, or oftener daily. The al- lowance of sufificient liquid with each meal to dilute and thus lessen the acidity of the gastric juice will often assist in relax- 408 THE GASTRO-INTESTINAL CLINIC ing the spasm of the pylorus and thus in curing the dilatation; but the amount of liquid taken should never be enough to over- distend the stomach. No cases are so difficult to diet as those of hyperchlorhydrics, whether or not their stomachs happen to be dilated. In the higher classes of society especially strongly seasoned, stimulat- ing proteid viands usually predominate in the daily diet. Caterers, cooks, and waiters all seem in a conspiracy to force on hyperchloriiydric patients foods and drinks prepared so as to suit especially atonic stomachs, and therefore injuriously irri- tating for the opposite kind. Then, if, after indulging liberally in the customary stimulating foods and beverages, such a patient suffers from burning pains, as he is very apt to do, the trouble is often aggravated instead of relieved by the treatment prescribed. Whether he tries some quack medicine, consults the drug-store man, or calls in a .physician who knows only one form of dyspepsia, the chances are that the remedy depended upon will be a combination of ginger or capsicum with pepsin and a bitter tonic, and often full doses are added of the very drug from an excess of which he is suffering — that is, hydro- chloric acid. Medicines, especially alkalies and antispasmodics, will usually be required in the cases of dilatation dependent upon hyperchlorhydria, and you may administer bicarbonate of sodium in half-teaspoonful, or even one- or two-teaspoonful, doses two hours after meals, or prepared chalk instead when there is diarrhea, or calcined magnesia when there is constipa- tion. Atropine sulphate, grns. g^ir to -jV several times a day, may be needed also in the worst cases to control the excessive secretion, and I have found that the addition of 3 to 4 grns. of extract of yerba santa to a pill containing atropine or bella- donna and nitrate of silver, grn. ^, tends to the production of more prompt results. But many of these cases resist both diet and the strongest medication for some timiC, and here intra- gastric faradization with the current of high tension will prove the most effective of any means at our command, except when TREATMENT OF DILATATION OF STOMACH 409 the hyperchlorhydria is due to a latent ulcer, or possibly when perigastric adhesions complicate. It serves at once to increase muscular contractions and diminish secretion, as fully ex- plained in Lecture L. on the Treatment of Acid Gastric Catarrh. Massage of the abdomen is contra-indicated in all cases of excessive HCl. The necessity for mental and sexual rest cannot be too strongly insisted upon. The excessive HCl secretion sometimes causes an intolerable gastralgia, but in such cases opium and morphine should be avoided, as tending to increase gastric secretion according to recent ex- periments. Administer instead very large doses of alkalies with atropine either hypodermically or by the mouth, dissolved in warm, not hot water, after emptying the stomach by lavage. This may be followed, when necessary for stubborn pain, by a spray of menthol or cocaine, one grain to the ounce, applied inside the stomach by the Einhorn spray apparatus. Gym- nastic exercises designed to strengthen the abdominal and trunk muscles generally assist greatly also in toning up the musculature of the stomach itself, when the hyperacidity has been controlled by the means already discussed. Intragastric Electricity — But electricity is the prince of remedies in these cases of dilatation associated with, and often dependent upon, an excessive secretion of HCl. Large doses applied percutaneously through from the spine to the stomach can often help decidedly, as many observers have testified, but with nothing like the certainty and rapidity of effects obtain- able by the high-tension induced current (faradism), applied with one pole within the stomach and the other either on the spine or over the epigastrium. The technique of such applica- tions is fully described in Lecture XXX., under Methods of Treatment. Let me add here, however, that with a suitable electrode such as my modification of Einhorn's, the procedure is not difficult nor troublesome, except for patients who have an irritable stomach. (See page 330 for several other im- portant contra-indications). Any form of instrument will an- swer which carries the current into the water with which the 4IO THE GASTRO-INTESTINAL CLINIC stomach must be partly filled, this water really acting as the in- tragastric electrode and distributing the current very gently to all those parts of the viscus with which it is in contact. But the smaller this current-carrier is the better, provided it has sufficient rigidity to be easily introduced. It is usually best to have the stomach empty when electricity is given in this way, especially if the stomach is inclined to be irritable, and in the latter case, it is sometimes necessary to wash out before begin- ning the treatment. No method so certainly tones up the weak- ened gastric muscles, and at the same time it sooner or later lessens the excessive secretion of HCl ; and also of mucus, when there is a complicating catarrhal process. For reports of several bad cases of dilatation cured in this way see Lecture XLIV. (Splanchnoptosis Concluded, etc.) and also especially Lectures XXIX. and XXX. (Intragastric Methods of Treatment). Treatment of Atonic Dilatation. — X^ext let us consider the cases of so-called atonic dilatation. A certain proportion of these probably owe their origin to a former hyperchlorhydria, which through lack of treatment persisted until the gastric glands became exhausted. Under this head of atonic dilata- tion it will be convenient to class all cases in which there are no indications of obstruction of the pylorus, either mechanical or spasmodic — no tumor, adhesions, or kinks affecting the stomach or the duodenum — and no existing excess of hydro- chloric secretion. In the treatment of this class the diet will differ mainly (i) in not requiring so rigid an exclusion of the irritants, stimu- lants, and sour things; (2) in not permitting a liberal use of fats, which would lessen still further the gastric secretion and aggravate the indigestion; (3) in requiring a greater restric- tion of the amount of fluid ingested; and (4) in permitting a much freer use of meats, meat juice, fish, oysters, and all the more digestible forms of animal foods, since the stimulating property of this kind of diet is no objection, but rather an advantage in the atonic conditions now under consideration, TREATMENT OF DILATATION OF STOMACH 4II and such foods contain usually a large amount of nourishment in a small bulk. They are besides less fermentable than most other forms of nutriment. But care must be taken that an undue proportion of proteid food is not too long continued, or nutrition will suffer; and it will often be necessary to assist its digestion by administering artificial digestants at the same time. An exclusive milk diet usually aggravates these cases, on account of the excessive bulk of it necessary, and for this reason the full Weir-Mitchell rest cure, notwithstanding its brilliant success in so many other ailments, frequently fails in patients who have true atonic dilatation of the stomach. On the other hand, the worst cases will generally respond satisfactorily to a modified rest tveatincnt, in which concen- trated foods, both proteid and carbohydrate, take the place of milk, especially when, in administering the massage and elec- tricity, an unusual amount of time and attention is devoted to the abdominal region. The abdominal massage, both in gas- trectasis and gastroptosis, needs to be given by specially trained manipulators, with the particular object always in view of crowding upward the stomach and intestines while the patient exhales, and effecting contractions of the visceral muscles as well as those of the abdominal wall by very deep and thorough, but never rough or painful, kneading while the patient's hips are kept higher than the shoulders, so that gravity may assist the replacement. The aggravated cases demanding such modified rest treat- ment are nearly always in women and are in large part attribut- able to their exceedingly irrational and unhygienic mode of dress. Hence, when these patients again begin to go about, it should be made plain to them that it will be impossible to , complete the cure and make it permanent, unless they will wear instead of the usual corset either a straight-front corset fitted snugly in its lower part only, or better yet a reform waist, which causes only a slight or no constriction of the upper abdominal organs, while it admits of having the skirts all suspended from the shoulders. A snug-fitting elastic belt for 412 THE GASTRO-INTESTINAL CLINIC the lower abdomen, however, often proves of great service by limiting the sagging tendency of the viscera. Faradic electricity, in the atonic cases also, can generally be given effectively through the stomach from front to back, using as full doses as can be borne with the largest-sized electrodes, and this treatment can be repeated daily with advantage for many weeks at a time. More speedy results can be obtained by the employment of the current from a coil having a short coarse wire applied directly to the inner walls of the stomach by means of the intragastric electrode ; but this should not, as a rule, be used oftener than every other day, nor be continued longer than four weeks at a time without an intermission of a week or two. During its use, too, the stomach contents should be analyzed at least every two weeks (better every week), to note the effect upon the secretion, which is usually stimulated by such a current at first, but later depressed. The simpler forms of hydrotherapy applicable in atonic dilatation include cold sponge baths and salt rubs to the whole body, followed by friction with a coarse towel, -and locally alternate hot and cold jet douches, or alternate affusions of hot and cold water to the epigastric region. The gymnastic exercises need not differ from those recom- mended for the hyperchlorhydric cases. Pulley exercise is often, helpful, even for patients in bed, the pulley being attached to the ceiling or foot of the bed; and for others rowing is particularly useful. The series of exercises described in Lecture XXIII. are also very useful. The cases of atonic dilatation in which downward displace- ment has contributed to the causation need the same treatment already described, except that in these the abdominal massage, electricity, and exercises need to be more energetically and persistently carried out, and in addition a special abdominal supporter with truss-like springs may be worn constantly with much advantage, except when the patient is in bed. For patients not under regular mechanical treatment strapping the abdomen with strips of adhesive plaster, as described in Lee- TREATMENT OF DILATATION OF STOMACH 4I3 ture XL., affords the most complete palliation possible with also a decided curative tendency. The modified rest treatment is often indispensable in this form of dilatation. Of course, in all cases of dilatation secondary to tuberculosis, heart 'disease, Bright's disease, or other systemic affections, no treatment would be effective which did not include especial at- tention to the primary malady. General debility, anaemia, etc., whether a cause or consequence of the dilatation, would demand their appropriate treatment, which should include all the possible hygienic and climatic aids as well as suitable tonic medication. In all the forms of gastric dilatation, it is necessary that the stomach should be completely empty at least once in the twenty- four hours. AAdien its propulsive powers cannot effect this (especially in the obstructive forms) lavage must be resorted to. The washing out is best done before breakfast. I shall not discuss here more fully the technique and indications for lavage, since it has been fully considered in Lecture XXIX. In addition to lavage for lessening fermentation antiseptic remedies may often prove of some service if the effects are carefully watched. These are fully considered in Lecture XXXIV. The Treatment of Gastric Tetany is not a promising one, about three-fourths of the reported cases having proved fatal. Xarcotic drugs fail to cure by themselves, and naturally so since the disease is believed to be due to poisons formed and retained in the system. Flushing the colon thoroughly with weak alkaline and antiseptic solutions is certainly indicated, both to supply the system with needed liquid and to eliminate poisons. Lavage would be efficient as a cleansing agent, but is not likely to be practicable in a fully developed attack. The administration of nerve sedatives is advisable to lessen as much as possible the abnormal reflex excitability. I would suggest as a safe method of effecting this, either the hypodermic in- jection of atropine in full doses — grn. -^-^ — repeated cautiously in smaller doses once in two or three hours till the pupils begin 4H THE GASTRO-INTESTINAL CLINIC to dilate, or, what might answer the purpose better, the em- ployment, after irrigating the colon, of enemas containing in solution dram doses of sodium bromide with half-dram doses of chloral, guarded, if necessary to prevent cardiac depression, by lo-grn. doses of camphor. LECTURE XL SPLANCHNOPTOSIS, OR DOWNWARD DIS- PLACEMENTS OF THE ABDOMINAL OR- GANS GENERALLY (NEPHROPTOSIS, GASTROPTOSIS, AND ENTEROPTOSIS)— MOVABLE KIDNEY These are associated conditions and several of them are likely to be found coexisting-. That is, it is comparatively rare to have one or both of the kidneys prolapsed and movable without finding the, stomach and usually also the colon, as well as frequently the small intestines, displaced downward at the same time. It is equally uncommon to find the stomach and colon in abnormal positions with both kidneys in their places, though this may occur. The same causes, a loss of the abdominal fat and weakening of the muscles aided by the mechanical action of the corsets and heavy skirts hung from the waist, permit the customary supports of all these organs at times to give way and their ligaments to be stretched and elongated, so that some or all of them fall or gradually sink to lower positions in the abdominal cavity. The liver and spleen also are liable to be displaced downward. It was Glenard who, in 1885, first described these displace- ments and explained their clinical significance, though other writers had previously recognized the possibility of a prolapse of certain of the viscera. It matters little which one of the various associated ptoses is first considered here, but since the surgeons by the great prominence which they have given to movable kidney (nephroptosis), have familiarized the profession and laity both with this particular displacement much more than with the 4lC THE GASTRO-INTESTINAL CLINIC Others, we may as well begin with it. Probably the most frequent one of the group, however, is gastroptosis, and we shall consider that next. In a paper entitled Movable Kidneys; Their Effect upon the Gastric and Intestinal Functions, which I read before the Medical Society of Pennsylvania in 1901, I discussed this whole subject of the abdominal ptoses rather fully and shall draw largely upon the contents of that paper in this considera- tion of nephroptosis. I call your attention particularly to the nomenclature of these displacements. Most authors have fol- lowed Glenard in applying the term enteroptosis to the entire group of displacements above mentioned, though it is derived from a Greek word meaning intestine and therefore applies appropriately to a descent of the intestines only, and not to that of other organs. I much prefer the now accepted term splanchnoptosis, which is derived from a Greek word meaning viscus, and, therefore, is a far better name for the disease which describes a falling of the viscera generally; and the affection is also frequently called Glenard's disease. Movable Kidneys — Nephroptosis. — Glenard described a sagging of the colon, stomach, and one or both kidneys, the liver being also sometimes involved. Such a dropping of the viscera is exceedingly frequent among women, and Stockton estimates that over half of them are thus afflicted. He says :^ " The fact that more than 50 per cent, of all civilized women in all classes of life have developed the condition known as enteroptosis, which means that the stomach, intestines, very often the kidneys, and sometimes the liver, are dragged down and remain permanently out of their position, is not generally known. Such, however, is the case ; and this condition more than any other cause is responsible for the constipation, back- ache, debility, biliousness, early loss of complexion, headache, and that long list of ailments of which so many women in all civilized countries are victims." '"A Manual of Personal Hygiene," Philadelphia, 1900; Article on Hygiene of Digestive Apparatus, by Charles G. Stockton. M. D., p. 47. SPLANCHNOPTOSIS 417 This group of ptoses directly causes a large proportion of uterine displacements, and in such cases the latter are often treated in vain for years by means of pessaries, tampons, etc., and sometimes even by operation, while the unrecognized ab- normality above continues its disturbing action, the right kid- ney, stomach, and colon, all or one or more of them dropping down into the pelvis and resting directly upon the bladder and uterus whenever the patient is upon her feet. Scarcely a month passes in which such aggravated cases are not en- countered in my practice.^ Some of the ablest gynecologists now recognize this sequence of events. Gill Wylie, in recently discussing melancholia, hysteria, hypochondria, etc., said :" " These cases are fre- quently associated with relaxed abdominal organs, when there are loose kidneys, ptosis of the stomach with omentum and intestines crowding down in the pelvis on top of a retroverted or flexed uterus, and the patients have been treated indefinitely with pessaries for falling of the womb." Edebohls has referred to the same condition^ and, going further, insists that right movable kidney is often the cause of chronic appendicitis by pressure upon the superior mesenteric vein, a branch of which carries the blood from the appendix.^ There is no denying the very frequent coexistence of movable right kidney and chronic thickening of the appendix, and it has been noted by many observers, including myself. There is much plausibility in Edebohls' view that movable kidney by its pressure may produce a stasis of venous blood in the cecum and appendix and thus gradually cause chronic in- flammation in the latter. The same explanation may help to ■■ See reports of cases in Lecture XLIV. further on. ' Ansemia as Observed in a Gynecological Clinic, etc., by W. Gill Wylie, M. D., Medical Record, May 20, iSgg. ^Relations of Movable Kidney and Appendicitis to Each Other, etc., by George M. Edebohls, M. D., Medical Record, March 11, 1899. * Chronic Appendicitis the Chief Symptom and Most Important Com- plication of Movable Right Kidney, by Geo. M. Edebohls, M. D., The Post-Graduate, February, 1899. 41 8 TflE GASTRO-INTESTINAL CLINIC account for the constipation and chronic catarrh of other por- tions of the colon which so commonly accompany movable rig^ht kidney. Nephroptosis, or prolapse of the kidney, is conveniently divided into four stages : ( i ) that in which a part only of the kidney can be felt below the ribs upon very deep inspiration; (2) that in which the entire kidney descends into the flank, between the last rib and the ileum, and usually returns with each expiration; (3) that in which the kidney may be found floating anywhere in the abdominal cavity between the last rib and the pelvis; and (4) that in which the kidney is fixed by adhesions in a wrong position. Etiology. — It is of practical value to know that chief among the causes of movable kidney are inherited weak constitutions, a lack of development of the abdominal muscles by exercise, and women's very unhygienic dress, including corsets ^ (espe- cially the short corsets formerly in vogue, since these constricted the waist, thus helping to force the stomach and other viscera down), tight waistbands, and heavy skirts exerting downward traction upon the abdominal walls. The old theory, that preg- nancy and its results have most to do with causing loose or 1 Einhorn* considers the corset as an important factor in the causation of the abdominal ptosis, and Kellogg,-}- as wqll as Dickinson,:}: has been ver^' emphatic in condemning this injurious, article of attire. The latter found that the total pressure of the corset varies between thirty and eighty pounds, and the capacity of the chest for expansion is restricted one-fifth while it is worn. He added: "The abdominal wall is thinned and weakened by the pressure of the stag's. The liver suffers more direct pressure and is more frequently displaced than any other organ. The pelvic floor is bulged downward bj"- tight lacing one-third of an inch." Kellogg, in 150 cases of pelvic disease, reports the stomach and bowels displaced in 138. * Remarks on Enteroptosis, by Max Einhorn, M, D., Medical Record, April 13, 1901. f The Influence of Dress in Producing the Physical Decadence of American Women, bj^ J. H. Kellogg, M. D., Tratis. Mich. State Med. Soc, 1891, p. 41. :): The Corset, Questions of Pressure and Displacement, by R. L. Dick- inson, M. D., N. V. Med. Jour., November 5, 1887. SPLANCHNOPTOSIS 4I9 floating kidneys, has been disproved. Roskam, in a very recent elaborate article on the subject based upon a study of 147 cases, stated that all but 4 of these were in women. Of these 143 women, 83 were young girls at the time the ptosis began and only 60 were married.^ There are some anatomic peculiarities in the conformation of women that probably render the kidneys and other viscera more liable to become movable in them than in men, especially their broader pelves with relative narrowness of their chests and upper abdomens; and another setiologic fact in them is thought to be a periodic congestion of the kidneys at the menstrual periods. The kidneys may also be dislocated by traumatism such as falls, blows, or strains. Albarran cited by Roskam reports that of 1176 cases, 87 per cent, were in women ; and Kiister, quoted by the same, had 97 per cent, of cases among women. It is nearly always the right kidney which is involved. Edebohls has never seen the left kidney alone movable, noi have I, though Einhorn " and other observers report a very small proportion of such cases. Of Roskam's 147 cases there was but one in which the kidneys were both movable, all the remaining 146 having involved the right side only. Stiller first made the observation that in congenitally weak persons, those inheriting a tendency to neurasthenia, tuber- culosis, anjemia, etc., the tenth rib is usually loose or floating — and sometimes also the ninth — not attached as it should be to the sternum. Such patients are said to have the atonic or enteroptotic habit, and are much more prone to displacements of the viscera than others. They should have an extra amount of attention given to their hygiene from infancy, especially to their muscular development. Symptomatology. — The symptoms of movable kidney may include pain, felt nearly always in front over the region of the ^ Le rein Mobile et son traitement {traitement chirtirgical excepte) by Dr. Roskam, Annates de la Socidte Medicochiriirgicale de Lidge, March, 1901. I ■2 See note *, p. 418. 420 THE GASTRO-INTESTINAL CLINIC kidney or below the liver — usually over the site occupied by the displaced organ at the time. There is generally more pain in \he first and second stages of the affection than in the third, that of true floating kidney; but in a large proportion of all the cases there is no local pain, except occasionally. Disturbances of the digestion constitute the most frequent symptoms. These include predominantly those of hyperchlor- hydria — pain, or burning, coming on at times shortly after eat- ing, but more commonly toward the height of the digestive period, one to three hours after eating. I had flattered myself that I was the first to observe, in the year 1899, ^^^^ movable kidney tended in many cases to stimulate reflexly the gastric glands to excessive secretion, the dyspepsia in such cases be- ing generally, at least at first, of the hyperchlorhydric form. I find now, however, that our French confreres seem to have made the same observation before. Rosewater, of Cleveland, O., in a paper ^ published in the year 1900, referred to gastric hyperacidity as, one of the neuroses that may result from enteroptosis. Of the eight cases of the latter reported by him four had movable kidney, and in two of these both the right and left kidneys were thus affected. He also mentioned dilatation of the stomach as a disease that " may result through traction or by pressure of the right kid- ney upon the pyloric end." As usual when the HCl of the gastric juice is in large excess, there is much flatulency, sour eructations, often waterbrash, and sometimes crises of severe pain in the stomach, followed by the vomiting of a thin liquid which is so acid as to set the teeth on edge, but without the sour odor of fermenting ingesta. There is very generally constipation also as a result of the HCl excess, even if not from pressure of the displaced kidney upon the duodenum or upon one of the large veins, as men- tioned by Edebohls. There are also frequently insomnia, mental depression, and when the mobility of the kidney con- 1 Enteroptosis Relative to Disorders of the Digestive Tract and Circu- lation, by N. Rosewater, M. D., Cleveland Jour, of Med., June, 1900. SPLANCHNOPTOSIS 421 tinues long, especially when it is a part of a general sagging of the abdominal organs, neurasthenia is almost sure to de- velop, even if not present before. The kidney may be very sensitive on palpation, especially in the first two stages of nephroptosis, but, according to my experience, one may cjuite as frequently meet with kidneys which are movable and in either the first or second position of descent, without being painful on moderate pressure. In time the stomach may become dilated as a result of the frecjuent and prolonged pyloric spasm from hyperacidity, or from pressure by the kidney as stated by Rosewater, and then the familiar symptoms of dilatation develop, though rarely in the same degree that they do in cases of permanent ob- struction of the pylorus as from tumor, or the scar of an ulcer. Diagnosis of Movable Kidneys. — Displaced or movable kid- ney can easily be differentiated from any other abnormal con- dition, and in most cases by palpation alone. The numerous possible symptoms are never by themselves diagnostic, and indeed are often all absent. The kidney must be palpated and recognized by its peculiar shape and smooth feel in its wrong position, and, when freely movable, can be felt to slip through between the fingers with one hand placed over the loin behind and the other in front. With the patient lying supine, her bands loosened and knees flexed (or as Noble ^ prefers, stand- ing and the upper part of the body bent forward almost at right angles while her hands rest upon a table or desk), the physician should press the finger tips of one hand deeply into the loin just below the normal position of the kidney, and press the fingers of the other hand over the corresponding region in front. Then, with the two hands thus brought near to- gether, the patient is caused to inhale and exhale very deeply, and if the kidney is movable, it will be plainly felt to slip out on inspiration and return through the fingers to its normal site ^ Nephrorrhaphy, by Charles P. Noble, M. D. Presented to the Section on Obstetrics and Diseases of Women, Am. Med. Assoc, June 5-8, 1900. 422 THE GASTRO-INTESTINAL CLINIC on forcible expiration with the mouth partly open/ (See accompanying illustration.) When this procedure fails to detect it, gentle but deep palpation should be practiced all over the abdomen, while the recumbent patient relaxes as much as possible and continues deep breathing. In this manner a floating kidney which no longer returns to its place, or one Fig. 54. — Palpation of movable kidney. Reproduced from an article by- Henry Morris, in Lancet, November 30, 1901. which is held by adhesions or otherwise in a false position, can generally be discovered, except when it has become fixed be- hind some other organ. By percussing over the renal region behind and evoking tympany there where there should be dullness, confirmation may be obtained of the absence of the kidney from its place. Prognosis.— Clinicians who have had most experience in treating these cases agree that a cure may now be obtained in a certain proportion of them, even without surgical interven- tion, when the patients can afford to take the necessary care of themselves and be under skilled medical supervision ; and when a complete cure cannot be obtained, the patients can nearly always be relieved of the painful and harmful symptoms, and ■* The above-described method of examining for movable kidney with the patient recumbent was demonstrated to the author by Oser of Vienna, in 1885, and again by Ewald and Kuttner at the former's clinic in Berlin in 1S95. Even a very slight mobility can be detected in this way when one has had sufficient practice in palpation. SPLANCHNOPTOSIS 423 that, too, very speedily. My own most recent experience has encourag-ed me to hope for a definite cure in the mild or less aggravated cases by mechanical, hygienic, and medicinal measures in patients possessing the leisure and means to com- mand appropriate treatment. Even nephropexy by no means always cures; after the operation a relapse of the trouble often occurs. Treatment of Movable Kidneys. — This should begin by confinement to bed under some form or modification of the rest-cure method in all cases in v/hich the movable kidney is either spontaneously painful or tender on palpation. If, even with the patient recumbent, the kidney descends below the ribs during moderate inspiration, retentive apparatus must be put on and worn in bed. Strapping the Abdomen for Displacements. — At one time I employed in most of my cases of movable kidney an oblong pad, which was attached to an abdominal belt in such a way as to afford support directly to the kidney. This could usually be made to effect the object and in most of the cases prevent any demonstrable prolapse, but was troublesome to adjust by the patient, often uncomfortable and what was worse, some- times, especially when not skillfully adjusted by the patient or her maid before dressing in the morning, the pressure of the pad seemed to interfere with the return flow of blood from the veins of the lower abdomen, and, in one case at least, I had reason to believe that an aggravation of a previously existing chronic catarrhal appendicitis resulted from this cause. Therefore I have been depending of late in most cases upon either a well-fitting elastic abdominal belt, or upon what has proved a much more satisfactory method of retaining movable kidneys as well as other displaced abdominal organs in their normal positions. This is by means of strapping the abdomen with adhesive plaster as first recommended and practiced by Dr. A. Rose of New York, except that in most cases I apply much less of the plaster than Rose does, not finding it necessary 424 THE GASTRO-INTESTINAL CLINIC to cover in this way a large part of the lower abdomen. As car- ried out in my practice, the technique is as follows : While the patient lies on her back with the hips well raised to assist the replacement by gravity, she is directed to exhale several times very forcibly and hold the breath out afterward as long as possible. Meanwhile the physician makes upward pressure wath both hands placed over the lower abdomen. In this way it is usually easy to replace the organ completely. After this has been effected the patient should again hold the breath momentarily while the physician applies the first strip of plaster on the right side. In applying this one end of a roll of the best Z. O. adhesive plaster, 25/^ inches wide, is attached firmly to the skin as near to the groin on the left side of the body as the pubic hairs will permit, and then brought diagonally upward and to^ the right, passing usually a little below the umbilicus and on around over the region below the liver anteriorly and the right side of the thorax, to a point near the spine in the mid-dorsal region or sometimes a little higher, the exact course and upper limit of the plaster depend- ing somewhat upon the size and shape of the thorax. After attaching the lower end of the plaster to several inches of the surface it will generally adhere sufficiently to permit of moderate upward traction while the remainder of the strip is applied, or if it does not stick well enough without, an assistant may need to hold one hand firmly over the part first applied while such traction is being made. The first strips of plaster need to be drawn upward with just sufficient force to hold the lower abdomen nearly, but not quite, up to its normal place, else the patient will be rendered uncomfortable and very likely refuse to let them remain ; but after wearing them a week or two she will tolerate them better, and full replacement can then usually be effected and maintained by the plaster strips without more than a slight inconvenience. I speak of this in connec- tion with the application of the first strip, since the others must bea])[)lie(l similarlv in order to have the abdomen symmetrically supported. The second strip is applied to the opposite side in SPLANCHNOPTOSIS 425 an exactly reverse way from the first. In the cases of thin women without much accompanying displacement of the stomach or intestines, I often find one pair of such broad strips of adhesive plaster all-sufficient to maintain adequate support, but in others additional ones are required. In such cases the first pair of strips are placed nearer to the umbilicus and the second adjoining the first on the outer side. When, on account of warm weather or other cause, the strips show a tendency to slip upward, not holding well, I apply other strips trans- versely over them so as to secure them more firmly. The same precaution is sometimes necessary also on the back. The foregoing is the technique which I have worked out for myself, not having had the opportunity of seeing Dr. Rose apply the plaster. Doubtless my technique can be improved upon, but it has produced satisfactory results in numerous cases. Occasionally patients having very sensitive skins complain of annoyance from the itching sensation produced by the plaster, and in some a temporary papular eczema is likely to result when it is worn beyond three or four weeks at a time. In such cases I have an elastic belt fitted, to be worn as an abdominal supporter until the skin will again tolerate the plas- ter. The support furnished by the latter is so much more complete and satisfactory than that obtained from any possible form of belt that most patients are very willing to put up with the comparatively slight inconvenience which it involves. After four to six weeks the plaster strips need to be renewed, in any case, since they have generally become loose in that time, and it is well to have then some sort of a belt worn as a pro- visional support for a day or two before new strips are applied, so as to allow the skin to be thoroughly cleansed and dried and, I might add, rested, since any skin would be likely to become irritated after a too long continuous application of the plaster. OfJicr Rciuedial Measures. Patients who are neurasthenic enough to require the full rest cure, as well as those who need ,to be recumbent for a while at first because of the very sensitive 4^6 THE GASTRO-INTESTINAL CLINIC condition of the kidneys, will not, as a rule, have to be kept strapped while in bed. In most such cases the movable kid- ney or kidneys will remain in position so long as the patient is recumbent, or, if not, a simple elastic belt, 'snugly buckled, will furnish support enough under such circumstances. It is im- portant also during such a rest treatment to have the patient's abdomen unhampered so that really curative measures, such as massage and electricity, can be regularly applied. For the same reason, in the lighter cases of displacement, when these mechan- ical treatments can be had every day or every other day in the hope of permanently overcoming the abnormal condition, it will be advisable to put up with the less perfect support furnished by a simple elastic belt rather than to apply plaster strips, which somewhat interfere with an effective strengthen- ing of the abdominal muscles by the means mentioned. But, for the large proportion of walking patients, who cannot or w^ill not undergo a systematic treatment which must extend over months, the strapping with plaster affords by all odds the most efficient form of support I have ever tried. Indeed, since having learned how to use it properly I have not been obliged to have the operation of nephropexy performed in a single case. The latter, however, when it shall have been so per- fected as to retain the kidney in place during the remainder of the patient's life with a reasonable degree of certainty, will be indicated in many of the more aggravated cases of nephrop- tosis which are not associated with displacements of others of the abdominal organs, or after such other associated dis- placements have been remedied without overcoming the mo- bility of the kidney. Even in these exceptional cases of severe nephroptosis which persist when the stomach and intestines after a long siege with strengthening measures have been restored nearly to their normal positions, there is always some hope of effecting an ultimate cure by fattening the patient when possible, since this restores the normal cushion of flesh which constitutes a large part of Nature's dependence for the support of the kidneys. SPLANCHNOPTOSIS 427 The rest cure is a decided help in this direction when otherwise indicated, and is therefore to be recommended in such cases when practicable. The task of the physician will be, in brief, to fatten and build up his patient in every way, and above all to strengthen her abdominal muscles by exercises specially designed for this pur- pose, aided, when necessary, by short jet douches or affusions of cold water, as well as by electricity and massage very cautiously given, avoiding irritation of the tender kidneys. The diet should meanwhile be as nutritious as the patient can take and digest, regard being had, when practicable, to the results of an analysis of the stomach contents after a test meal. These patients are almost invariably thin in flesh, and, there- fore, fattening food is particularly suitable, with plenty of rest in a recumbent position, especially after meals, and when this rest can be taken in the open air, it is so much the better. Drugs are little needed for the displacement or mobility itself, but tonics may sometimes be used temporarily to fortify the constitution, when judiciously prescribed, and the usual remedies for an accompanying hyperchlorhydria are often re- quired at first. In my experience, the cases of movable kidney which are not at rest mentally, physically, and sexually, and which do not yield promptly to treatment, will frequently develop a stubborn form of hyperchlorhydria with its re- sulting burning pain in the stomach. Sometimes this cannot be controlled even by drugs and diet together with the aid of rest, and then, in the absence of peptic ulcer, may yield to a course of high-tension faradism applied intragastrically. These methods will usually reduce the HCl excess temporarily, but if the kidney be not retained in place by some means, the derange- ment of secretion will soon recur. Cases not amenable to milder measures should have the operation to anchor the kid- ney in place — nephropexy. This should always be done when a severe hyperchlorhydria due to the displacement cannot be relieved otherwise, and for all patients who cannot obtain suit- able medical and mechanical treatment. 428 THE GASTRO-IXTESTIXAL CLINIC Benninghoff has recommended a modified Trendelenberg position secured by raising the foot of the bed in the more stubborn ptoses of the viscera. Great Importance of Correcting Displacements No other remedial measure ever employed by me in any disease has produced even one-half the good that has followed the replace- ment and retention of prolapsed stomachs and other abdominal viscera by the methods herein described. A physician's wife in Los Angeles had suffered some years with aggravated neurasthenia, mental depression, and occa- sional attacks of acute pain in the right side. Cured at once of the worst symptoms by correcting a previously unrecognized nephroptosis, and good health restored after a course of rest treatment. The kidney had become swollen and very tender to the touch. A number of cases of previously intractable asthma have yielded after mechanically supporting displaced viscera. One great sufferer from asthma who had gone the rounds of the regular profession, besides having tried osteopathy. Christian. Science, etc., was found to have a particularly bad gastroptosis j with the stomach held down by adhesions. I advised operation, but the surgeons to whom she first applied could not confirm my diagnosis, not having either inflated the stomach or had an x-ray picture made. Some time later other surgeons con- firmed the diagnosis by both inflation and opening the ab-' domen, but the patient bore the ether so badly that the opera- tion could not be completed after some small ovarian C3'sts and a catarrhal appendix had been first removed. Her stomach is still partly in the pelvis, and she still suffers much from the^ asthma. In another case of severe asthma in a stout fleshy young' man seen by me at Dr. Corey's Sanatorium in Alhambra, Cal., a gastroptosis was overcome by strapping, as already de- scribed, with instant relief of the dyspnea, and there has been no trouble from it since, so long as his abdomen has been kept supported. LECTURE XLI SPLANCHNOPTOSIS, CONTINUED. DIS- PLACEMENTS AND DISTORTIONS OF THE STOMACH The stomach can be displaced in various ways — upward, downward, (gastroptosis), and in either direction laterally. Occasionally in women it is displaced upward in consequence of the constriction of the corset, when this article of attire is begun to be worn before the stomach has dropped or been enlarged downward , and the level of the constriction is well below the viscus. It may also result from contraction of the left lung and as a sequel of left-side pleurisy or of diaphrag- matic pleurisy. This accident is much less likely to produce symptoms than a ptosis or sagging of the organ, and is doubt- less often overlooked ; but palpitation of the heart might be expected to result from the distention of such a stomach with gas. Such a malposition would not be so likely as the opposite kind of displacement to cause a kinking of the duodenum, and even if it could, the resulting obstruction would produce a dilatation of the stomach which would again carry the greater curvature downward to a level at or below the normal. Lateral displacements are probably very rare and are likely never to be seen except as a result of the pressure of a tumor, or enlargement of one of the adjacent organs from any cause. The same methods already described, and those explained below, will enable you to diagnosticate with but little, if any, difficulty either an upward or a lateral displacement of the stomach. The only possible remedies for any of them are to be found in a removal of the cause, whether it be a faulty mode of dress or a morbid growth. 430 THE GASTRO-INTESTINAL CLINIC Since downward displacement of the stomach is exceedingly- common and the other malpositions very rare in comparison, I will proceed at once to the consideration of this highly im- portant condition. Gastroptosis. — This is by far the most common of all gastric derangements as well as one of the most frequent causes of im- paired health in women especially, and at the same time one of the most readily relieved, if not often radically cured. The greater curvature is usually considered to be in health well above the umbilicus — one-third to two inches or more, ac- cording to recent x-ray experiments. Numerous observers seem to have demonstrated also by the same means that the stomach should occupy a more vertical position than formerly thought, the pylorus being, in healthy children at least, a little lower than any other part — i.e. till unhygienic dress, overeat- ing, etc., have formed a dependent pouch at the greater curva- ture. Whenever the latter is found at or below the umbilicus, there must be either a gastroptosis or gastrectasis (dilatation) unless we are able to demonstrate enlargement without weak- ening of the walls, which would signify merely hypertrophy of the stomach (megastria). If at the same time the upper part of the stomach, as shown by the position of the lesser curvature and the fundus, is much too low, there exists evi- dently gastroptosis and not dilatation. jS^tiology. — The causes of gastroptosis are in the main the same as those of nephroptosis, and little space need be oc- cupied with a repetition of them. All authors with but few exceptions agree that prominent among them are the faulty dress of women who almost monopolize the disease, and the wasting diseases that cause a loss of fat and muscle tone. Nevertheless, the disease is not very infrequent in men, especially among heavy eaters and those accustomed to sup- port their trowsers by tight waistbands or belts. Perhaps you should be informed here also concerning the plausible theory of Glenard, though it is not now generally accepted. He believed that the first step in the chain of causes that led SPLANCHNOPTOSIS 431 finally to a dropping of all or several of the abdominal organs, was the fall of the right end of the colon at the hepatic flexure. Downward with this, according to his theory, then goes the entire ascending, and the right half of the transverse, colon so that the latter follows a nearly straight line diagonally from the cecum to the splenic flexure at the left, where there results Fig. 55. — Splanchnoptosis with marked gastroptosis, coloptosis, etc. i, liver. 2, stomach. 3, transverse colon. (From Prof. Dr. C. A. Ewald's " Krankheiten des Darms und des Bauchfells.") a sharp kinking with obstruction of the lumen. In consequence of this obstruction there follows a dilatation of all that part of the colon to the right of the kinking together with stagnation of its contents. The prolapsed transverse colon was then sup- posed to pull down, one after another, the other viscera whose ligamentous supports have become weakened. Ewald, Kutt- 432 THE GASTRO-INTESTINAL CLINIC ner, and others have proved that this theory was not in accord with all the facts, and though the falling of one organ does often prbduce obstruction by kinking, and though its weight, in- creased by an abnormal stagnation of its contents, helps to drag down others, the precise order of occurrences described by Glenard cannot be shown to exist as a rule. It is probable that in some cases of aggravated constipation the overloaded colon does first sag and then pull down the stomach with other organs, and quite certain also that in other cases a constantly overloaded stomach sometimes finall}^ gives way (especially in women who lace tightly and let their skirts drag upon their abdominal muscles instead of suspending them from the shoulders), and then crowds down before it the transverse colon; and very likely there may result further a prolapse of one or both kidneys in consequence of the changes in the posi- tion of such large viscera. Symptomatology. — The most constant symptom of gastrop- tosis is constipation, though even this is sometimes absent, and along with this there is usually associated a sluggish digestion, with flatulence, a lowered nerve tone with often insomnia and pronounced neurasthenia. In severe cases anaemia soon develops and ultimately profound debility. When, as usual, there is a complicating muscular insufficiency of the stomach or dilatation, you may observe the inevitable symptoms of such complication, viz., a splashing sound over the stomach, retention of food, greatly increased flatulence and diminution of urine with, in bad cases, vomiting of fermenting stomach contents from time to time. The more common dyspeptic symptoms which you will encounter in moderate cases of gastroptosis are sensations of dragging, weight or pressure in the epigastrium, and any of the uncomfortable feelings associated with dys- pepsia except that there is rarely burning or acute pain. The latter generally depends upon an excessive secretion of HCl when not a result of ulcer or cancer, though gastralgic pains do occur without any ascertainable cause except some fault in the nervous system. When the displacement is not marked and SPLANCHNOPTOSIS 433 the gastric muscle still strong", there may be no symptoms at all. Diagnosis. — Indispensable to the diagnosis of a displacement is a correct idea of the normal position, size, and form of the organ involved. As to the stomach, these are described and il- lustrated on pages 31 and 32. The stomach has been er- roneously described and pictured as occupying a vertical posi- tion because a swinging of the pylorus downward and to the left is such a very common displacement that some authors have considered it normal. Downward displacement of the stomach is often mistaken for dilatation, but cannot easily be con- founded with any other condition. To make the differential diagnosis between these two diseases you have merely to deter- mine first the position of the greater curvature, which any tyro should be able to do after a few minutes' instruction, by simply practicing percussion and clapotage, as described in Lecture VI., and then by inflating the viscus with carbonic dioxide and percussing again to find the position of the lesser curvature and of the fundus. When both curvatures are too low, you have, of course, gastroptosis. After a full inflation so that the stomach shall be markedly tympanitic everywhere, you. could not well be left in doubt as to the position of any part of the organ. Even when the pylorus and lesser curvature are up under the left lobe of the liver, deep percussion will bring out the tympanitic sound. Should there remain a doubt as to the diagnosis, the introduction of Turck's gyromele or the electric lamp (gastrodiaphane) into the stomach would help to solve it. In thin patients, too, a radiograph of the abdomen should settle the matter. Prognosis. — Gastroptosis can generally be greatly ame- liorated by medical and mechanical treatment and a symptom- atic cure thus effected, though it cannot be radically cured in all cases. Restoring the tone of the abdominal muscles by massage and electricity, aided when necessary by hydriatic measures, will often go far toward overcoming the milder cases and can markedly lessen the displacement in the severer 434 THE GASTRO-IXTESTIXAL CLINIC ones, insomuch often that the symptoms are mostly removed, but in the worst cases in which the hgaments that support the displaced organ have become greatly elongated, a complete cure cannot be promised, unless by means of surgery. When there is a complicating dilatation, intragastric electricity should be of Fig. 56. — Area of tympanj' in case of gastroptosis. Author's case. the greatest service both for its directly stimulating action upon the weakened gastric muscles, and also for its toning effect upon all the structures involved through its stimulant influence upon the sympathetic ganglia behind the stomach. Treatment — The same methods of therapy advised for gas- tric dilatation are worthy of trial in gastroptosis, and if the strengthening mechanical measures already described are per- sisted with long enough, virtual cures can be effected in the SPLANCHNOPTOSIS 435 majority of cases (excluding those in which adhesions hold the stomach down), and symptomatic cures in all except pos- sibly some of the very aggravated ones which are of long standing. For these such ingenious operations as that devised by Beyea are doubtless to be advised, especially in the case of persons who are not in a position to avail themselves of pro- longed treatment, and would find it probably impracticable to have the abdomen strapped with strips of adhesive plaster every four or six weeks, as described in Lecture XL., under the head of Displaced or Alovable Kidney. Abdominal surgery is be- coming constantly safer with the increasing skill of those who practice it, and it is not at all improbable that it will yet be the preferable method of treating the more stubborn cases; but at present the average patient afflicted with a chronic and intract- able displacement of one or more of the abdominal organs, would prefer to depend upon elastic belts or specially devised corsets and strapping with adhesive plaster, which will usu- ally relieve the symptoms, rather than incur the risks of a celi- otomy for a disease which does not ordinarily endanger life. For the report of a pronounced case of gastroptosis virtu- ally cured by mechanical treatment, see Lecture XLIV. Volvulus of the Stomach. — In the English translation of Riegel's " Diseases of the Stomach " (Philadelphia, 1903), Dr. Charles G. Stockton, the editor, interpolates the following note in the article upon Changes in the Position and Form of the Stomach : '" The stomach sometimes becomes twisted upon its axis, producing a state that may be called volvulus of the stom- ach, an instance of which has been reported by Wiesinger. Beck [Berg, the name should be] also has two cases in which he confirmed his diagnosis by operation, resulting in the com- plete cure of the patients." Streit, in 1906, reported a fatal case of volvulus in an insane patient confined in the Connecticut Hospital for the Insane. C. D. Spivak of Denver contributed to American Medi- cine of October 31, 1903, an interesting paper on the sub- ject. Li this he made an exhaustive study of the literature, 43^ THE GASTRO-INTESTINAL CLINIC which includes reports of eight cases of the kind. Four of the patients died without any attempt at operative intervention having been made, and at an autopsy it was discovered that the stomach had become twisted upon itself in such a way that its orifices were obstructed, and in several of them portions of the intestines, as well as sometimes the omentum, had been forcibly displaced and involved in the torsion. In two of these cases there were hour-glass contractions, and in several either a tu- mor or ulcers or cicatrices of former ulcers in one or more of the orifices. The four others were operated with a fatal result in one and recovery in the remainder. The findings were sim- ilar to those in the first four mentioned, the stomach having been twisted more or less completely upon itself in all, and in most of the cases either the omentum or some portions of the intestines, or both, w'ere displaced, torn, twisted, or otherwise involved in the tangle. During life the symptoms were pain, vomiting of an ex- tremely severe and obstinate type, restlessness, prostration, and generally complete obstipation — the symptoms, in short, of obstruction of the bowels, including in most cases great abdom- inal distention and tympany. Attempts to empty the stomach with the tube were made in several of the cases, but generally failed. Other medical measures seemed to be quite useless. The operation performed consisted of an incision through the abdominal walls, b}^ means of which alone in some of the cases the volvulus could be reduced, Ijut in most of them it was necessary to open the stomach also, so as to relieve the disten- tion, before the reduction could be effected. Hour-Glass Contraction. — This is a condition of much inter- est medically as well as surgically, though no medical measures are of any value in overcoming it. It may be either congenital or accjuired, most frequently the latter. Its usual cause is ulceration, extending a considerable part of the way around the stomach in its middle portion, or a short distance above the antrum pylori. It is, therefore, a sequel of gastric ulcer. The subsequent contraction divides the viscus into two SPLANCHNOPTOSIS 437 more or less unequal parts. Other rarer causes are cancer, inflammatory adhesions of the stomach to neighboring organs, and, very much more rarely, if ever efiicient in this way, corro- sive gastritis. Tight lacing has enough other sins to answer for, and I do not, therefore, care to follow Riegel in even sug- gesting that it may be a possible additional cause of hour-glass contractions, especially since it is a very improbable one. This affection is not likely to produce any symptoms in the milder cases, and is then very difficult to diagnosticate; but in the severer forms in which the contraction is very marked, the upper part becomes in time dilated with the usual symptoms of tliat condition.. The diagnosis in such marked cases can often be made after inflation by the peculiar figure formed by the dis- tended stomach. Riegel gives, as a means of diagnosing even mild cases, the fact that a splashing sound may be obtained after an attempt to empty the A'iscus by the tube has failed; but this could scarcely be a certain diagnostic sign, since the splash may at times be elicited over the transverse colon or cecum, when these are much relaxed and dilated. Stockton, in the American edition of Riegel already cited, mentions a much more certain sign, which should be decisive when it can be obtained. In a suspected case he empties the first portion of the stomach with the tube and then manipulates the abdomen, so as to cause some of the contents of the second cavity to pass into the first. This fluid can then be extracted, and will usually show different reactions from the first, demonstrating that it has been taken from a different cavity. Then, after having the tube arrested at the constriction, Stockton has sometimes suc- ceeded in coaxing it through into the second portion, which would be strong evidence of a stomach divided by some sort of a contraction. As stated above, the only remedy for the con- dition is a surgical operation. Abnormally Small Stomachs — Microgastria. — The stom- ach may be abnormally small as well as large. This condition is likely to be found after a long period of partial starvation or prolonged fasts, and after contraction of the cardia has 438 THE GASTRO-INTESTINAL CLINIC existed for some months. It may usually be demonstrated by percussion after a full inflation of the viscus, except when the c^rdia is obstructed, but in the latter cases can only be inferred. CONGENITAL ANOMALIES OF THE STOMACH Various abnormalities of the stomach occur at times con- genitally. Among these the forcstomach is really a widened or sacculated condition of the lower part of the esophagus. ^^^len the extreme end of the esophagus adjacent to the cardia and below the diaphragm is congenitally dilated, it is called an f rum cardiacuui. These anomalies are not infrequent and generally produce no symptoms, but Riegel is authority for the statement that when coarse particles of food become lodged in such pouches, serious symptoms may result. Hour-glass contraction of the stomach has already been described as an acquired abnormality which results usually from the cicatrization of an extensive ulcer, but a similar con- dition is sometimes encountered as a congenital anomaly. • The stomach at birth may also present various abnormalities as to size and form, most of which are not of much clinical importance. Congenital Stenosis of the Pylorus is, however, a condition which is serious and seems to be comparatively common. Nu- merous reports of such cases have appeared recently in medical literature. Shaw ^ has found records of between thirty and forty authentic cases, and many others have doubtless been unrecog- nized, the resulting deaths having been attributed to marasmus, etc. The children are usually otherwise normal at birth. They show no symptoms until they are from a few days to a few weeks old, when vomiting sets in and nearly always proves fatal — in most cases within two or three weeks, but sometimes not till after several months. At autopsy the stomach is usually found dilated, the intestines empty and collapsed. The pylorus is thickened to about half an inch, from two-thirds to one inch ' Brooklyn Med. Jour., May, 1903. SPLANCHNOPTOSIS 439 long, exceptionally resistant and usually of conical form. The lumen is greatly diminished, barely admitting a small probe in typical cases, and generally impervious to licjuids. In a case reported by Schwyzer,^ a microscopic examination of sections of the pylorus showed all the layers exceptionally thick and the circular muscular layer greatly hypertrophied. In some cases characterized by recurrent spells of incoercible vomiting beginning soon after birth, the attacks will at first yield to treatment, showing that the stenosis is incomplete except when aggravated by spasm or inflammatory swelling. This affection is highly important for pedologists and gen- eral practitioners, since it is nearly always fatal sooner or later, unless recognized and surgical intervention invoked. Treatment, by small doses of calomel and very careful diet — especially small and frequent, feedings with the most digestible or predigested liquid foods — assisted, when necessary, by lavage, have often effected apparent cures, when the stenosis has been incomplete, but in time, a more stubborn attack in such cases nearly always occurs, and the child finally succumbs. When a tumor can be felt in the pyloric region, this, with the symptoms, should make the diagnosis easy, but obstinate vomiting in an otherwi&e healthy and carefully fed infant should awaken your suspicion that a congenital stenosis of the pylorus may exist, and when the vomiting persists for weeks, in spite of treatment, or frequently recurs without ascertainable cause, an exploratory incision may properly be advised. The risk of this is small, and the pyloric stenosis not operated is inevitably fatal in the end. ' New York Med. Jour., November 27, 1897. LECTURE XLII SPLANCHNOPTOSIS, CONTINUED— DIS- PLACEMENTS OF THE COLON Coloptosis. — Displacements of the colon in various direc- tions are exceedingly prevalent — much more so than is usually supposed. You will easily demonstrate the truth of this state- ment by applying in your practice the instructions given in this series of lectures concerning the determination of the boundaries of the viscera and the diagnosis of abnormalities in them. Hitherto most cases of colonic displacement have not been recognized during life, but in the records of autopsies in the hospitals of the world large numbers of them have been recorded. Among the most valuable of such reports was one contributed at my request to the International Medical Maga- zine (March, 1901) by Dr. W. AVayne Babcock, one of the ablest of the younger surgeons of Philadelphia, at a time when he was assisting me in editing that journal. The paper was entitled Common Anomalies of the Colon. Both by the condensed, but nevertheless graphic, descriptions and by the illustrations of various singularly bizarre dislocations of the colon which it contains, it exemplifies most strikingly the im- portance of the subject, besides shedding much light upon it, and with Dr. Babcock' s consent I have reproduced below his valuable article in full. The curious circumstance noted by Dr. Babcock, that in none of the seven cases of coloptosis described and figured by him was there observed any gas- troptosis or gastrectasis, is very remarkable considering the extreme frequency with which such abnormal conditions are usually found in life associated with displaced colons. The most reasonable explanation for this is, that either these cases 440 SPLANCHNOPTOSIS 44I were most anomalous in this respect as well as in the extraor- dinary positions of the colon, or else that there had been dis- placements of the stomach which were overcome by the dorsal decubitus and limited dietary during the final illness. It is believed, too, that even very much enlarged stomachs may often undergo considerable atrophy during the protracted ill- ness preceding death, when very little food is taken or retained for weeks or months. ''Of the viscera for which fixed positions are accepted, probably none shows deviations from the usual location so frequently as does the colon. Many of these anomalies of position are clearly explained by imperfections in the develop- mental process of this part of the intestine. Originating as a portion of a simple tube, the early position of the colon is nearly vertical ; the primitive cecum lying above. The developing small intestines, however, soon push the colon to the left side of the abdominal cavity. At first, as the ab- dominal walls are too imperfect to retain all of the intestines, a portion including the cecum lies through the umbilical open- ing, and without the splanchnic cavity. A\^ith the develop- ment of the anterior parietes the cecum recedes into the abdomen, and from a relative position below and to the left it finally passes above and anterior to the duodenum to the right hypochondrium, where it turns downward to its final position in the right inguinal region. This partial rotation of the large bowel forms the transverse and descending por- tions of the colon and is accompanied by a compensatory partial rotation of the small intestines to the left. An absence 1 of the ascending or of the ascending and the transverse colon, the presence of the cecum upon the left side or in the sac of a congenital inguinal hernia, are conditions satisfactorily ex- plained as due to the failure of the colon to complete this rotation or even to re-enter the abdominal cavity during the process of development. Treves suggests that incomplete rotation of the colon often results from the binding effect of adhesions following a fetal peritonitis. 442 THE GASTRO-IXTESTINAL CLIXIC " Much more common are the alterations in position and in the form of accessory loops and tortuosities, that seem chiefly t® be due to an increase in the total length of the colon, a lack of equable distribution of length in its various portions, or to the abnormal mobility permitted by a mesentery of unusual length. " The length of the large bowel is said to vary normally between thirty-nine and seventy-eight inches, and apparently these variations bear no definite relationship to the size and gen- eral development of the individual, or to the length of the small intestine. The relative lengths of its constituent portions are also subject to wide variations without the production of evi- dent abnormality. Disproportion without the normal range may result, however, from the persistence of a fetal type in the adult. Thus, in the fetus the sigmoid is greatly exaggerated and attains a length of ten inches. Should the sigmoid, after birth, keep pace with the growth of the rest of the bowel, it is evident that it would soon exceed its normal length in the adult of seventeen inches. Such a progressive growth associated with an elongated meso-sigmoid is probably an important factor in the formation of the unusually long and displaced sigmoids that are so frecjuent. " The transverse colon is also subject to wide variations in length, and considering its lax attachments it is not surprising that deviations from its usual transverse course are common. The cecum shows deviations in position and direction more frequently than does the ascending colon, while congen- ital anomalies of the descending colon are practically never seen. " Displacements or elongations of portions of the colon may also be the result of acquired causes, such as the overloading or overdistention of the bowel, the traction resulting from adhesions, and the pressure from displaced or enlarged organs or from tumors. In none of the cases here recorded, which illustrate common types of deviation in the course of the colon, was such an acquired cause apparent. In no case was the SPLANCHNOPTOSIS 443 condition diagnosed during life, nor was it evident that the lesion of the colon was in any case responsible for the fatal result. Unfortunately, the clinical notes describing the ab- dominal symptoms are found to be very incomplete. The frequent occurrence of these anomalies is shown by the fact that the seven well-marked cases here described occurred in thirty consecutive necropsies which I held at the Philadelphia Hospital during November and December, 1900. Indeed, marked deviations from the usual course of the colon are so common and so frequently are without very evident symptoms, that it is not improbable that a proportion of the reported cases of severe abdominal disorder attributed to this cause may have been founded upon a coincidence rather than a true setiologic relation. Conversely, it is probable that obstinate constipa- tion, tympany, and other abdominal symptoms of obscure setiolog}^ may depend in quite a proportion of cases upon the elongation, displacement, or tortuous course of portions of the colon. In the investigations for disease of the upper intestinal tract the condition of the large bowel seems frequently to be neglected. " The precise diagnosis of anomalies of the colon is often difficult. Careful abdominal percussion, aided by the inflation of the bowel through the rectum by water or gas, may fre- quently fail accurately to outline the colon, especially when there is a marked and complicated deflection. In certain cases the position of the colon is very accurately shown by skiagraphs taken after the large bowel has been filled with an emulsion of bismuth-subnitrate or other substance with a sim- ilar resistance to the x-rays. " Abnormalities of the colon may often interfere with the diagnosis of other abdominal disorders. Thus, in Case I. it would have been very difficult to outline the stomach by the conventional methods, as it was behind a greatly dilated por- tion, of the sigmoid flexure. Such a dilatation might readily have been mistaken for a dilated stomach. The introduction of liquids or gases into the stomach would probably have had 444 THE GASTRO-INTESTINAL CLINIC little effect upon the physical signs ; while the introduction of a rectal tube might have reduced the area of tympany. t " It has been asserted that the diagnosis between enlarge- ments or tumors of the spleen or left kidney may be accurately determined by inflating the descending colon and ascertaining its relation to the enlargement. This assumes that the trans- verse colon has its line of attachment external to the left kidney, and that the splenic flexure lies below and internal to the spleen. Assuming that this relation is always borne out in enlargement of these organs, it is evident that in cases similar to I., II., III., or IV., the entrance of gas through the rectum would chiefly distend the elongated and displaced omega loop, which would almost certainly be mistaken for the descending colon. The frequency of these deviations of the sigmoid would indicate the unreliability of the method, especially in those cases in which the colon is found only internal to or below the new growth. " In many cases the malformation interferes so slightly with the normal physiology of the large intestines that little or no treatment is required. When the symptoms are more severe, various therapeutic measures will suggest themselves upon the determination of the character of the abnormality. In obstinate cases of a severe type, surgical intervention has, in isolated cases, given very encouraging results, and deserves a wider trial. Of the surgical measures the methods of anastomosis or resection of portions of the colon, when feasible, are to be preferred to the commonly employed colotomy with its ensuing discomforts. " It is significant that in not one of the following cases was there a gastroptosis or gastrectasis, nor was a single case noticed in the series of thirty necropsies. " Case I. Russian, male, tailor, aged fifty, was admitted December 12, 1900, and had suffered from cough, expectora- tion, and progressively increasing weakness for the past three months. The chest and abdomen are greatly emaciated, the SPLANCHNOPTOSIS 445 temperature is of the hectic type, the urine contains hyahn casts and a trace of albumin. The patient is constipated. " Necropsy, December 31, 1900. The body shows extreme emaciation. The cecum hes in the right inguinal region above the brim of the pelvis. The colon passes upward for 6 cm. I Fig. 57. — Case I. Anomalous course of the first portion of the ascending colon. Unusual course and dilatation of the omega loop. Trilobed stomach. then bends upon itself and passes downward into the pelvis, curves and returns upward to the concavity of the right ileum, where it forms a third decided curve with its convexity directed upward. It then ascends to the inferior surface of the liver, becomes somewhat distended and crosses transversely to the spleen. Diminishing in caliber, it turns downward to .the left pelvic brim. It now bends and ascends along the 446 THE GASTRO-IXTESTIXAL CLINIC descending colon to the diaphragm, where it becomes greatly, dislended, measuring 12 cm. in its transverse diameter, and lies in front of the preceding portion, the stomach and the median portion of the transverse colon. It now passes down- ward, becomes constricted just above the promontory of the sacrum, and enters the pelvis. The transverse colon is ad- herent to the liver. The stomach is narrow and rather elongated, with two distinct constrictions producing three lobes. The upper constriction is a short distance below the cardia and is the more pronounced. The lower constriction is about 5 cm. above the pylorus. Below the duodenum the mucosa of the intestines is the seat of many ulcers until the dilated sigmoid flexure is reached, where the ulcerative process ceases. The ulcers are rounded, shallow, with necrotic irregular bases, and vary from a few mm. to i cm. in diameter. They are evidently tubercular. Associated lesions are those of pneu- monia, pulmonary tuberculosis, and parenchymatous degenera- tion of the kidneys. " Case II. German, male, laborer, aged sixty-nine, admitted December 12, 1900, complaining of pains in the chest, dyspnoea, and weakness. The family history was obscure. Has been ill with cough and expectoration for a year. There are evidences of consolidation of a large portion of the right lung, but signs of abdominal disease are not found. The clinical diagnosis is phthisis pulmonalis. " Necropsy December 24, 1900. The body is that of a well- developed, but aged, white man. The ascending transverse and descending portions of the colon follow the conventional course. The ascending as well as the descending colon lies well to the rear. The sigmoid is in the form of a long loop, which touches the transverse colon 6 cm. above the umbilicus and to the left of the median line. The descending portion of the loop passes downward into the pelvis. The liver is 4 cm. above the costal margin. Associated are the lesions of miliary tuberculosis of the right lung Avith bronchiectasis, marked oedema of both lungs, and parenchymatous degeneration of the kidneys. " Case III. Irish, aged seventy-two, housewife, widow. The patient was admitted April 4, 1899, complaining of burn- ing pains in the hand's, shoulders, and ankles. She was free from illness until forty years of age, when she had an attack of acute articular rheumatism. This recurred about eighteen SPLANCHNOPTOSIS 447 months ago, and became chronic. The face is red and shghtly puffy, the extremities cedematous, the joints deformed, the skin shiny. The patient is constipated. No thoracic or abdominal disease is detected. On April lo, 1899, the urine Fig. 58. — Case II. Elongation and displacement of the sigmoid flexure. was negative; on December 27, 1900, before death, it con- tained casts and a large amount of albumin. *' The necropsy, December 28, 1900, shows a moderate amount of subcutaneous fat, an exaggerated sigmoid loop, the apex of which is in contact with the lower portion of the left kidney. The intestines are otherwise negative. The stomach is small and elongated. There is an associated right lobar pneumonia, marked pulmonary oedema, and parenchymatous nephritis. The liver has a marked transverse furrow, and 448 THE GASTRO-INTESTINAL CLINIC there are several deep vertical grooves upon the anterior upper surface of the right lobe. An accessory renal artery enters the upper pole of the left kidney. " Case IV. White, male, aged twenty-two. Admitted December 19, 1900, complaining of cough and expectoration. I Fig. 59. — Case III. The sigmoid loop touches the lower border of the left kidney. Enlarged liver with marked transverse furrow. with pain in the chest and abdomen. Has suffered from pain in the epigastrium for the past year. About nineteen days ago had a chill, followed by fever and sweating. The bowels are said to be " regular.'' (?) He is thin, pale, with crusted lips; dry, furred tongue, and abdominal tympany. The Widal reaction is present and the urine contains hyahn and granular casts. The clinical diagnosis is typhoid fever. SPLANCHNOPTOSIS 449 " Necropsy, December 2.y, 1900. follow the usual course until the sigmoid was reached The colon is found to This forms a much exaggerated loop. It passes at first upward and to the right until about 4 cm. above and slightly to the right of the umbilicus, where it curves downward and to the Fig. 60. — Case IV. Exaggerated and displaced sigmoid loop. left until it reaches the concavity of the left ileum, after which it passes almost directly downward to the rectum. The in- testinal adhesions are noted. The ileum contains many typical typhoidal ulcers. A Meckel's diverticulum is present. The spleen is enlarged and hypersemic ; there are areas of sub- mucous ecchymosis in the renal pelvis. The lungs show a congestive oedema. The stomach is very small and covered by the left lobe of the liver. Its position is nearly vertical, the cardia being above and only 2 cm. to the left of the line of the pylorus. 450 THE GASTRO-INTESTINAL CLINIC " Case V. White, male, aged thirty-three, cigar-maker, of rather dissolute habits, admitted December lo, 1900, having suffered for the past month with a pleuro-pneumonia. On ad- mission there was " shifting " dullness over the lower left thorax, A considerable quantity of pus intermixed with air Fig. 61. — Case V. V-shaped course of the transverse colon. The appen- dix lies behind the cecum within the layers of the meso-cecum. was withdrawn by aspiration of left thorax. A few days later the man died. No notes relative to the gastro-intestinal con- dition are found. " Necropsy, December 14, 1900. The body shows a fair muscular development and is sixty-eight inches in height. The mesentery covers the small intestines. The transverse colon forms the letter V, its apex being at the umbilicus. The hepatic and splenic curves are in their usual positions. The appendix lies behind the cecum, between the folds of the meso- SPLANCHNOPTOSIS 451 cecum. The predominant lesions include a large subpleural pulmonary cavity of the left lower lobe with associated atelec- tasis, and a localized hydrothorax. There is a chronic miliary tuberculosis at the apex of the lungs. The kidneys show cloudy swelling. " Case VI. American, white, housewife, aged thirty-eight. Her father died of intestinal tuberculosis. The patient on ad- FiG. 62.— Case VI. Exaggerated V-shaped course of the transverse colon. The liver is enlarged from a fatty infiltration. mission, September 13, 1900, was thin and anaemic and suf- fered from extensive surface burns received about two months before. There was also a watery diarrhea and abdominal tenderness. The temperature was hectic. The patient de- 452 THE GASTRO-INTESTINAL CLINIC veloped delirium and died about three months after admission. The chnical diagnosis was intestinal ulceration. 1 " Necropsy, December 6, 1900. The body is sixty-one inches in length and shows a moderate degree of emaciation. The subcutaneous abdominal fat was 25 mm. in thickness. The abdominal muscles were poorly developed. Beginning in Fig. 63.— Case VII. Anomalous direction of the transverse colon. the right iliac fossa, the colon ascends in the usual manner to the inferior surface of the liver ; it then turns downward and inward to the pubes, from which it ascends to the left inferior costochondral junction and bends transversely inward, forming the sigmoid flexure. The omentum hangs below the colon and is adherent at one point to the uterus. The intestines are not SPLANCHNOPTOSIS 453 adherent and are apparently free from other gross lesions. The stomach is so small and contracted as to resemble intestine. It measures 5x25 cm,, and its mucosa contains, near the pylorus, a rounded undermined ulcer 2-3 mm. in diameter. The predominant lesions are miliary tuberculosis of the lungs, left pleura, and spleen; fatty infiltration of the liver and parenchymatous degeneration of the kidneys. " Case VII. White, housewife, aged thirty-one, height five feet, and of fair development, was admitted to the hospital December 12, 1900, sufifering from weakness, depression, and delusions of persecution. These symptoms had appeared after the curettement of the uterus five weeks previous to admission. No abdominal abnormalities were noticed, but special notes relative to the intestinal tract were not taken. The urine con- tained albumin and casts. The patient sank and died. The clinical diagnosis was uraemia. " Necropsy, December 24, 1900. The mesentery is found above the colon. The cecum is in its usual position, and the ■ascending colon ascends nearly vertically to the liver, where the colon bends abruptly upon itself and returns along, and internal to the first portion until the cecum is reached, where it again sharply turns and passes upward to the ensiform appendix. Here the colon again turns downward and some- what outward to the hollow of the ileum, where it turns trans- versely inward, becoming continuous with the sigmoid flexure. No lesions of the stomach or small intestines are found. There were no adhesions. The kidneys are apparently the seat of a parenchymatous degeneration." The Symptoms of Coloptosis. — What is said in Lecture XLIII. concerning the symptoms of dislocations of the small in- testines applies with equal force to those of the colon. Consti- pation is the most frequent one, but may sometimes be replaced by diarrhea, and when the displacement is decided, one of these is usually present, though in exceptional cases the bowels may act normally. Mucous colitis has been said to be a constant symptom, but this is not true. Dragging sensations in the lower abdomen, flatulency, colics, and all grades or forms of minor discomfort in the same region may occur. After read- ing Dr. Babcock's paper and especially noting the extraor- 454 THE GASTRO-INTESTINAL CLINIC dinary contortions which the colon is capable of making, we cannot be surprised that patients whose large bowels have never been mapped out and therefore may be as badly dis- placed, should complain of persistent abdominal pains and derangements in spite of all sorts of remedial measures em- pirically applied. It should lead us to see the necessity of determining with the greatest possible care the position and course of the colon in any obscure case of abdominal trouble in which our investigations of the other organs have not helped us to a satisfactory diagnosis and treatment. Diagnosis. — It is exceedingly rare that an anomalous position of that viscus itself or of any neighboring organ could prevent a well-trained diagnostication from determining the boundaries of the stomach, and this having been done, the position of even a badly twisted or displaced colon should be made out as a rule by inflating it first with warm water and later with air or other gas, especially when both the stomach and colon have previously been emptied. But, if percussion with these helps should fail, you should try to pass through the whole course of the colon a very flexible metal bougie, such as the cable of Turck's gyromele or of my intragastric elec- trode, which could easily be palpated, and then, if necessary, have made a radiograph of the colon with this in situ. This would show all the possible sinuosities and the position of them. As Dr. Babcock says, there would be difficulty in the worst of the above described cases in inflating the entire colon with gas, but a cable of suitable flexibility could nearly always be introduced. Treatment. — The various hygienic and mechanical meas- ures which I have already described to you, as helpful in over- coming the malpositions of the other viscera, may often suf- fice to overcome displacements of the colon. Long percus- sive sparks from the static machine and the interrupted electric current (faradism) can effect much in bringing up the nerve tone generally and still more by strengthening the muscles of the abdominal wall and of the visceral walls — perhaps also SPLANCHNOPTOSIS . 455 the tone of the supporting ligaments. Massage skillfully apphed helps decidedly in the same direction, as do also rowing and the special exercises for the abdominal muscles which were described in Lecture XXIII. , and various hydriatic pro- cedures, especially jets of hot and cold water directed against the bare abdomen. Whatever may be their modus operandi, it is certain that a course of treatment embracing several of these methods properly carried out results nearly always in decidedly elevating the displaced viscera, including usually the colon, and not infrequently entirely overcome the displacement. For patients who cannot have such a thorough course of curative treatment the most complete and effectual palliative relief possible can be afforded by the method of strapping the abdomen described in Lecture XL., under the head of The Treatment of Movable Kidneys; and holding the displaced parts well up for months at a time, by means of such strap- ping, should conduce much toward a cure. In stubborn cases which are causing serious symptoms, surgical intervention may be necessary and justifiable. Reed and Robinson ^ reported 50 cases of gastroptosis in tuberculous patients seen in the Pottenger Sanitarium in Mon- rovia, Cal., in 1907 and 1908. These were treated mainly by diet and rest with the other usual remedies for tuberculosis, and also, in addition, strapping with adhesive plaster or spe- cial abdominal supporters for those out of bed. The results were very satisfactory in nearly all the cases, the patients being relieved as a rule of their abdominal symptoms, and the course of the tuberculosis was thereafter more favorable. 1 Gastroptosis in Tuberculous Patients — A Report of Fifty Cases. By DrS: Boardman Reed and Frank Neall Robinson. So. Calif .Practitioner, Nov. '08. LECTURE XLIII SPLANCHNOPTOSIS, CONTINUED: DIS- PLACEMENTS OF THE LIVER, SPLEEN, AND SMALL INTESTINES — GENERAL CONSIDERATIONS CONCERNING DIS- PLACEMENTS AND DILATATIONS Not more than a very brief account will be given here of the ptoses of the liver and spleen, which have comparatively little to do with diseases of the stomach and intestines. There are no characteristic symptoms by which you may be able certainly to recognize or differentiate any of the above-named displace- ments. This can only be done by means of the physical signs. The symptoms produced by them are usually indistinguishable from those of gastroptosis, nephroptosis, etc. Hepatoptosis is not likely to cause any constant or well- defined symptoms, and, as can be well understood, on account of its weight and anatomic position, the liver can scarcely sink downward without causing the rig'ht kidney at least, and gen- erally the stomach, to become also displaced. Any symptoms, therefore, could be attributed to the associated displacement of the adjacent organs. A sense of weight or dragging sensation, more pronounced than would follow the falling of the smaller organs, should be expected and will generally be encountered in such cases. Yet, by the physical signs, any displacement of the liver can, as a rule, be promptly ascertained. So large a body can have its boundaries easily mapped out by percussion, whatever its position, except in the case of peculiar abdominal conditions, such as ascites, an ovarian cyst, tumor of the omen- tum adjoining the liver below, tumor of the right kidney, hydro-thorax or hydro-pneumothorax, perforation of the peri- 4S6 SPLANCHNOPTOSIS 457 tonetim with escape of gases into the peritoneal cavity, etc. Those of the above-named conditions which would be likely to present difficulties in the determination of the boundaries of the liver are mostly complications of diseases of such a serious nature that an experienced diagnostician would scarcely fail to recognize them, and these diseases would be of such paramount importance that the presence or absence of hepatoptosis at the same time would scarcely claim very much consideration. An accumulation of feces in the right flexure of the colon, and tumors adjoining it below, might cause a continuation of per- cussion dullness, resembling that over the liver on down for a little distance over the abdominal cavity, but it is usually pos- sible in such cases to insinuate the fingers between the lower edge of the liver and the other dullness-producing bodies when the effort is skillfully and persistently made. Enlargement of the liver under ordinary circumstances can be readily differenti- ated from a displacement of it by the increased area of percus- sion dullness. The liver may be found in various degrees of ptosis, but the more marked grades of its displacement are so extremely rare that I have personally never seen a case in which the organ sank further than to a point where its lower border appeared two to three inches below the lowest rib with the patient in a standing position, though I am constantly meeting with dis- placed kidneys, stomachs, and intestines in a considerable pro- portion of which the prolapse is very marked. I have almost constantly under treatment one or more cases of gastroptosis in which the stomach has descended as far as it can go, resting upon the pelvic organs. Movable Spleen is occasionally encountered in consequence of the elongation of the gastrosplenic ligament and of the blood-vessels supplying the organ, but is a rare accident, and has only an incidental interest in this connection. Displacements of the Small Intestines. — When there is hepatoptosis or marked gastroptosis, there must be more or less enteroptosis ; both the colon and small intestines, especially the 458 THE GASTRO-INTESTINAL CLINIC duodenum, are almost necessarily dislocated as a consequence. But while the position of the colon can generally be determined with an approach to exactness, it is often difficult or impossible to do the same for the small intestines. The development of // A- 1 Fig. 64. — Downward displacement of the liver and intestines. (Splanch- noptosis.) d, duodenum; //, liver; v, gallbladder; <:, carcinoma nodule on the tongue-shaped prolongation of the hepatic lobe, immediately above the symphysis; c.tr., transverse colon; c.d., descending colon; z, ileum. (From Prof. Dr. C. A. Ewald's " Krankheiten des Darms und des Bauchfells.") obstinate constipation following a recognized descent of the stomach would, of course, render it probable that there was a kink in the intestines somewhere, and this is most frequently found at the beginning of the duodenum near the stomach. Indeed, a marked falling of the stomach produces almost un- avoidably a flexure of the small gut at this point. (See Fig. 64, showing the ileum displaced into the pelvis.) SPLANCHNOPTOSIS 459 The symptoms of a displacement of the small intestines, besides constipation, which results in most cases, though by no means in all, are deranged intestinal digestion with discomfort some hours after eating, incarcerated flatus with rumbling, gurgling (borborygmi), and colicky pains. There may be also any of the symptoms of neurasthenia. After inflating the stomach and colon, and then with the help of percussion, clap- otage, etc., determining the position of these viscera to be nor- mal or only moderately low, the finding of marked tympany and swelling, or a bulging forward in the lowest parts of the abdominal cavity, would be evidence that the small intestines had undergone a considerable downward displacement. Treatment. — Many of these ptoses can be decidedly ame- liorated by the same forms of treatment recommended for dilatation and displacement of the stomach. Frequent manual replacements of the prolapsed organs while the patient lies on the back with the hips raised, followed by vigorous stimulation of the abdominal muscles through massage, electricity, appli- cations alternately of hot and cold water, etc., with daily exer- cise of the same muscles by gymnastic exercises, and the wearing of some retentive apparatus, such as either an elastic abdominal supporter or adhesive straps (see Lecture XL.) between times, will often accomplish much in the way of im- proving the condition and the removal of the symptoms, even if they cannot always definitely cure. Doubtless, in some of these cases, as in the worst of the other displacements, surgery may yet be able to acomplish such successful results and so safely that it will become the proper resource. Then, of course, all hygienic measures which improve the general health and nerve and muscle tone must assist in reme- dying the trouble under consideration. Hence, for the stronger patients, active outdoor exercise should be prescribed, such as horseback riding, rowing, golfing, etc., as well as gymnastics for the abdominal muscles, etc. For the weaker ones, a rest-cure is often more suitable. The induced electric current (faradism), locally applied, may usually be hopefully employed in all the 460 THE GASTRO-INTESTINAL CLINIC cases. The foregoing measures, together with some sort of abdominal support, will usually benefit greatly any form of abdominal ptosis and effect a cure in many of them. In a paper which I contributed to the Therapeutic Gazette for September, 1899, I discussed at length the various ptoses, their causes and treatment. Extracts from that paper may be usefully inserted here to emphasize some of the more impor- tant points already sought to be made, and also to illustrate what can be done in the classes of cases mentioned by means of medical and mechanical forms of treatment. Following are the extracts : Some Statistics of Displacements, etc. — " A very large pro- portion of uterine flexions and versions in the non-child- bearing woman certainly, and probably also in parous women, are for the most part a direct mechanical result of the press- ure from above of displaced colons heavy with retained feces, and low-lying dilated or displaced stomachs, which after a full meal may often be found resting immediately upon the bladder and uterus. " Displacements of the abdominal viscera are very much more frequent in women than in men. In a large number of examinations of abdomens of which full records have been preserved, made during a period covering less than three years, and including the cases of 710 different persons, there were 362 patients in whorn the greater curvature of the stomach was found at or below the level of the umbilicus as a result of either displacement or dilatation. There were many other cases in which the departures from the normal were present to a less extent. In exceedingly few — in not more than one per cent. — of these 362 displacements and dilatations had the condition been previously recognized, so- far as could be learned. " Of the above mentioned 362 abnormal stomachs, 122 were in men and 240 in women. Almost exactly two-thirds were .thus in 'the female sex and only one-third in males. Of the displacements, in which the whole organ had descended instead I SPLANCHNOPTOSIS 461 of a part only having been stretched downward, the dispropor- tion is stin more strilhen there is concomitant intestinal indigestion, and then.it usually aggravates the latter condition. The spirituous liquors, though not acid, stimulate the gastric glands in very small doses, and act injuriously, when long con- tinued in any dose, upon the liver, which, in these cases, is damaged soon enough anyway b}' the auto-intoxication result- ing especially from the intestinal complications. The most important articles of diet contra-indicated and to be forbidden entirely are the sharper condiments, such as pepper, horse-radish, mustard, spices of all kinds, vinegar, garlic, onions, and the hot or stimulating sauces. An exces- sive amount of salt is also objectionable. Meat fiber, unless finely hashed, tends to overstimulate all the more decided cases of hyperchlorhydria, and should be much restricted at least. The vegetables, like peas, beans, and corn, except when prepared in puree form, contain much tough and irritating in- digestible residue and do not suit such cases well. Coarse oat- meal with its sharp husks, and any of the cereals when only partly cooked, are likely to aggravate. These foods irritate be- cause of their physical properties, and also because the starch cannot be well insalivated. When one considers that in most American restaurants, hotels, and boarding-houses, as well as in the majority of pri- vate households, the soups are fiery hot, the steaks and chops prepared with butter and pepper, and the coarser cereals that are almost universally furnished, rarely more than half cooked, is it any wonder that an excessive secretion of HCl, with or without gastritis is the most prevalent form of dyspepsia in this country, and that it is, under ordinary conditions, very difficult to cure? Patients thus afflicted should not do more than a very moderate amount of micntal work, and, though they need to be as much as possible in the open air and sunshine, should not exercise even their muscles excessively — to the point of marked fatigue. They should be very moderate in sexual indulgence TREATMENT OF CHRONIC STHENIC GASTRITIS 519 and avoid entirely sexual excitement which remains ungrati- hed. They should, above all else, have an abundance of sleep. Cold or tepid sponge baths (preferably with salt w^ater), salt rubs, and various other tonic hydriatic procedures are helpful. A very valuable and, in many cases, an indispensable means of combating the sthenic, as well as the asthenic, anacid, or atrophic, forms of chronic gastritis is lavage. In most of the advanced cases, and in all of those with dilatation and stagnation, which may result from spasmodic contraction of the pylorus in this disease, you will need to wash out the stomach every day, or, at the very least, every two days. Dis- solve two teaspoonfuls of bicarbonate of soda in each quart of w^arm water, and have the lavage continued with this solu- tion until the last comes away clean, without even small frag- ments of mucus. When the stomach is badly infected with yeast fungi, or other micro-organisms, I have found the solu- tion of one-fourth to half a teaspoonful of alum, along with a teaspoonful of soda, in the last quart of water a helpful resource. The lavage, as a rule, should be done in the morning, at least twenty to thirty minutes, if possible, before breakfast, though there is no objection to washing out later in the day, provided a time can be found when the stomach is practically empty, so as not to involve the harmfulness of removing di- gested nutriment almost ready for absorption. A practical wrinkle which I have hit upon, and found very useful, is to precede the lavage proper by having the patient drink two or three glasses of the prepared solution (or if this has too bad a taste, of plain warm water), and then assume such different positions upon a couch or a carpeted floor as will bring the fluid into contact successively with every part of the stomach, meanwhile taking deep inspirations and forcibly contracting the abdominal muscles so as to make the contained water wash the walls of the stomach. For ex- ample, the patient should do this at first while lying on the back, then on either side, on the face, and, finally, in the knee- 520 THE GASTRO-INTESTINAL CLINIC chest position. These movements in such positions, kept up for three to five minutes in all, will enable the stomach to be washed out afterward completely in one-third the usual time. Intragastric Electricity. — You need to be fully informed as to another valuable measure, which is especially adapted to those serious cases of chronic sthenic gastritis which have be- come complicated by dilatation of the stomach with delayed emptying of its contents and all the dismal train of troubles which follow. It is intragastric electricity. By means of my modification of the intragastric electrodes previously in use, an illustration of which is shown on p. 324, it is possible for any physician to treat in this way the most delicate patients, in- cluding some of those who cannot retain in position the ordi- nary stomach tube long enough to admit of a complete lavage. This is owing to the fact that the cord carrying the current is very small, perfectly insulated, and covered besides by thin rubber, while at the same time the lower end is so stiffened as to facilitate its introduction. The end-piece is also so im- proved in form as to be easily swallowed, and, what is equally important, may be withdrawn without difficulty. ( See cut No. 50, on p. 324, and also Lecture XXX. on Intragastric Elec- tricity.) But electricity will fail and may even do harm when ulcer is present in either the stomach or duodenum. To carry out this special treatment, connect one pole of a good, high-tension faradic battery (one of Kidder's latest has served me well) with a well-wetted pad, about 4x6 inches, which is to be placed over the epigastrium, or dorsal spine, against the bare skin. The patient then, while sitting, drinks a full goblet of water, swallows the intragastric electrode, and lies down on the back on a comfortable couch or gynecologic chair. The other pole of the battery is now connected with the cord attached to the electrode and the current turned on gradu- ally. No unpleasant sensation should be experienced. For the cases with a large excess of HCl, the coil with the finest and longest wire (not less than 3000 feet of a No. 36 wire) should be used. A current as strong as can be borne easily may be TREATMENT OF CTIROXIC STHENIC GASTRITIS 52 1 used for five to eight minutes on alternate days. The vibrator or interrupter, too, should work smoothly, and be capable of such rapid interruptions as to produce a uniform musical sound. Such treatments are often rapidly effective, in the absence of ulcer, not only in lessening the excessive secretion, but also in curing the catarrhal process and strengthening and contracting the dilated stomach, but should not, as a rule, be persevered with for more than a month at a time without intermitting them for a week or two. 'My later experience proves that a mild current will often accomplish better results than stronger ones in these cases. Other Methods of Applying Electricity. — The galvanic current used in the same way, with the positive pole inside, is sometimes more effective in controlling gastric pain. The ordi- nary faradic coils, with short, coarse wires, are more stimu- lating and suit better in deficient secretion. Wdien for any reason electricity cannot be applied directly to the inside of the stomach, by the method just described, something may be ac- complished by external applications of the same. Despite claims to the contrary, my belief is that strong currents can be made to penetrate the abdominal walls sufficiently to enable both the muscular and glandular structures of the stomach to be affected favorably, though probably in only slight degree directly. At all events, with a large pad over the epigastric region, and a small electrode moved slowly upward and down- ward over the spine, the nerve centers and ner\'es supplying the digestive organs can be influenced in a helpful way. I gener- ally use 3 to 10 ma. of galvanism in this way, with positive to the spine ; or 20 to 30 ma. may be applied through the stomach from side to side. With the positive pole in the form of a very small electrode, i to 3 ma. may also be passed through the pneumogastric nerves on the sides of the neck (under the edge of the sternocleido-mastoid muscle) with good results in most of these cases. The negative pole should be over the epigastric region as before. The seances should be from five to eight minutes every other day, or even every day at first. Only the 522 THE GASTRO-INTESTINAL CLINIC very small doses mentioned are helpful when thus applied to the neck. General massage, avoiding the abdominal region, except for the lightest surface rubbing, is an adjuvant of value, especially in the worst cases in which active exercise is not practicable. The Medicinal Treatment. — The use of drugs in this disease requires much care and discretion. The patients are usually the better for nerve tonics, if given through any other avenue than the stomach, and will often require temporarily anti-spas- modics or even sedatives and analgesics. But alkalies must play the largest role in the medicinal treatment. Calcined magnesia has far greater acid-neutralizing power than soda and most other alkaline drugs, and is the preferable remedy, especially when, as usual, there is associated constipation. The dose required to neutralize the excess of acid, and gradu- ally to lessen its secretion may be anywhere from lo to 30 grains (or even more) three times a day, an hour after meals. In very severe cases it is best to give a dose of alkali, also just before the meals, so as to prevent interference with starch digestion. When the larger amounts of magnesia are required, and in other cases when there is no constipation, it is necessary to combine 5 to 10 grains of bismuth with each dose. It is, too, often advisable to replace a part of the magnesia b}^ a portion of sodium citrate, which is also an effective alkali. The following is a good combination for such cases : I^ Magnesise ust£e 3i — 3 iv Sodii citrat 3 ii— 3 ii Bism. subnitrat 3 i — 3 ii M. et ft. Chart No. XII. Sig. : One mixed with a wineglassful of milk or water an hour after each meal. In particularly stubborn cases (and plenty of such will be met with), the addition to the above prescription of i to 2 grains of pulverized extract of belladonna, or 1-20 grain of atropine, will render it more effective, though in that case, as TREATMENT OF CHRONIC STHENIC GASTRITIS 523 these drugs powerfully lessen the secretion of the saliva as well as of the gastric juice, it will be well to administer with each meal a dose of some good preparation of diastase. Atro- pine usually succeeds better in simple hyperchlorhydria than in acid gastritis, and should never be pushed long. The following prescription, recommended by Dr. Stockton of Buffalo, has been largely used for excessive HCl secretion by him, and by Dr. Allen A. Jones of the same city : I^ Cerii oxalat 3 iv Bism. subcarb 3 viii Magnes. carb. levis. § ii » M. Sig. One-fourth to a heaping teaspoonful in water two hours after each meal. When the bowels are inclined to looseness, and the mag- nesia cannot be made to agree, the sodium bicarbonate may be used instead. But, in that event, do not make the mistake of ad- ministering it in too small doses, which would aggravate the disease. I have often seen even half-teaspoonful doses of soda followed at first by an increase of the hyperchlorhydria. In the severe cases it is safest to give the remedy in teaspoonful doses three times a day, and even then it may fail. I have seen some such combination of magnesia and bismuth as those above given succeed promptly, when soda in the fullest doses had only aggravated the disease, and vice versa. There should be a cjuantitative test of the stomach contents at least every week, during any such course of treatment, to ascertain the result, and avoid going too far. These alkaline remedies may be repeated safely as often as may be necessary to con- trol any existing burning pain, or discomfort due to the ex- cessive HCl. In cases in which the alkalies are not well borne, I have seen the following prescription occasionally succeed : i^ Ext. belladonnse gr. i — gr. ii Ext. yerbae santae 3i ■ M. et. ft. mass, in pil. , No. XVI. dividend. Sig.: One after each meal. 524 THE GASTRO-INTESTINAL CLINIC In other stubborn cases in which alkahes do not act well, large (toses of bismuth, such as are suitable for gastric ulcer, according to Fleiner's method, may effect good results. For example : I^ Bismuthi subnit 3 vi — § i Ft. chart No. XII. Sig. ; One mixed with milk or water half an hour be- fore each meal. Possibly in the exceptional cases, in which this prescription proves successful, there are latent ulcers which keep up the Ir- ritation of the glands. Nitrate of silver in doses of 1-8 to 1-4 grain is sometimes a very useful remedy. It may be combined effectively as follows : I^ Argent, nitrat gr. ii — gr. iii Ext. bellad gr. i Bism. subnit 3 ii M. et. ft. mass, in capsulae, No. XVI. dividend. Sig.: One after each meal. This combination is adapted best to cases in which the bowels are too loose, or may be given additionally to correct the overlaxative effect of the treatment by magnesia. In stubborn cases frequent changes of the remedy are neces- sary. Musser recommends the largest practicable doses of nux vomica as very efficient, and Goodman found that hydrogen peroxide would very markedly lessen the secretion of HCl. Another Useful method of treating the disease under con- sideration is by spraying the inside of the stomach with a o. i to 0.2 per cent, solution of nitrate of silver, after first washing out the viscus. In most cases of acid gastric catarrh, when the patient can rest, eat, and drink rationally, and reform all hygienic faults, it is not so difficult to remove all symptoms, to stop virtually entirely the excessive secretion of mucus, and to bring the HCl within normal limits, as it is to maintain this improved condi- tion. The trouble is that the patient, while often rapidly re- TREATMENT OF CHRONIC STHENIC GASTRITIS 52$ lieved of all that he complained of, will rarely continue treat- ment till the physician finds by his tests, chemical and micro- scopic, that the disease has been really cured. A low-grade inflammation of the gastric mucous membrane persists, and when treatment with the careful diet, and attention to hy- gienic requirements otherwise are abandoned, the symptoms soon return. The only safe plan is to insist upon careful living, with some mild treatment, until the disease can be shown to be well ; and, even then, to warn the patient that only by persevering with a reasonable amount of care can he continue well.* The Treatment of Hyperchlorhydria will be referred to again' in Lecture LI., but differs in no wise from that de- scribed above, when it is severe, or inclines to be persistent, and, indeed, I believe with Hayem, that in such severe cases at least, there probably exists a real proliferation of the secret- ins: structures. But in the milder cases, much less need be done than is required for well-marked sthenic gastritis. Com- plete rest of both mind and body, or at least a lessened demand upon the nervous energies in all ways, with a carefully regu- lated diet, suffices usually to effect a recovery in such cases within a few weeks. When these hygenic measures alone fail, toning up the nervous system by means of electricity, and hydriatic applications, with or without the administration of moderate doses of alkalies two hours after meals, and perhaps also a small dose of bromide of sodium combined with a little hyoscyamus or belladonna at bedtime, will nearly always promptly succeed. I A large experience with chronic acid gastric catarrh convinces me that the importance of this disease and of all the more stubborn forms of hy- perchlorhydria is greatly underestimated by the profession generally. In such cases when alkalies, sedatives, and intragastric electricity have all failed, the treatment for gastric ulcer ought to be insisted upon, especially its main features, rest in bed, rectal feeding, etc. LECTURE LI HYPERCHLORHYDRIA AND HYPERSECRETION In discussing chronic sthenic gastritis in Lectures XLIX. and L., I touched incidentally upon simple hyperchlorhydria, a con- dition which is supposed by most authorities to be neurosal merely. It is often impracticable for even an expert to diag- nosticate between a case of marked hyperchlorhydria and in- cipient or mild acid gastritis, and the treatment of the two affections is the same precisely, except that lavage, which is probably indispensable in advanced cases of the inflammatory affection, is not necessary in the simple neurosis. For the sake, however, of completeness in this series, and also because gastrox)^nsis and Reichmann's disease, forms of hypersecretion of the gastric juice, are important, I have de- cided to devote a brief separate lecture to this group of affec- tions. Keeping in mind the essentially practical character sought to be given to the instruction herein imparted, I shall avoid dis- puted questions and the citation of many authorities, even at the risk of being considered dogmatic; but anyone desirous of delving more deeply into these subjects will naturally obtain some one of the numerous complete treatises upon them now accessible, even in English. It is my own opinion, that there rarely occurs a long con- tinuance of an excessive secretion of the gastric juice or of its most active ingredient, free HCl, from whatever cause, with- out some proliferation of the secretory glands. 526 EXCESSIVE SECRETION OF THE GASTRIC JUICE 527 Symptomatology.- — Simple hyperchlorh3'dria presents the symptoms already described under Chronic Sthenic Gas- tritis in Lecture XLIX. If they have not lasted long, it may be inferred that they probably arise in consequence of a reflex disturbance in some other part, such as a movable kid- ney, hepatic or renal calculus, or some disorder in the nervous or sexual system, and they are not necessarily a result of a sthenic (acid) gastritis. If they have existed either per- FiG. 71. — Magnesium phospiiate-crystals from stomacli contents in a case of hyperchlorhydria and neurasthenia. The same crystals were found in the urine. sistently or intermittently for years, or even many months, there may well be a strong suspicion of cell proliferation, and it may then be expected that the disease will not yield easily or quickly. The excessive secretion then may be speedily les- sened, often by full doses of the alkalies or belladonna, but then soon returns after the remedy has been suspended. 528 THE GASTRO-INTESTINAL CLINIC In gastroxynsis, or gastrosiiccorrhea chronica periodica, there are sudden and severe attacks of nausea, vomiting, and gastric pain, in which quantities of fluid mixed with mucus, and sometimes bile, are brought up, showing a large excess of HCl, and accompanied usually by headache, which may be in- tense, and by depression or prostration. The attacks come on suddenly, most frequently in the night, and last one or several days. They recur at varying intervals, sometimes as often as once a week, though rarely so often, and sometimes they are a year or more apart. Between them the patient may seem well, though often a considerable excess of HCl will be found in the stomach during the digestive periods. Hyperchlorhydria is very much more frequently encoun- tered than either of the forms of hypersecretion. Gastroxynsis is now generally believed to be only a symptom, in some cases of tabes and in others probably of pyloric obstruction due to ulcer, excessive HCl or some one of various other causes. It is possible, too, that this symptom may be only a periodical ex- acerbation of the continuous form of hypersecretion. The contimious hypersecretion or Reichmann's disease, often called also gastrosiiccorrhea chronica continua, is exceed- ingly rare as a pure neurosis, if ever such, most of the cases probably being the result of peptic ulcer and an obstructed pylorus with gastric dilatation. The symptoms are those of hyperchlorhydria, except that they persist during the intervals between the digestive periods — -that is, not only when there is food in the stomach, but also when there is not. Considerable fluid containing the elements of the gastric juice, in which the proportions of free HCl and other acid elements are generally decidedly excessive — though not always — can be found in the stomach in the morning fasting, and not mixed with remains of food, even when the stomach has been washed out thor- oughly the preceding evening. Marked nervousness, with usu- ally constipation, and most commonly insomnia, are further symptoms of importance. Differential Diagnosis — This must turn almost entirely upon EXCESSIVE SECRETION OF THE GASTRIC JUICE 529 the chemical and microscopic examinations of the stomach contents. When an abnormally high percentage of HCl is present during digestion only, and, besides an absence of any considerable amount of mucus of gastric origin, there "is an absence also of cell elements coming from the gastric mucous membrane and showing proliferation, the case is one of hyperchlorhydria, probably without any gastric catarrh. When there are the same findings at all times of the day, in the morn- ing fasting as well as at other times, the trouble is most likely to be Reichmann's disease. When the symptoms and signs of HCl excess come on peri- odically, and with violence, yielding to treatment in a clay, or in two or three days, and leaving the patient between times well, except nervous symptoms, or with only a moderate hyper- chlorhydria, the trouble may be set down as gastroxynsis. The diagnosis from gastric ulcer is not always easy. In- deed, it is rarely possible to exclude ulcer positively in any case of painful indigestion, especially with an excessive or normal percentage of HCl. But in most cases of ulcer there are markedly sensitive spots over the epigastric region — usually near the ensiform process — and very often at the left of the spine near the origin of the eleventh and twelfth ribs. Even moderate pressure upon these spots elicits decided pain. Then hemorrhage from the stomach, shown either by the vomiting of blood, or altered blood, or passing the same with the stools (coflfee-ground vomit or stools), occurs at times in at least four-fifths of all cases of ulcer, and not in the uncom- plicated forms of excessive HCl or of hypersecretion. The pain is more severe, and longer lasting usually in ulcer, and is aggravated, almost never relieved, by food, especially by solid food. Let me guard you against one mistake, which is often made by good clinicians, and by some even who consider themselves stomach specialists — that is, relying upon Congo red paper in testing for free HCl. Congo red is changed decidedly in color to a bluish tint by any kind of free acid, even by organic 530 THE GASTRO-INTESTINAL CLINIC acids, especially if present in considerable amount, though the change !s to a more pronounced blue in the presence of free HCl. It is wholly unreliable except as an evidence that some form of free acid is in the stomach contents. There are other almost equally convenient tests for HCl, which are always re- liable — especially the phloroglucinvanillin (Giinzburg) test. The Prognosis is good in simple hyperchlorhydria, but in the two forms of hypersecretion it depends upon the cause — good when this can be removed. The severer cases are always stubborn, and are very liable to relapse. Treatment. — I can add very little to the measures previously advised for the major affection — acid gastric catarrh. In gas- troxynsis no food should be given the first day, and after that, feeding should be resumed very cautiously and tentatively with spoonful doses of milk and limewater or beef juice, white of egg and such predigested aliments as Somatose powder with milk, or the Somatose biscuits, Bovinine (one or two tea- spoonfuls in a wineglassful of milk or water), Plasmon, and Eskay's Food with milk. After a day or two of small feed- ings with one or more of these every two hours, the diet may be gradually enlarged to that prescribed in Lecture L. for chronic sthenic gastritis, which is the same as that suitable for simple hyperchlorhydria, as well as for Reichmann's disease. During an attack of gastroxynsis the patient should be kept in bed, and lavage with an alkaline solution will help most. Anodynes are often required. A partial rest treatment is often helpful during the first month or so of the management of other severe cases of hypersecretion. Rest on the back a part of every day, with massage, except over the abdomen, Swedish movements and electricity are often very advantageous, bat a complete rest from mental occupation and from sexual excite- ment is still more important. Eisner insists that patients with hypersecretion need the treatment for ulcer. This is true of any refractory case of overacting gastric glands. In simple hyperchlorhydria lavage and intragastric elec- EXCESSIVE SECRETION OF THE GASTRIC JUICE 53 1 tricily are not often necessary, but in Reichmann's disease they may both prove very useful, provided ulcer can be excluded. (See Lecture L., on the Treatment of Chronic Sthenic Gastritis and HCl Excess.) The medicinal remedies advised for acid gastric catarrh act equally well usually in the nervous forms of excessive HCl and in hypersecretion. In Reichmann's disease, it is important above all to ascertain and treat the cause. Atropine in fairly full doses often needs to be administered, but it should not be forgotten that when the remedy is carried to the point of dry- ing the mouth, it is very desirable to give some active diastasic preparation with or near the meals — preferably the Taka Diastase. Nitrate of silver is another remedy which should be remembered, both for its tonic action on the central nervous system, and for its astringent, antiseptic, and locally sedative action on the gastric mucous membrane. Hydrogen peroxide is also both sedative and antiseptic. Alkalies and alkaline spring waters, especially Carlsbad and Bedford, can be employed helpfully, if carefully watched and stopped in time. Hyperacidity is not the same as hydrochloric acid excess. Before leaving this subject, I desire to impress upon you a few words of caution : A relic of the old days, when all of us had to guess at the probable character of the contents of our patients' stomachs, is the ambiguous and very mischievous word hyperacidity. The term acid dyspepsia has also come down to us from the same hazy prescientific period. Some writers, unfortunately, still designate indigestion with HCl excess as acid dyspepsia, and refer to hyperchlorhydria as hyperacidity. This is a vague- ness which has caused much very bad therapeutics. An excess of organic acids, such as lactic, acetic, butyric, etc., often produces a marked and painful acidity of the stom- ach contents with very injurious results to the intestinal di- gestion as well as to the intestinal mucous membrane and the nervous system. Even spasm of the pylorus and dilatation may probably be results of this form of acidity. Such a hyper- 532 THE GASTRO-INTESTINAL CLINIC acidity is caused by an opposite condition to that found in hydrocWoric acid excess — that is a condition of debihty, or more or less complete atrophy of the gastric glands which re- sults in a deficiency or even total absence of secretion of the gastric juice. To treat this markedly asthenic condition by alkalies and other remedies designed to diminish the activity of the glandular structures of the stomach would naturally lead in the end to a disastrous aggravation of the disease and all its symptoms ; yet this is frequently done by men who do not analyze the gastric contents of their patients, on the suppo- sition that the vomiting or gulping up of intensely sour ingesta signifies hyperacidity, or acid dyspepsia, and that this always demands an alkaline treatment. In such cases, when the vomited ingesta are sour from an excess of organic acids with absence or a deficiency of HCl and pepsin, an exactly contrary line of treatment is usually re- quired — to wit, the administration of these deficient elements of the gastric juice as medicines, together with roborant treat- ment generally. Von Noorden' has brought forward a new theory as to the causation of the various forms of hyperchlorhydria. He con- siders the excessive secretion of HCl. when not secondary to organic disease, to be a direct result of constipation — intestinal paresis. He holds that it can be cured by the saline waters, such as those of Homburg and Kissengen, and an abundant coarse diet — a regimen similar to that employed by him in colica mucosa which is described at length in Lecture LXXHI. ' Arch, de med. No. 34, 1905. Gaz. med. Beige, January 4, 1906, LECTURE LII ROUND ULCER OF THE STOMACH Ulcer of the stomach, called also round or peptic ulcer, is often latent, running its course either entirely without symp- toms, or with only such as are ordinarily referred to dyspep- sia. Pain, and the loss of blood, either by vomiting or by way of the bowels, though present in a large proportion of cases, may both be absent. In consequence of this frequent latency of the disease, and of the fact that it has not yet become customary to make thorough examinations in cases presenting merely the symptoms of indigestion, gastric ulcer often runs its course unsuspected. It may then terminate in a spontaneous cure (as in numerous reported cases in which, after death, the scars of healed ulcers have been found), or in sudden death from hemorrhage or perforation. Every practitioner of the healing art needs to be very fa- miliar with the symptoms and signs of gastric ulcer, because of its insidiousness and the grave dangers attending a failure to recognize and treat it in time ; and since it so frequently mas- querades in the garb of a more or less severe dyspepsia, you should look upon chronic indigestion not as a trifling matter, but always as a condition demanding a careful inquiry, and thorough physical examination at least. When the results of these, taken in connection with the symptoms, point toward the probability of ulcer, you will do well to give your patient the benefit of any doubt by instituting at once the very hopeful treatment hereafter to be described. -Etiology. — It has not yet been decided positively what causes ulcer of the stomach, but it probably results from the corroding action of a gastric juice excessively strong in HCl, 533 534 THE GASTRO-IXTESTINAL CLINIC under certain predisposing conditions, such as chlorosis, and others not fully understood. The causes of hyperchlorh3-dria are, therefore, probably prominent among the causes of ulcer. The disease is said to be almost unknown among simple peas- ant populations that subsist upon vegetables mainly, or other plain, unstimulating food, and live almost entirely in the open air. The Incidence of Ulcer as to Sex and Age. — Alost authori- ties agree that gastric ulcer is more frequent among women than men, though a few report a contrary experience. Chlo- rosis, which is very often accompanied by hyperchlorhydria, is rarely seen, except in women, and movable kidney, which certainly predisposes strongly to HCl excess, is almost monopolized by women; and HCl excess is at least a nearly constant accompaniment, if not a demonstrable cause, of ulcer. Even in the cases in which the ulcer is apparently the primary condition there was probably a previous latent hyper- chlorhydria. The young are more subject to ulcer of the stomach than the old, while the contrary is true of cancer; three- fourths of the cases of ulcer are said to be in persons between the ages of twenty and sixty, and the largest propor- tion occurs between twenty and thirty. Numerous cases in children ha^•e been reported. The only really reliable statistics concerning gastric ulcer are those from the deadhouse. These show two important facts ; 1. Ulcer of the stomach is rather a frequent disease, va- rious authors cited by Riegel having reported percentages of bodies found with either open ulcers or scars of healed ones, ranging from one to twenty. This would indicate an average of lo per cent., which is doubtless too high; but it is alto- gether probable that at least 5 per cent, of persons dying from all causes either had gastric ulcer at death, or had had it at some time before. 2. The numerous autopsies made in all parts of the world have proved, beyond question, that a large percentage of gas- tric ulcers recover spontaneously, since the proportion of dead ROUND ULCER OF THE STOMACH 535 bodies found with open ulcers, to those showing scars of healed ulcers is scarcely one to two, and according to some it is only one to three. Pathology. — Gastric ulcer is the result of self-digestion of some portion of the mucosa during life. How this autodiges- r / ^. ^4 \ !_2i Fig. 72. — The pyloric end of a stomach, showing an ulcer on the posterior wall. (From a preparation in the Museum University College. 3 About natural size. The ulcer measures 3/4 by 9/16 inch. It is oval, with deeply-cut overhanging margins; complete perforation of the coats of the organ having taken place so that there is a small cavity outside the organ. The floor is formed by thickening omental or mesenteric tissue. Bristles are placed in three openings, which are erosions into large arteries, branches probably of the coronary artery. From a young male who died from repeated hematemesis. (From Sidney Martin's "Diseases of the Stomach.") tion takes place we are not in a position to explain, nor why. Weinland has recently claimed that an antibody (antipepsin) is normally present in the gastric mucosa. Deficiency of tliis, from unknown causes, in any part, leaves it vulnerable. Virchow suggests that thrombosis or infarction of the nutrient blood-vessels brings about conditions favorable for autodiges- 536 THE GASTRO-INTESTINAL CLINIC tion. This view was long generally accepted, but it is much questiAied now. A general condition of ill health, and espe- cially ansemia, seems to be a frequent predisposing factor. Gastric ulcer is circular or oval, having a punched-out appear- ance, with the edges but slightly changed. It thus differs from ulcers of inflammatory origin. It is cone-shaped, the ex- cavation tapering by a series of terraces towards the serous layer. This form of the ulcer suggests its origin from an in- farct, as the shape corresponds to the distribution of an end arter3\ The diameter of the ulcer varies from two to six cm. It may be larger and possess serrated edges. It is, as a rule, single, but may be multiple. Gastric ulcer is essentially chronic in its course, and heals generally by scar formation. It may lead to fatal hemorrhages, to perforation, or to ad- hesions with the neighboring structures. The cicatrix may bring about stenosis of either orifice, especially of the pylorus, or the hour-glass form of contraction, which sometimes divides the stomach into two almost separate pouches. The following, from Welch's article on Simple Ulcer of the Stomach, in volume ii. of " Pepper's System of Medicine," shows the relative frequency with which the ulcer affected the d-fferent parts of the stomach in 793 cases : Lesser curvature, 28S (36.3 per cent.) ; posterior wall, 235 (29.6 per cent.) ; pylorus, 95 (12 percent.) ; anterior wall, 69 (8.7 percent.) ; cardia, 50 (6.3 per cent.) ; fundus, 29 (3.7 per cent.) ; greater curvature, 27 (3.4 per cent.). , Acute gastric ulcer is usually small, punched-out, with clean- cut edges and smooth floor. It may be round or oval, or a mere fissure, but even from this last a fatal hemorrhage is said to be possible. There is no thickening and the ulcer may be hard to find. Symptomatology. — The three most prominent symptoms of gastric ulcer are pain, hemorrhage, and circumscribed tender spots. The pain is distinctly digestive, coming on usually shortly after the taking of food. It is proportionate in degree to the solidity or roughness and the quantity of the food in- ROUND ULCER OF THE STOMACH 537 gested, and, as a rule, to which there are some exceptions, dis- appears when the stomach has been emptied either by vomit- ing or in the normal way by propulsion into the intestine. The pain may be of any degree of severity. It is usually of a per- sistent burning or boring character, but may be violent or spas- modic. It is localized generally in the epigastrium somewhat to the left of the middle line and may radiate to the spine. Rarely the pain is felt in the back opposite the stomach, and not at all in front. The fact that it is not felt, or only very exceptionally felt, when the stomach is empty, and is either absent or greatly less in degree when only licjuid food has been taken, is almost diagnostic of gastric ulcer, though the pain of hyperchlorhydria is sometimes similar in its manifestations. The latter pain, however, usually comes on later, not often until an hour or two after eating, and is apt to increase in severity up to the time when digestion is at its height, and taking more food, especially if richly nitrogenous, or large doses of alkaline drugs, relieves it, while the pain of ulcer fol- lows often immediately upon the taking of food, and the more food generally the greater the pain. It may be nearly as se- vere at first as later, or become lighter as digestion pro- gresses, and as the gastric contents are licjuefied. But it is to be borne in mind that ulcer and hyperchlorhydria very often go together, and when they do, the pain resulting from the two combined conditions is likely to increase up to the acme of digestion from one to three hours after a meal, just as in cases of uncomplicated hyperacidity. The hemorrhage may reveal itself either by the vomiting of fresh red blood (sudden and severe hemorrhage), or by dark changed blood (coffee-grounds vomit), or by the passage of tarry stools of altered blood (melena). The amount of blood lost may be very small — the so-called " occult blood " — from the erosion of minute vessels, and be recognizable only by painstaking examination of the stools ; or very large, amount- ing sometimes to eight, sixteen, or even twenty-four ounces at one time. A very copious hemorrhage from the stomach, 538 THE GASTRO-INTESTINAL CLINIC showing itself by both sudden and severe hematemesis and black stools of altered blood, points to ulcer rather than to cancer of the stomach, since in cancer large hemorrhages are unusual. In either disease the hemorrhage may be entirely oc- cult. In all cases of suspected ulcer or carcinoma without open hemorrhage frequent tests of stomach contents or stools for occult blood should be made. In carcinoma the bleeding is apt to be less marked than in ulcer, but more constant. Marked tenderness on pressure over a small circumscribed area in the epigastrium (as well as often on the left side of the spine, over the origin of one of the last two or three ribs), is a very constant sign of ulcer — probably the most constant of all its signs and symptoms. The painful spot in front is in most cases very marked or acute, and is situated usually either just below the ensiform process nearly in the median line, or a little to the left of it. Exceptionally, it is lower down or still more to the left, and may even be found to the right of the median line. In such tender spots pain is evoked by a much lighter pressure than over the tender regions so often found in neurasthenics, which are just above or to the right or left of the umbilicus. The tender spots to the left of the spine are not so constantly present, but are found in about one-third of all cases of gastric ulcer. You should not forget, however, that in neurasthenic and hysteric patients there may be tender- ness on pressure alongside the spine at various points, even in the absence of gastric ulcer. Vomiting after taking food is another rather frecjuent symp- tom of gastric ulcer. The vomiting of ulcer often occurs one or two hours after eating, when digestion is approaching its height, and is easy, as a rule, not accompanied by much strain- ing. Moreover, its occurrence is followed by a cessation of the pain. In these two respects it differs from the vomiting of cancer, which is likely to be difficult, and is followed b) little or no relief of the pain. The ejecta are most frequently partly digested food containing either a normal percentage or ROUND ULCER OF THE STOMACH 539 an excess of free HCl. These should be filtered, and careful quantitative test of the filtrate for excess of HCl should be made. If you are not prepared to make quantitative tests, it will be of importance to learn at least whether free HCl is present or not. To determine this, drop into the stomach contents — after filtering, if possible, 2 or 3 drops of a one-half of i per cent, solution of dimethyl-amido-azo-benzol in alcohol. A brilliant red color will result if free HCl is present; otherwise the licjuid will assume a yellow color. A very large excess of lactic, or possibly other organic acids may also produce a red- dish color, and in doubtful cases, you should verify such find- ings by the Giinzburg test described in Lecture IX. Hypersecretion of gastric juice — i.e. an excessive amount of juice with a high or normal percentage of HCl — is also a fre- quent accompaniment of ulcer. This hypersecretion may oc- cur only during digestion or also during fasting — continuous hypersecretion. • It is exceptional in ulcer to find deficient HCl, though this occasionally happens. The almost constant excess of HCl is one of the important corroborative signs of gastric ulcer. A stubborn chronic hyperchlorhydria or hypersecretion may be the sign of a latent ulcer. It is therefore important in such intractable cases to put the patient to bed and give the ulcer cure. The use of the tube in suspected ulcer is to be avoided as endangering perforation, though it is customai'y for experts to employ it cautiously in chronic cases of ulcer. The complexion of the patient may be ruddy and fresh, though more frequently it is pale, especially after hemor- rhages. Loss of flesh occurs sooner or later, but this is less progressive and extreme than in carcinoma. The appetite is generally good — often excessive. This as- sists especially in differentiating ulcer from cancer and chronic asthenic gastritis, though not from simple hyperchlorhydria or sthenic gastritis, in both of which a sharp appetite is the rule. Ulcer patients will often say the appetite is poor when 540 THE GASTRO-INTESTINAL CLINIC they mean that they restrict food on account of its conse- quences. Constipation often coexists with gastric ulcer. A tumor can be sometimes felt, especially in old ulcers in- volving dense cicatrices or adhesions \vith neighboring organs and when much hypertrophy of the pylorus has resulted. Such a tumor is usually small, of cylindric shape, smooth and less movable than the irregular, nodular cancers of the pylorus. Complications — The most important are ( i ) rapid and possibly fatal collapse from the eroding of a large vessel with resulting serious loss of blood, which is not always vomited, and is to be recognized by the usual symptoms of shock (faint- ness, pallor, cold extremities, etc.) ; (2) partial perforation with consecjuent patches of local plastic peritonitis and the ) Fig. 73. Perforated chronic ulcer. (From a preparation in the Museum of the Royal College of Surgeons. By permission of the Council.) Twice the natural size. The ulcer is shaped like an oyster-shell. It is funnel-shaped, and the ridges formed by the submucous and muscular coats are well seen. The peritoneum is perforated by an oval opening with clean-cut edges. (From Sidney Martin's " Diseases of the Stomach.") formation of adhesions, a condition very difficult to diagnosti- cate, since the only symptoms are a more persistent pain, and increased sensitiveness to movements of the adjacent structures, with sometimes very slight fever; (3) perforation with es- cape of gastric contents into the peritoneal cavity, with the usual immediate symptoms of perforation — sudden intense ROUND ULCER OF THE STOMACH 54I pain, fall of temperature, rapid pulse, leucocytosis, etc. — and a rapidly supervening general peritonitis which is almost in- variably fatal without prompt surgical intervention; (4) sub- phrenic abscess, which is a rare complication of ulcer, but a serious one. As a result usually of a small perforation and the slow escape of the stomach contents into some portion of the space between the stomach below, diaphragm above, and, laterally, the liver, spleen or one or more of the other ab- dominal organs, a localized abscess forms which is walled off and is liable to rupture into any of the adjacent viscera, into the lung, finding its outlet, in the latter event, through one of the bronchial tubes, or into the peritoneal cavity, producing general peritonitis. The abscess often contains gas as well as fetid pus and food particles. The recognition of this condi- tion must be made mainly from the physical signs after a thorough examination of both the thorax and abdomen, and the subject you will find fully discussed in the works on phys- ical diagnosis. An examination of the blood in the event of such complication should reveal leucocytosis, which would be a corroborative sign. Sequels of Gastric Ulcer. — A contraction, or even complete closure of either the cardiac or pyloric orifice of the stomach can result from the cicatrix of an ulcer. This very rarely happens to the cardia, since it is seldom the seat of ulcer, but is a very frequent occurrence in the pylorus or its vicinity. Such a stenosis of the gastric outlet becomes the cause of marked dilatation of the stomach with either rapid exhaustion and death, or a gradual, but very serious, and often fatal, im- pairment of the health. The crampy pains which had ceased with the healing of the ulcer may then recur, and vomiting of large accumulations of fermenting food occurs at intervals of a day or two, with scanty urine, and the physical signs of a dilated stomach, as well as sometimes the finding of a small, smooth, elongated, not freely movable tumor in the pyloric region. When extensive ulceration has existed around rny part 542 THE GASTRO-INTESTINAL CLINIC of the visctis, near its middle especially, there may result from the scars'»such a marked constriction as to produce the hour- glass stomach. Great prostration, profound anaemia, even ca- chexia may be caused by frequent bleedings and vomitings, or from ingestion of too little food through dread of pain. In 5 to 6 per cent, of cases, according to Boas, gastric ulcer is followed by cancer, which develops in its site, beginning usually at the edges of the scar. The Mayos and other surgeons give a much higher percentage. (For diagnosis see Lecture LXI.) Hour-GIass Stomach. — C. L. Scudder {Boston Med. and Sur. Jour., Dec. 22, 1904) states that the symptoms of hour-glass stomach are those of chronic gastric ulcer plus food-stasis. Several important physical signs are given, and the diagnosis while difficult is not always impossible. Moynihaji' s szgji : If the stomach be percussed and then distended with air and after 20 or- 30 seconds percussed again, the resonant area will have increased at the cardiac end of the stomach, but will remain the same over the pyloric end, demonstrating a constricting part. Wolfler's 1st Sign. — If a tube is passed and the stomach washed with a known quantity of water, upon measuring the return water there will be found a loss corresponding to the water which has passed through the constricting part into the pyloric pouch. (This sign is very questionable — the water may pass through the pylorus.) Woijler's 2d sigfi : If the stomach is washed until the water returns clear, a sudden gush of foul cloudy fluid may occur from the pyloric pouch, demonstrating a separa- tion between the two parts. JaTvorski's " paradoxical dilatation." — A succussion splash is obtained, the tube is passed and the stomach is emptied apparently, and still a suc- cussion splash can be obtained. Eiselsberg pointed out the importance of the following two signs: (a) Upon distending the stomach with gas or air a bulging on the cardiac side is visible and evident to percussion. This bulging gradually subsides as the air passes to the pyloric loculus. (b) As the gas passes from one side of the constricting part to the other the stethoscope will detect a bubbling sound. Stockton {Jour. A. M. A., Dec. 11, 1909) gives the following sign: The tube passed a few inches beyond the cardia obtains stomach contents; then, being pressed farther, after a little resistance it apparently gets into a second cavity from which contents of a difi^erent character are obtained. This indicates either an hour-glass stomach or a spasmodic contraction between the second and last thirds of the stomach. The Roentgen rays used after administration of a bismuth suspension should be a decided aid in the diagnosis. LECTURE LIII THE DIAGNOSIS OF ULCER OF THE STOMACH The diagnosis of peptic ulcer may in certain cases be mani- fest at once from the group of symptoms present without any further examination than is required to find that the character-- istic tender points are present ; or, on the other hand, as Riegel forcibly puts it, one may meet with cases of it in which, " with the help of all our methods of investigation, it will be impos- sible to make even a probable diagnosis of the disease." This is especially true in the earlier stages, before large hemor- rhages occur. Indeed, Ewald, Leube, Riegel, and other emi- nent authorities agree in admitting that an absolute diagnosis in suspected cases is often impossible, and all these strongly advise that in such cases the therapeutic test be made — that is, that the patients be placed upon the treatment appropriate to ulcer, when, if a cure or marked improvement result, it may be inferred that ulcer had been present. The probability that ulcer is present, and that, too, in an advanced form, is very great, however, whenever there are hemorrhages from the stomach which recur irregularly from time to time, without a very marked or steadily progressive loss of flesh and strength or the gradual development of cachexia, especially if- there are no signs of hepatic cirrhosis or indications of so-called vi- carious menstruation. If, besides, there are the characteristic pain and marked tenderness on pressure over the epigastrium near the ensiform process with or without a like tenderness to the left of the spine over the origin of any of the three lowest ribs, the diagnosis becomes reasonably certain. Vomiting daily after one or more of the meals, especially when the ejecta 543 544 THE GASTRO-INTESTINAL CLINIC contain a large proportion of free HCl, would, with the other symptoms mentioned, leave scarcely any room for doubt. Hemorrhage from the stomach being the most diagnostic of all the single symptoms of ulcer, it is very important to ex- clude all other possible sources of hemorrhage. These are chiefly: the lungs, throat and nose; the gums; hepatic cirrhosis with resulting gastric congestion; heart disease causing stasis; aneurismal and atheromatous changes in the arteries of the stomach (probably rare) ; vicarious menstruation; scurvy, pur- pura, and other hemorrhagic diseases; and hysteria. A very careful history and physical examination will usually leave little doubt. It is to be remembered that blood from the lungs is usually coughed up, and is apt to be bright red and somewhat frothy; that from the stomach is usually dark. However, blood from the lungs or upper air passages may be swallowed, and vomited after remaining some time in the stomach. It is desirable to make the diagnosis early, before hemor- rhage and other certain signs are present. Various tests have been devised as aids to this end. Among these is morning lavage of the fasting stomach. If microscopic food remnants are found in the wash water it suggests ulcer; these micro- scopic food remnants may simply be retained by the ulcer surface or they may be due to slight stagnation caused by spasm of the pylorus, the result of an ulcer in or near the lat- ter. Grandauer {Dent. Med. JVoch., Aug. 5, 1909) has de- veloped his " remains test " on this principle. He gives 2 gm. of bismuth the previous evening; in the morning a fat-zwie- back test breakfast is given, and one hour later the stomach is washed with 100 c.c. of water and then washed again until clear. When large amounts of bismuth are recovered it points to ulcer or catarrh. The latter is easily excluded and the diagnosis of ulcer is reached. If more than a few c.c. of active gastric juice is found in the morning in the fasting stomach, without food remnants, DIAGNOSIS OF ULCER OF THE STOMACH 545 this means a continuous hypersecretion, a frequent accompani- ment of ulcer. Bonniger {Berl. Klin. Woch., 1908, No. 8) advises pour- ing a dilute solution of HCl into the stomach of the patient with suspected gastric ulcer. If ulcer is present pain arises promptly, which never occurs in the healthy stomach. The orthoform test is the converse of this : 8 grains of orthoform are administered during the pain of suspected ulcer; if the pain subsides within a few minutes it points to ulcer, as orthoform is almost inert except upon raw or abraded surfaces. The finding of occult blood in the vomitus, lavage water or stools, has much the same significance as open hemorrhage. Care must be taken that the patient be on a blood- free diet for a sufiicient time before the test, and to exclude other sources of blood. Einhorn {Med. Rec, April 3, 1909) has devised an ingeni- ous test which has led him to the diagnosis of ulcer in a num- ber of cases which had been doubtful, especially of duodenal ulcer : The patient swallows in the evening the duodenal bucket in a gelatin capsule. To the bucket is attached a braided silk thread, English No. 5, long enough to allow the bucket to pass 75 cm. from the teeth and the thread to be at- tached to the patient's shirt or ear. The bucket is withdrawn from the fasting stomach in the morning and the thread care- fully inspected for brown or black discoloration. According to the distance of the stain from the lips the ulcer is diagnosed as in the oesophagus, cardia, lesser curvature, pylorus or duode- num. The test is not available for other parts of the stomach. Adler and Ashbury ^ have found the x-rays of considerable value in the diagnosis of ulcers of the stomach and duodenum. The examination is made four to six hours after the admin- istration of a single dose of bismuth. Other investigators also report favorable results. But dependence must not be placed on any one test. The whole picture obtained by careful history and painstaking ex- ^ Journal A. M. A., May 21, 1910. P. 1721. 546 THE GASTRO-IXTESTIXAL CLIXIC amination must be considered in any doubt'ful case. It is to be remembered that ulcer patients characteristically have their symptoms in attacks of variable duration, with intervals of complete or partial relief; that during the attacks the symp- toms recur regularly every day and with definite relation to the taking of food; that the attacks are likely to recur indefinitely and with increasing severity until cured by medical or surgical treatment. The Diagnosis from Ulcer of the Duodenum. — Round ulcer of the duodenum needs to be differentiated. It usually affords symptoms similar to those of gastric ulcer (though more fre- quently even than the latter it runs its course without any symptoms), except that hematemesis is much less common, the blood in case of hemorrhage being more likely to pass ofT by the bowels exclu5i\"ely. and the pain, as well as the area which is painful on pressure, is more on the right side, usually in the prolonged right parasternal line about one or two finger breadths below the gall-bladder. Pain usually begins 2 to 5 hours after eating, and is relieved by taking more food. Vom- iting may occur, as a reflex probably of the pain, but usually does not relieve the pain, as it does in gastric ulcer. Hyper- chlorhydria is by no means so frequent an accompaniment as in ulcer of the stomach. Duodenal is less prevalent than gastric ulcer, and. unlike the latter, is \'ery much more frequent in men than in women — 79 per cent, are in men according to Collin — and about one-seventh of all the cases are in children under ten years. ]\Iayo finds duodenal, more frequent than gastric, ulcer, but, as Einhorn well says, this is probably due to the fact that duodenal ulcer is much more likely to result in surgical complications. You will need to think also of the pain from gall-stones — hepatic 'colic — but here the pain and tenderness are consider- ably to the right of the median line, the pain is usually far more intense, and there is no connection bet^^"een the attacks and the period of digestion. Hemorrhage will be absent, and jaundice with some fever often present. DIAGNOSIS OF ULCER OF THE STOMACH 547 Differential Diagnosis — In summarizing the points in the differential diagnosis between gastric ulcer and the diseases which resemble it, I cannot do better than to follow the lead of Ewald and other authors, who have grouped the symptoms in a tabular form. This I have done, and present for you the results in the following table, in which the observations of numerous high authorities, as well as my own, have been care- fully compared and sifted, all statements having been omitted as to which there is not a concurrence of several observe ers : Pain Hemor- rhage Vomit- ing Ulcer of the Stomach There may be all forms and degrees. Comes on at variable periods after eating, often within half an hour, and lasts till the stomach emptiesitself either in the normal way or by vomiting. May be boring or burning, but is often spasmodic. Worse after solids.' Felt in certain spots and in- creased by pressure there. Either small or large amounts of blood may be vomited, of either red or dark color, and this is apt to recur one or more times before controlled. Then no further hemorrhage usually for weeks or months. Following the hematemesis brownish-black altered blood ; occult blood in stools. A frequent symp- tom, and liable to oc- cur daily. Comes on either .shortly after eating or later. It is usually easy, not ac- companied by strain- ing. Amount propor- tioned to size of last meal. Ejecta rarely rancid, but show free HCl. Vomiting usii- ally relieves the pain. Excess of HCl, with or without Gastritis Comes on one to three hours after eating, and apt to continue during remaining period of digestion. Usu- ally of burning character. Re- lieved by more food, especially nitrogenous, or large doses of al- kalies. Pressure neither increases nor relieves it. No blood vom- ited or passed by bowels. Cancer of the St07nach Less frequent, but happens in the worst cases, when it occurs at about the acme of digestion— one to three hours after eating. Vomiting usually relieves the pain. Usually not violent, but continuous. Not relieved by vomiting, by more food or by alkalies. Not in creased by moderate pressure, though deep palpation may aggra vate. .Small (rarely large) amounts of blood are vomited at times, usually dark like cof- fee grounds. The relatively small hem orrhages may recur frequently, the blood showing both in the vomit and stools, as altered or occult blood. Likely to occur once in two or three days only, when large amounts of sour and offensive matter ejected, showing ab sence of free HCl and often presence of lac- tic acid. The vomit- ing often accompa- nied by straining. Vomiting does not relieve the pain as a rule. Gastralgta Not connect- ed with the taking of food or limited to the period of digest ion. Comes on in spells at irreg- ular intervals, often many days apart. Often relieved by pressure. A s sociated sometimes with neuralgia elsewhere. No blood is omited o r passed with stools. Vo m i t ing exceptional, and w^hen it does occur, in no way char- acteristic. 548 THE GASTRO-INTESTINAL CLINIC Gastric Secre- tiofl and Diges- tion Tumor Ulcer of the Stomach Free HCl usually in excess and very active digestion of meat, eggs, and milk; starch digestion de- layed. Perfora- tion Com- plexion Flatu- lence and Belch- ing Appe- tite Tongue Excess of HCt, with Q}- without Gastritis Free HCl al- ways in excess during digestion, which is active for proteids and slow for starch. Age Sex None except in old complicated cases, when a small, smooth, cylindric or egg- shaped resistance maj' sometimes be made out in the re- gion of the pylorus. It is usually fixed and immovable. Always possible, and may occur in per- sons who have not previously com- plained. Fresh and ruddy often, except when ulcer has long con- tinued; anaemia and pallor follow each hemorrhage, but are soon recovered from, except when ulcer is associate d with chlorosis. No offensive belch ing, but likely to be much flatulence in the bowels. Apt to be much fermenta- tion of the carbo- hydrates. Generally good but patient often pre- vented from eating by fear of the pain. Red and often dry ; may be coated at the back. Pale after hemorrhage. Most frequent be- tween twenty and forty, but very com- mon in middle age and occurs in old age. About twice as fre- quent in women as in men. None at all. Never occurs. Variable ; often sallow from intes- tinal and hepatic complications, but sometimes health f ul in recent cases. The same as in ulcer. Usually sharply increased, but ex ceptionally poor in advanced cases with gastritis. Clean and red as a rule, but often coated at the back. Most frequent in middle life, but may occur at any age. Probably no marked differ- ence. Caticer of the Stomach Free HCl generally absent or deficient, and digestion of pro- teids poor, except in that form of cancer which develops in the site of an ulcer. Lactic acid usually present. Boas-Oppler bacilli usually discov erable in stomach contents. A palpable tumor develops at some stage in nearly all cases. It is usually uneven, sensitive on palpation, and mov able, not fixed. Never in the earlier stages, but in the last stage occurs in six per cent, of all cases. Bad after the first stage, and becomes progressively worse until cache.xia estab lished. Usually marked flatulence: much of- fensive gas passing both ways. No constant departure from normal cond i t i on s. Digestion usually good. No tumor. Gastralgia Bad nearly always, Pale and badly furred. Rare before thirty ; most frequent in ad- vanced years. Statistics disagree. Probably no impor tant difference. Never occurs. Most fre- quently pale, from impaired general health. Little or no gas may pass either way, butsometimes excessive ner- vous belching of odorless gas. Good as a rule, but may be capricious. May be nor- mal or in any condition, ac- cording: to complications. Most f r e- quent between the ages of eighteen and thirty-five. Much more frequent in women. LECTURE LIV THE TREATMENT OF GASTRIC ULCER- EROSIONS OF THE STOMACH The mortality from gastric ulcer has greatly lessened as a result of recent improvements in the treatment. Brinton esti- mated it at 50 per cent., whereas it is now stated by several authors as not exceeding 10 per cent. In any case, the prog- nosis will depend upon many things — the absence of serious complications, the youth and vigor of the patient, and, above all else, his ability and willingness to submit to a course of methodical treatment in bed. When the special ulcer rest cure is instituted and strictly carried out during an early stage of the disease, recovery nearly always follows within a few weeks, and is often permanent. When the affection has long existed, and the ulcer is deep, as shown by large hemorrhages, the outlook is less favorable. When complicated by gastritis or adhesions, the disease is likely to be very obstinate, and when stenosis of either orifice has resulted, a cure is impossible with- out surgery. A considerable proportion of cases heal sponta- neously in the course of time — often many years — under favor- able circumstances, in consequence probably of a diminution in the secretion of the gastric g-lands, the excess of HCl hav- ing, as a result of exhaustion or atrophy, given place to a de- ficiency of the same. But there are few, if any, diseases in which skilled treatment at the proper time can accomplish such brilliant results. Treatment, Prophylactic — In every case of marked HCl excess, especially if there is pain at the height of digestion, you should consider that ulcer is threatened, if not already present, 549 550 THE GASTRO-INTESTINAL CLINIC and insist upon a rational and persistent treatment until normal conditions have been restored, and even then urge strenuously that the patient so alter his diet and unhygienic mode of life, t^at there shall not be a speedy return of the secretory derange- ment. For instance, it is quite useless to cure a patient of hyper- chlorhydria, if, so soon as you pronounce the percentage of HCl in the stomach contents to be normal, he be permitted to eat ir- regularly, hastily, and excessively a diet consisting mainly of meat and other stimulating animal foods, with acids, alco- holic liquors, the sharpest condiments, and other things that are highly exciting and irritating to the gastric glands, es- pecially if at the same time he exercise little and overtax his brain and nervous system in many ways. It ought to be pos- sible to make such a patient understand that the same causes which produced his disease before will still more easily pro- duce it again, if he continue to keep them in action. Cure the hyperchlorhydria, then, by the methods which I have hitherto described, including full doses of alkalies and belladonna or 'atropine, a bland diet, and by insisting upon the proper use of the teeth. Thorough chewing of the food spares the stomach' mechanically; the abundant saliva thus produced does its own work, and also neutralizes much acid; and slow eating is one of the best preventives of overeating. Moreover, since anaemia and chlorosis predispose strongly to ulcer, you should endeavor always by exercise out-of-doors, cool or cold sponge baths and other measures, both hygienic and medicinal, to improve the quality of the blood. When in such cases the stomach is not too sensitive, you may often administer safely such mild ferric preparations as Blaud's pills, neutral solution of the albuminate of iron, etc., and when these do not suit, preparations of bone-marrow often meet the requirements well, increasing the number of red-blood cor- puscles without disturbing the stomach. The tincture of iron, which is usually remarkably effective in other cases, will ag- gravate any case in which there is excess of HCl, and the milder preparations of iron should, therefore, be chosen here. THE TREATMENT OF GASTRIC ULCER 55 1 I have sometimes found i- to 2-teaspoonful doses of Roncegno water to suit well. Treatment, Curative — A recent French writer, Lemoine, lays down two fundamental indications in the treatment of gastric ulcer : ( i ) To put the stomach at complete rest, and (2) to modify the gastric secretion, that is, reduce the hyper- chlorhydria. To do these things effectively is often sufficient, but Lemoine very properly adds these further special indica- tions : (i) Quiet the pain. (2) Allay vomiting. (3) Prevent dilatation of the stomach. (4) Preclude or arrest hema- temesis. To which I may add: (5) Prevent perforation. The diet with confinement to bed must be depended upon mainly for the fulfillment of all the above-mentioned indica- tions. To put the stomach at rest physically and functionally, it will be necessary, first, to keep the patient in bed for a time — three weeks at least, and four to six weeks are better — and for one week to feed exclusively per rectum, or longer in the worst cases. Fox, Forster, and Williams first advised such a rest cure for ulcer of the stomach, but to Ziemssen and Leube in Germany belongs the credit of proving the efficacy of the method and establishing it in the favor of the profession. Be- sides complete physical rest with rectal feeding at first, the Ziemssen and Leube method comprises also the use of hot poultices or hot compresses over the stomach. These should be kept constantly in place. The nutrient enemas should be introduced two to four times a day, according to the tolerance of the bowel, after a prelimi- nary cleansing enema. (See Lecture XXL for particulars con- cerning rectal feeding. ) Dorkin, in a large series of cases, has continued rectal feed- ing for twenty-three days with good results, and in one case in my own practice the patient was nourished exclusively by the rectum for four weeks without serious loss of flesh or nu- trition, but in gastric ulcer, unless hemorrhage should con- tinue (a most unlikely event under such a method of treat- 55- THE GASTRO-IXTESTIXAL CLIXIC ment), xery cautious feeding by the mouth can be resumed usually l3y the end of a week. ]\Iilk and limewater. equal parts, will constitute the best food to begin with, and when tjhere is any remaining irritability of the stomach, it will be well to give half a tumblerful every hour for a day or two, though sometimes it is necessary to begin with a tablespoonful every half hour. After the first few feedings, and with the vomiting over, ecjual parts of milk, lime water, and ricewater, or barley water may be taken in the same way. After two days, the amount of this combination can usually be increased to one or one and a half tumblers every two hours, provided there be no decided atony or dilatation of the stomach. Alean- while, it will be advisable to continue the administration daily of two enemas at least for another week. Beef tea and bouillon are little more than solutions of the meat salts, which are exceedingly stimulating to the gastric glands, and are there- fore best not introduced into the stomach in such cases. Raw, lightly boiled or poached eggs without pepper, and only slightly salted, are much safer, and one of these may be allowed once a day in addition to the milk mixture from the fourth to the seventh day ; twice a day from the eighth to the eleventh day, and thereafter three times a day. Calf's-foot jelly makes an- other bland and nourishing addition at this stage. After the eighth day, the patient is to be allowed every three hours a larger feeding as follows : two tumblers of the milk mixture, in which a cracker may be dissolved, and besides, once a day, instead of the milk, a tumbler of a smooth, well-strained puree made of corn, peas, celery, or asparagus; this, in ad- dition to the eggs or calf's-foot jelly, provided always the stomach proves to be tolerant of the additions. By the end of two weeks it is usually safe to add some of the blander starchy preparations, such as flaked rice. Cream of \Mieat, Oat Flour, and other similar finely ground and bolted cereals, which are to be thoroughly well cooked and served with fresh milk or even good fresh, sterile cream, when the latter is well tolerated, but not with stigar. Still better are the THE TREATMENT OF GASTRIC ULCER 553 well-dextrinized cereal foods now on the market, includins- o Force, Grape Nuts, etc. Small feedings every three hours, lim- ited strictly to such viands as those above mentioned, with the early addition of good stale bread and butter, and baked white potato, thoroughly masticated, should be insisted upon for fully three weeks, and then a more liberal, but rational, diet may be gradually resumed. The patient will be safer without meat, especially meat fiber not hashed, for months after his ap- parent recovery, and should avoid still more stringentlv, for a longer period yet, all alcoholic beverages, spices, or condiments (except sparingly table salt), the sharper acids, as vinegar and very acid fruits, the coarser or cruder vegetables, fried foods, pickles, and all the coarser grains. The ordinary rough, un- bolted oatmeal and bran bread, as well as the hard crust of any bread, dry toast, zwieback, etc., are hurtful in these cases, be- ing mechanically irritating, unless previously softened or chewed a very long time before swallowed. (See Lecture XX.) Massage, during the rest in bed, should be given once or twice daily over the entire body, except the abdomen, which must be strictly avoided — because of the stimulating effect upon the gastric glands. Constipation may be overcome by saline laxatives. It is a general custom to give a glass of warm Carlsbad water or a teaspoonful of Carlsbad salts in a glass of warm water every morning. This aids in preventing con- stipation, and also in reducing the hyperchlorhydria. By the end of three or four weeks, in most cases, you should begin very gradually to accustom the patient to exercise again, in the same way as after the Weir-Mitchell rest treatment of nervous diseases. Treatment, Medicinal,— The milder cases, that receive this treatment by rest, rectal feeding, and very restricted diet, will require little medicine for the main disease, and there are not likely to be any complications demanding special treatment in cases thus managed. If there should be pain or vomiting in spite of the regimen 554 THE GASTRO-INTESTINAL CLINIC just described, pellets of ice swallowed and allowed to dissolve in the stomach will frequently afford relief. These are useful also to quench thirst during the period of exclusively rectal feeding, and at the same time the mouth may be rinsed as often as desired with cold w^ater. If there should be very much thirst in spite of these measures, small sips of cool water may be allowed as often as necessary. When there is per- sistent pain or burning, with no food or only liquids being taken by the mouth, it is usually dependent upon excessive HCl, and relief will then usually follow the administration of half to one teaspoonful doses of sodium bicarbonate dissolved in a tumbler of warm (not hot) water, given half an hour be- fore the three chief feedings daily. In all cases that prove stubborn, and in the severe or advanced ones from the start, it is well to institute the Kussmaul-Fleiner treatment. Fleiner washes out the stomach before breakfast, and then introduces through the tube lo to 15 grams of bismuth, suspended in about 6 ounces of water. But I have found that administering 40 to 60 grains in a draught of water, three times a day an hour before food, usually answers every purpose. Singularly enough, so far from always constipating, I have found these large doses sometimes to aid in overcoming constipation. When, however, there is a contrary result, enemas of 4 to 12 ounces of olive oil, or cotton-seed oil, every two or three nights, will usually secure good movements without irri- tation. The design is to have the bismuth form a protective coating over the mucous membrane of the stomach. In cases com- plicated with acid gastric catarrh, in which a profuse secretion of mucus covers the membrane, it is better, provided there has been no hemorrhage for a long time, to first wash out and then introduce the remedy through the tube, the patient mean- while being caused to lie down in such a position as to allow the bismuth to fall especially upon the part of the stomach where the ulcer is located. There would be a manifest ad- vantage in thus following the Fleiner method exactly, when THE TREATMENT OF GASTRIC ULCER 555 the tube can be used skillfully and gently without endangering- a hemorrhage. My own experience with the bismuth treatment has been very satisfactory, and I have not found it necessary to use the tube at all in ulcer cases ; but have administered the drug in 30 to 40 grain doses in water, every three to six hours before food — /. e., on an empty stomach. The Lenhartz Cure. — I have never used the Lenhartz treat- ment, and have had such uniformly satisfactory results from the routine laid down above that other methods seem hardly necessary. Various observers, however, are reporting good results from the Lenhartz routine, and the essential points of the latter are presented below. Lenhartz protests against a regimen which tends to further deplete the blood and lessen the vitality of a patient who is already anaemic and under-nour- ished as the result of more or less hemorrhage and starv^ation; accordingly, he begins at once, even if hemorrhage has oc- curred the same day, a diet rich in albumin, rapidly increasing the same until a- high caloric value is reached. The diet is as follows : First day after last hemorrhage, 2 eggs, 200 c.c. milk. One additional tgg is given each day until eight are taken; this number is continued daily. 100 c.c. milk are added each day until a liter is reached; this is continued daily. On the third day 20 gm. of sugar are given, with the eggs; this is in- creased by 10 gm. every second day, until 50 gm. are reached; this amount is continued daily. On the sixth day 35 gm. of raw chopped meat are given ; this is increased to 70 gm. on the seventh day, and the same amount continued. On the seventh day 100 gm. of milk-rice are given; this is increased to 200 gm. on the ninth day, and to 300 gm. on the eleventh day ; this amount is continued daily. On the eighth day 20 gm. of zwieback are given ; ninth and tenth days, 40 gm. ; eleventh and twelfth days, 60 gm. ; thirteenth day, 80 gm. ; fourteenth day, 100 gm. On the tenth day and daily thereafter 50 gm. of raw ham are given. Butter is also given on the tenth day, 20 gm. ; on the eleventh day this is increased to 40 gm., and con- 556 THE GASTRO-INTESTINAL CLINIC tinued in this amount. The patient receives 280 calories the first day, 3073 calories the fourteenth day. The milk is iced and fed with a spoon; the eggs are beaten and the cup and spoon stood in ice. After the seventh day four of the eggs may be cooked. An ice bag is applied to the epigastrium almost continuously for two weeks. No effort is made to move the bowels for at least one week. Rest in bed for at least four weeks is essential. Bismuth in 2 gm. doses is given two or three times a day for ten days. Iron is given later. Minkowski, Senator, Lambert, and others have used the diet, somewhat modified, with apparently good results. Cohnheim, in his textbook, recommends the use of olive oil in ulcer, claiming good results in numerous cases which had obstinately resisted other forms of treatment. He gives one- half to one wineglassful of oil in the morning before break- fast, and a half ounce or less before the noon and evening meals. The treatment is said to be especially effective when pylorospasm is present. When the oil is objectionable, an al- mond oil emulsion may be substituted. Treatment of Complications and Sequels. — Copious hemor- rhage is not to be feared while the patient is on a strict rest cure with the diet already laid down. If it should occur under other conditions, put the patient immediately to bed, feed by the rectum, administering small pellets of ice by the mouth, and place an ice bag over the epigastrium. The tube is dis- tinctly dangerous in these cases in most hands, yet Ewald re- cords having checked otherwise uncontrollable hematemesis by washing out the stomach with ice water. You will do well to give large doses of bismuth suspended in limewater. A good soluble form of ergot should also be promptly administered, and repeated if necessary. Stimulate per rectum and hypo- dermically only when collapse threatens ; keep the head low and maintain the body heat. The patient should be quieted and peristalsis checked by sufficient doses of morphine, hypo- dermically. Calcium chloride may be given by rectum or THE TREATMENT OF GASTRIC ULCER 557 cautiously by mouth, in an effort to increase the coagulabihty of the blood. Gelatin for the same purpose is also much used, a 2 per cent, sterile solution being given by hypodermoclysis, or frequent small doses of a lo per cent, solution by mouth. Adrenalin or suprarenal extract may be given by mouth, some- times with good results. Some authors even give it hypo- dermically, but this is probably unwise; the raising of the gen- eral blood pressure would be apt to more than offset any local contracting effect upon the bleeding vessel. In the case of a complete perforation into the peritoneal cavity, a skilled abdominal surgeon should be summoned im- mediately, and meanwhile absolute rest of the patient secured with abstinence from food or drink (except ice pellets), and an ice bag should be placed over the abdomen. Opium in full doses is also desirable for its cjuieting effect. Complete per- foration is almost invariably fatal unless the patient is operated upon within a few hours after this accident; hence no time should be lost. In doubtful cases also, when a partial per- foration only is suspected, a surgeon should be called at once, to share the responsibility of deciding upon the treatment to be followed. It is not possible to say that a partial perforation may not soon burst through the plastic adhesions and set up a general peritonitis. If no operation is performed in cases of partial perforation, the pain of the resulting adhesions may be somewhat relieved by massage (after the case has become chronic) and sometimes by percutaneous galvanism; but late surgery is often indicated to relieve the symptoms — pain, func- tional disturbance, and at times obstruction — caused by these adhesions. Cicatricial contraction of either orifice of the stomach con- verts the case into a surgical one, and operative intervention should then be insisted upon as indispensable. When this is declined, something can be done in moderate strictures of the pylorus producing gastric dilatation, by lavage daily or even twice daily (Riegel), and by controlling the hyperacidity. Full doses of sodium bicarbonate, or, sometimes better yet, a 558 THE GASTRO-INTESTINAL CLINIC mixture of other alkalies, as magnesia usta, prepared chalk, and bismuth subnitrate, so combined as to keep the bowels in a proper condition of openness without looseness, will in most cases effect this, and thereby generally lessen the dilatation by preventing spasmodic closure of the pylorus. When cancer develops in an ulcer surgery is demanded. Erosions of the Stomach. — A pathologic condition of the gastric mucosa characterized by pain, weakness, emaciation, and sometimes hemorrhages which may be severe, showing in the lavage water shreds of membrane, has been described by numerous writers, and been variously classified. It presents analogies both to chronic gastritis and to ulcer, but does not correspond entirely with either in its symptomatology. It is relatively very much less frequent than either, and quite rare in a severe form. Its pathology is not understood. Einhorn classifies this as a separate disease which he considers to have resulted from chronic gastritis. The condition would appear to be one of superficial exfoliation of the upper layer of the mucosa, the name Erosions of the Stomach implying that raw surfaces are left in places which account for the pain after taking food, as well as for the occasional hemorrhage. Hemmeter, who does not consider erosions of the stomach as a separate disease, finds this condition generally character- ized by hyperacidity, and finds that it yields often to a milk diet. Einhorn has observed it in association with both an ex- cessive and deficient secretion of HCl, but more frequently the latter. Riegel makes no special mention of it, but describes a similar condition in his account of the complications of gastri- tis, while Stockton, in a note to the American Edition of Riegel, inclines to Einhorn's view of the trouble. The treatment of this condition when it complicates a chronic gastric catarrh, should, in the main, be the same as for ulcer, but may include also lavage and other intragastric methods which would be unsafe in ulcer. Einhorn recommends lavage and spraying with a o. i to 0.2 per cent, solution of nitrate of silver; also intragastric galvanization. LECTURE LV ROUND ULCER OF THE DUODENUM Peptic or round ulcer of the duodenum is probably less frequent than gastric ulcer, and is still more likely than the former to run a latent course until a severe hemorrhage, or even perforation and general peritonitis call attention to it. Mayo finds duodenal ulcer more frequent than gastric, and other surgeons report a high ratio of duodenal ulcer. The probable explanation of this is that duodenal ulcer is more likely to have complications demanding surgery. Duodenal ulcer differs from gastric ulcer in several notable particulars. The former is more common in men, and be- tween the ages, of 20 and 60; the latter in women, and between the ages of 20 and 30. Ulcer of the duodenum not only oftener runs a latent course, but is also much more refractory to treatment, decidedly more liable to perforation as well as to obstructive cicatricial contraction, and in consequence is a more dangerous disease than ulcer of the stomach. It also occurs relatively often in infancy and childhood, while ulcer of the stomach is rarely ever encountered under the age of 10. Its most usual site is at the upper end of the duodenum, be- tween the pylorus and the opening of the common bile duct and pancreatic duct. Generally it is quite close to the pylorus, though it sometimes appears lower down, and exceptionally may be found in any part of the duodenum, or even in the upper part of the jejunum. It varies in size from that of a pea to that of a twenty-five-cent piece, or even, exceptionally, to that of a dollar. .ffitiology and Pathology. — The causes and histologic pe- culiarities of ulcer here are practically identical with those of 559 560 THE GASTRO-INTESTINAL CLINIC gastric ulcer, except that extensive burns of the skin may often in some obscure way produce the former, and the ulcers from such burns are usually much longer than broad and are jagged in outline. Boas mentions also as possible causes, freezing, erysipelas, septicaemia, etc. It may complicate nephritis. Being supposedly dependent upon the same digestive action of the gastric juice upon mucosa of lowered vitality, the result is the same — a punched-out, funnel-shaped ulcer, usually single, though sometimes multiple, extending down through the submucosa and muscular layer, and still more frequently than when in the stomach perforating with the result of producing either adhesions to adjacent viscera or general peritonitis. Duodenal ulcer when it heals is likely to produce more serious results from scar formation than when situated in any part of the stomach, other than the pylorus, because the duodenum is so much smaller that obstruction of the lumen more certainly follows cicatricial contraction. The Symptoms of Duodenal Ulcer. — As already mentioned, there may be no symptoms at all, and such a latent course is far more frequent in this than in gastric ulcer. The symptoms when present are very similar to those in the former disease, and yet present some decided differences. There is likely to be the same burning or boring pain, but instead of coming on di- rectly, or within a very short time after food has been taken, it is rarely felt until at the end of two to four hours, and often not until after five or six hours, that is, not until the con- tents of the stomach at the termination of peptic digestion, are passing into the duodenum. The pain does not, as a rule, radiate toward the back, but upward or downward. The pain, too, is not increased by taking more food or alco- holic drinks as in gastric ulcer, but may rather be helped by these. There is also usually tenderness on pressure, but it is almost uniformly felt to the right of the middle line near the lower border of the liver, or a little lower down in the right hypochondrium. But since the site of the ulcer is usually very near the pylorus, and the latter is not infrequently much ROUXD ULCER OF THE DUODENUM 561 displaced downward, the situation of the pain and tenderness may be changed accordingly. Vomiting may occur, but more rarely than in gastric ulcer. Hemorrhage is quite as likely to result, but when it does, is usually different from that seen in ulcer of the stomach, in one very important respect especially. That is, blood is rarely vomited without at the same time some of it passing off by the bowels, either in an unchanged or slightly changed form or as melena, w'hereas, in ulcer of the stomach it frequently happens that all the blood lost is vom- ited, none being left to escape by the bowels. And, on the other hand, it is much more common in duodenal ulcer to find evidences of blood in the stools when none at all has been vomited. Exceptional cases, however, have been reported of duodenal ulcer in wdiich there was hematemesis without blood in the stools. Another feature of the hemorrhage in these cases is that when hematemesis occurs, the vomitus wdll at first contain nothing but food remains or chyme, and then, later, the blood will come up, possibly mixed with bile. In the hematemesis of gastric ulcer the blood is likely to come up at once W'ith the food previously taken. This is a highly im- portant diagnostic point. The bleedings may be moderate and recur frequently or speedily cause death. Ewald insists that according to his experience the gastric juice in duodenal ulcer more frequently than otherwise shows only a normal or sub- normal percentage of HCl, instead of an excess, as is the rule in gastric ulcer. Boas and Einhorn report a contrary experi- ence, and have usually seen hyperchlorhydria with ulcer of the duodenum. Attention is called to the fact that it is precisely those cases which have been wdthout symptoms, the patients feeling and looking well, that are most likely to develop se- rious hemorrhage or perforation, while those in which there have been long-continued symptoms, such as pain after food, tenderness on pressure, etc., more rarely experience such ac- cidents. Constipation very often coexists wdth duodenal ulcer, but perhaps not oftener than in most other dyspeptic troubles. 562 THE GASTRO-INTESTINAL CLINIC Jaundice is a somewhat rare symptom, but when encountered is very significant as to the situation of the lesion, increasing the probabiHties that any existing ulcer is in the duodenum, and not in the stomach. Diagnosis. — Notwithstanding that the above described symptoms present numerous marked differences from those found in ulcer of the stomach, it is often difficult, and some- times impossible to decide whether the ulcer which is the ob-. vious cause of bleeding, pain, tenderness, etc., is situated in the stomach or intestine. Whether the ulcer is just above or just below the pyloric opening might be manifestly at ti^s very hard to determine, especially when the stomach is small, and lies further to the left than usual, since then, an ulcer in the upper part of the duodenum might produce all the symp- toms and signs of one in the pyloric part of the stomach. So, with an enlarged stomach or one much displaced downward and to the right, a pyloric ulcer might closely simulate one in the duodenum. (For Einhorn's thread test see Lecture LIII.) Boas has experienced the greatest difficulty in differentiating between duodenal ulcer and hyperchlorhydria. In both, pain comes on two to four hours after eating, and is usually re- lieved by taking more food or alkalies. The pain is also often referred in both, chiefly to the region of the pylorus, and there may be even in hyperchlorhydria some sensitiveness in the same region. He believes that frequently in such cases the diagnosis cannot be made, and whenever the patients do not improve speedily upon the diet suitable for hyperacidity, he advocates instituting the accepted cure for ulcer with con- finement to bed, rectal feeding, etc. For the rest, the differ- ential diagnosis of duodenal ulcer must be made from the crises of locomotor ataxia, gall-stones, cancer, and sarcoma or other morbid growths. In tabetic crises there would be the usual symptoms of tabes, though the crises may be among the earliest symptoms, and there would be no hemorrhage or pain on pressure, and no relation generally between the at- tacks of pain and the taking of food. Some forms of hepatic ROUND ULCER OF THE DUODENUM 563 colic are at times accompanied by a slight passage of blood with the feces, but the pain in these cases has again no con- nection with eating or drinking; the attacks do not usually last so long as the exacerbations of an ulcer and the pain is generally more violent. Jaundice is much more common in gall- stones, but may be present in duodenal ulcer, as a result of catarrhal swelling, etc. Palpable swelling and tenderness of the gall-bladder, and tenderness and enlargement of the liver, point rather to gall-stones. A right posterior point of tender- ness is also more common in the latter disease. Gall-bladder teiii^erness is best elicited by pressing the ends of the fingers upward under the right costal arch as the patient takes a deep breath. The sensitive gall-bladder is thus forced down against the fingers, and the patient will wince or cry out. Ulcer ten- derness, on the other hand, is best brought out by pressure directly backward in the pyloric or duodenal region. When ulcer is suspected palpation should be very gentle, as there is danger of causing perforation or hemorrhage. Cancer or sar- coma of any of the structures in the right hypochondrium might raise some doubt in any case which has been only a short time under observation, but the course of either disease is so entirely different from that of ulcer that the diagnosis could soon be positively established. Other morbid growths in the same region could scarcely mislead you, since they would not be painful or cause hemorrhage and could usually be palpated. Complications and Sequels. — Chief among these, in addition to the hemorrhage, are local peritonitis resuhing in adhesions to adjacent viscera with kinking, displacements, etc., causing possible obstruction of the bowels and gastrectasis, general peritonitis from perforation, cicatricial contractions narrowing the lumen of the gut and leading to dilatation of the stomach; or the perforation may cause fistulous connections between the duodenum and any of the neighboring organs. Carcinomatous degeneration may happen in duodenal as in gastric ulcer, but fortunately much less frequently, as excision is almost never possible. It would be revealed by the develop- 564 THE GASTRO-INTESTINAL CLINIC ment of the usual symptoms of malignancy, including a progressive lowering of the general health, more steady and continuous pain, cachexia, etc., and by early obstructive symp- torps. Prognosis. — In duodenal ulcer consequent upon burns of the skin, the prognosis is absolutely bad, there having been no case of recovery so far reported. Medical treatment fails, and c ■% v,_,y Fig. 74. — Carcinomatous ulcer of the duodenum, {a) the duodenal ulcer, the thickened edges of which, resembling a rampart, are the seat of carci- nomatous infiltration ; {b) transverse section of the thickened and infil- trated intestinal wall ; {c) pylorus, which is also thickened ; {d) stomach. (From " Krankheiten des Darms u. des Bauchfells," von Prof. Dr. C. A. Ewald.) the condition of the patient does not usually admit of opera- tive intervention. In other ulcers of the same part the prog- nosis is always much more serious than in those of the stom- ach for the reasons fully stated above. Treatment — In the main, the treatment of duodenal ulcer ROUND ULCER OF THE DUODENUM 565 should follow the same lines as that of gastric ulcer. Rest in bed, however, and the withholding of all food and of disturb- ing medicine by the mouth are more imperative than in the case of the latter. Full doses of bismuth should be administered as directed in the lecture devoted to that subject, and the other remedies therein recommended, including hot poultices, are equally applicable here, unless the tests of the stomach contents should show a deficiency of HCl, when alkalies need not be given. Orthoform in 5- to 7-grain doses may be added to each dose of the bismuth when there is much pain. The danger of hemorrhage, perforation, etc., being greater than in gastric ulcer, and the results of such accidents more to be feared, when they do occur, the stomach tube ought not to be used, in any case in which ulcer of the duodenum can be reasonably suspected, except on a patient who is known to tol- erate it well. It is the violent efforts of gagging and vomiting which are to be feared. In another respect the course of procedure is different from that suitable in gastric ulcer. In the latter disease, non-opera- tive measures, including a very careful diet and medicinal and mechanical therapeutics, have won some of their most brilliant victories, and good results are always to be expected from such measures, in the beginning at least; but in duodenal ulcer the prognosis being much less favorable, you should proceed more cautiously and protect both your own reputation, and the in- terests of the patient, by associating with you at the outset a competent abdominal surgeon. Then if the treatment pre- scribed succeeds, and the symptoms promptly subside, well and good; but if "not, the surgeon will be in a better position to afford you efficient assistance, than if suddenly called in after a serious turn in the case. In the former event, continue the rectal feeding for one or two weeks, and then resume feeding by the mouth with even more caution than was advised for the treatment of gastric ulcer. If you should be so fortunate as to secure a recovery by these, or by any means, see to it that the patient thereafter so orders his diet and way of liv- 566 THE GASTRO-INTESTINAL CLINIC ing generally as to avoid a recurrence of such a dangerous condition, and this, notwithstanding the varying testimony upon the subject, will probably be best accomplished by com- bating any tendency of his gastric glands to secrete HCl excessively. For practical suggestions on this subject, see Lecture LIV., under the head of the prophylactic treatment of gastric ulcer. If, after the disappearance of the symptoms in whole or part, there should be a return of them, indicating that the ulcer persists, by all means advise operative intervention with- out further delay. In the event of perforation, immediate operation will be necessary. In these, as in all cases in which surgical aid is likely to be needed, there should be the most cordial co-operation between the physician or physicians, and the surgeon. The life-saving achievements of both belong to the glory of the profession. LECTURE LVI TUBERCULAR ULCERATIONS IN THE STOMACH AND INTESTINES Contrary to a prevalent impression, there is often present in the gastric juice an excess of free HCl in the early stages of phthisis. Numerous observers testify that digestive derange- ments of one kind or another are in a considerable proportion of cases the first symptoms complained of in conditions which later develop the usual signs of tuberculosis in the lungs or elsewhere. The most frequent tuberculous involvement of the stomach is by miliary tuberculosis. In such cases the gastric mucosa may be studded with tubercles. But true tubercular ul- ceration is rare in the stomach at any stage, especially without a similar involvement of the intestines. This is probably due to the fact that the acid of the gastric juice impairs the activity of. the tubercle bacilli, and prevents their proliferation when swal- lowed with the sputum. When tubercular ulcers exist in the stomach, the symptoms are practically the same as those of simple peptic ulcer, and the treatment may be the same, plus the general roborant measures, especially hygienic and cli- matic, required for the constitutional condition. The absence of free HCl in cases showing the usual signs and symptoms of gastric ulcer might well lead you to suspect a tubercular origin, especially when either some part of the respiratory tract or any region of the body presents tubercular lesions. Tubercular Ulcers of the Intestines. — The same holds true for ulcer of the duodenum. Neither in the stomach, nor as a rule in the duodenum, will tubercular ulcers be found so long as there is regularly a normal percentage of HCl secreted by the gastric glands, and it is probable that even a very limited 567 568 THE GASTRO-INTESTINAL CLINIC secretion of the same, so deficient as to leave no surplus in the free form, may yet exert such an inhibitory effect upon the swallowed bacilli as to prevent the development of tuberculous ?ilcers in these regions. In the remainder of the intestine such ulcers more com- monly occur, especially, according to Nothnagel, Boas, Pick, and others, in the lowest part of the ileum, and in the cecum, as well as in the sigmoid flexure and rectum, where there is more stagnation of the feces than elsewhere. Primary tuber- culosis of the intestine in adults is exceptional, resulting then generally from infection through non-sterilized milk or other uncooked or insufficiently cooked animal foods. It is more frequent jn young infants, and to a much less extent in older children. While the HCl of the gastric juice usually exerts a sufficient antiseptic effect to protect the stomach and duo- denum, it does not necessarily kill the bacilli, so that when the food containing them passes on into parts of the bowel, the contents of which are alkaline, a favorable culture medium is met with, and infection may take place. But, except in young children, tuberculosis of the intestine is nearly always a secondary process, the source of infection being as a rule the swallowed sputum. The affection is then usually characterized by diarrhea as well as the familiar symp- toms of phthisis, viz., cough, profuse expectoration, emacia- tion, debility, fever, and night sweats. Sometimes palpation reveals swollen mesenteric glands, and often sensitive areas over the lower abdomen, corresponding to the sites of the ulcers. Tubercular ulcers in the jejunum or upper part of the ileum, without involvement of the lower bowel, may be accom- panied by constipation. Pathology. — The standard works on pathology have little or nothing to say of tubercular ulcer of the stomach, and the reports of such cases in medical literature do not for the most part go at all deeply into the subject of their pathology. It is believed, however, that the infection usually comes through the circulation, and not directly from food or sputum infected TUBERCULAR ULCERATIONS IN THE STOMACH 569 with the bacilh. The ulcers may be either single or multiple, and of any size from that of a pinhead to that of a silver dol- lar. They rarely extend below the submucosa. Various authors are of the opinion that previously existing ulcers or erosions become the seats of the tuberculous process, the loss of substance, as in other cases, facilitating infection. Tubercle bacilli may usually be found in the necrosed tissue lying upon the surface of the ulcers as well as in remains of the glands. Tuherculous ulcers of the intestines occur very much more frequently and their character has been exhaustively studied. They have been found in from 50 to 70 per cent, of all ad- vanced cases of pulmonary tuberculosis. The infection is be- lieved to be rarely primary except in infants, but as a rule secondary resulting from the bacilli in the swallowed sputum. The usual situation of such ulcers, according to Green, is the lower end of the ileum, but Ewald^ says they are not only very common in the ileo-cecal region, but also in the descending colon, and wherever else the feces most stagnate. Some other writers assert that such ulcers are found most frequently in the rectum. They develop from miliary tubercles and chiefly in the solitary follicles and Peyer's patches, those occurring in the former being usually round, and those in the latter, oval in form. They often become confluent, and may then produce an extensive loss of tissue. They frequently perforate the walls of the intestine, producing, as in similar perforations elsewhere when the process is slow and adhesions have had time to form, patches of local peritonitis, or when the progress has been more rapid, a direct opening into the peritoneal cavity with a re- sulting general peritonitis. Healing of tubercular ulcers is not common, but when it does occur, is likely to produce ob- struction of the bowel by the contraction. Symptomatology. — In Lecture LVIII. on Intestinal Ulcers Generally, you will find described with sufficient fullness the symptoms which are fairly characteristic of any kind of ulcera- ' Die Krankheiten des Darmsu. des Bauchfells, von C. A. Ewald, Berlin, T902. SyO THE GASTRO-INTESTINAL CLINIC tion in the intestines anywhere, especially below the duodenum. The round ulcer of the duodenum has some features peculiar to itself. Apart from the general symptoms of tuberculosis, it woyld usually be impossible to determine from any local symp- toms present that an ulcerative process revealed by the char- acter of the stools, as well as by pain and tender spots over portions of the bowel, was of tubercular origin rather than due to some other cause. Bleeding is less common from tubercular ulcers than from those arising in the course of typhoid fever or dysentery, but this is equally true of catarrhal ulcers of the intes- tine. Boas cites Girode as authority for the statement that the stools passed in intestinal tuberculosis are often of a brown- ish-black color, similar to the coffee-grounds vomit seen in cancer of the stomach, and reports that this observation has been confirmed by his own experience, though, at the same time, he cautions that such peculiar stools are by no means always to be considered as having an admixture of blood. Diagnosis. — The constant presence of abundant tubercle bacilli in the stools, or the occasional finding of even small quantities of the same at a time when the patient was not hav- ing any sputa at all, would render it very probable that some form of tuberculosis existed somewhere in the alimentary canal, especially if the same findings should persist after the patient had been placed upon a strictly vegetable diet so as to exclude the possibility of the bacilli having been ingested with tuberculous meat, milk, or other infected animal food. Gen- erally speaking, however, the surest evidence that an intestinal ulceration was of tubercular origin would be the coexistence of the symptoms and signs of tuberculosis elsewhere in the body; and if at the same time numerous bacilli were regularly found in the evacuations, the diagnosis might be considered established. The ttihercuUn test should be resorted to in any doubtful case in which there is a strong suspicion of primary intestinal tuberculosis, since in this way only can the diagnosis be cer- tainly made, and you may now accept it as definitely decided TUBERCULAR ULCERATIONS IN THE STOMACH 571 that this is not only a reliable, but a perfectly safe test when properly carried out. Several methods of making the test are now in common use : Calmette's ocular test consists in the dropping of a small amount of tuberculin upon the conjunctiva of one eye of the patient. The prompt development of a more or less marked conjunctivitis in this eye constitutes a positive reaction. The test is quite delicate, but dangerous. Numerous cases of seri- ous destructive inflammation have been reported. The method would best be abandoned. Von Pirquet's skin test is consid- ered safe, and is fairly delicate : the skin is scarified in one or two places, just deeply enough to avoid drawing blood, the scarification being done through a drop of diluted or strong tuberculin previously placed upon the skin. A control scarifica- tion is made with a clean instrument close by. In twenty-four to forty-eight hours, usually, a hyperemic areola forms about the scarifications when the test is positive, the control scarifica- tion showing no areola. Moro's test is made by rubbing a small bit of tuberculin ointment into the patient's skin. When positive, an eruption of papules, vesicles or possibly pustules, ensues. The skin should be thoroughly cleansed with ether be- fore these tests. The subcutaneous test has been largely supplanted by the foregoing, but is still used and is safe in skilled hands. The beginning dose must be very minute. If no reaction follows, it is customary to repeat the injection, giving twice the amount, and to give a third still larger injection if necessary. The reaction after a sufficient dose is generally both local and general. The latter is shown by a rise of from i to 2 degrees in the temperature at the corresponding times of the day, together with lassitude and more or less vague distress, including often headache and sleeplessness. The local reac- tion consists usually of pain and tenderness in the affected parts, or if these symptoms existed before, they are much in- tensified. If there be a lesion in the lung, there are rales and disturbed respiratory rhythm where nothing of the kind may 572 THE GASTRO-INTESTINAL CLINIC have been heard before. In the case of an intestinal ulcer there should be markedly increased pain and tenderness, with pos- sibly an increased looseness of the bowels. Prognosis. — Secondary tuberculosis of the intestine is prac- tically a hopeless condition, and, as a rule, therefore, only a palliative treatment is possible. But the infrequent cases of primary tuberculosis of the bowel as well as of the stomach, when uncomplicated, should be curable if properly treated be- fore the vital forces have been seriously impaired. Then, too, the cases in which incipient tuberculosis of other regions first reveals itself by symptoms of indigestion are to be considered. Hence the extreme importance of making the diagnosis at the earliest possible moment. Whenever persistent derangement of either the gastric or intestinal digestion is accompanied by progressive wasting, and even a slight regular or frequent rise of temperature after midday, tuberculosis may well be sus- pected, and the patient should be given the benefit of the doubt by instituting the appropriate treatment. Treatment. — When there is stubborn diarrhea with fetid stools and sensitiveness upon pressure over circumscribed spots in the bowels, ulceration of some kind is to be feared, and there is the possibility, at least, that it may be tubercular. In such a case involving the colon the diseased process should be attacked with vigor locally, by the use of antiseptic colon douches, one of the most effective of which you will find to be a solution of carbolic acid in glycerin, i to 8, of which a teaspoonful may be diluted with a quart of water. Of this solution inject far up into the colon i to 2 quarts every other day, while on the al- ternate day the bowel is flushed out with a normal salt so- lution. Such simple curative measures should be carried out in any case, provided there are no contra-indications, since they are very helpful in even catarrhal ulceration of the intes- tines. But my own experience has shown that carbolic acid or creosote administered in any considerable dose, either by the mouth or per rectum, will greatly stimulate the gastric glands, TUBERCULAR ULCERATIONS IN THE STOMACH 573 increasing- decidedly the secretion of HCl, so that in the consid- erable proportion of cases of early tuberculosis with gastric de- rangement, in which the HCl is in excess or at least fully up to normal, such remedies cannot be given without the risk of a marked aggravation of the indigestion, or even producing an acid dyspepsia where none existed before. These are the cases in which cod-liver oil, even in pretty full doses, is well borne and acts so favorably, and the explanation is furnished by ex- periments which have demonstrated that all oils and fats, in- cluding butter, tend to lessen the secretion of HCl. The creosote treatment, and the use of carbolic acid per rectum, suit best in the cases in which the HCl secretion is much below the normal, but even then, if there be chronic gastritis present, full doses by the mouth are likely to disagree. The Tuberculin Treatment — My observations as consulting gastro-enterologist at the Pottenger Sanatorium for Diseases of the Throat and Lungs during a period of four years have con- vinced me that some of the preparations of tuberculin have, in the most skillful hands, increased decidedly the proportion of obtainable cures in uncomplicated tuberculosis of the lungs as well as in some other tuberculous affections. Dr. F. M. Pot- tenger, director of the above mentioned institution, and a recognized expert in the use of the tuberculins, employs some one of these preparations in most of his cases, selecting that one which has proved most helpful in his large experience un- der like conditions. Of Von Ruck's watery extract he gives usually, at first, doses of .001 to .01 ; his beginning dose of Koch's old tuberculin is .001 ; of tuberculin Denys it is .0001 ; of tuberculin R, it is .001 to .002 of the solid substance. The following extract from Dr. Pottenger's article on the Treatment of Tuberculosis just prepared for Hare's Modern Treatment affords in brief a fair idea of his views as to the management of the remedy under consideration: Dr. Pottenger's Method ~" In general, however, I would suggest the following as a safe plan for the administration of tuberculin. First, no matter what preparation is given, begin 574 THE GASTRO-INTESTINAL CLINIC with a dose so small that it is practically certain no reaction will be produced. This dose, of course, will vary materially accbrding to the preparation used and according to the condi- tion of the patient. Second, always keep the dose short of pro- ducing a general reaction. The patient who has very slight S3aTiptoms of tuberculosis is more apt to react than one who has more marked symptoms. I usually begin to treat patients who are extremely nervous, and those who have had recent ad- vances in their disease, also those who are inclined to run a temperature, and those whose reactive powers are low, with smaller doses than I do others. I also give smaller doses to young individuals than I would do to older ones. "If the first dose is borne well the dosage can usually be in- creased as follows : — i -2-3-4-5-6-7-8-9-10-15-20- 30 - 40 - 50 - etc. ! The same preparations in careful and ex- perienced hands can be advanced much faster than in inex- perienced hands. If one is to err in dosage let it be on the side of advancing too slowly rather than too rapidly. The in- tervals of dosage should be gradually increased as the dose be- comes larger. My custom has been to begin with a small dose, administering it every day or, more commonly, every second day, and then increasing the intervals so that, by the time the large doses are given, the interval has been increased to from 7 to 10 days, according to the preparation of tuberculin used. I consider it very important in beginning the administration of tuberculin to increase the dosage as rapidly as the patient will bear it. By increasing the amount of tuberculin rapidly, the tolerance of the patient is materially increased, and the danger of hypersensibility is decreased. I have noticed many pa- tients who have been treated by small doses, given at infrequent intervals, who finally developed a state of hypersensibility which manifested itself by either a local or temperature reac- tion every time a dose is given. Very often this is interpreted to mean that the patient bears tuberculin very poorly. The proper interpretation to my mind is, that the patient has been treated in a faulty manner and has become hypersensitive in- TUBERCULAR ULCER.\TIONS IN THE STOMACH 575 stead of tolerant to the remedy. Such patients can usually be treated successfully by changing to another preparation of tuberculin and increasing the dose rapidly." Hygienic and Climatic Measures, etc. — In the treatment of tuberculosis of the gastro-intestinal tract, most of the usual modern methods are applicable, especially the hygienic, cli- matic, etc. These include a residence in a healthy climate, where the air is as pure as possible and not too moist. Sun- shine is most important, and when practicable, a considerable elevation is of undoubted advantage to the majority of cases. But of even more importance than the choice of any particular climate is the indispensable condition that the patient shall be kept out of doors substantially all the time, even at night, when possible, properly clothed to prevent chilling and pro- tected from rain or high cold winds. When there is fever, a recumbent position should be maintained out of doors, and complete rest is then desirable. It is the oxygen of a pure, un- contaminated air that is probably the most valuable curative agent we have £or tuberculosis. The diet should be suited to the condition of the digestive organs, but as abundant and nourishing as practicable. By practicable here I mean as much as the patient can be made to digest, oxidize, and assimilate. In a paper read before the American Climatological Associa- tion, in 1894/ I maintained that to force upon tuberculous pa- tients an excess of food beyond that which can be oxygenated, can only work injury in the long run; that there is a direct ratio between the amount of oxygen consumed in the system (wdiich is largely increased by both exposure to pure outdoor air and by exercise) and the amount of food that can be safely and helpfully ingested. This statement was acquiesced in by the distinguished speakers who discussed the paper, and it has not been since disputed. Only a patient, unwearying study of each case by itself, with the help of occasional tests of the stomach contents, frequent iThe Ratio which Alimentation Should Bear to Oxygenation in Disease of the Lungs, Transactions American Climatological Association, 1894. 5/6 THE GASTRO-INTESTINAL CLINIC analyses of the urine, a study of the blood, and in some cases chemical and microscopic examinations of the feces, can enable you to adapt to the varying conditions the diet both in quality and, quantity, so as to bring up the nutrition to the highest pos- sible point. Medicines by the mouth need to be administered with much discretion. This is the rock upon which some good physicians split in managing tuberculosis. Not enough atten- tion is paid to the reaction of the digestive organs to the reme- dies administered. Many cases would do better without any drugs at all than with such as are commonly given, and in the usual doses; i- or 2-drop doses of Fowler's solution of arsenic or of creosote suit most cases well, though I have seen some with a weak, irritable stomach in which tablets containing i-io drop of creosote acted most favorably; but when there is no ex- cess of HCl, moderately full doses of the same remedies often do good. The same may be said of the hypophosphites, glyc- erophosphates, strychnine, and the stronger preparations of iron. They all disagree in the usual doses when the gastric glands are in an excited or irritated condition. Cod-liver oil, as mentioned above, may suit well w^hen there is a normal or excessive percentage of HCl in the stomach, and then acts best when taken about two hours after meals. In cases of deficient gastric juice, HCl and pepsin should be administered, and small doses of creosote or carbolic acid may then be added to the mixture, when needed for excessive fermentation. When the ulcers involve the small intestine so that antiseptic or astrin- gent remedies cannot be hopefully introduced by enema, full doses of bismuth by the mouth with ichthalbin or tannalbin, or tannigen, in combination, or pills of silver nitrate with bis- muth and opium will usually assist in controlling the diarrhea, at least temporarily. With the exception of the opium, the same remedies may often be continued for weeks at a time, with some hope of exerting a favorable influence upon the ulceration. Hydrotherapeutic measures, especially the tonic use of cold water, as in sponge baths, cool or cold affusions, etc., are TUBERCULAR ULCERATIONS IN THE STOMACH 577 often very useful. Breathing exercises and gymnastics to ex- pand the chest, and for the development of the trunk muscles generally, are excellent ; horseback riding is most valuable, and for those having a good circulation, cautious bicycle riding and mountain climbing are to be recommended. Patients should be under the constant watchful care of a physician until well advanced in convalescence, and be cau- tioned especially against excess of every kind. In certain selected cases of tuberculosis of the intestine with- out a serious involvement of other organs, surgery may now be resorted to hopefully. In the International Medical Maga- zine for November, 1899, there was published an abstract of an interesting paper by Mayo, giving the history of seven such cases operated on, with one death, the others having been cured. LECTURE LVII SYPHILIS OF THE STOMACH AND INTESTINES^ A MAJORITY of authorities on diseases of the stomach make no mention whatever of syphihs; and in truth it is not fre- quently encountered in practice. Perhaps it would be more correct to say that the disease is not frequently diagnosticated. Every physician with a large practice doubtless meets with cases of gastric syphilis, but to search by exact methods for the various diseases and disorders of the stomach has not yet become the rule, so that the true nature of these is very fre- c[uently overlooked. Syphilitic affections, even when existing, therefore, are not often recognized. In any case in which there are undoubted syphilitic lesions in the liver or elsewhere, we may well suspect that it has a luetic origin, and should then have had made one or both of the now available diagnostic tests for syphilis — a microscopic examina- tion of the blood for the Spirochaeta pallida or the Wasser- mann serum test, both of which are accepted as of value, espe- cially the former. The finding of the spirochetes in any case is generally conceded to be proof positive of a syphilitic infection. - lA part of this lecture appeared as the author's contribution to Syphilis; a Symposium; New York, E. B. Treat & Co., 1902. 2The spirochetes are in the form of slender spirals like a corkscrew. Scholtz thus describes a method of staining them : A small drop of the serum on the slide is mixed with a small drop of distilled water and a small drop of the mixture is transferred to another slide. Half this amount of India ink is then added and mixed and spread out over the slide with the edge of another; the material is then dry and ready to be examined in half a minute. The objects in the field are comparatively colorless against a dark background. (Abs.iny. A. M. A. of Mar. 12, 1910, from Deutsche Med. Woch. (Berlin) of Feb. 3, 1910 ; No. 5.) 578 SYPHILIS OF THE STOMACH 579 The serum test sometimes, though rarely, reacts to advanced cases of carcinoma, tuberculosis and some acute conditions, but a positive reaction, especially in the absence of the diseases just named, would warrant you in instituting anti-syphilitic treat- ment. It is possible that we may have a syphilitic chronic gastritis, though this is questionable. It is well established that there may be syphilitic ulcers in the stomach, and syphilitic neo- plasms or infiltrations in the same viscus, involving any part of the organ, especially the pylorus. Very exceptionally, also, hemorrhage of supposed syphilitic origin, but not dependent upon ulcer, may take place in the stomach. Syphilitic Chronic Gastritis. — There has existed consider- able doubt whether pathologically the frequent cases of chronic gastritis encountered in patients who are affected with syphilis are really different from the similar forms of gastric inflam- matory processes due to other causes. IMost authors do not admit that gastritis can result directly from a syphilitic infec- tion. Secondary- results of the obstruction of the portal cir- culation caused by syphilis certainly occur in the stomach. Hemmeter and Stokes ^ have reported a case of chronic hyper- trophic gastritis in a syphilitic patient who was operated for stenosis of the pylorus, resulting from hyperplasia as deter- mined afterward by an autopsy. The latter showed further a marked thickening of the gastric walls in various parts by a characteristic luetic infiltration, and also a localized sub- hepatic abscess. The patient had been infected with S3'philis two years before admission to the hospital, and had been dys- peptic before that. His symptoms, while under observation, were those of pyloric stenosis — pain or discomfort and vomit- ing, especially after solid food, relieved by lavage. The usual tests showed the absence of free HCl and the gastric ferments. There were numerous manifest lesions of syphilis elsewhere in his body. Hemmeter holds that " if characteristic syphilitic ij. C. Hemmeter and W. R. Stokes, Archiv f. Verdauungskr., B. VIIL, Heft 4 and 5. 580 THE GASTRO-INTESTINAL CLINIC lesions exist in the liver, kidneys, spleen, pancreas, or intes- tines, the chronic gastritis should be attributed to syphilis." ^ He believes further that, " in tertiary syphilis the remarkable malnutrition is due to a chronic gastritis," which appears very likely to be true. The former statement seems open to ques- tion. The syphilitic form may resemble closely the ordinary chronic gastritis, showing no difference pathologically any more than symptomatically, except possibly, the greater amount of small round-cell infiltration. In some cases, how- ever, there will be found gummata, or possibly gummatous ulcers when the disease has progressed to the tertiary stage. The diagnosis will turn upon the results of the tests and of the treatment. If the disease yields to the usual methods of treating chronic gastritis, it is not likely to be syphilitic. Per- sonally, I doubt that a true primary syphilitic gastritis ever occurs. Einhorn - believes that in the secondary stage of syphilis, " the digestive disturbances are attributable to the constitu- tional condition, to the fever, etc., and hence are to be re- garded as concomitant phenomena of the original disease with- out any special involvement of the stomach," but considers the gastric affections in the tertiary stage as anatomic processes of a true syphilitic character. He further states that probably in a majority of the cases in which syphilitic persons suffer from diseases of the digestive tract, there is not " any connection between the latter and the antecedent lues." Syphilitic Gastric Ulcer. — There can be no question as to the fact that syphilis occasionally causes gastric ulcer. Large numbers of cases have been reported in medical literature which leave no room for doubt on this point. While the authorities do not agree as to the comparative frequency of syphilitic ulcer of the stomach, the following conclusions seem warranted : 1 J. C. Hemmeter, " Diseases of the Stomach," second edition, p. 597, Philadelphia, igoo. 2 Max Einhorn, " Prog. Med.," vol. iv., 1900, p. 35. SYPHILIS OF THE STOMACH 581 (i) Many gastric ulcers occurring in persons who were manifestly or demonstrably syphilitic in other ways may be presumed to have been of luetic origin. (2) These had been in most cases treated previously by the methods usually successful in relieving, if not curing, simple round ulcer of the stomach, without improvement. (3) They respond promptly and rapidly to antisyphilitic treatment. In numbers of cases, too, post-mortem examina- tions have revealed gummata and gummatous infiltrations in the same stomachs, and in some instances the ulcers had evi- dently resulted from the breaking down of gummata. Stockton^ cites the case reported by E. Frankel, of a man, aged 47, who died from perforative peritonitis after suffering seven years from subjective gastric symptoms, with an ab- sence of free HCl. Thirteen ulcers were found in his stom- ach, besides many in the intestines, of which eighteen had perforated. The histologic examination showed the case to have been syphilis. Stockton also cites the views, of Dieula- foy,- who has studied this subject somewhat exhaustively. The latter summed up his conclusions as follows : " ( I ) Syphilis of the stomach is not as infrequent as might be thought. " (2) Syphilitic lesions of the stomach occur in various forms, hemorrhagic erosions, ecchymoses of the mucous mem- brane, gummatous infiltrations of the submucosa, gumma- tous plaques, circumscribed gummata, gummatous ulcerations and their resultant scars. It is probable that here, as in other losses of substance of the stomach, the gastric juice augments this ulcerative process. " (3) The symptoms of syphilitic ulceration of the stonir ach may resemble completely those of simple gastric ulcer; pains over the ensiform process, besides backache, intolerance of the stomach, vomiting of food, small and large gastric hemorrhages, melena, and marked emaciation. ■■ " Progressive Medicine," vol. iv., 1899, p. 34. "^ Bulletin Med., 1899, No. 40. Quoted also by Einhorn in Phila. Med. Jour., of February 3, igoo. 582 THE GASTRO-IXTESTINAL CLINIC " (4) Xone of these symptoms (alone) permits us to as- sume the syphihtic nature of the stomach lesions. As soon as the signs of a simple gastric ulcer occur in a syphilitic person, we» are warranted in suspecting the syphilitic nature of the stomach lesion. " (5) ^^ e should never, therefore, neglect to seek in a pa- tient presenting symptoms of gastric ulcer, for a possible ante- cedent history of syphilis. " (6) In the latter case an appropriate treatment with mer- curial preparations and potassium iodide must be at once ini- tiated. " (7) The recognition of syphilis as a cause of gastric ulcer is the more important, since this enables us to cure pa- tients who otherwise might have been subjected to surgical intervention." With our present light, Dieulafoy's conclusion 6 would doubtless be modified, so as to require one of the tests for syphilis to be made before instituting treatment therefor. Stockton, in the same article, refers to contributions by Allen Jones and others concerning gastralgia of apparent syphilitic origin, and in view of recent developments showing the frecjuency of gummata, luetic infiltrations, etc., in the stomach, inclines to the belief that the gastralgia of syphilis may " more frequently depend upon a lesion than has been supposed." Cases of S3^philitic gastric ulcer, thus, do not seem to pre- sent any particular symptoms different from those occurring in ordinary gastric ulcer. The patients have, as a rule, acute pain after taking solid food, frequently vomit the stomach- contents, and in a considerable proportion of cases may pre- sent the usual signs of hemorrhage, with often perforation. Syphilitic Ulcers of the Intestines. — ]\Iost authors make no mention whatever of a syphilitic enteritis or colitis. Among those who have written books on diseases of the intestines, without including any reference to such an affection, are Ewald, Nothnagel, Penzoldt, Boas, and Einhorn. Since, SYPHILIS OF THE STOMACH 583 therefore, it is at least questionable whether a catarrhal in- flammation in any part of the alimentary canal can be due di- rectly to syphilitic infection, and even when suspected to have such an origin is confessedly not to be differentiated by any histologic phenomena from the ordinary chronic catarrhal in- flammation, I shall not attempt to describe to you a syphilitic enteritis. Syphilitic ulcers do occur in the intestines, though rarely above the colon, except the congenital form in children. They are found most frequently in the rectum. Syphilitic ulcers of the colon are commonly the result of gummata which have broken down, and when luetic ulcers appear in the small in- testines they oftenest arise in a similar manner; but they may also originate from ulceration of Peyer's patches, and some- times be produced by ulceration or a specific amyloid degener- ation having its seat in the intestinal mucous membrane. The symptoms of specific intestinal ulcers, as in other forms of intestinal ulceration, may be entirely wanting, or they may give rise to pain, -tenderness on pressure, and either constipa- tion or diarrhea; blood, pus, and shreds of necrosed tissue are also discoverable at one time or another in the stools. They differ in no marked way from those of other intestinal ulcers. The diagnosis cannot usually be made from the latter by the tests already mentioned, except from the signs of syphilis else- where in the body and the therapeutic test. Syphilitic Neoplasms of the Gastro-intestinal Tract. — These are often mistaken for carcinomas. They may be recognized by palpation when they have attained a sufficient size, and the existence of palpable thickening or tumor in any part of the abdomen in a case presenting undoubted luetic lesions else- where, should at once lead to a suspicion of a syphilitic growth. When a gummatous infiltration involves the pylorus, we have superadded, of course, the usual symptoms of pyloric ob- struction. That is, there will be pain and vomiting, followed later usually by dilatation of the stomach, and then by the usual signs of retention, including the vomiting, at intervals 584 THE GASTRO-INTESTINAL CLINIC of one to two days, of large amounts of highly offensive fer- menting ingesta. Treatment of Syphilitic Disease in the Stomach and In- testines. — No special therapeutic measures are required in these cases. They are likely to respond to any of the usual forms of antisyphilitic treatment energetically carried out. In cases of chronic gastritis in syphilitic subjects, it will be well to try a course of mercury by the mouth, or better, by inunc- tion, or possibly even hypodermically. The ulcers, infiltra- tions, gummata, etc., all belong to the tertiary stage and are best controlled, as a rule, by full doses of the iodides. It is the custom of many syphilographers, however, to employ mercury with the iodide at this stage, and the results in some stubborn cases seem to be better than when the latter is used alone. Tertiary manifestations of syphilis may be found both in the alimentary canal of patients suffering from acquired, and those having hereditary, syphilis. The need of bearing in mind the possibility that gastric symptoms may depend upon a syph- ilitic lesion is clearly most important. To ignore it is to risk serious aggravation through erroneous treatment, and even the dangers of an unnecessary operation. The same is true of patients showing signs of ulceration in the bowels. In all such cases exhaustive search should be made for specific lesions elsewhere, since the finding of these, if followed by a positive response to the newer tests for syphilis, would insure a rapid cure usually of what would other- wise likely be very tedious cases. Ehrlich's " 606."— While the third edition of this work has been going through the press the medical profession has been profoundly stirred by the reports of extraordinary results obtained abroad by the use of Ehrlich's " 606" (dioxydiamidoarsenbenzol) in the cure of syphilis. This new remedy is an arsenical compound elaborated by Professor Ehrlich after several years of patient research and experimentation and is admin- istered in a single large dose hypodermically with results which, accord- ing to the testimony of numerous eminent syphilographers, can only be characterized as marvelous. LECTURE LVIII INTESTINAL ULCERS GENERALLY— HEM- ORRHAGE FROM THE STOMACH AND INTESTINES Various Forms of Intestinal Ulceration. — Authors of the most elaborate treatises upon diseases of the intestines treat of the ulcers of these parts under a dozen or more separate heads ; but having devoted special lectures to tuberculous ulcers, syph- ilitic lesions of the gastro-intestinal tract including syphilitic ulcers, and dysenteric ulcers under the head of Dysentery, I think it will be more practical and less confusing to you if the other forms of ulceration of the intestines shall be con- sidered here together. In this respect I shall be more nearly following the distinguished lead of Ewald, in whose recently published admirable work entitled " Die Krankheiten des Darms und des Bauchfells," which has not been translated into English, all the forms of intestinal ulcers are discussed in a single lecture. Hemmeter, in considering the treatment of this subject, after referring to duodenal, syphilitic, and dysenteric ulcers, says under the head of Treatment : " All other ulcera- tions I can safely say will not be diagnosed except the catarrhal and tuberculous ulcers." Besides the varieties of intestinal ulcers already described, and to be described under the head of Dysentery, Tubercular Ulcerations, and Syphilis of the Stomach and Intestines, some mention should be made of the following, which are given in the order of their relative frequency and importance, rather than in accordance with the very elaborate classifications of Nothnagel and others : I. Ulcers complicating acute infectious diseases, such as the fevers, exanthems, etc. 585 586 THE GASTRO-INTESTINAL CLINIC 2. Catarrhal and stercoral ulcers, that is, those occurring in the inflammatory affections of the intestinal mucosa, and from the pressure of fecai masses in constipation. tQ. Toxic ulcers resulting from poisoning by alcohol, uraemia, or any of the active poisons. 4. Embolic and thrombotic ulcers. 5. Ulcers resulting from faulty constitutional states, such as gout, scurvy, and leukemia. 6. Amyloid ulcers. The general features of these forms of intestinal ulceration I shall here take up for brief consideration in the above order. 1. Typhoid fever, smallpox, erysipelas, diphtheria, anthrax, and the acute septic conditions are chief among the acute in- fectious processes which are often complicated by ulceration in the intestine. Dysentery belongs in the same category, but this disease will claim separate consideration as belonging es- pecially to the affections of the gastro-intestinal tract, and the ulcers peculiar to it will be therein discussed. In some of the acute infectious fevers, including especially typhoid, intestinal ulceration is frequent, and highly important, but I quite agree with Ewald in the opinion that this is not the proper place for the detailed consideration of such ulcers, since .they are complications of maladies which cannot justly be classed among the diseases of the stomach and intestines. The sub- ject is fully discussed in the standard works on the practice of medicine. 2. Catarrhal ulcers and those resulting from fecal accumu- lations are both frecjuent and important. Moreover they be- long especially to the classes of diseases which we are studying in this series of lectures. They begin as erosions involving the superficial layers of the mucosa only, and may either directly, or by coalescing, extend over a considerable part of the bowel. When the catarrhal process or the fecal stasis persists for a long time, the ulcers thus produced are liable to erode all the layers of the intestinal walls, and even produce perforation. The catar- rhal ulcers may affect any part of the bowel, but are most fre- INTESTINAL ULCERS GENERALLY 58/ quently encountered in the colon. Stercoral ulcerations affect especially those parts where the feces are most prone to lodge, such as the cecum, the flexures of the colon, and the rectum. Like the constipation upon which they depend, they afflict par- ticularly persons of a sedentary habit. Both these forms of ulceration, when they involve large por- tions of the bowel, are liable in healing to cause contractions with resulting obstruction, and yet such a mishap seems to be uncommon. 3. Toxic ulcers may be caused by a great variety of irri- tants, and the poison may come from within or without the body. The character and pathology of them will vary some- what with the cause — the particular kind of poison producing them. Alcohol less frequently expends its morbid influence in this than in other ways upon the tissues of the body; yet it is one of the recognized causes of intestinal ulceration. The graver cases of uraemia may be complicated by such ulcera- tions, but these in such serious conditions are naturally of less importance than the primary disease. Mercury in the massive doses formerly given, and sometimes still prescribed for syph- ilis, can easily produce intestinal ulceration of a very aggra- vated type. Numerous poisons, especially arsenic, antimony, etc., are capable of exciting like lesions, though their toxic ef- fects are more commonly expended upon portions of the ali- mentary canal higher up, as in the esophagus and stomach. 4. Embolic and thrombotic ulcerations possess some clinical importance, but can scarcely be differentiated from other forms during life, except in the course of operations for surgical com- plications. They may arise in consequence of endocarditis, septic processes, or arteriosclerosis, and also from any of the causes capable of producing thrombosis. The emboli lead to obstruction of vessels — most frequently the smaller ones — in the mucosa, and the resulting hemorrhagic infarcts undergo necrosis with the formation of ulcers. These, according to Boas, occur oftenest between the duodenum and the cecum. The ulcers vary greatly in size ; this depending upon the ex- 588 THE GASTRO-IXTESTIXAL CLINIC tent of the hemorrhage. The ulceration may be deep and lead to perforation of the peritoneal cavity. In septic embolism from ulcerative endocarditis, Boas points out especially that tliere may be very small embolic abscesses between the submu- cosa and mucosa, which open within the lumen of the bowel with the production of numerous ulcers. 5. Gouty ulcers are so rare that many authors deny that they ever occur, while though scorbutic ulceration involving Peyer's patches is a frequent complication of scurvy, this dis- ease itself is becoming very uncommon, except in hand-fed in- fants. Intestinal ulceration has been exceptionally observed in leukemia as a consequence of infiltration of the lymphatic structures in the bowels and secondary necrosis of the same. 6. Amyloid ulcers of the intestines may possibly complicate amyloid disease of the liver and kidneys or other organs, but are exceedingly seldom encountered ; probably never diag- nosed. They may be of any size, and sometimes involve large portions of the gut, but do not cicatrize, so that obstructive con- traction never results. Symptoms of Intestinal Ulceration. — These are very sim- ilar for all the varieties of ulcers occurring in this region. As a rule, you will not be able to distinguish between them by any symptoms or physical signs, though the character of the ac- companying disease, as in the case of tuberculosis or syphilis, may sometimes enable you to make the diagnosis. We can only study the symptomatology of intestinal ulceration as a whole. There are many cases which present no symptoms, and even some very mild ones in which the usual symptoms or sign of tenderness on pressure over the corresponding part of the abdomen cannot be obtained. Then again, the catarrhal inflammation which always accompanies ulcers of the intestine greatly obscures the clinical picture. Xevertheless a patient watching of the stools, and study of them microscopically as well as chemically, would rarely fail in such cases to reveal from time to time indubitable indications of the ulcerative process. INTESTINAL ULCERS GENERALLY 589 Pain of the spontaneous kind, though present at times in these cases, is quite frequently absent even when the ulcers are nu- merous and large, especially when there is neither severe diar- rhea nor marked constipation. Pain on pressure or palpa- tion is very much more frequently present and to be discovered by a careful search for it. Very deep pressure while the pa- tient relaxes his abdominal muscles by flexing the knees, and keeps up slow, sighing respiration, will often reveal tenderness otherwise not to be elicited. Tenderness ascertained in this way would assist in confirming the diagnosis of ulceration in the part directly beneath the tender spot, though over the cecum it might mean a catarrhal appendix, and over anv por- tion of the abdomen it might signify simply a catarrhal in- flammation. But the tenderness over an ulcer is generally more acute. Then, in neurasthenic patients you may often find tender spots over the sympathetic nerve plexuses of the abdomen, but a peculiarity of this latter tenderness is that by persistent and not too severe pressure in such places it gradually diminishes, often disappearing entirely, while the pain caused by pressure over an ulcer will usually persist and even increase as you press longer. Constipation and Diarrhea. — One or the other of these is nearly always present in marked cases, and it is the rule, to which, however, there are many exceptions, that in cases in which there are many ulcers, especially in the lower bowel, diarrhea will be a rather persistent and troublesome symptom. But sometimes even under these circumstances constipation will exist ; and exceptionally you may be misled by the bowels' continuing to act normally. Blood, pus, and necrotic tissue are to some extent character- istic, but all of them may come from abscesses, and pus, if present in large amount, would point decidedly to the latter. Mucus alone might well signify nothing more than catarrh. Blood may arise from various congestive conditions, but in large quantity nearly always signifies the erosion of a vessel 590 THE GASTRO-IXTESTIXAL CLINIC by ulceration in some part of the gastro-intestinal tract. AMien it is fresh, and of a bright red color, it has generally come from some place in the rectum or colon, though when the peristalsis is vuiusually active, as in diarrhea, you should not forget that blood originating in the small intestine, and, very exception- ally, even in the stomach or esophagus, may pass the anus without having undergone any marked change. Usually the more altered the blood is, and the more intimately intermingled blood or pus or necrotic tissue is with the feces, the higher up in the tract it has originated. Tubercle bacilli in the feces are not necessarily significant of tubercular ulceration, unless found at a time when the patient is not having any sputa or are present constantly in large num- bers ; and on the other hand, the failure to find the bacilli at a single examination would not prove that tuberculosis was not present, and that the ulcers were catarrhal or of any non- tubercular origin. Fever indicates nothing in regard to intestinal ulceration, since it can proceed from so many other causes. The general condition of the patient may or may not be so much affected by intestinal ulceration as to awaken a suspicion of its existence. As a rule in those ulcers, for example, which are likel}^ to develop in chronic intestinal catarrh, you will nearly always find a marked lowering of the general health, but this verv often results from the catarrhal inflammation alone, be- fore the ulceration has developed. Very exceptionally the flesh, strength, and color may remain about as in health, in spite of both the catarrh and ulceration. In the other form of intestinal ulcers also, the general state would depend chiefly upon the primary disease and the extent to which it had re- duced the patient. Diagnosis. — As previously intimated, it will often be ex- tremely difficult, or even impossible, to differentiate between the different varieties of intestinal ulcers except when it is prac- ticable by the symptoms of the primary disease, or the clinical picture as a whole, to make the diagnosis. Even to determine IXTESTIXAL ULCERS GEXEIL\LLY 591 positively, in certain of the less pronounced cases, that ulcers of the intestines exist is by no means easy. AMien blood passes the anus in either small or large amounts, and at the same time, small, or very moderate amotmts of pus and necrotic tissue are found frequently in the stools without the existence of fever and the other signs of abscess, you may well suspect the presence of ulceration^ especially if you can also find cir- cumscribed spots over portions of the intestines which are painful on pressure. Then the coexistence of a disease, such as dysentery, typhoid fever, or a long-standing enteritis or colitis, would greatly increase the probability of ulcer, and, in fact, in most cases suffice to determine the diagnosis posi- tively. Treatment. — As in the case of the diagnosis, so the treat- ment of ulcers of the bowels must depend in large measure upon the character and requirements of the primary disease. In the ulceration, for example, which so often occurs as a complication of typhoid fever, you will insist upon the most absolute rest for the patient, the blandest possible diet, and then prevent peristalsis by a bold emplopnent of opium and astringents with the help of ice-bags locally, knowing that it is a tempo- rary matter, and that with the subsidence of the fever, the hemorrhage, as well as the ulceration which causes it, will speedily cease. In the ulcers from embolism or thrombosis, you will devote yourself to the task of curing the endocarditis, septicaemia or other disease upon which it depends, with the ad- dition of any needed local measures to control hemorrhage or pain. In the catarrhal or follicular forjii of ulcers the problem will be somewhat different, and here you will need to rely largely upon the local measures of treatment in addition to the general mode of therapeusis. dietetic and otherwise, which is required for the intestinal catarrh. Full directions on this head will be found in Lecture LX\'I. devoted to that subject: and indeed, the methods of applying antiseptics and astringents by the rectum for the cure of intestinal catarrh, will prove, in the 592 THE GASTRO-INTESTINAL CLINIC main, the most efficient for the ulceration. Ewald refers to the difficulties usually encountered here on account of the ex- treme irritability which the intestinal mucosa often manifests, antl recommends suppositories of cocaine to overcome it. I have found 3-grain or 5-grain suppositories of ichthyol, in- serted in the rectum once or twice a day, to answer this pur- pose admirably, and at the same time to aid much in disin- fecting and healing the lesions. The infusion of slippery elm recommended by Turck of Chicago, as a menstruum for medi- caments in chronic catarrh of the colon, is still more helpful by its demulcent influence in these cases. A large and free use should be made of bismuth, and every effort be made to have an emulsion of it with slippery-elm infusion introduced high enough up into the bowel to reach any ulcers that may be in the cecum or ascending colon, which can be accomplished usually by position, as advised by Turck, or in some cases, better by the use of a long and semi-flexible rubber tube. Ewald strongly advises the injection of a 0.2 per cent, to 0.3 per cent, solution of nitrate of silver, and I have seen ex- cellent results from the introduction every other night of a solution of carbolic acid and Listerine, according to the for- mula given in Lecture LXVI. on Chronic Catarrh of the In- testines. In all these cases, whether the prevailing condition of the bowels seemed to be one of constipation or diarrhea, I have noticed favorable effects, as a rule, from the administration every day or two of a small dose of castor oil, or some other equally gently acting and effective laxative. Even when there are loose stools passing daily, there are often hard fecal masses lodged in the flexures or other stagnant pouches of the colon, and not until these are removed and prevented from re- accumulating, will the catarrhal, and still less the ulcerative, process take on a healthy reparative action. I have at times administered the more highly refined prepa- rations of petroleum such as vaselin, albolene, etc., pleasantly flavored, and been pleased with their results upon the bowels INTESTINAL ULCERS GENERALLY 593 in such cases ^s are now under consideration, and more fre- quently still in cases of simple constipation from chronic in- testinal catarrh. One or two teaspoonfuls of vaselin at bed- time would often overcome the constipation in the most gentle and satisfactory way, and at the same time exercise apparently a soothing and healing effect upon the lesion in the mucosa. But in persons with any cardiac weakness, I soon noticed that the circulation was depressed by the remedy, and as many of the patients afflicted with these troubles have at the same time weak hearts, I was obliged to abandon the use of it. Quite re- cently I have been prescribing a still more highly refined preparation of the kind called Purpetrol, said to be made from a Russian petroleum, and find it effective in doses of about 1-2 an ounce, given once or twice a day on an empty stomach. So far, I have not noticed any marked cardiac depression from its use, though should be watchful as to this in the case of any patients having a particularly weak heart. Its influence is very bland and soothing and the stool results without griping, as a rule, but it is truth to say that it is in no sense an active purgative, and in persons who are at all obstinately consti- pated, needs to be supplemented by some more decided aperi- ent. The valuable feature of such a mineral oil is, that it is absolutely non-irritating to the whole digestive tract, which is a great desideratum. Olive oil or cotton-seed oil, which in doses of o'l to ovi, in- troduced at bedtime by enema and retained till morning, is so highly effective in overcoming the constipation of chronic in- testinal catarrh and muco-membranous colitis, may fail, or prove wholly unsuitable in cases of intestinal ulcers, especially when these are in the colon, because of its slightly disturbing effect. Even when combined with full doses of bismuth, as I have been accustomed to direct in certain cases of the former ailments, it is by no means sure not to disagree in the presence of complicating ulcers affecting the lower colon. Since the treatment of syphilitic, dysenteric, and tuberculous ulcers of the intestines is sufficiently discussed in the lectures 594 THE GASTRO-INTESTINAL CLINIC devoted to those subjects, I need not take up here the treat- ment of those special forms of ulceration. HEMORRHAGE FROM THE STOMACH AND INTESTINES In various lectures of this series I have considered the more frequent causes of hemorrhage from the gastro-intestinal tract, such as round ulcer of the stomach or duodenum, cancer, syphilitic, tubercular, dysenteric, and simple catarrhal ulcer- ation of the tract, and also the rare possibility of hemorrhage from benign polypoid growths in either the stomach or in- testines. In Lecture XV. under the title of A Symptomatic Guide to Diagnosis, practically all the known conditions which are capable of causing blood to appear in either the vomit or the stools are catalogued, so that those not fully considered else- where in this book can easily be looked up in other works in which the causative diseases or disorders are discussed. But, besides the gastro-intestinal causes of hemorrhage, there are some others of sufficient importance and frequency to merit special mention here. Then there are the cases in which the hemorrhage is from the respiratory tract, mouth, pharynx or gullet, the blood appearing either in the vomit or stools, and a hurried resume of all the possible causes of the appearance of blood in either the vomit or stools may be of assistance to you. For our purposes the appearance of blood in either may be divided into the following five classes: 1. Small quantity of either fresh or changed blood vomited with usually no signs of blood in the stools. 2. Moderate or large quantity of blood vomited and usually altered blood resembling coffee-grounds, with possibly some clotted fresh blood in the stools. 3. Small amount of bright or dark-red blood in the stools, but none in the vomit. 4. Altered blood in the stools with usually none in the vomit. HEMORRHAGE FROM THE STOMACH AND INTESTINES 595 5. Large or small amounts of blood in the stools, some of it often of dark red color, and some of it brownish and altered, with usually blood or altered blood also in the vomit. We may add : Minute invisible quantities of blood (occult blood) in both stomach contents and feces detected by chem- ical tests only. (See page 599.) The Significance of Blood in Vomit or Stools. — i. The vomiting of small amounts of blood is more likely to signify cancer than ulcer or any other disease, but may result from an ulcer in the mouth, pharynx or nasopharynx, esophagus, stom- ach, or even the duodenum. It may proceed from the gums, the socket of a recently extracted tooth, or from any other tri- fling injury in the mouth or the mucous tracts opening into it. What has been called vicarious menstruation, but is probably really a leakage from a congested gastric mucosa aggravated, as all digestive troubles are prone to be at the menstrual period, may be responsible for the presence of either small or large Cjuantities of blood in the vomit. So, also, may erosions of the stomach, and hepatic cirrhosis, heart disease with fail- ing compensation, or any other cause of passive congestion in the portal vessels. The unskillful use of the stomach tube may possibly provoke small bleedings from a hypersemic gastric mucosa, and in such cases I have sometimes seen a few drops tinge the wash water during the lavage, even when the tube was introduced with the utmost possible gentleness and the patient had not struggled or had spasmodic contractions of the gastric musculature to produce an injury of the membrane. As a rule, in the smaller hemorrhages from the stomach, the vomited blood is changed in character by digestion and is of a dark brownish color resembling- coffee-grounds. It is rare for small amounts of blood to be vomited in the fresh state, unless when the stomach is exceedingly irritable, so that emesis is occurring almost constantly. Then much, too, depends upon the activity of the peptic digestion. When a normal proportion of pepsin and HCl is secreted, a small amount of blood leaking out into the viscus is very rapidly changed by digestion so that, 59^ THE GASTRO-INTESTINAL CLINIC in even half an hour, it would no longer appear as blood, whereas, with a very deficient secretion of HCl and the fer- ments, the blood is changed more slowly, and after a copious hemorrhage, even with a very active digestion, vomiting is commonly provoked more speedily and much of the blood may then come up in an unchanged form. Blood may be vomited, or at least tinge the vomitus, in any of the severer forms of ansemia, or in purpura, scurvy, or in other constitutional affections which greatly alter its crasis. The Source of the Larger Gastric Hemorrhages. — 2. -A relatively large hemorrhage is more likely to have come from a peptic ulcer in the lower end of the esophagus, from the stomach itself (most frequently) or from the duodenum, than from cancer or any other cause, though you should not forget that in either cancer or ulcer, either large or small amounts of blood may be vomited, and that such blood may be bright and red or dark and partly digested, whatever the cause of the hemorrhage may have been. A moderately large hemorrhage, or small hemorrhages from the stomach may result from any of the conditions mentioned above as causes, except that in the cases of slight injuries in the mouth or its vicinity, or irritation of the gastric mucosa from the use of the tube, there is very rarely any considerable loss of blood unless the tube should perforate an ulcer. The most profuse and dangerous hemorrhages from the stomach arise from the eroding of a blood-vessel of consider- able size by the extension of a peptic ulcer, or less frequently from the ulceration of a cancer. A large amount of blood, often of a bright red color, may be vomited when its source has been the rupture of a vessel in a tubercular cavity of the lungs. It is possible, too, though less common, to have a small quantity of Ijlood swallowed and afterward vomited in altered form, during, or subsequent to, a pulmonary hemorrhage. In such a ca.se the blood would almost certainly be digested and changed to a dark brown color, except when the gastric juice was very deficient. • HEMORRHAGE FROM THE STOMACH AND INTESTINES 597 Less Frequent Causes of Hematemesis. — Other much less frequent causes of hematemesis, which is then usually rather copious, are aneurisms of the esophageal or gastric arteries or varices of the veins in the same parts, and erosions of the ves- sels in the same by the action of strong acids or other irritant poisons or foreign bodies swallowed. Very hot ingesta are also said to have caused the vomiting of blood, and the amount lost would be large in case a vessel should be thus eroded. Moderate hemorrhages occasionally result also from the con- gestion of the gastric mucosa, or are due to changes in the blood itself, incident to the course of severe cases of the acute infectious diseases, especially yellow fever, acute yellow atrophy of the liver, cholera, and in the severer forms of ma- larial fevers ; also in typhoid fever, relapsing fever, smallpox, typhus fever, scarlatina, and exceptionally even in measles. Other causes of considerable gastric hemorrhages mentioned by authors are melena neonatorum, nephritis, and so-called idiopathic gastric hemorrhage, but in all these cases the cause, it seems to me, can be traced to one of the conditions already described above. The exceedingly rare instances of blood vomited in nephritis have been shown to be dependent upon miliary aneurisms in the gastric mucus membra*ne due, as all aneurisms are, to an atheromatous condition of the vessels. The loss of blood in the new-born through the stomach and in- testines is of unknown origin, but apparently the cause is a depraved state of the blood itself. The Source of Blood Found in the Stools. — 3. Fresh blood in the stools, with none in the vomit, comes most commonly from hemorrhoids or ulcers in the rectum or lower colon ; but a cancer or even polypi, in the same region, may also give rise to such bleedings. 4. Altered blood in the stools, with usually none in the vomit, points to ulcer, cancer, or rarely to polypi or other innocent form of tumor rather high up in the bowel — in the cecum, as- cending colon, hepatic flexure, or ileum most frequently. It may also be due to any of the forms of intestinal ulcera- 598 THE GASTRO-INTESTINAL CLINIC tion already described in this and the preceding lectures, or to such acute infectious diseases as typhoid fever, etc. 'Blood in Both Vomit and Stools. — 5. There has generally been a copious hemorrhage in either the stomach or duo- denum — except in the case of hemoptysis with a large portion of the blood swallowed — when you find blood both in the vomit and stools in considerable quantities, whether all of that in the stools be dark and altered, or a part of it is still recognizable as blood. The most frequent cause of such a large hemor- rhage is an eroded vessel as a result of either ulcer or cancer — more frequently the former — in the stomach or duodenum. Symptoms. — Small bleedings may occur in the stomach or bowels without symptoms other than the appearance of blood, either fresh or altered by digestion, in the vomit or stools as above described. But a large hem.orrhage, besides nearly al- ways revealing itself by hematemesis as well as by bloody stools, will necessarily produce a feeling of weakness, faint- ness, or even collapse with unconsciousness, and sometimes convulsions. The face and mucous membranes will also become pale, and fever generally develops after a copious hemorrhage. AMien the blood comes from an artery and is vomited very soon, it may be bright ; but when from a vein it will be darker, and in either case, if long retained in the stomach, or even if re- tained a comparatively short time when there is an abundance of HCl and pepsin, it may be completely changed by digestion and present the brownish appearance of coffee-grounds. In very serious forms of hematemesis, blindness or other dis- turbances of vision have exceptionally been noted. Diagnosis. — You will not usually have much difficulty in recognizing fresh blood by its naked-eye appearance, especially if present in much quantity. When the amount is very small, you can sometimes identify it by recognizing the blood corpuscles under the microscope. Or the modified Weber test may be employed. The method is thus carried out : HEMORRHAGE FROM THE STOMACH AND INTESTINES 599 Tests for Occult Blood.— The ModiHed Weber Test; 5 to 10 CO. of the filtered stomach contents are thoroughly mixed in a test tube with one-third of their volume of glacial acetic acid. To this mixture add one-third to one-half volume of ether. ]\Iix very thoroughly, without shaking hard, for four or five minutes, and then allow the mixture to stand a few minutes. Decant or remove the clear ethereal extract which separates at the top of the mixture, and test this by adding 10 to 20 drops of a freshly prepared alcoholic solution of guaiac, and 20 to 30 drops of old well-oxidized turpentine (or better, a like amount of hydrogen peroxide solution). The mixture will promptly turn a violet blue when blood is present. Greenish or reddish-brown changes must not be considered posi- tive. The patient should not have eaten meat or meat products shortly before this test. The aloin test is made in the same manner as the above, except that a fresh alcoholic solution of aloin is substituted for the guaiac tincture, and here the tur- pentine has been found more delicate than the peroxide. A positive reaction consists in the production of a cherry-red color in the final mixture. The two tests are about equally delicate, the aloin test being perhaps slightly the more so. The henzidin test, originally proposed by O. and R. Adler, was too delicate for practical work; but, as modified by Schles- inger and Hoist, this objection is removed. F. W. White [Boston Med. and Surg. Jour., June 10, 1909) has made a thorough comparative study of the benzidin and guaiac tests, and concludes that with proper reagents, cleanliness, and care, the benzidin test is reliable and not too delicate, being slightly more so than the guaiac test. He recommends the following technic: I. A few c.c. of gastric contents (filter if food pres- ent), or a pea-sized piece of feces mixed with 4 c.c. of water, are boiled in a lightly stoppered test tube for not more than one-half minute. H. A knife-point of benzidin is shaken into 2 c.c. glacial acetic acid ; an ordinary conical minim glass is filled to the lo-minim mark with this solution, and commercial dioxygen (Oakland) is added up to the one-drachm mark, and 600 THE GASTRO-IXTESTIXAL CLIXIC the mixture stirred with a glass rod and ahowed to stand a few minutes (to test the cleanness of the conical glass, etc.). III. Three drops of the boiled stomach contents or feces are added, with or without stirring. A clear green or blue color appears in one to two minutes when blood is present. Essential to the success of the test are the following: Absolute cleanness of glassware, etc. ; exclusion from the diet of meat and fish and their juices and broths (for three or four days when feces are to be tested); exclusion of iron salts, KI, CuSOi, and other metal salts, charcoal and formaldehyde. The stool must be reasonably fresh — less than 24 hours old. Failure sometimes results from untrustworthy reagents. AMiite has had uni- form satisfaction in the use of ^Merck's " highest purity " ben- zidin or " benzidin for blood test," and Oakland dioxygen. For very small amounts of blood, especially where a few streaks are present, not mixed through the specimen, the hemin crystal test may be safest. . Test for Hemin Crystals. — The old Teichmann test may be made by adding two or three crystals of XaCl to a bit of the dried specimen to be tested, on a slide, covering with a cover- glass, running a drop or two of glacial acetic acid under the cover-glass, heating almost to the boiling-point for a minute or two, and examining for the characteristic dark-brown or black rhombic crystals of hemin. The test as modified by Stryzsisowski is probably somewhat more delicate and satis- factory. His reagent is made by mixing i c.c. each of glacial acetic acid, alcohol, and distilled water, and adding three to five drops of hydriodic acid of a specific gravity of 1.5. The specimen is dried on a slide, a cover-glass applied, two or three drops of the reagent added, and the process completed as with the Teichmann test. The Iron Test for Blood. — Place in a small porcelain dish a little of the blackish sediment from the stomach contents or feces. To this add a small amount — a few crystals will an- swer — of chlorate of potassium, as well as one or two drops of concentrated HCl, and heat slowlv over a flame. If neces- HEMORRHAGE FROM THE STOMACH AND INTESTINES 6oi sary add enough more HCl to make the dark color of the sedi- ment entirely disappear. When all the chlorate has dissolved, add a few drops — i to 2 — of a 5 per cent, solution of po- tassium ferrocyanide. If iron be present, the pronounced blue color of Prussian blue will develop. This is a very trust- worthy test provided the patient has not been taking iron as a medicine, nor recently eaten raw or rare meat, which could give the same reaction. Blood from the stomach and that from the lungs or upper air passages. — In Lecture LIII. I have given the chief diagnos- tic differences between blood proceeding from the lungs or other parts above the stomach and from that viscus itself. When a tubercular involvement of the lungs has been diag- nosed, and there is, at the same time, a gastric ulcer or a congested condition of the gastric mucosa, vomited blood might possibly have come from either, though usually the fact of a preceding hemoptysis would be known, and then the probability would be that the blood originated in the lung. The finding of tubercular bacilli in the ejecta would be decisive, as a rule. Treatment. — In Lectures LIV. and LXII. in connection with the treatment of ulcer and cancer of the stomach, I have con- sidered the principal remedies for gastric hemorrhage, what- ever its immediate cause. These include absolute rest, withdrawal of all food and drink by mouth, except possibly cracked ice, morphine hypoder- mically, an ice bag to the abdomen, gelatin by mouth or sub- cutaneously, calcium chloride, adrenalin, ergot. Bismuth and astringents, e.g. gallic acid, are sometimes used, especially for intestinal hemorrhage. If the pulse is full and tense, aconite may be given. Salt solution by rectum or sub-cutaneously must be given when collapse threatens. LECTURE LIX CARCINOMA AND OTHER TUMORS OF THE STOMACH In considering the subject of cancer of the stomach, I shall limit myself to its more practical aspects, summing up the well-established facts that will be of use at the bedside, or in the consulting-room. The minuter pathology, and the still un- settled questions regarding the aetiology of the disease, are all discussed at length in treatises which are accessible to you. Nearly one-half of all cancers, according to Riegel, involve the stomach. Hahn, quoted by Boas in his textbook, gives the following: Pylorus, 35.5 per cent.; cardia, 23.5 per cent.; lesser curvature, 15.9 per cent.; greater curvature, 4.7 per cent.; diffuse infiltration, .12.3 per cent.; posterior wall, 4.1 per cent. ; anterior wall, 4. i per cent. Boas, Cohnheim, and others claim that the lesser curvature is the usual point of origin, the pylorus or cardia being involved secondarily. Cohnheim explains this on the ground that the lesser curvature is more exposed to mechanical, chemical, and thermal irritation from the ingesta. Frequency and Incidence of the Disease. — Statistics in Eng- land show that in 1905 one death in seventeen from all causes was due to cancer, and it is shown that of all persons reaching the age of 35 one man in eleven and one woman in 8 become the victims of cancer. Since at least one-third of these can- cers, probably, are gastric, the frequency of the disease is ap- parent, though it is less common than most of the other organic and functional gastric diseases. As a rule, cancer of the stomach, like the same disease elsewhere, does not often oc- cur before middle age, being rare under thirty; yet it is im- 602 CARCINOMA OF THE STOMACH 603 portant for you to bear in mind that exceptional cases have been encountered in children, and even in infancy, so that there is always the possibility that a doubtful tumor, even in the young, may be malignant. The two sexes are about equally subject to this disease. As to its aetiology, not much can yet be said with certainty, but the large amount of active research being made by numer- ous cancer commissions and individuals gives great hope of the early solution of the problem. Heredity seems to be a factor, but this point is doubtful. The question of infectious origin is still unsettled; some modern workers of high authority claim that the parasitic theory is refuted, others that it is substan- tiated. Traumatisms or irritations frequently seem to exert a causative influence, and gastric ulcer stands in frequent setiologic relation to cancer. The Varieties of Cancer which may affect the stomach are : 1. Medullary carcinoma. 2. Scirrhous cancer. 3. Adeno- carcinoma, or destructive adenoma. 4. Colloid or gelatinous cancer. 5. Squamous epithelial cancer. Scirrhus is the form most frequently encountered in the stomach, comprising, according to Brinton, ^2. per cent, of all gastric cancers. Pathology. — 1. Medullary or soft cancer involves the gas- tric glands, and while rich in cells (cancer nests), it is poor in stroma. It is the predominance of cells over the connective tissue that imparts to this form of cancer its soft structure. It usually occurs as a soft fungus or rounded swelling about the pylorus. As the tumor grows, the blood supply becomes les- sened, the nutrition impaired, and the central portions of the growth become softened and undergo necrosis. This gives rise to the formation of large ulcers with raised borders, which distinguish them from peptic ulcers. The floor of the ulcer is, as a rule, indurated and infiltrated with round cells. Hemor- rhages are common in this form of cancer, and metastases are numerous. It often happens that, owing to destruction of the cell-nests and proliferation of the connective tissue stroma, a 6o4 THE GA5TRO-IXTE5TIXAL CLINIC soft cancer becomes hard and shrunken, thus changing into a scirrhous cancer. 2. A scirrhous cancer is made up of a relatively small number of cells and a large amount of connective tissue stroma. It appears in the form of a diffuse thickening of all the layers of the stomach wall. It involves more especially the pylorus, which then becomes obstructed, giving rise to dilatation. There I- ■'\ V >K- l\ ?a Fig. 75. — Cancer of the posterior wall of the stomach. (From Sidney Martin's " Diseases of the Stomach.") is a general fibrous hyperplasia. The mucous membrane is thickened, and the submucosa and muscularis particularly in- durated. This form of cancer is with difficulty diagnosticated from inflammatory thickening or sarcoma. In scirrhus of the body of the stomach the viscus may be greatly contracted, but when it involves especially the pylorus, stenosis and dilatation occur. 3. Adenocarcinoma arises in mucous membranes covered with cylindric epithelium. In this form of cancer the glandu- lar epithelium proliferates, forming tubular gland-like struc- tures. In the stomach it forms soft nodular growths, which CARCINOMA OF THE STOMACH 605 eventually break down and ulcerate. The stroma is scanty and infiltrated with leucocytes. The base of the ulcerated growth is almost always indurated and thickened by fibrous hyper- plasia. 4. Colloid cancer, or as it is sometimes called, alveolar can- cer, consists essentially of an infiltration of the neoplasm with ^ f ,^^\ I- Fig. 76. — Diffuse cancer of the stomach. (From Sidney Martin's "Dis- eases of the Stomach.") a colloid substance (pseudo-mucin). The growth forms nod- ular swellings or a diffuse wide-spread infiltration. It in- \olves all the coats of the stomach, and frequently spreads to the peritoneum and neighboring organs. Ulceration is un- common. This form of cancer usually occurs in young persons. 5. Sqiianious epithelioma is rare in the stomach. When it does occur, it affects the cardiac end and the neighboring parts of the esophagus. The secondary pathologic manifestations in gastric cancer 6o6 THE GASTRO-INTESTINAL CLINIC include the cachexia and metastases. The cachexia is brought about by the disturbed nutrition due to inanition, as well as by the toxic- products of the cancer itself. It is noteworthy that Adamkevitch isolated from the cancer juice a toxic ptomain, cancroin, identical with cadaverin. The metastases involve the lymphatic glands, and other organs, especially the liver. The blood in gastric cancer is greatly impoverished, the number of red blood corpuscles being reduced in advanced cases to 1,500,000 per c.mm. The red corpuscles show the poikilocytosis of a grave anjemia. Clerc and Gy ^ claim that idiopathic pernicious anaemia is waning as an entity, the blood picture being frequently secondary to latent carcinoma (or other cause), though there is nothing in the blood findings to distinguish it from true pernicious anaemia. The leucocytes are increased and the normal hyperleucocytosis which occurs after digestion is as a rule absent. The hemoglobin is de- creased in proportion to the anaemia. Complications, Sequels, etc. — Gastric cancer involving the orifices causes organic changes in them usually of an obstruc- tive character, or less frequently by a process of infiltration stiffens them in such a manner that the muscular fibers are no longer able to contract. Cancerous stenosis of tJie pylorus produces dilatation of the stomach, which often attains finally an enormous size, filling in some instances nearly the entire abdominal cavity. This results in the peculiar periodic vomiting described further on, of very large quantities of offensive, decomposing ingesta. Obstruction of the cardia by a cancerous growth, or ob- struction in like manner of the esophagus, produces a gradual contraction of the stomach until at death the latter may hold a few ounces only, the esophagus dilating above the stricture. Diffuse scirrhus of the gastric zvalls may also cause a sim- ilar contraction. An unyielding non-contractile condition of the circular mus- "^ Arch, des Maladies du Cceur, April, 1909. CARCINOMA OF THE STOMACH 607 cular fibers of the pylorus, due to a cancerous infiltration with the result that it cannot close, produces, as a rule, no noteworthy anatomic changes elsewhere in the viscus, but aggravates the impairment of nutrition by allowing a reflux into the stomach of bile and other contents of the small intestine, including not infrequently feces. Hour-glass contraction of the stomach has been noted in a few instances as a result of cancer. Distortions of the stomach occur very often in consequence of the cancerous process having involved the peritoneal laver with the development of local inflammation which produces adhesions to adjacent organs. There may exceptionally be per- foration into the peritoneal cavity, the pleural cavity, or even the pericardium. Tetany, which is referred to in Lecture XXXVII. , is a rare complication of cancer of the stomach. Dropsy is a not uncommon late development, and coma, closely similar in all respects to diabetic coma, may usher in the final stage of the disease. Gastrocolic Fistula is scarcely mentioned by most authors, but is an occasional noteworthy complication of gastric cancer This condition, though rare, is one of extreme seriousness, and it thus becomes important to recognize it early so that a cor- rect prognosis may be given, and in certain instances, remedial operation be resorted to. Aitiology. — Gastrocolic fistula occurs most frequently as a complication of gastric cancer, but may complicate gastric ulcer or rarely cancer of the colon. The most frecjuent cause next to cancer is ulcer of the stomach. Of the remaining causes, mention should be made of double perforation of an abscess, and the congenital existence of the condition which is, however, questionable. Symptoms. — At the time of the perforation the patient may complain of acute pain, but more frequently experiences the sensation of something having given way. This may be fol- lowed by prostration, and even collapse, as well as the appear- 6o8 THE GASTRO-INTESTINAL CLINIC ance in the vomit of red blood and shreds of tissue, the whole resembling the vomitus after a recent attack of hematemesis. The symptoms vary much in different cases. There may occur, for instance, cases of such a fistula w^hich do not ex- hibit any positive clinical evidence of the lesion. Such cases are of interest chiefly to the pathologist. Then you will en- counter cases in which fecal vomiting is a pronounced symp- tom. You will need to depend then upon the concomitant symptoms to make a correct diagnosis. Roughly speaking, fecal vomiting occurs in a fraction over one-half the cases observed. Its existence is not in any respect diagnostic of gastrocolic fistula, since it has been reported in a number of cases of pyloric cancer in which the pylorus was permanently patulous, being unable to contract ; also in hys- teria, intestinal obstruction, and some other conditions. But in the absence of evidence of any of the above mentioned affec- tions, fecal vomiting should lead you to think at once of the complication now under consideration. It comes on quite suddenly, as a rule, when due to gastro- colic fistula, its feculent character becoming at once noticeable. The offensive feculent odor, the brownish color, and at times the presence of well-formed feces from the lower bowel make positive the nature of the vomit whenever the characteristic ap- pearances are present. In such cases the breath is likely to have constantly a fecal odor. There usually results, also, a persistent and troublesome lien- teric diarrhea, the patient passing at stool, soon after eating, large quantities of partially or wholly undigested food. Thus the rapid passage of the food undigested into the lower bowel brings about a consequent rapid and marked emaciation, which is often out of all proportion to the possible effect of the exist- ing carcinoma. The patient, as Bouveret states, practically vomits persistently into the larger bowel. This happens es- pecially when there is a sudden cessation of the usual upward vomiting, the diarrhea developing generally a short time afterward. CARCINOMA OF THE STOMACH 609 Substances introduced into the rectum may sometimes be found in the vomit a very short time later. After lavage of the stomach it may be noted that a more than usual decrease has taken place in the amount of fluid recovered, as compared with the amount introduced. This is out of all proportion to the loss of liquid after washing out a non-perforated stomach. Then the patient experiences soon afterward a desire to evacu- ate the bowel. Inflation of the stomach may cause a secondary prominence over the colon, although this result has not, as a rule, proved so striking as when the air is introduced by way of the lower bowel. In the latter case, the sigmoid, and at times the trans- verse colon may become sufficiently distended to be recogniz- able. After such a distention the air will rapidly enter the stomach and be followed by marked eructations of gas from the patient's mouth. In a case reported by Edsall and Fife^ the patient presented many symptoms of gastrocolic fistula, such as the presence of cancer and persistent feculent vomiting especially, and the vomitus contained shreds of tissue. Inflation of the lower bowel resulted in a marked belching of a foul gas, in consider- able quantities, with a consequent subsidence of the distention. A large percentage of fat appeared in the vomit while the pa- tient was receiving enemas of milk and eggs. The autopsy, however, showed the pylorus to be infiltrated with cancer which had converted it into a firm non-contract- ing patulous tube. No fistula was to be found. Symptomatology of Gastric Carcinoma. — Cancer of the stomach usually begins with the symptoms of chronic gastric catarrh, mildly and often very insidiously. It is quite impos- sible to make the diagnosis at first. When, however, a person of middle age or beyond, who has not previously suffered from indigestion, begins, without any particular fault in diet, to complain of slight discomfort after eating, with gaseous eruc- tations, falling off in appetite, especially for meats and fats, and ' Am. Med., October 10, 1903, p. 584. 6lO THE GASTRO-INTESTINAL CLINIC loss of strength, these symptoms persisting and becoming grad- ually and often rapidly worse, in spite of appropriate treat- ruent, you may suspect carcinoma. If, then, the usual tests should show a diminished percentage of HCl, and still more if there should be found constantly a failure of free HCl and the presence of much lactic acid during the period of digestion, together with a progressive impairment of motor power in the stomach walls, with or without the development of cachexia, the likelihood of a malignant process would be considerable. The above-named symptoms, even w^th nausea, copious vomiting, and pain in the stomach added, would not be conclu- sive as to the existence of carcinoma, since chronic asthenic or atrophic catarrh, with dilatation from myasthenia or from any of the benign forms of obstruction of the pylorus, might ac- count for all of them. If, however, in addition to such a group of symptoms growing worse in spite of good treatment, there should appear vomitings of blood, or coffee-ground matter in either the vomit or stools, and the pain should increase and be- come fairly constant without regard to the digestive periods, es- pecially if lactic acid should be found in the proportion of i to looo, with or without the Boas-Oppler bacilli, there would be sufficient cause for venturing the diagnosis of probable cancer, and advising an exploratory incision, even before a tumor could be recognized. But you will rarely find all these typical symptoms in any one case — at all events rarely before a tumor has become mani- fest. Even when all or most of them are present, there is by no means always the typical progressive downward course. Under suitable treatment, there are often short periods of im- provement which tend to awaken false hopes and sometimes shake the faith of even the doctor himself as to the correctness of his own diagnosis. The pain may be referred to any part of the region usually occupied by the stomach, or far below the navel, as the organ, by dilatation or displacement, not infre- quently extends into the pelvis. It may radiate to either hypo- chondrium or to the back, and may be felt in the left shoulder, CARCINOMA OF THE STOMACH 6ll especially when the cardia is involved. It is generally dull, though there may be acute exacerbations. Its most marked pe- culiarity is its relative constancy, as compared with the inter- mitting pains of other gastric diseases. Vomiting is an extremely frequent symptom, and when, as is most usual, the growth causes pyloric obstruction, with result- ing dilatation and stagnation, it is peculiar and characteristic. The vomiting is then apt to come on every second or third day, when large amounts of undigested and partly decomposed gas- tric contents will be brought up, in which there may be yeast germs, the Boas-Oppler bacilli, changed blood and possibly pus, as well as much mucus, but rarely sarcinse. When the cancer is near the cardia, vomiting is apt to occur more frequently and rather soon after the taking of food. Fever is included by some writers among the symptoms of gastric cancer, but is only exceptionally present and then usually toward the end of the disease. Constipation, another alleged symptom of cancer, is often replaced by diarrhea, and it prevails also in most other diseases of the stomach. Anorexia, debility, and emaciation all develop more uniformly and rapidly, as a rule, than in other gastric affections, and cachexia shows itself certainly at some stage, though not often to a marked extent, long before a tumor can be recognized. The most constant signs during the first six months, or before a tumor can be felt, are a peculiarly dirty tongue, fail- ing appetite, flesh, strength, and color, and, when the growth involves the pylorus, the evidences of gastric dilatation, in- cluding a splashing sound obtained by tapping over the stom- ach, or, when this fails, by detecting the splash of the retained gastric contents by palpation, while the patient is caused to contract the diaphragm by his own efforts. Such a splash, either heard or felt over the region occupied by the organ, sig- nifies weakened stomach walls, as well as the presence at once of liquid and gas produced by fermentation; when heard or felt below the umbilicus, it means that, whether there be can- cer or not, there exists a dilatation or displacement of the 6l2 THE GASTRO-INTESTINAL CLINIC stomach, if the other signs show that the latter extends that far. Neither of these signs is diagnostic, and the splash may ^e elicited in merely atonic or displaced stomachs. After cathartics or enemas, or even without these, fluid and gas in the transverse colon may cause confusion by giving a well- marked splash. This must be excluded. We know, also, that the absence of free HCl, and even the presence of a considerable proportion of lactic acid, are not pathognomonic of carcinoma, though lactic acid, in the pro- portion of I to looo or above, when the test breakfast has been given as directed by Boas, consisting of oatmeal or barley gruel without milk or cream, and preceded the evening before by a thorough lavage, affords strong presumptive evidence of can- cer, being only very exceptionally found in other conditions, such as aggravated cases of asthenic gastric catarrh, with great stagnation of the stomach contents. A shredded-wheat biscuit and ten ounces of hot water or clear tea constitute a convenient lactic-acid-free test breakfast. But the absence of free HCl of itself need not even raise a suspicion of cancer. Samples of stomach contents without free HCl are examined almost daily in my laboratory from patients with various non-malignant troubles, especially asthenic and atrophic catarrhs and some of the neuroses of the stomach. On the other hand, the presence of a full or normal percentage of free HCl does not preclude the existence of cancer, especially that form which arises in the site of an ulcer. The sediment of the wash water after lavage should be studied to ascertain whether there are present fragments which show the cancer cells or the histologic structure peculiar to car- cinoma, the Boas-Oppler bacilli, microscopic food remnants, pus or blood. The first named probably constitute the most certain of the earlier signs of gastric carcinoma, though fail- ure to find them by no means excludes the possibility of malignancy. Hemmeter reports having obtained positive evidences of the existence of a malignant growth in the stomach from the pe- CARCINOMA OF THE STOMACH 613 culiar character and arrangement of the cells, one to three months before a tumor could be felt. His method in suspected cases is to feed by the rectum exclusively for forty-eight hours, then wash out the stomach with the normal salt solution, using for this purpose a soft rubber tube provided with edges of un- usual firmness around the lower opening, so as to facilitate the dislodgment of fragments of the tumor. As to the Boas-Oppler bacilli, while their presence would not alone warrant a positive diagnosis of cancer, or their absence exclude it, they constitute one of the most valuable confirmatory signs, especially when they are very plentiful. They are long, filiform, and non- motile bacihi, abundantly forming lactic acid from sugar. They stain yellow with Gram's stain, while the leptothrix stains purple. In the terminal stage of gastric cancer, there is likely to be, along with extreme emaciation and prostration, dropsy of the extremities, and coma, — the coma carcinoniatosiiiu. Symptoms of Cancer as Affected by its Location. — The foregoing account of the symptoms applies especially to the most prevalent forms of gastric cancer, in which the growth has originated in or near the pylorus, where it sooner or later obstructs the onward passage of the food into the bowel. In these cases the tumor at first, before dilatation has taken place, occupies a position just to the right of the middle line, where it is covered by the liver, except when there has been previously an enlargement or downward displacement of the organ. It is always difficult, and often impossible, to palpate the tumor in this position, but later, when the inevitable dilatation has re- sulted, it appears below the liver and is more easily within Fig. 77. — Boas-Oppler bacilli. 6i4 THE GASTRO-INTESTINAL CLINIC reach of the examining fingers, except when the stomach is ad- herent to the left lobe of the liver. Indeed, in some cases the growth may be felt below the level of the umbilicus. Cancer of the Cardia. — When the disease involves primarily the cardiac orifice the clinical picture is very different. The first complaints then are usually of difficulty in swallowing, and of the regurgitation of food which has failed to pass the obstruction. The patient is conscious of a stoppage in the Fig. 78.— Cancer of the pylorus. (From Sidney Martin's " Diseases of the Stomach.") lower part of the esophagus, and of the necessity of taking an unusually large amount of fluid to facilitate the passage of the swallowed bolus into his stomach. There is emaciation, in spite of possibly at first a good appetite and fairly full feeding. The stomach contracts, and may become very small. The CARCINOMA OF THE STOMACH 615 esophagus dilates. The matters ejected contain undigested ahment with saHva, mucus, and often blood, but no HCl or gastric ferments. An abundant bacterial flora is present, in- cluding frequently Boas-Oppler bacilli. There is pain re- ferred to the site of the cardia or sometimes to the back op- posite. The obstruction at the cardia may usually be easily \- Fig. 79.— Cancer of the cardia, (From Sidney Martin's " Diseases of the Stomach.") recognized by the use of stomach tubes or esophageal bougies of graduated sizes. In doubtful cases, to decide whether food is retained in the esophagus, you should first introduce a large stomach tube as far as it will go, noting the point where it is arrested, and then, with the help of a Kuttner aspirator, inserted in the tube (a cut of this instrument is shown on page 114), bring up what- ever will come. Afterward pass into the stomach through the 6l6 THE GASTRO-INTESTINAL CLINIC Stricture, if possible, a smaller tube, and extract some of the contents in the same manner. V If the contents first obtained were coarse, undigested, and free from peptones, HCl, or the usual gastric ferments, while those obtained with the smaller tube are different, the fact of retention in the esophagus would be established. A stenosis of the cardia determined positively by such in- strumental methods, taken in connection with localized pain, steadily failing strength and flesh, and the development of a cachexia would justify a diagnosis of cancer in that region. Another sign of some confirmatory value is a delay of ten to fifteen seconds in the time of hearing the gurgling sound which is normally heard about seven seconds after swallowing liquids. To recognize this, you should place the stethoscope over the region of the cardia and hold it there while the patient swallows. Benign stricture should be excluded. Here there is usu- ally a definite history of caustics swallowed or a lacerating foreign body; the course of the disease is commonly slower and the loss of flesh and strength less extreme. Blood and pus are less likely to be present in the ejecta. Cardiospasm, or spasm of the esophagus, is usually found in young neurotic individuals. The onset may be sudden. The stenosis is apt to vary from day to day, fluids being taken with difficulty at one time, and coarse solids easily swallowed soon after. A large-caliber bougie passes the stricture as freely, or more so, than a small one; and all obstruction disappears under anesthesia. In cancer of the body of the stomach the organ does not usually dilate (though it will often be found to have been en- larged before), and it may even contract. The vomiting, therefore, will seldom be of such large quantities of stagnant contents as when the growth involves the pylorus, but the pain, cachexia, hemorrhages, and other symptoms are very similar. Hemorrhage from a gastric cancer may not reveal itself by SARCOMA OF THE STOMACH 617 the vomiting of blood, but in such cases, besides the appearance of altered blood in the stools, there will be usually such symp- toms as pallor and weakness, or dizziness when the loss has been large — possibly fainting or collapse. SARCOMA OF THE STOMACH Sarcoma of the stomach being so rare a disease, and usually not to be diagnosed from carcinoma, its pathology is of com- paratively little interest or importance to clinicians. It may be primary or secondary and may affect any part of the viscus, though it is most likely to be found on the greater curvature. With the exception of the lymphosarcoma the secondary form is even less frequent than the primary. The varieties of sarcoma which have been described by gas- trologists are the spindle-celled, the round-celled, including lymphosarcoma, angiosarcoma, myosarcoma, and fibrosar- coma. -Etiology, Incidence, etc — We know no more as to the origin of sarcoma than of carcinoma, except that it often oc- curs in a part which has been subjected to repeated irritation or injury. It affects both sexes about equally, so far as has been ob- served. Some of the forms of sarcoma, especially primary lymphosarcoma, according to Schlesinger, may appear at any age, but oftenest in the young — between the ages of twenty and thirty-five years. The same author holds that the other forms, contrary to the prevailing opinion, are rather more likely to occur in the old than in the young. Symptoms and Diagnosis. — As with cancer of the stomach, sarcoma usually begins insidiously, and, especially when there is a diffuse infiltration of the greater curvature or body gen- erally, may for some time remain without symptoms. In other cases you will observe the same symptoms already described as occurring in carcinoma. In these typical cases both the local gastric and the general or constitutional symptoms may be ex- pected, even to the vomiting of blood or altered blood, though 6l8 THE GASTRO-INTESTINAL CLINIC this symptom would seem to be less frequent than in the case of cancer. Fever and persistent albuminuria point rather to s?^rcoma (Fenwick^). There may be dilatation of the stomach with all its serious train of consequences, including sometimes tetany, when the sarcoma involves the pylorus in such a way as to produce stenosis; and lymphosarcoma is said to be capable of produc- ing dilatation, even without having obstructed the pylorus. The chemical findings difTer in no essential respect from those present in cases of gastric cancer Schlesinger emphasizes certain points, however, as useful in making the differential diagnosis : Swelling of the spleen is more frequent in sarcoma, and there is a greater tendency to develop metastasis in the intestines as well as in the skin, where various-sized nodules may frequently be found. Metastasis in the pericardium has been reported. As the disease does not generally cause stenosis of the gut, it may, therefore, be in- ferred, when a tumor of the stomach produces a metastatic growth in the bowels without obstructing them, that it is sar- comatous rather than carcinomatous. Sarcoma usually grows faster and is likely to attain a much larger size than cancer. The tumor usually is smoother — not knobbed or nodulated as a rule. And, if its more frequently observed course in the bowels can be accepted as a criterion, it kills sooner than cancer of the stomach. The fatal result may occur within less than a year, though Riegel is authority for the statement that it may be exceptionally delayed as long as three years. Except for the fact of its more rapid course, it would seem of little clinical importance to make the diagnosis of sarcoma from carcinoma of the stomach. BENIGN TUMORS OF THE STOMACH These include myoma, fibroma, lipoma, papilloma, cyst, and lymphadenoma, the first four of which tend to produce polypi. These are practically never recognized in the stomach 1 Cancer and Other Tumors of the Stomach, p. 280. BENIGN TUMORS OF THE STOMACH 619 during life, and they are, therefore, of very trifling cHnical im- portance. A few cases, however, are on record in which such growths have been the cause of symptoms — pain, vomiting, and even hematemesis, and very exceptionahy obstruction of the pylorus with dilatation. In any anomalous case, therefore, which may confront you, it is well to remember that such symptoms can possibly arise from a no more serious cause. Lymphadenoma. — Lymphoid tumors in the stomach, though exceedingly rare, have by extension to various other organs, including the spleen and intestines, been known to result in death. Nodules were found scattered through the afifected parts, and diarrhea was among the symptoms noted. Foreign Bodies in the Stomach. — Hysteric women will oc- casionally swallow enough of their hair to produce, in time, palpable and movable tumors in the stomach. Numerous cases of the kind are on. record, in some of which the diagnosis of cancer has been made. Serious failure of health results and continues till the tumor is removed. The swallowing of knives or other objects, in imitation of jugglers, has been responsible for other factitious tumors in the stomach. In a few instances, also, indigestible portions of food seem to have been agglutinated into a hard mass which re- mained in the stomach with the result of producing a palpable tumor, which mechanically impaired digestion and injured the general health. Any such tumor should be easily diagnosed by its perfect mobility. Treatment. — None' of the benign tumors or foreign bodies in the stomach are amenable to other than surgical treatment. In any such case in which a tumor is palpable, an exploratory incision should be made with a view to a prompt removal of the offender whenever practicable. Thickening of the Pylorus. — Under various conditions a thickening or swelling of the pylorus can occasionally be made out by palpation, when no malignant growth exists. This gen- erally coincides with a stenosis of the pyloric outlet with con- sequent obstruction and dilatation of the stomach. Indeed the 620 THE GASTRO-INTESTINAL CLINIC obstruction of the outlet is primary, and the thickening of the muscles a result. It is easily intelligible that, whatever the cause of the stenosis, the consequences to the stomach are much the same, though in cancer or sarcoma there is an added cause of rapid failure of health. The most frequent origin of a non-malignant thickening or resistance felt in the pyloric region is the cicatrix of a healed ulcer. This subject is discussed in Lecture LII. in connection with the sequels of gastric ulcer. Such a swelling is small and elongated or oval in form, and is frequently immovable. When the stomach is in normal position and of normal size, such a tumor cannot be felt — at least until after the viscus has been strongly inflated — because of its being covered by the left lobe of the liver. But in displacement, and in dilatation, of the stom- ach, one or both of which nearly always develops soon after the occurrence of an}^ mechanical obstruction of the pylorus, the thickened pylorus may often be felt, especially in thin persons, just to the right of the median line, and somewhere at or below the level of the navel. Hypertrophic stenosis of the pylorus resulting from the pro- liferative form of gastritis has been described by Boas and others. This is another condition in W'hich there is obstruction of the gastric outlet, with sometimes a sufficient amount of re- sulting swelling of the mucous membrane and hypertrophy of the muscularis to form a palpable tumor. The diagnosis of all such pyloric hypertrophies is from cancer of the pylorus, which is by all odds the most frequent cause of a tumor in this region. In cancer, beside the compara- tively rapid loss of flesh, strength, and color, with the develop- ment usually of cachexia, there are certain local peculiarities in the tumor which help to differentiate it from a thickened and swollen pylorus. The latter is usually small and narrow as well as smooth, while carcinoma is likely to develop irregularly, producing a nodular swelling, and moreover, soon grows to a much larger size than the benign form of swelling ever attains. LECTURE LX THE DIAGNOSIS OF CARCINOMA OF THE STOMACH There should be no difficulty in recognizing a typical cancer of the stomach, when the tumor is palpable. The diagnosis can then be made certainly from the unevenness of the growth, its mobility, as a rule, and its association with the symptoms de- scribed in the previous lecture, especially the presence of pain, which is more or less constant, cachexia, anorexia, and vomit- ing, with the occasional appearance in the vomited matter as well as in the stools, of blood, usually in small amounts and of dark altered appearance, or occult; but sometimes in larger quantity, when it may be bright red. Further diagnostic points are the characteristic chemic and microscopic findings previously described, the marked insufficiency of the gastric muscular power and the comparatively rapid and usually pro- gressive loss of strength and flesh, the muscular tissues being lost faster than the fatty — ^just the contrary from what hap- pens in tuberculosis. But it is exceedingly important to make the diagnosis of gastric carcinoma at the earliest possible moment and before a tumor can be made out. Often when a tumor is palpable, the time for operation has already gone by. It is your duty to make,, or have made for you, a probable diagnosis in such cases at a time when, if, after an exploratory incision, cancer be found, an operation can be done with the reasonable hope of at least considerably prolonging life. You should consider the possibility of cancer or some other important lesion in the case of every patient whose dyspepsia, especially if recently accjuired, does not within a week or two 621 622 THE GASTRO-IXTESTINAL CLINIC show improvement after a proper regulation of the diet and hygiene generally, and a trial of simple remedies. The history should be patiently taken in full detail. Repeated physical ex- aminations should be made, especial pains being taken to de- tect a possible tumor or enlarged glands; an enlarged gland above the left clavicle behind the margin of the sterno-mastoid is said to occur in about 15 per cent, of the cases. You ought then to test the stomach contents and gastric motility. If, with increasing debility, emaciation, and anaemia, you find free HCl absent, or present in very low percentage, or steadily fail- ing; if you find lactic acid present in considerable amount, such as a proportion of i in 1000 or higher, after a Boas test meal, which contains no milk products, and if you find occult blood occasionally in the stomach contents or stools, the case becomes very suspicious, and you would be justified in summoning a surgeon at once to consider the propriety of an exploratory in- cision. Before resorting to surgery, however, you should make a microscopic examination of the sediment of the wash- water, after morning lavage of the fasting stomach; this ex- amination requires patience and skill, but it will often furnish important corroborative evidence, and sometimes warrant a certain diagnosis. This certain diagnosis can be reached only when you find undoubted fragments of the tumor, showing nests of cancer cells or other characteristic structure of carci- noma. Such satisfactory results are certainly rare, but they would probably be much less so if we were willing to give the time and patience necessary to the search. I agree with Hemmeter that, considering the seriousness of the disease, we are justified, if necessary, in "curetting" in a cautious w^ay with a rather sharp-eyed rubber tube for fragments of a sus- pected growth in the stomach. Be sure to blow out and in- spect carefully any mucus caught in the eye of the stomach tube, as tumor fragments are most apt to be found in this. If no tumor fragments are found it is still important to examine the sediment, after centrifuging or settling, for can- cer cells. The finding of numerous cells showing karyokinesis DIAGNOSIS OF CARCINOMA OF STOMACH 623 or irregular mitosis is at least very suspicious, and G. Marini ^ claims that carcinoma can often be diagnosed from the cells ob- tained by sedimentation. The Boas-Oppler bacilli and their significance have been noted in the preceding lecture. (See Fig. yj?) Pus cells in large numbers may be present in the stomach contents in a small proportion of cases of gastric cancer in the stage of ulceration, but not plentifully in other cases, except when there is an abscess in, or discharging into, the stomach. Blood cells have the same significance as occult blood. Cohn- heim considers the presence of infusoria suspicious of extra- ostial carcinoma. The repeated finding of microscopic food remnants in the morning lavage water is also considered sus- picious by some authors. Though there is always anaemia in cancer of the stomach, which increases as the disease advances, finally developing into a positive cachexia, there are probably no constant changes in the blood that would distinguish it certainly from other forms of ansemia. A disproportionately low percentage of hemo- globin and, also, an absence of the usual leucocytosis after eat- ing, have been observed, but are by no means present in all cases, and, therefore, are not pathognomonic. Too much time should not be lost over laboratory tests ; yet all proper diagnostic means should be employed, and a number of the more recent tests bid fair to be of real value. Chief among these, perhaps, is the use of the x-rays after the ad- ministration of a bismuth suspension. G. E. Pfahler - con- cludes that the diagnosis of gastric carcinoma can be made earlier by means of this aid ; that carcinoma is demonstrable W'hen it changes the course of food through the stomach; when it decreases the volume of the stomach ; when it interferes with peristalsis; when it causes an indentation of the outline of the stomach; when it fixes or displaces the stomach, or modifies the rate of evacuation of contents. As the examina- ^Arch.f. Verdauungskra7ikheiten, Bd. xv., Hft. 6. '^Jour. Amer. Med. Assoc, Mar. 13, 1909, p. 853. 624 THE GASTRO-INTESTINAL CLINIC tion is tedious and expensive, the case should first be well studied clinically. Great skill and caution are necessary in in- terpreting the findings, and all clinical data should be at the command of the operator. Salomon's test^ is made as follows: On the previous day the patient takes an albumin-free diet, and his stomach is washed out in the evening. In the morning the fasting stom- ach is washed with 400 c.c. of normal salt solution, introduced twice. This fluid is then tested for nitrogen by the Kjedahl method, and for albumin by the Esbach method. In cancer the nitrogen is said to range from 10 to 70 mgm. in 100 c.c, 20 to 30 mgm. or over being very suspicious. The albumin ranges from i-io to ^ per 1000 in carcinoma. The hemolytic test has been found positive in a high per- centage of carcinoma cases by various observers. This con- sists in the destruction of normal human red corpuscles when mixed with the serum of the patient tested. As the test is not positive in all cases, and is positive in some other conditions, its ultimate diagnostic value remains to be determined, but there is ground for hope of definite aid from this direction. Pfeiffer and Finsterer - claim that guinea-pigs injected with the serum of a carcinoma patient, and 48 hours later injected with carcinoma juice, show a marked anaphylactic shock and fall of temperature, these being absent in untreated pigs or those injected with normal serum. The discovery of this anaphylactic property in a patient with a tumor is said to con- firm the diagnosis of carcinoma. If it disappears after opera- tion, the cure may be considered definite ; its reappearance is a signal for fresh intervention. Neubauer and Fischer ^ report the finding in the stomach contents of patients with gastric carcinoma of a ferment pro- duced by the carcinoma which is capable of splitting polypep- tids. For practical tests they used the artificial polypcptid glycyltryptophan, which yields tryptophan on hydrolysis. The ^ Jcntrnal A. M. A., Sept. 12, 1903, p. 694. 2 IVtener klin. Wochenschrift, July 15, 1909. ^Deutsche Arch./, klin. Med., 1909, xcvii. p. 499. DIAGNOSIS OF CARCINOMA OF STOMACH 625 technic is not difficult, and their results were positive in a high percentage of cases, but whether the test will be of real value in making an early diagnosis remains to be demonstrated. Ascoli and his pupil Izar ^ have recently sought to apply their " meiostagmin " reaction to the diagnosis of malignant neo- plasms. This reaction consists in the definite lowering of sur- face tension (measured by the stalagmometer of J. Traube) of Fig. 80. — Section from carcinoma of the pylorus. an immune serum when mixed with its specific antigen and in- cubated for two hours at 37° C. The patients examined in- cluded sixty-two suffering with malignant growths, carcinomas or sarcomas. Of these fifty-eight gave a positive meiostagmin reaction. Forty-eight patients suffering with various other diseases all gave a negative reaction. These results are most promising, but, as in the case of some of the preceding tests, the practical value of the method remains to be demonstrated. '^ Miinchen Med. Wochenschrift, 1910, Ivii, 182. 626 THE GASTRO-INTESTINAL CLINIC Boas considers cedema of the ankles or feet, even though only transitory, a sign of cancer of the stomach — and one which may be present in the beginning of the disease. In cancer of the cardia, besides the symptoms previously mentioned, pain is Hkely to be ehcited by pressure or percussion over the lower end of the sternum, and the stomach will be ul- timately contracted, rather than dilated as when the pylorus is involved. In cancer of the body of the stomach, the organ may be either of normal size or contracted, rarely enlarged, unless the enlargement antedated the tumor, and there is more likelihood of the disease running a latent course here than in other parts of the organ. Not seldom it is unsuspected until a tumor is palpable. The diagnosis of cancer from ulcer, from hyperchlorhydria and acid gastric catarrh, as well as from gastralgia, is fully given in a tabular statement which will be found in Lecture LIIL, on the Diagnosis of Gastric Ulcer. It is also further discussed in Lecture LXL, entitled the Differential Diagnosis between Gastric Carcinoma and Round Ulcer. Carcinomatous Ulcer. — Carcinoma which has developed in an ulcer can be differentiated from simple ulcer by the history, there having been at first the usual symptoms of ulcer, followed by cachexia with loss of strength and flesh, and a change in the character of the pain, from one that was acute, paroxysmal, and much aggravated by food, to a dull or moderate pain that is more or less constant with no, or only an unimportant, in- crease after eating. Later the presence of a movable, uneven tumor would clinch the diagnosis. The persistence of free HCl with the symptoms and signs of cancer usually means a carcinomatous ulcer. From chronic asthenic gastritis cancer of the stomach cannot at first be positively diagnosticated, since more or less catarrh accompanies cancer. In both, much mucus, a heavily furred tongue, and nausea may occur ; and in both there is usually sensitiveness to pressure over the organ; but chronic catarrh of the stomach is rarely painful, especially in its earlier stages, DIAGNOSIS OF CARCINOMA OF STOMACH 627 while cancer may be almost from the start. When there is pain with gastritis, it is nearly always digestive, /. e., confined to the period of two to six hours following meals when diges- tion is in progress; while in cancer, though the pain may be aggravated somewhat after, eating, there is likely to be, at least, an uncomfortable sensation, even when the viscus is empty. Besides, in the later stages of cancer, changed blood nearly al- ways appears from time to time, both in the vomit and stools, but anything of the kind rarely occurs in gastric catarrh. Apart from the pain, hemorrhages, and tumor of cancer, the most striking difference is, that in catarrh, the symp- toms will nearly always steadily improve under a proper treat- ment, strictly and persistently carried out, while cancer, with the exception of possible brief spells of relief, or even gain in appetite and digestive power, tends to grow surely worse in spite of any treatment. Besides the motor power of the stom- ach walls, which is so constantly and usually markedly lowered in cancer, is often good or fair during a large part, at least, of the course of chronic gastritis, and may be quite normal for years. Finally, the appetite, color, flesh, and strength, which are not necessarily much impaired in gastric catarrh of moder- ate degree and are often well maintained, are always progress- ively lost in carcinoma from a comparatively early stage, as a rule, with possible slight exceptions for a week or two. From atrophy of the stomach, which is the final stage of chronic gastric catarrh, it is also difficult sometimes to diag- nosticate cancer, since there may be a complete absence of free HCl and of the ferments in both, and exceptionally there may be much pain in atrophy. But the pain of atrophy is digestive, and in my experience exceptional, and the tongue is likely to be rather clean, and the wash water after lavage free from mucus, while in cancer the pain is more constant, the tongue always dirty, and the stomach generally full of mucus. The nervous forms of lowered digestive ability should never be confounded with cancer, since they are generally improved by tonic treatment and generous feeding, and are very change- 628 THE GASTRO-INTESTINAL CLINIC able as to both the secretion of HCl and all the symptoms, in- stead of showing an almost continuous and rapid downward course, as does cancer. Pain is not very often present in them — never constant pain — and hemorrhage is wanting. Dilatation of the stomach, dependent upon a spasmodic contraction of the pylorus, an actual narrowing of the outlet, as the result of a healed ulcer, or obstruction from other mechanical cause not malignant, needs to be differentiated from pyloric cancer, since in the former there may be, though ex- ceptionally, marked anaemia, and there is often severe pain, though paroxysmal in character, as well as, generally, the form of vomiting characteristic of stagnation and retention of food. But in benign obstruction HCl is usually present in normal or excessive proportion, and the ferments also ; conse- quently meat fibers and other albumins are usually digested, and mucus is not abundant. Sarcinse are commonly present in great numbers, as well as yeast-colonies, though the latter may also be abundant in cancer. Then, there is not often so bad a tongue, nor so persistent a failure of the appetite with an especial disgust for meats in the dilatation from other causes, as in that from malignant disease of the pylorus. The stenos- ing form of gastritis also produces a dilatation with symptoms very similar to those resulting from other non-malignant forms of pyloric stenosis. For the recognition of a cancerous tumor of the stomach, in- spection, percussion, and palpation may all help somewhat, but the last will yield by far the most information to the physi- cian with skilled fingers. You should examine the patient by all these methods in various positions of the body — lying su- pine and prone, and on either side, as well as standing — ^both before and after inflation of his stomach with gas, as well as before and after letting him drink a pint of water. Inflation with gas is often particularly useful in bringing hidden tu- mors into view. In the case of tumors of the anterior wall, transillumination by means of the Einhorn electric lamp, intro- duced into the stomach after the patient has drunk one or two DIAGNOSIS OF CARCINOMA OF STOMACH 629 glasses of water will sometimes help in the diagnosis. But the Roentgen rays will often afford more positive information. The Differential Diagnosis of Gastric Cancer from Other Abdominal Tumors. — The annexed table, taken from Boas' " Diagnostic und Therapie der Magenkrankheiten," cannot well be improved upon. The stomach is first to be inflated with air, or with carbonic acid gas ; afterward the colon is filled with warm water by a fountain syringe. The results upon tumors in different locations are recorded in the table as follows : Turners of the I. Stomach, {a) pylorus, (fi) anterior wall and g r e ater curvature (c) the lesser curvature 2. Liver, 3. Spleen, 4. Colon, 5. Kidneys, 6. Omentum, 7. Pancreas, Up07t Inflation of the Stomach, Upon Filling the Colon with Water, Move to the right and downward. Feel broader and less dis- tinct at their margins. Disappear entirely. Move upward and to the right, so that the anterior border of the organ becomes more distinctly palpable. Move towards the left ; often also downward. Move upward. Move downward. Disappear upon inflation of the stomach. All tumors of the stomach simply move upward. Raise the lower border upward ; a tumor of the gall bladder is drawn forward. With very large tumors there may be no change of position. Move upward and to the left. Movable tumors may thus become recognizable in the normal splenic region. Do not move upward. At first they may ascend a little, but finally disappear. Mov- able kidneys return to the proper renal region. In large tumors of the kidneys the median border only be- comes indistinct. Move downward. LECTURE LXI THE DIFFERENTIAL DIAGNOSIS BE- TWEEN GASTRIC CARCINOMA AND ROUND ULCER The diagnosis of carcinoma of the stomach has already been quite fully discussed, and in the lecture on The Diagnosis of Gastric Ulcer a table is included, in which are given in a con- densed form the chief distinguishing characteristics between that disease and others with similar symptoms, including gas- tric cancer. But the differential diagnosis between these two may with advantage be further amplified and emphasized. For the expert gastrologist it is, as a rule, easy enough to di- agnosticate a carcinomatous growth in the region of the stom- ach from a gastric ulcer. When a tumor can be felt in a posi- tion, or of a size or form, which would exclude the elongated cylindric thickening of the pylorus due to an ulcer in that re- gion, cancer must always be suspected, and may be diagnosti- cated positively if tliere are present also the symptoms of the latter disease — viz., a progressive loss of flesh and strength, pain, vomiting, hematemesis, cachexia, and an absent or markedly lowered secretion of the HCl and ferments of the gastric juice. Indeed, when such a tumor can be made out, and a part only of the above symptoms are present, including pain, emaciation, and a rapid loss of strength, or even the latter two without pain, you may be sure enough of cancer to advise an exploratory incision, provided there be no signs of metastases or involvement of neighboring glands. But it is in the beginning of the disease before a tumor is demonstrable that it is very difficult to recognize. The early stages of carcinoma involving the body of the stomach or the 630 GASTRIC CARCINOMA AND ROUND ULCER 63 1 pylorus are more likely to be confounded with gastric ulcer than any other disease, especially by physicians who do not make a practice of testing, or having tested, the stomach con- tents in every suspicious or stubborn case of indigestion. Moreover, an analysis of the gastric contents with the finding of HCl in moderate excess, though it affords strong presump- tive evidence that such symptoms as pain in the stomach, with occasional vomiting, with or without hemorrhage, are due to ulcer, does not exclude the possibility of cancer which has de- veloped in the site of a previous ulcer ; and, still less, on the other hand, would the failure of HCl alone prove certainly the existence of cancer. The totality of the chemic and micro- scopic findings and the symptoms, as well as the results of treatment, must decide in the absence of a palpable tumor. Cancer of the Cardia, Differentiated from Ulcer, — You are not likely to mistake cancer of the cardiac orifice of the stom- ach for ulcer, since the symptoms of these two affections are widely different. In the former, the pain and sensitiveness to pressure are both usually experienced over the lower end of the sternum, rather than over the stomach itself, and careful sounding will discover an obstruction at the cardiac opening. There is difffculty in swallowing, and finally regurgitation from the esophagus of wholly undigested food, not true vom- iting. In the other forms of gastric carcinoma, the main points in which the symptoms differ from those of ulcer are the tend- ency of the pain to persist during most of the twenty-four hours, without regard to the digestive process, whereas, in ulcer, there is usually an entire absence of pain until food is taken, when it shortly comes on more or less acutely and per- sists until the meal has been completely digested — often until it has been evacuated from the stomach. After its evacuation, there is generally an entire cessation of the pain from ulcer. As to hemorrhage, there may be none at all in either disease until it is considerably advanced. The most important differ- ences are that in cancer there are likely to be frecjuently re- 632 THE GASTRO-INTESTINAL CLINIC curring small bleedings after ulceration of the growth has begun, but rarely a large or serious one. In ulcer, while the bleedings may be either large or small, there are apt to be spells of hemorrhage at long intervals, and generally they are larger and involve a greater loss of blood than in the case of cancer. During such a spell, the loss of blood may be temporarily con- trolled by remedies, but will often recur within a day or two, and such recurrences may continue until the ulcer can be healed, or till a clot becomes organized in the bleeding vessel. Then there may be no more for weeks or months, even though the ulcer persists with its other symptoms, pain, tenderness on pressure, etc., except, of course, when treatment has been so thorough and effective as to produce entire healing. Chief Diagnostic Points. — Bear in mind that in cancer there is a progressive loss of appetite, Hesh, strength, and color, al- most from the beginning, while in ulcer there is most commonly a sharp appetite with other indications of a good nutrition, ex- cept when the ulcer is very chronic, or has developed after such a long persistence of a neglected and marked hyperchlorhyd- ria as to have seriously impaired the health. The pain, as well as the hemorrhage in ulcer, is likely to be more severe than in cancer. It needs to be repeated also, that the pain in ulcer is, almost without exception, limited to the time when the stomach contains food; and the more irritating the form of the food, the greater the pain, whereas, in cancer, though there may be somewhat more pain during digestion, it is the rule that a dull, gnawing ache persists pretty constantly, particularly in pyloric cancer, so that sleep is generally prevented, except with some help from anodynes. Sleep is also often impaired in ulcer, as well as in excessive HCl secretion merely, but not usually from pain, unless hearty meals are taken at night. In both cancer and ulcer, there may be vomiting of changed blood resembling coffee-grounds, instead of fresh blood, but this is rather more frequent in cancer. Altered blood or occult blood may also be mixed with the feces in either disease, even when there has been no recent hematemesis. GASTRIC CARCINOMA AND ROUND ULCER 633 This results usually when there has been too small a bleeding to provoke emesis, and, in the absence of hematemesis, points rather to cancer than to ulcer. Tenderness on pressure in or near the median line, just below the lower end of the sternum, as well as to either side of the spine at the level of the two lowest ribs^ is often demonstrable in ulcer, but much less frecjuently in carcinoma of the stomach. It is not rarely present, however, in other diseases, as in neu- rasthenia. Yet when such tenderness is very acute and marked, especially posteriorly, you should think, first of all, of ulcer. It is noteworthy, however, that many of the diagnostic symptoms, above mentioned, may be wanting particularly in the earliest stages of the twO' diseases. The most help may then be obtained from the chemic and microscopic examina- tion of the stomach contents, and the microscopic examina- tion of particles accidentally or purposely scraped off from the gastric mucous membrane. The finding of a normal, or es- pecially of an excessive, percentage of HCl would speak in favor of ulcer, while a very low percentage, or absence, of HCl would render the diagnosis of cancer decidedly more probable. The presence of a considerable percentage — one part in a thousand or more — of lactic acid would still further increase such a probability, as would also the finding of the Boas- Oppler bacilli, or the histologic changes characteristic of car- cinoma. Carcinomatous ulcer is that form of gastric ulcer in which cancerous degeneration has taken place, and the disease thence- forth behaves like cancer. It does not differ materially from other forms of carcinoma of the stomach, either as to its signs or symptoms, except that a normal or excessive percentage of HCl usually persists in such cases, thus tending to mislead the physician who bases his diagnosis too exclusively upon the re- sults of a chemic analysis of the gastric contents. You should suspect the presence of carcinomatous ulcer whenever you find the symptoms and cachexia of cancer to have gradually de- veloped in a case with a history of gastric pain and hemorrhage 634 THE GASTRO-INTESTINAL CLINIC running back over a long period, especially when the disease has lasted more than two years. Primary gastric carcinoma most fi^quently comes on suddenly in persons who have previously had a good digestion. The Therapeutic Test. — In doubtful early cases, the diag- nosis may often be made by the therapeutic test. For ex- ample, if you should have a patient complaining of pain in the gastric region, directly after meals, but to a slight extent also at other times, with occasional vomitings, beginning loss of flesh and strength without much change of color, and no tumor to be felt, you might well be in doubt as to what form of dis- ease existed. The fact that the pain persisted to some extent after the stomach was empty, would look much more like car- cinoma than either ulcer, hyperchlorhydria, or gastritis. Still, it w'ould not exclude the possibility of a gastralgia of nervous origin, and the pain between meals might be due to fermenting portions of undigested food in the small intestine, or to large amounts of gas, with marked distention of the stomach. On the other hand, there might be a similar case in which pain was experienced only when the stomach contained food, which would, of course, suggest the probability of ulcer or gastritis, rather than cancer. And yet, in the early stages of cancer, es- pecially when the body of the stomach, and not the pylorus, is involved, the pain may be only complained of during the di- gestive act, and sometimes not even then. In all such doubtful cases the diagnosis can be pretty certainly determined by put- ting the patient to bed and feeding by the rectum, together with the other curative measures advised for ulcer. In any recent case of ulcer, rest in bed, with rectal feeding, and 30- to 60- grain doses of bismuth subnitrate, three or four times a day, with sometimes large doses of an alkali to neutralize the ex- cessive HCl, will almost certainly remove the prominent symp- toms within a few days, and if persisted in for a w^ek or two, followed by a longer continuance of the bismuth, with a liquid diet by the mouth, gradually increased, will insure usually a speedy and complete cure of the disease. Marked relief, too, GASTRIC CARCINOMA AND ROUND ULCER 635 would likely follow if the cause of the symptoms were chronic gastritis, although not so certainly then, since lavage would often need to be added to the treatment. But in a case of cancer, while certain of the symptoms might be favorably in- fluenced at first, the growth would usually progress in spite of all treatment, and after a week or two of possible slight ameli- oration, the symptoms would recur and become increasingly troublesome. This is a valuable method when patients can be sufficiently controlled to carry it out, and when there is even a possibility of so grave an organic disease as carcinoma of the stomach, it is vitally important to exhaust every means to ar- rive at the diagnosis at the earliest possible moment, in order that the surgeon may be summoned in time to afford the pa- tient the only chance of recovery. Many observers have lately testified to the great value of the more delicate tests for minute traces of blood in the stomach contents and feces in the diagnosis of gastric ulcer and cancer. See Lecture LVIII. LECTURE LXII THE TREATMENT OF CARCINOMA AND OTHER TUMORS OF THE STOMACH The prognosis of gastric cancer has, until quite recently, been considered absolutely hopeless. However, since the sur- gery of the abdomen has been so extraordinarily perfected, oc- casional cases of apparent cure by early operative intervention have been reported. Then, too, the achievements of the Roentgen rays, violet rays, the Finsen light, and radium, in ameliorating, and apparently, in some isolated cases, even cur- ing malignant growths in various other parts of the body, naturally awakened the hope that cancer of the stomach, and of the other abdominal viscera, would ultimately yield to some of these mysterious agents, but after some years of thorough trial this hope is yet to be justified. More encouraging, per- haps, are the results being obtained by the many investigators into the nature and cause of carcinoma, and one need not be branded as visionary who looks forward to the discovery of a curative serum. Treatment with X-Rays, etc. — The results of the trial of x-rays in this region hitherto have been much less encouraging than elsewhere in the body. Caldwell ^ cites one case reported by Despeignes - in which carcinoma of the stomach improved under daily applications of the x-rays, and quotes Skinner ^ as having treated five cases of intra-abdominal tumors, with the result that two of them became smaller, and in two of the others there was gain in the constitutional condition. 1 "The Roentgen Rays in Therapeutics and Diagnosis," by W. A. Pusey and Eugene W. Caldwell, Saunders & Co., Philadelphia, 1903. "^ Semaine Mid., 1896, xvi. p. cxlvi. ^ Rev. Int. d' Electrothirapic , 1902, xii. p. 28. 636 TREATMENT OF CARCINOMA AND OTHER TUAIORS 637 Dr. Wm. B. Coley wrote the author in 1894 as follows: " I belie\'e that the x-ray gives the greatest promise when used as a prophylactic, after primary operation, although, even here, the data are insufficient and contradictory." Dr. W. B. Snow, a prominent authority in electro-thera- peutics, reported a case of pyloric cancer in the Journal of Ad- vanced Therapeutics, of June, 1902, in which, though the dis- ease was far advanced, and the patient in a critical condition when the treatment was instituted, six x-ray applications pro- duced remarkably favorable results, including a cessation of severe hematemesis as well as all nausea, vomiting, hiccough, and dyspnoea, an improvement in the pulse, and especially a decided softening of the tumor itself. Later, the patient be- came suddenly worse and died with symptoms pointing to gen- eral auto-infection. This is one of the dangers attendant upon the rapid resolution of an internal malignant growth by means of the x-rays. So much has already been done with these new agents that we are justified in hoping for still more. The most recent reports, from entirely trustworthy sources, leave little room for question that some of these forces are now causing the disappearance — a gradual melting away, as it were — of a cer- tain proportion of cancers and sarcomas on the exterior parts of the body, as well as in the more accessible cavities. It has not been proved that these are definite cures, but the results are nevertheless encouraging. Two difficulties are in the way of the achievement of like re- sults in the stomach and intestines: ( i) The depth of the overlying tissues which the rays must penetrate before they can effectively influence the diseased structures, and (2) the ina- bility, under present conditions of the operator, to see how to apply the rays in just the right position, and at the proper dis- tance from the point to be affected. Neither of these, how- e\'er, would seem to be insuperable. Carl Beck ^ of New York has recently reported cases of ^ N. V. Med. Jour., Mar. 27, 1909. 638 THE GASTRO-INTESTINAL CLINIC pyloric and other abdominal cancers in which he made an > incision and stitched the growth to the abdominal wall, after- ward applying the x-rays. In some cases the results were ap- parently favorable. Storck of New Orleans reports ^ a case of undoubted carci- noma of the stomach which was greatly relieved after a few treatments with radium. He applied it by means of a con- trivance of his own invention and called by him an intragas- tric radiode. He thus describes it: " It consists of an aluminum capsule containing 10 mg. of 7000 radioactive radium attached to a flexible copper wire passed through a suitable rubber tube (a stomach tube will answer every purpose), the capsule being allowed to project beyond the end of the tube. The intragastric radiode is so manipulated as to come immediately, or as nearly as possible, in contact with the growth." Einhorn in his textbook on gastric diseases describes his methods. The radium receptacle, of glass, is enclosed in a hard-rubber capsule; to this a silk thread is attached, long enough to reach to the patient's ear or shirt when the capsule is in the stomach. The capsule is swallowed and allowed to remain in the stomach from one-half to one hour. In cardiac and esophageal cancers he uses a similar capsule, but this is attached to a soft rubber tube containing a mandrin to facil- itate introduction. The mandrin is removed after the in- troduction, and the capsule is left in contact with the tumor for one-half to one hour. In the latter class of cases Einhorn reports definite and marked alleviation of symptoms- — in- creased permeability of the stricture, etc. ; but in the gastric carcinomas proper the results were much less encouraging. Even the slightly encouraging results so far obtained from the experience with x-rays in malignant growths of the ab- dominal viscera are enough to warrant a trial of them in in- operable cases, and especially after an operation for the re- moval of the tumor has been done, so as to accomplish as much ^ Am. Med., May 21, 1904. TREATMENT OF CARCINOMA AND OTHER TUMORS 639 as possible in this way toward the prevention of a recurrence. We should stop at nothing that promises in howsoever small a degree to lessen the danger of recurrence, and even though it should recjuire hundreds of treatments, and involve severe burnings of the skin, these would be gladly undergone by many patients if thereby they could be encouraged to hope that the tumor would not recur, or even that it would only recur after a respite of some years. The arguments advanced in favor of following every opera- tion for the removal of cancer with a prolonged treatment by the x-rays seem to be strong, and there are also equally strong reasons for beginning the treatment of the same with this agent whenever, from any cause, the operation has to be deferred, though it be for even a few days only. If the x-rays could save only one case in a hundred, or only prolong by a few months the lives of such patients in a small proportion of cases, it should be employed, since, whatever its inconveniences, it can scarcely add to the dangers of a fatal termination, but, to some extent at least, lessens them. Later Reports Concerning the X-Ray, Radium, etc., in Cancer. — The foregoing reports, conclusions, and comments concerning these newer therapeutic forces were mainly written in the years 1903 and 1904, before the appearance of the first edition of this work. Since then there have been waves of pessimism and optimism as to their value. Meanwhile the x-ray specialists have m.ostly continued to claim good results in many cases of external cancer and in those involving the cavities easily accessible from without — the rectum, vagina, mouth, naso-pharynx, etc. — though there has been little re- liable evidence pointing to permanent cures even in such cases. It has been generally conceded that in the more deep-seated malignant tumors, as in the stomach and intestines, nothing was to be expected even in the way of palliation or temporary sub- jective improvement except from the knife, and then only in case the exceedingly difficult and mostly impossible task of making a very early diagnosis — even before the finding of a 640 THE GASTRO-IXTESTIXAL CLIXIC tumor — could be accomplished. However, some compara- tively recent reports are somewhat encouraging again. In ^Germany the Institute for Cancer Research in Heidelberg, un- der the direction of Prof. Dr. V. Czerny, has been furnished with liberal amounts of some highly concentrated preparations of radium for experimental purposes, including a radium powder said to be so powerful that it can exert a force of 99,000 volts for each 125 grams of the drug per hour, a strong radium salve and a solution of the remedy which can be ef- fectively employed both by applying compresses soaked with it for six to eight hours at a time, and by having the patient drink it freely for malignant tumors in the stomach or esoph- agus. By pushing the drug boldly, which has been found safe, often by the combined use of several of these methods, and at the same time employing when practicable the x-rays and all the other approved remedies. Dr. A. Caan reports from this Cancer Research Institute that while permanent cures can- not yet be claimed, provisional results have been achieved which " show encouraging progress in the therapy of the ma- lignant neoplasms." ^ In all Caan reports the results in no cases, including 88 of carcinoma, 9 of sarcoma, 8 of generalized lymphosarcoma, and 5 of non-malignant affections. In some 70 cases the treatment was followed by notably favorable results. In 30 cases of recurrent mammary cancer decided improvement occurred in 23 both objectively and subjectively. Of 14 cases of car- cinoma of the stomach 8 were improved especially in their sub- jective condition, though only exceptionally was the ob- jective condition bettered, in one only the weight increased. So also with the cancers of the esophagus. Of rectal can- cers 3 cases were on the whole favorably influenced, as also were 3 cases of inoperable carcinoma of the pharynx which showed a strikingly favorable response to the treatment. Here in one case a tumor as large as a plum disappeared in four 1 Concerning the Radium Treatment of Malignant Tumors. Muen.' che7ier Med. IVoc/i., Oct. 19, 1909. TREATMENT OF CARCINOMA AND OTHER TUMORS 64I Aveeks. The most remarkably favorable results were ob- tained in the treatment of the 8 generalized lymphosarcomas, in all of which there was a decided decrease in the swellings and in several of them a complete disappearance of the tumors together with a marked gain in the subjective state. The writer ends by expressing a " well-grounded hope in spite of all scepticism " in view of the experiences described, that " with the help of radium or, still better, by means of a com- bination of it with other means," further progress can be made in the fight against the malignant tumors. Other Recent Therapeutic Measures. — J. W. Vaughan,^ of Detroit has lately reported a series of carcinoma cases treated by the injection of nontoxic " cancer-residue," preferably pre- pared from the patient's own carcinoma. The aim is to in- duce the formation in the body of a ferment capable of de- stroying the growing cancer cells. The writer is conservative in his conclusions, but his results are very encouraging, and should certainly stimulate further investigation along this line. Bertrand - reports the apparent cure of a recurrent car- cinoma and marked improvement in another patient, who re- fused operation, by the injection of an emulsion of carcinoma- tous tissue so finely divided as to assure the disintegration of every cell in the emulsion. Bertrand's method is somewhat similar to Vaughan's in principle, and his results are therefore to a certain extent corroborative. (See also note on page 651.) Trypsin Treatment. — Various investigators have reported upon the use of this ferment. Some have claimed cures. But the majority are conservative and claim only palliative im- provement. Pain is relieved in some cases. Nutrition may be improved and hemoglobin increased. Eosinophilia is in- duced, which is considered an evidence of increased resistance. In some cases the injections seem to cause disintegration of the cancerous tissue in the center of the mass, but the periphery continues to grow. (Bainbridge, Med. Record, July I'J, ly. A. M. A., May 7, 1910, p. 1510. ^Gazette Med. Beige, Mar. 31, 1910, p. 252. 642 THE GASTRO-INTESTINAL CLINIC 1909.) The improvement of symptoms may justify further trial of this agent in inoperable cases, but a cure is hardly to he expected. The trypsin is administered by deep hypodermic injection. The injections may be alternated with injections of amylopsin. You will find the technic detailed in the cur- rent literature on the subject. Thymus Treatment. — F. Gwyer ^ has used powdered thymus gland in doses of 1.8 to 7 gm. three or four times daily in a series of inoperable carinomas, and reports relief of pain and diminution in the size of the growth. Early Diagnosis Indispensable. — Of two well-established truths regarding gastric cancer you may rest assured : ( i ) That the disease cannot at present be cured by any medicinal means; and (2) that surgery, even with the help of the new and remarkable agents above mentioned, will be equally power- less with medicine to effect a cure, except in those cases in which you, with possibly the help of medical experts, shall have succeeded in accomplishing two difficult things. One of these is to make a probable diagnosis of the disease at a very early stage, before the neighboring glands have become involved, or strong adhesions have bound the part occupied by the new growth to adjacent organs, and usually before the tumor itself can be felt, or cachexia has developed. The other is to induce the patient and his family to consent to an exploratory incision before it is too late. You should remember that an explora- tory incision involves very little risk, when done after all necessary preparations by a skillful laparotomist in a person who is still well nourished. You should all strive to acquire skill in physical examination and special training in the recent methods of examining the stomach as to its size and position, and also as to its motor and secretory functions. Even with the aid of these methods of precision, it will not be possible, always, to make the diagnosis at a time when an operation can offer hope of a radical cure; but it sometimes can, and with- out them such a consummation is impossible. ' '^ N. Y. Med. four., Feb. 19, 1910. TREATMENT OF CARCINOMA AND OTHER TUMORS 643 Indications for an Exploratory Incision — Indeed, whenever a case presents the symptoms of a severe chronic gastric ca- tarrh, with or without the absence of free hydrochloric acid, and tliere is at the same time much lactic acid present, a per- sistent pain localized in the stomach, and marked loss of motor power in the organ, as well as weakness and emaciation, and these symptoms not only continue, but get worse, in spite of lavage, appropriate diet, tonics, and digestive aids, not longer than three, or at the most four weeks, should be wasted in ex- pectant treatment. Under these circumstances, the susj^icion of carcinoma should be strong enough to warrant summoning the best obtainable laparotomist and re-examining the patient thoroughly under an anaesthetic. This might reveal an in- cipient tumor not palpable before; also sufficient glandular or other complications already to render any operation inad- visable, or to limit the surgical intervention to some palliative procedure merely. But supposing that, in such a case, under anaesthesia no contra-indications should be found, there would be warrant, according to the best recent authorities, for making an exploratory incision with preparations for some remedial operation, radical or palliative, if a tumor should be discovered. Operative Treatment — An operation having been decided upon, the surgeon may, hopefully extirpate the pylorus (pylo- rectomy) for a growth in that region; or remove any other part of the stomach, or even the whole organ — gastrectomy, in- complete or complete. Or, if a cancer obstructing the pylorus has progressed to a hopeless stage, a direct communication may be established between the body of the stomach and the small intestine — gastro-enterostomy. This often prolongs life for many more months, and gives the patient increased com- fort. When a tumor obstructs the cardiac orifice, the usual operation is gastrostomy, which consists in making an open- ing directly into the stomach through the abdominal wall. Through this the patient can be fed while life lasts. Sounds can sometimes be passed and the stricture be thus dilated from below, through the same orifice. 644 THE GASTRO-INTESTINAL CLINIC Medicinal and Palliative Treatment. — Naturally, you will be likely to look upon a case of beginning carcinoma of the Stomach as simple indigestion, or catarrh, and treat it ac- cordingly. At first, before cancer is even suspected, nothing better could \\'ell be done. But when you put the patient upon thorough and appropriate treatment, you have reason to ex- pect improvement if no more serious condition exists than ner- vous dyspepsia, or even a moderate gastric catarrh, with the usually accompanying neurasthenia. If, instead of improve- ment, there results a further downward progress, which is not checked, or the symptoms are only temporarily ameliorated, with then further aggravation in spite of treatment, even lavage affording slight or no relief, you will have strong reason for suspecting that something more serious is the matter. You will, in that case, of course, leave nothing undone that will help to decide whether or not you are dealing with a case of cancer in a stage when it may still be curable by surgical meas- ures. You should then proceed as already advised for such cases. But when you have taken the alarm too late, or, if not, have failed to get in time the consent of the patient for an explora- tory incision, some palliative operation may still prolong life, and if this should be declined, you can yet do much by medical treatment to defer the inevitable fatal termination, and render the condition of the patient more tolerable while he lives. The difficult task now devolving upon you will be : 1. To relieve the accompanying asthenic gastric catarrh, and the symptoms dependent upon it, including the nausea and vomiting, the failure of the secretion of HCl and of the fer- ments, and, in part, the lowered nutrition. 2. To combat the decreasing gastric motility as well as the anaemia, debility, and emaciation. 3. To control hematemesis. 4. To assuage the pain, secure sleep, and make the patient as comfortable as possible. Dietetic Treatment. — All these objects may be promoted to TREATMENT OF CARCINOMA AND OTHER TUMORS 645 a considerable extent by a suitable diet, and the indications here are not wholly the same as in ordinary chronic gastric catarrh of asthenic type, except when this is complicated by failing motor power of the stomach. The weakened motility, or propulsive power, is always a conspicuous feature of ad- vanced gastric carcinoma, and this calls imperatively for small and relatively frequent feedings with the blandest and most easily digestible nourishment. In probably a large majority of cases, good, fresh milk, in some of its forms or preparations, will agree best, and will need to be prominent among the nutri- ments depended on. Usually plain sterilized or boiled milk, with 1-12 to 1-4 part limewater, according to the degree of ir- ritability, is as suitable as any form, if digestives are given after the meals, but sometimes it agrees much better when pre- digested or peptonized. Other excellent foods for aggravated cases are the whites of eggs beaten up in water, well-cooked gruels, peptonized or not as found necessary, whey, koumiss, gelatin, the juice pressed out of lightly broiled steak, and vegetable purees. Any of the liquid foods may be thickened by the addition of beef powder or of plasmon. The various proprietary foods, both the albuminous and non-albuminous kinds, will often suit well, and will help to afford variety in the worst cases, especially. In the earlier stages, and in those cases with less irritability and more digestive power, stale bread or toast and butter, crackers, fish, oysters, hashed lean meat, soft- boiled or poached eggs, thoroughly cooked cereals (the finer kinds), with milk or cream, and even the blander vegetables in which the starch has been well dextrinized by cooking, may be allowed, but all these should be finely divided before eaten. As to beverages, the previous habits of the patient will often de- cide. The lighter wines in small quantities may add slightly to the nutrition, and tea and coffee, unless they specially dis- turb the stomach, should not be denied to patients who have been accustomed to them, though they should be taken with- out sugar whenever fermentation is very troublesome. The richer chocolates will almost certainly disagree, and often 646 THE GASTRO-INTESTINAL CLINIC the choicest cocoa, though these are all highly nourishing. An infusion of cocoa shells is more suitable, and there is no ob- jection to the cereal coffees without the addition of sugar. Sugar, being the most fermentable of all foods, should gen- erally be avoided. As the disease advances, and the ability of the stomach to empty itself lessens more and more, the amount of the liquids taken by the mouth will have to be dim,inished — especially the amount taken at a time. It will seldom be well to allow more than half a pint of liquid at any one time in this way, and much less in far advanced cases. Toward the last the demand of the system for liquids may have to be met in part by injecting water into the bowels, and the feeding in the later stages may be supplemented by nutrient enemas. A case of cancer of the stomach and pancreas is reported by A. Martinet ^ in which pain and vomiting were constant until the patient was given a kind of kefir described by him as " Bulgarian clotted milk prepared with Maia." 1, Treatment of Accompanying Gastritis and its Re- sults. — In Lecture XLVIII. on The Treatment of Chronic Asthenic Gastritis, the methods applicable in endeavoring to ameliorate the catarrhal complication of gastric carcinoma are fully discussed, besides some, such as the application of elec- tricity and massage to the abdomen, and various forms of ac- tive exercise, which are not suitable in cancer of the stomach, for obvious reasons. In a disease which reduces the strength and flesh so rapidly, and increases markedly the retrograde tissue metamorphosis, the strength needs to be consented as much as possible, and exercise should be limited to the milder forms, and never allowed to fatigue. General massage and general faradization, avoiding, as a rule, the epigastric region, are, however, passive forms of exercise, which should be help- ful to the nutrition except in the later stages. Lavage is the most important of all the mechanical forms of treatment and in the cases of pyloric obstruction, with re- ^ Presse mtd., Paris, XIV, No. 16. Jot{r. A. M. A.. May 5, 1906. TREATMENT OF CARCINOMA AND OTHER TUMORS 647 tention and dilatation, it is indispensable. It will do more usually to relieve the nausea and vomiting, and to lessen most of the symptoms resulting from the gastritis, than any other of our therapeutic resources. Sweetnam ^ has found cerium oxalate 6 grains combined with lo grains of bismuth very efficient in controlling the vomiting and pain from cancer as well as from other forms of gastric disease. , Condurango, a drug largely used in Germany, and less by American physicians, is believed now to be helpful mainly be- cause of the good effect it has upon the accompanying gastritis. At all events, there is much testimony from many sources to the effect that the symptoms may all lessen in severity, the ap- petite increase, and life often be somewhat prolonged as a result of persevering with a course of condurango. This may be given in the form of the fluid extract in doses of a dram or more, three times a day, or, as preferred by Ewald, in a macer- ation decoction to which he advises the addition of appropriate doses of HCl and some carminative. Boas, Riegel, and most German writers also speak well of this remedy, while admit- ting that in bad cases it often fails to effect even temporary im,- provement. 2. Measures Against the Debility, etc. — To combat the asthenic condition, in addition to the remedies and measures already mentioned as helpful for the gastric catarrh, including especially lavage with cleansing and antiseptic solutions to lessen the auto-intoxication, it is necessary to overcome any ex- isting constipation with preferably douches of the colon, since they do not irritate the stomach, while they supply needed water to the body; though, when moderate doses of mild laxa- tives prove effective, they may answer, and are less troublesome and fatiguing. Diarrhea needs a more careful diet, possibly antiseptic colon douches, often full doses of bismuth, and some- times stronger astringents with opium. Iron, arsenic, and strychnine, when well tolerated, may be administered to enrich '^Dublin Joiir. of Science, February, 1906. 648 THE GASTRO-IXTESTIXAL CLIXIC the blood, stimulate appetite, etc., preferably in small and often repeated doses to avoid irritation; but frequently they will do most good with least harm when given in suppositories. In cancer obstructing the pylorus, nothing will have more effect in staying the progressive dilatation of the stomach than lavage, and a careful regulation of the diet as above advised, but strychnine hypodermically may occasionally do something temporarily. Intragastric electricity, which, in simple atonic dilatation, is our most powerful weapon, is ineffective and even harmful here. HCl and pepsin, or some preparation of papaya, may help the patient to digest more food. 3. To Control the Hematemesis. — This is usually much less serious in cancer than in ulcer of the stomach, and may be often avoided merely by enforcing the diet above outlined. W^hen it occurs the patient must be kept at rest, recumbent, all food by the mouth stopped, and in the moderately severe cases the patient may be caused to swallow frequently small pieces of ice. Sometimes small draughts of quite hot water are still more efficient. Twenty- to 30-grain doses of bismuth in a mixture with limewater, and a little essence of peppermint, may next be tried, and these are very eft'ective also in vomit- ing and diarrhea. The stronger astringents, as ergot, gallic acid, etc., rarely do good in this fonii of hemorrhage when taken by the mouth. Ergotin or ergotol promise better. Three to 5 grains of suprarenal extract may be given several times a day. Locally applied, this remedy has a greater astringent effect than any other known. In the more aggravated cases, it is safer to give nothing whate\'er by the mouth — not e\-en pellets of ice. Adrenalin chloride may, in proper cases, be given by mouth — ten to fifteen drops of the solution. Some have used it hypodermically, but the safety of this is questionable, as the raising of the general blood-pressure is likely to more than offset the constriction of the bleeding vessel. Calcium chloride is given in lo-grain doses, in water, every three or four hours; or Tremoliere's solution may be TREATMENT OF CARCIXOMA AXD OTHER TUMORS 649 used. This is a 5 per cent, gelatin solution containing 2 per cent, calcium chloride. One-half to one ounce may be given every four hours; or gelatin alone in 5 to 10 per cent, solution, may be administered in small frequent doses by mouth. A 2 per cent, solution of gelatin, sterilized, may be given by hypo- dermoclysis, three or four ounces at each injection. 4. To Relieve the Pain — External applications will some- times relieve the pain of gastric cancer. ^lustard, painting with iodine, liniments, and hot wet packs are the most easily applied, and will sometimes suffice. Among the milder in- ternal sedatives, chloral and cannabis indica are frequently effective in allaying the pain and procuring increased sleep, and the former has useful antiseptic as well as sedative vir- tues. Condurango is believed by various authors also to ameliorate the pain along with most of the symptoms. Boas praises potassium iodide, especially in carcinoma of the cardia, and arsenic is thought to help often in malignant growths any- where. ]^Iethylene blue has accjuired some reputation on ac- count of its supposed sedative properties in gastric cancer. Jacobi claims that it even prolongs life. It is to be given in doses of 3 to 5 grains, in a capsule daily, and V'an Valzah and Xisbet advise that a little powdered nutmeg be com- bined with it " to correct its slightly irritant action on the urinary tract." Marcus Fay recommends aniline sulphate, holding that it delays metastasis and cachexia and relieves the pain better than opium. But sooner or later, in all cases, opiates will become necessarv'. They can be given in any of the usual ways, but will be most effective hypodermically. Codein should be preferred so long as it continues to prove efficient, but at all events the patient should be made com- fortable. In a series of seventeen cases of inoperable carcinoma, in- cluding two of the stomach, Bra of Paris, and Mongour of Bordeaux, have reported (Medical Reviezv of Reviews, April 25, 1900), some remarkably favorable palliative results from injecting a purified culture of the nectria ditissima, a parasitic 650 THE GASTRO-INTESTINAL CLINIC growth found on trees and considered a kind of vegetable cancer. Treatment of Sarcoma and Benign Tumors. — The treat- ment of sarcoma need differ ^"ery little from that of carci- noma of the stomach, except that even greater efforts should be put forth to make, at the earliest possible moment, the diagnosis of malignancy, so as to secure operative interven- tion at the only time when it can be of any possible use. In the inoperable cases Coley's fluid (the mixed toxins of streptococcus Erysipelatis and Bacillus Prodigiosus) should be given a thorough trial. Coley ^ reports fifty-two cases of in- operable sarcoma successfully treated by this method. The duration of the cure varied from three and one-fourth to six- teen years. There is reason for hope that a curative serum will be pro- duced in the not distant future. Ewing - states that in nine consecutive cases a malignant sarcoma in dogs has been cured by bleeding the animal and transfusing it with the blood of dogs immunized to this tumor. The ablest pathologists in ever}' country of the world are giving their best efforts to the solution of the cancer problem — its cause, its diagnosis, and its cure — and it is to be fervently hoped that the problem will soon be solved. Riegel advises the administration of arsenic in h^mphosar- comatosis, though I do not know of any reports of cases in which it has proved of any avail. The treatment of the benign tumors of the stomach must be almost exclusively surgical. It is not likely that galvan- ism, which can accomplish so much for such growths in the pelvis, could be employed in sufficient strength within the stomach to be efficient. In every swelling or apparent tumor of the pyloric region, producing symptoms of obstruction, an operation at tlie earliest possible moment is the imperative indication. In cer- i\V. B. Coley; Practitioner, London, Nov. 1909. ''■Journal A. M. A., Jan. 22, 1910, p. 269. TREATMENT OF CARCINOMA AND OTHER TUMORS 65 1 tain cases something might be accomphshed in a palHative way by dilating the pylorus through the stomach as recommended bv Hemmeter ; but it is true conservatism here to insist upon radical measures promptly — gastro-enterostomy, pyloroplasty, or pylorectomy. Injection of Ascitic Fluid from a Recovered Case of Cancer. — Hodenpyl/ pathologist to the Roosevelt Hospital, New York, made during the current year (1910) a preliminary re- port on the treatment of carcinoma by the injection of ascitic, fluid from a practically recovered case of the same disease into or near the tumor after several removals and recurrences. He reported in brief that forty-seven human cases, mostly " distinctly unfavorable, many of them hopeless and inoper- able," had been treated in this way. The effect, he stated, was " nearly uniformly to induce a temporary local redness, tenderness, and swelling about the tumors, which soon subside. Then occur softening and necrosis of the tumor tissue, which is now absorbed or discharged externally, with the subsequent formation of more or less connective tissue. In all cases the tumors have grown smaller; in some they have disappeared altogether." Dr. Hodenpyl died of pneumonia shortly after making this most interesting report, and his collaborators have not yet reported as to the further results. Coca and Oilman 2 report a series of 14 cases of carcinoma, some f^r advanced, nearly all of which were apparently cured by the injection of a single dose of an extract of the patient's own carcinoma partly or wholly removed by operation the same day as the injection. The injections were followed in a few days by the softening and absorption of the portions of the tumor left behind. This apparent cure had lasted several months in some cases, the patients having had no recurrence up to the time of their report. This method is now being tested by other observers, in Los Angeles and other Pacific coast cities. ^N. V. Med. Record, Feb. 26, 1910. 2 Coca and Q\\ma.n—Phtltppme Jour, of Science, Dec, 1909. LECTURE LXIII TUMORS OF THE INTESTINES CARCINOMA AND SARCOMA Cancer of the intestines is an infrequent disease, especially in the parts above the rectum. In some large series of cases nearly 90 per cent, of such cancers were in the rectum. It is a singular fact that while carcinomas are much more frequent in the stoiiiach than in any other part of the digestive system, and comprise nearly one-half of all cancers found anywhere in the human body, they are least common in the small in- testine, and the frequency of their occurrence in the intestinal tube is in direct proportion to the distance below the stomach. The explanation of the fact that cancer so much oftener at- tacks the stomach and rectum than other portions of the digestive system is that these regions suffer most from irrita- tion — the stomach from indigestible and insufficiently chewed food, and the rectum from the pressure of impacted feces. The other sites where such growths are found with compara- tive frequency are in the cecum and the flexures of the colon, including the sigmoid, all of these being places where the feces are prone to lodge. Intestinal cancer seems to be a little more common in men than in women. It is most prevalent in middle and advanced age. as in the case of similar growths in the stomach. The disease is generally primary in the intestines, but may extend to them by contiguity from adjacent organs, or ex- ceptionally, by metastasis. Sarcoma of the intestines is very much rarer even than carcinoma. .Etiology. — The origin of carcinoma and of sarcoma is still unknown, and I will not attempt to repeat here all the 652 TUMORS OF THE INTESTINES 653 guesses upon the subject. There is much evidence, however, going to show that various forms of trauma — direct injury to the tissues or irritation of any kind long continued — predispose to both kinds of mahgnant neoplasms, especially in persons having impaired constitutions, whether the impairment be in- herited or acquired. Infection may also have to do with the production of sarcoma and carcinoma. Metastases. — Cancers of the intestine are less disposed than those of any other parts, according to Ewald and various other authorities, to spread or reproduce themselves by metas- tasis, and when this does occur, it is more likely to be late in the case. This is exceedingly important and should en- courage you to advise, and even urge, surgical intervention whenever the disease can be diagnosed before it has advanced to a manifestly fatal extent. Metastasis in these cases is most frequently to the lymph- glands of the peritoneum. Ewald has observed that next after these, the tendency is to involve the liver, and then the peritoneum itself, the lungs, the uterus, etc. ; also, that in cancer of the flexures of the colon, the infection tends most toward the lumbar glands, and, in that of the transverse colon, to the omental glands. Such pointers from an exceptionally experienced pathologist and clinician are valuable. The same author cautions us not to forget that the existence of cancer in the bowels does not exclude the possibility of another pri- mary growth of the kind in some other part at the same time. Both sarcoma and lymphosarcoma are almost invariably pri- mary when they involve the intestines, and they are more prone to invade other parts by metastasis than carcinoma. Pathology. — The several varieties of carcinoma which occur in the stomach or elsewhere may also be encountered in the intestines. The adenocarcinoma predominates. The colloid form is often found in the rectum, and less frequently the pavement-celled cancroid variety. Again, as in the stomach, intestinal cancer may be hard (scirrhus) or soft (colloid), and beginning usually in the mucosa, tends to develop outwards 654 THE GASTRO-INTESTINAL CLINIC through the other layers successively. The disease shows a great tendency also to extend itself around the entire circum- ference of the bowel, producing ring-shaped or sometimes cylindric thickenings, which result in partial or complete ste- nosis. The intestine above these narrowed parts becomes dilated — often even when the obstruction is not complete — and Ewald has seen, at autopsy, pouches thus produced as large as the stomach. The scirrhous form has a marked tendency to ulcer- ate with the production of small quantities of pus and blood, which may be found in the stools, and when a vessel is thus eroded, larger hemorrhages may result. Perforation is not infrequently caused by such ulceration, and in this way gen- eral peritonitis may be get up, or more commonly when ad- hesions have attached the diseased intestine to a neighboring structure, local peritonitis develops; or the perforation may produce a fistulous connection between the intestine and the stomach, or other adjacent viscus. Local peritonitis may also result from the extension of the growth through to the peri- toneum. The formation of a gastrocolic fistula through the perforation of a cancer, in either the stomach or transverse colon, gives rise to a peculiar group of symptoms, which are described in Lecture LIX. The pathology of sarcoma and lyiuphosarcoiiia in the intes- tines does not differ from that of the same growths as found in the stomach. All the varieties of these tumors may be en- countered here, but the small round-celled sarcoma is most frequent. They usually take their origin in the submucosa and extend to the muscular and serous layers of the gut. The lymphosarcoma arises from either the solitary or agminated lymph follicles. The most frequent site of sarcoma is in the duodenum or rectum. It is asserted by numerous authorities that sarcoma of the intestine, in contrast with carcinoma, en- larges by its growth the lumen of the bowel, instead of lessen- ing it; but this is certainly not always the case. Symptomatology. — Gradually increasing debility, anaemia, cachexia, and emaciation, with usually, but not alwavs loss of TUMORS OF THE INTESTINES 655 appetite, are general symptoms of malignant growths in any part of the body. Naturally these symptoms do not appear to any noticeable extent at the very outset of the disease. The tumor must have progressed for weeks, and sometimes months, before they have become prominent enough to attract the attention of the patients or their friends. There are not certain to be any symptoms or signs which could lead you even to suspect either a cancer or sarcoma anywhere in its incipi- ency, and in so far as concerns such a tumor in the intestines, it is more likely there, than elsewhere, to run a latent course for a long time. Pain is the symptom most commonly thought of in connec- tion with malignant neoplasms. Cancer of the intestines is painful, as a rule, but the pain is often quite moderate and tolerable until a far advanced stage, and is often diffuse, re- ferred vaguely to a large part of the abdomen, or to the lower back. It is comparatively seldom limited to the locality of the tumor. It is frequently not persistent, but spasmodic, like neuralgia. In cancer of the flexures, the pain is often felt in the hip joints or loins, but in such cases the pain may change about, being felt sometimes in one place, and again in another. Then, in a certain proportion of carcinomas, and in a still larger proportion of sarcomas of the intestines, no pain may be complained of until very near the end. The pain is often due to adhesions, and to the dragging which results upon adjacent organs, especially during exercise or while massage is being given. The Unding of a tumor by palpation is the chief sign of an intestinal neoplasm. This is rarely possible at an early stage, and when the growth is in certain positions, such as in the flexures, which, with the exception of the rectum, are the most frequent sites of intestinal cancer, you will not often be able to feel it before it has attained to a large size. Tumors of the in- testine, except they be in the lowest part of the duodenum, or in tlie cecum or rectum, or have become attached by adhesive inflammation to some neighboring part, are more or less 656 THE GASTRO-INTESTINAL CLINIC movable, and can be pushed from side to side. When they arise from the transverse colon, or its flexures, or from the small intestine, except the third portion of the duodenum, they very commonly pull the bowel down by their own weight into the pelvis after they have attained to a considerable size. In palpating the abdomen, therefore, you should be careful to feel thoroughly every inch of it, including especially the lowest zone. You should never neglect to examine per rectum, and in women per vaginam as well, by bimanual palpation, since in this way tumors otherwise undiscoverable, attached to va- rious parts of the intestine, may be recognized. When rigid- ity of the abdominal muscles prevents satisfactory palpation, you may need to etherize the patient, but examination in a warm bath will sometimes cause relaxation. Malignant neoplasms in the intestines after the earlier stages are generally somewhat sensitive to pressure, though by no means always — Ewald says most of them are but slightly so. When there is a local low-grade peritonitis, from a slowly developed perforation, the tenderness will extend for a little distance on all sides from the site of the tumor. Quite fre- quently in the case of cancer, it has been observed that there is a slight oedema under the surface of the overlying region. The tumor is at first smooth and oval or roundish in form, but the carcinomatous kind are likel}^ soon to become irregularly knobbed, so as to present an uneven surface. Sarcoma is usually smooth and hard throughout, and grows at a phenome- nally rapid rate. The temperature in cancer is rarely above normal, until the growth begins to ulcerate, and is often subnormal. When dis- integration is in progress, there may be chills and fever. Fever is more frequently observed in sarcoma. The stools do not present any uniform appearance char- acteristic of malignant growths in the bowel, unless pieces of tissue found upon a microscopic examination contain evi- dences of malignancy; and this does not often happen. Small amounts of pus or blood, or still more, both at once, may TUMORS OF THE INTESTINES 657 awaken suspicion of a growth, and would be to a certain extent confirmatory in case a tumor could be felt; but the various forms of intestinal ulceration give the same findings. There may be regular normal evacuations until the lumen of the bowel is so much narrowed that hardened feces, gall stones, or a bunch of worms produces complete obstruction. Not infrequently a persistent diarrhea complicates the disease from first to last, or there may be either constipation or normal stools at times, alternating with diarrhea. In the case of car- cinoma, sooner or later obstruction of the bowel nearly always occurs as a result of a gradually increasing encroachment upon its lumen. This is finally closed completely by an ob- turation from within — most commonly in the form of an ac- cumulation of hard fecal masses or undigested substances in the dilated pouch above. Sometimes such an accumulation may be forced through the stricture once or even oftener, by purgatives aided by atropine, olive oil, or perhaps metallic mercury, but at last the obstruction recurs and cannot again be overcome by anything short of laparotomy. For some time before the final obstruction suddenly brings such a grave and generally fatal crisis in the case, the stools, •when the tumor occupies the colon, may give evidence of the existence of a permanent stricture, by being constantly rib- bon-formed, or of lead-pencil size and shape. According to some authors, stools composed of small, hard balls, like bullets (Schafkoth) may also point to such a stricture, but such stools as the last mentioned are very common in torpid liver or sluggish bowel — constipation — from various causes. The rib- bon-like or pencil-formed stools may occur as a result of spasmodic contractions in certain neurotic conditions (see the description of spastic constipation in Lecture LXIX.), but in such cases the stools will usually be at times of normal size and form, especially after full doses of nerve sedatives, while, when the stricture is due to a tumor, a normal stool is never possible. QEdema of the feet and legs is very commonly present, and 658 THE GASTRO-INTESTINAL CLINIC sometimes ascites, during the latter part of a course of a malignant tumor in the abdomen, as a result of the obstructed return flow of the blood. The former symptom often disap- pears a short time before death. The ascites frequently re- sults from the involvement of the peritoneum in the malignant process. Distention of the abdomen generally, or of particular loops of the intestines, does not^ differ in the cases under considera- tion from the same symptom when resulting from other forms of bowel obstruction. It simply points to obstruction, though the persistent inflation of a certain loop may help to locate the trouble. Disturbances of digestion may be absent, or at least not marked in tumors of the lower bowel until the disease is far advanced, but even in these cases there generally develop pari passu with the cachexia and debility, a falling off in appetite and an increasing difficulty in the digestion of a normal amount of food. Very commonly there is a distaste for meat ; often also nausea and vomiting as well as the diarrhea already referred to. When the tumor is in the small intestine, espe- cially if near the stomach, the obstruction resulting tends to produce gastrectasis with its peculiar train of symptoms, the same as when it involves the pylorus. In most of the cases as- sociated with failing or absent appetite, the gastric juice will be found very deficient in HCl, and often in the ferments as well. A malignant tumor of the colon causes more disturbance of the bowels, flatulence, colic, etc., with generally constipation, or an alternation of this with diarrhea. Cancer of the rectum, the most frequently encountered of intestinal neoplasms, is considered in the special lecture on Diseases of the Rectum and Anus, but will be referred to here briefly. In this region you have the very great ad- vantage of being able to make a certain diagnosis, both by the touch and by sight, with the help of a good speculum. The pain of both cancer and sarcoma here is usually worse than in TUMORS OF THE INTESTINES 659 those higher up in the bowel, and is increased during defeca- tion. Tenesmus is also a marked, and often a most distressing symptom. When the tumor is not recognized in time, its ravages by direct extension to the adjacent pelvic structures are likely to be serious, but fortunately metastasis does not, as a rule, occur early, and when the patient applies for medical Fig. 81. — Ulcerating carcinoma of the rectum with the formation of pouches and sinuous invaginations of the mucous membrane. (After Quenu et Hartmann.) advice reasonably soon, the diagnosis should be made promptly enough to warrant hopeful treatment. The symptoms of intestinal sarcoma differ from those of carcinoma by ( i ) the much greater energy and rapidity of its 66o THE GASTRO-INTESTINAL CLINIC growth; (2) the very much greater size to which it may at- tain, notwithstanding that it kills so much more quickly; (3) the markedly rapid development of cachexia, debility, and the other signs of constitutional involvement; (4) the far shorter duration of life after the disease develops (usually less than a year) ; (5) the comparatively great rarity of intestinal hemorrhage during its course; (6) the infrequency of any re- sulting intestinal obstruction, in consequence of the fact, stated by most authors, that it causes dilatation rather than contraction of the bowel at the point attacked, and (7) the almost uniformly smooth surface of the tumor itself. In addition to the foregoing important and well-defined dif- ferences, Boas mentions also, as of possible value, the early development of ascites in sarcoma, and irregular — sometimes regular — fever in the same disease. Regarding sarcoma of the rectum, its objective symptoms or signs differ decidedly from those of carcinoma of the same re- gion in two noteworthy respects : ( i ) The tumor can be felt as smooth and not nodulated; and (2) ulceration or disin- tegration, which nearly always speedily develops in epithe- lioma everywhere, is commonly absent in sarcoma of the rectum, and this can be quickly determined positively by a digital examination. Course and Complications. — The duration of cancer of the intestines is longer on the average than that of the same dis- ease elsewhere — often three or four years when uncomplicated. It begins very insidiously and pursues a comparatively latent course in many of the cases. Besides such frequent accidents as intestinal hemorrhage, diarrhea, etc., cancer here finally always invades the peritoneal layer of the bowel, and then there may result any one of a variety of complications — local peritonitis with adhesions to any adjacent organ or other in- testinal coil ; perforation with a resulting localized abscess or general peritonitis. By such perforations fistulas may be established between the loop of intestine involved and some neighboring one, with the stomach (as in gastrocolic fistula), TUMORS OF THE INTESTINES 66 1 with the bladder, gall bladder, etc. Or in the same way a fistulous opening may occur through the abdominal wall. Qidema of the lower extremities or effusion into the peritoneal cavity — ascites — may occur. When operative intervention is not invoked sufficiently early, cancer of the intestines most frequently effects its fatal result by causing obstruction of the bowels, with the conse- quent autotoxgemia and almost incessant vomiting. In the absence of obstruction death comes from exhaustion as a result of the toxaemia, and often in coma — coma carcino- matosum. In cancer of the" duodenum or jejunum, as in pyloric cancer, death results much sooner than when its seat is lower in the alimentary canal, since digestion is seriously embarrassed, and nutrition suffers more. Sarcoma, in both its forms, runs a rapid course in the in- testines as elsewhere (though a very rare disease there) and does its fatal work within nine months or a year — often in less time. Kundrat of Vienna, whose experience has been largest in this disease, and whose figiuTS all authors cite, in- sists that it does not generally cause any stenosis of the bowel, but the opposite condition of dilatation. All its characteristic phenomena, already referred to, develop much more quickly than in the case of carcinoma. Diagnosis. — The differential diagnosis between carcinoma and sarcoma in the intestines (unless the tumor is in the rectum) can rarely be made at once, when the case first comes under medical oversight. But after any doubtful tumor has been carefully observed for a few weeks, it ought usually to be possible to decide which form of tumor is present from the rate of growth, the feeling of it, the degree of development of cachexia, etc., and by the other differences mentioned under the head of Symptomatology. This is an important diagnosis to make, since surgical intervention is generally to be urged in intestinal carcinoma, except when metastases are demon- strable, but rarely advisable in sarcoma after a tumor is 662 THE GASTRO-INTESTINAL CLINIC clearly palpable, for the reason that other parts are then almost certain to have been already attacked by it. You may certainly diagnose cancer or sarcoma of the in- testines, only when you can either find the elements of such a growth in the stools along with some other decided symptom or sign of the same, such as a tumor or steady loss of flesh, strength, and color in spite of remedies which should have checked such a tendency, or find a tumor connected with the bowel, together with such marked symptoms of failing health as above mentioned, especially when there are also symptoms of gradually increasing intestinal obstruction, point- ing then to carcinoma. Finding any of these symptoms alone, or even all of them without being able either to make out a tumor, or discover the elements of a malignant growth in the stools, should render you suspicious and watchful, but cannot be decisive. Various other conditions, such as a stricture from a healed ulcer, chronic appendicitis, adhesions, twists, and other causes of intestinal obstruction might produce similar symp- toms. To determine in what part of the intestines a tumor is sit- uated, you may, in any case which has not progressed so far with disintegration as to endanger a rupture, inject carbonic dioxide, air, or a warm weak saline solution into the colon. These, in case of a complete occlusion of the intestine by the tu- mor, will be arrested at the site of the latter. In any case, the injection of air or gas will distend the colon, and thus help you by means of percussion to determine more nearly the location of the growth when it is in the large bowel. This would aid little, however, in fixing the location of a tumor of the small intestine, except by exclusion. You will need to differentiate between a malignant neoplasm of the bowel and the following especially: a hard fecal tumor; a kidney fixed in a wrong place ; a benign tumor connected with one of the pelvic organs, intestines, or other abdominal viscera; an encapsulated peri- toneal exudation; a tuberculous growth in, or adjacent to, the TUMORS OF THE INTESTINES 663 bowel ; actinomycosis in, or near, the same ; a scar and thick- ening which may have resulted from a healed ulcer of any kind, whether syphilitic, tubercular, dysenteric, or as a com- plication of chronic intestinal catarrh or typhoid fever. To discuss here in extenso the diagnosis of a malignant tumor of the intestines from each of the above-mentioned con- ditions, would require more space than is at my disposal. But with regard to most of them the diagnosis is easy, since the steadily increasing cachexia, debility, etc., of cancer are almost never present in any of them, except possibly those involving tuberculosis, and this could be differentiated quickly by the tuberculin test (see Lecture LVL). Actively progressing syphilis, too, might mislead, but this would speedily respond to the fullest practicable doses of the iodides. To decide whether a growth in the cecum is carcinomatous or tubercular is sometimes very difficult, and Boas, in his " Darmkrankheiten," has given the following tabular state- ment of the differential diagnosis between the two conditions : DIFFERENTIAL DIAGNOSIS BETWEEN TUBERCULOSIS AND CARCINOMA OF THE CECUM Carcinotna of the Cecum. Seldom before the fourth decade. Tuberculosis of the Cecum. Age Generally in the second to fourth decade. Duration. Very chronic. Ltcngs. Often show more or less decided tubercular processes. Tumor. Shows a marked extent in length; also the bowel itself, in conse- quence, can be felt as an infiltrated organ. Signs of Always present and dis- Stenosis. tinguished by decided sounds. Stools. Contain blood and pus very seldom, but often tubercle bacilli. Fever. Not seldom present. Urine. Shows Ehrlich's diazo reaction. That usually of cancer generally. Negative. Is sharply circumscribed and usu- ally limited strictly to the cecum. This cannot be palpated as such at all. May be wholly wanting. If pres- ent, less markedly audible than in cecal tuberculosis. Blood and pus not rarely observed. Tubercle bacilli never found. Exceptional. Always fails to show the diazo re- action. 664 THE GASTRO-INTESTINAL CLINIC Other Diagnostic Points. — Fecal tumors have often been confounded ^vith malignant growths, and the diagnosis is •sometimes impossible at first, or till after a patient use of aperients, especially oil and warm saline solutions by enema, has had time to soften a fecal mass, as well as to diminish its size, and often to change its position. When the fecal tumor has not by long pressure inflamed the adjacent mucosa so as to be very sensitive to pressure, and at the same time is not very hard, the diagnosis can sometimes be made at once by denting it with the finger through the ab- dominal wall, or even breaking it in two ; but this is very often impracticable. Then the only way is to administer purgatives or enemas and aw^ait results. Another rather difficult condition to differentiate from an intestinal cancer or sarcoma, and yet one in which it is very important to be able to make the diagnosis, is that in which one of the kidneys — usually the right one — has been displaced and become fixed by inflammatory adhesions in an abnormal po- sition, especially in the case of a much weakened and emaci- ated patient, with, as not infrequently happens, Bright's disease developing as a complication. Here, the surest help to the diagnosis would be a radiograph. But careful palpation in the gentlest manner, Avhen the tumor can be plainly felt, should reveal the peculiar kidney form when it constitutes the tumor. Furthermore, the pallor of simple anaemia or of Bright's dis- ease is different from the yellowish dirty-white of cancer. Then a patient with a misplaced kidney, plus Bright's dis- ease, or neurasthenia, will generally improve when put to bed and carefully fed, but not often with cancer or very tempo- rarily, when the loss of flesh and strength will again progress. It is frecpiently still more difficult to diagnose cancer or sarcoma of the intestines from a like tumor of some other ab- dominal organ, but this is far less important, except for the purposes of prognosis. In so far as regards treatment, it makes comparatively little difference what particular abdominal structure is involved. If the tumor should be far advanced, TUMORS OF THE INTESTINES 665 speedy death would be inevitable anyway; and if it were recent, with the patient in fair condition, an exploratory inci- sion would be desirable in any event unless the growth occu- pied one of a very few situations, such as the cardiac orifice of the stomach, the liver, the pancreas (except impracticably early), and possibly one or two other viscera, or parts of vis- cera, which the surgeons would not risk invading. To reach a diagnosis, which should exclude a tumor of one of these parts, is generally quite possible from the symptoms and the results of a thorough examination. Prognosis and Treatment. — It is still generally believed that there is no sure remedy for either carcinoma or sarcoma, but that the surest is very early removal by the knife. This is doubtless true when the tumor is in a safely accessible situa- tion and when both the diagnosis can be made, and consent to an operation obtained, at a very early stage of the disease before any metastasis or glandular involvement has occurred. But several rivals of the knife are now coming forward in this field. One of them is Massey's semi-surgical method of driv- ing into the diseased tissue certain caustic metallic salts by the help of colossal doses of the continuous current (galvan- ism) under anesthesia. This method is described in its dis- coverer's own language in Lecture LXXIX., page 928. Massey claims exceptional success for this method, and re- ports numerous cures effected by means of it in cancer of the rectum and in other accessible cavities. Other physicians also are reporting well of it. Fulguration — Another measure much debated in Con- tinental literature is " fulguration," originated by de Keating- Hart of Marseilles. This consists in the application of the spark of a high-frecjuency current of high tension to the ma- lignant growth. Very favorable reports, including cures of inoperable cases, are given by the originator and some of his followers. Others condemn the method very positively, but its actual value is yet to be determined. The x-ray, violet ray, Finsen light, radium, etc., have all 666 THE GASTRO-INTESTINAL CLINIC been employed of late, and some of them, with alleged suc- cess, in malignant tumors of the rectum as well as in other cavities of like easy access; in cancer of the breast and uterus and in innumerable morbid growths of the skin. See Lecture LXII. on The Treatment of Carcinoma and other Tumors of the Stomach. The approved surgical operations in malignant intestinal neoplasms are, (i) when there is hope of extirpating the disease altogether, an excision of that part of the gut which includes the growth, followed by an end-to-end anastomosis of the severed parts of the bowel, and (2) when this is no longer possible, avoidance of further irritation of the diseased tissues by joining a healthy loop of intestine above to another below (entero-enterostomy or entero-colostomy), and then making an opening between them; or when the tumor is high up in the small intestine, the same object may be better ob- tained by attaching a loop of intestine below it to the stomach — gastro-enterostomy. ^ (3) When the tumor is in the rectum, or lower part of the colon, and none of the above operations is practicable, the establishment of an artificial anus in the colon (colostomy) may still be done with the prospect of pro- longing life thereby. In Lecture LXXIX. the various procedures practicable in malignant disease of the rectum are discussed. The palliative treatment of malignant neoplasms in the in- testines does not differ essentially from that of cancer of the stomach as described in Lecture LXIL just mentioned. When the bowels are loose, the methods described in the Treatment of Diarrhea — Lecture LXXL — will be applicable; and when there is constipation the very full account of the best methods of overcoming it, as described in Lecture LXX. — especially the employment of oil, both by mouth and by enema — will stand you in good stead. When the bowels are becoming obstructed by a tightening stricture, caution needs to be used in the administration of the stronger cathartics, since these may sometimes do serious TUMORS OF THE INTESTINES 667 harm. Lashing the intestines to greater efforts may produce a rupture of the dilated pouch above the stricture and speedy death. When surgery is impracticable, the better plan is to depend upon liquid diet, aided by nutritive and laxative enemas, such as saline solutions, molasses, and milk, etc., and give olive oil freely when it is well borne, or if not, liquefy the feces by a cautious employment of the purgative salts, or natural waters. BENIGN TUMORS OF THE INTESTINES Other neoplasms than cancer and sarcoma rarely occur in the bowels, except in the form of small polypi which cannot be recognized and seldom produce symptoms. The different va- rieties which may develop there are cyst adenoma, (which is the predominant kind,) fibroma, lipoma, myoma, and angioma. When any of these are attached to the mucosa by a distinct pedicle they constitute polypi. They do not often give rise to any derangement of function, except that, when large, they sometimes cause bleeding. Occasionally, too, they have been a cause of intussusception. Small growths or excrescences of these kinds are sometimes very numerous in certain portions of the intestines, especially in children. The most common form of them is the adenoma. This takes its origin in the mucosa, is prone to occur in groups, and is acini form in structure. Treatment. — When benign tumors of the intestines give rise to hemorrhage which cannot be controlled by astringents, laparotomy is necessary, as it may be also, occasionally, for obstruction or intussusception (invagination) from the same cause. Such tumors are most frequently encountered in the rectum, and are there more amenable to treatment than else- where. (See Lecture LXXIX.) LECTURE LXIV INTESTINAL OBSTRUCTION There are many conditions which by interfering with the passage of ingesta or flatus through the intestines produce either partial or complete obstruction of the bowels. It seems best for descriptive purposes to treat the subject under the two general heads of — I. Acute intestinal obstruction. II. Chronic intestinal ob- struction. As a rule when there is complete occlusion the obstruction is accompanied by acute symptoms, and when the occlusion is partial the symptoms are subacute or chronic in character. Exceptionally, however, complete obstruction may come on very gradually and for a time present no acute symptoms ; on the other hand, a partial obstruction may be accompanied by a sudden stoppage of the circulation with acute symptoms. Acute intestinal obstruction or Ileus may he divided into — 1. Congenital. ( (a). Adynamic. 2. Acquired. } (b). Dynamic. ((c). Mechanical. The most common congenital malformations are imperforate anus, absence of the anus and lower end of rectal pouch, mal- formations of the colon, and constriction of the bowel from intra-uterine peritonitis. These are all easily recognized, and with the exception of the imperforate anus, are generally rap- idly fatal. (a). The adynamic type (those cases primarily producing a loss of propulsive power) generally follows some injury to the spine or to Auerbach's and Meissner's plexus of nerves 668 INTESTINAL OBSTRUCTION 66g situated within the intestinal wall. It may be produced re- flexly from a disturbance of the peripheral nerves supplying- the intestines, mesentery and omentum. Inflammatory lesions of the lungs and pleura are known to sometimes cause in- testinal paresis, and two interesting cases have been recently reported by Dr. J. E. Adams of London, England, where it was produced apparently from an irritation of the splanchnic nerves, the result of a fracture of the ribs. (b). The dynamic type (those cases primarily producing ex- cessive power or contraction) forms an extensive group of dis- eases frequently encountered. They are generally compli- cated secondarily by a local or general peritonitis. But there are some infections so virulent in character that they paralyze the bowel and overwhelm the patient before the de- velopment of peritonitis. There are, on the other hand, less virulent ones which do not produce peritonitis at all, but re- flexly cause the bowel to become obstructed. Under the lat- ter class may be included great accumulations of gas, various traumatisms, such as operations upon the genital organs, the intestines, compression of a testicle, replacement of hernias, strangulation of pieces of omentum or powerful irritation of the peritoneum from any cause, and even hysteria may occa- sionally produce it. Embolism or thrombosis of the superior mesenteric artery constitutes a rare case of ileus, but one which produces a very early gangrene of the affected segment. The destruction of tissue is so rapid that the intestine is usually dark, friable, and gangrenous before the patient comes to operation. Individu- als in whom it occurs generally have some endocardial disease, which may show itself by a murmur at the apex. According to the experiments of Deckart, the reason for the rapid march of the gangrene is to be found in the fact that the vessels of the intestinal walls are in a sense like end arteries. While there is a rich anastomosis between the vessels of the walls of the small intestine, yet the connecting branches are very small, and, after the lodging of an embolus, the blood pressure 670 THE GASTRO-INTESTINAL CLINIC is SO low that an infarct is formed, and the tissue breaks down before the 'collateral circulation can be established. For- tunately this accident is very rare. (c) The mcclianical (those resulting from strangulation, compression or obturation), including the strangulation of hernias; intussusception; volvulus; kinking of the bowel; peri- toneal adhesions and the pressure of neoplasms; obstruction of the lumen of the bowel by enteroliths, foreign bodies, etc. The Symptoms of Dynamic Obstruction. — Since the va- rious causes of intestinal obstruction differ so widely from one another, and since many of them present distinctive symptoms which are peculiar and not common to the others, it will be best to describe separately under each group of setiologic con- ditions its characteristic symptomatology. Syiupfojiis of Intestinal Obstruction Generally. — Let me premise, however, that in every case of complete obstruction of the bowels, there is obstinate constipation — obstipation. There also develop, sooner or later, the inevitable conse- quences of such a condition, viz., pain, A^omiting, which in time becomes fecal, and great tympany or meteorism. There will also be found, as a rule, indicanuria, and a marked leuco- cytosis. Unless relief comes within a comparatively few days, the time depending upon the vitality of the patient, the part of the intestines obstructed and the extent of the traumatic in- jury involved, death ensues either from shock or from septic poisoning, starvation, and exhaustion. Within a few hours often after the pain and vomiting have become severe, the patient will be veiy pale, with pinched features, a haggard, anxious expression, and a very restless manner, while the pulse in mqst cases will be weak and rapid, rarely under 125 or 130, and often much higher — 150 to 160. The symptoms of ileus due to acute peritonitis, either local or general, are, in addition to those above mentioned which are common to all forms, the following, which are characteristic of the inflammatory affection itself. Besides acute spontaneous pain, there is very marked pain on pressure, the affected part of the abdomen becoming ex- INTESTINAL OBSTRUCTION 6)^1 quisitely tender. Vomiting is nearly always an early symp- tom. \Mien general peritonitis exists, the patient remains almost immovable, lying on one side or in the dorsal decubi- tus, with the knees drawn up to prevent the pressure of the bed-clothes, and breathes in a shallow way to avoid the in- creased pain that a deep depression of the diaphragm would cause. In this form of the disease, too, the pulse is rapid, usually 1 20 to 150 to the minute, very small, and often thready. There is fever in nearly all cases, though exception- ally this may be absent in some of the gravest cases, and in spite of the usual high central temperature, especially in the rectum, the skin, of the extremities particularly, is generally cold and clamm}'. In general peritonitis, after a short time, an effusion takes place, and liquid may be demonstrated in the abdominal cavity in dependent positions. WHien there has been perforation into the peritoneal cavity, the hepatic dullness disappears in the mammary line, and may be absent in other cases of obstruc- tion in consequence of coils of intestines having been crowded up over the liver. The Symptoms of Dynamic Obstruction from other Causes. — These do not call for extended description. When a com- pressed testicle, operations upon the intestines, attempts at replacement of a hernia, etc., reflexly produce paralysis or paresis of the bowels, the symptoms are less violent as a rule. AMien the cause can be removed, they usually do not persist long, unless the traumatism has set up peritonitis. When disease of the central nervous system or hysteria pro- duces a paralytic ileus, the symptoms are those of the setio- logic affection plus those of obstruction in general. Great ac- cumulations of gas, from autox?emia or other infections short of peritonitis, give rise to a paresis of the bowel which is usually mild in comparison with those which result from either peritoneal infection, or any of the mechanical causes. Pain, more or less stubborn constipation, anorexia, debility, and auccmia, with occasional, but not often persistent or vio- 6/2 THE GASTRO-INTESTINAL CLINIC lent vomiting, complete the picture in such a form of ob- struction in which the parent trouble can be remedied. The symptoms of a mesenteric infarct are a very sudden development of the clinical complex characteristic of ileus gen- erally, with at first large, ill-smelling stools, which are dark and tarry from their contained blood. There are, also, acute, severe pain, great sensitiveness to pressure, vomiting, etc., the usual symptoms of peritonitis, which grow very rapidly worse. In addition there is generally an exudate into the peri- toneal cavity, which gravitates into the flanks, and often be- sides, symptoms of a concomitant endocarditis. Death often closes the scene before fecal vomiting has occurred. MECHANICAL OBSTRUCTION The mechanical varieties of intestinal obstruction shall be here divided as follows : 1. Intussusception, the most frequent cause, which usually produces both (a) strangulation by a compression of the mesentery as well as of the vessels in the bowel itself, thus cutting off the circulation of the part, and (&) obturation, the segment of gut which forms the intiissiisceptum acting as a plug and closing the lumen more or less completely. In- tussusception thus usually produces both strangulation and obturation. 2. Those forms in which there is sudden occlusion of the intestine by some kind of external strangulation, as in vol- vulus, or torsion of an intestinal loop ; the strangulated her- nias, whether, through the usual openings in the abdominal wall into slits of the mesentery, omentum, etc., or behind a persisting Meckel's diverticulum whose free end has become adherent to some adjacent structure; and knotting of a por- tion of the intestine by long peritoneal bands. 3. Obstruction by any one of various outside agencies as follows: A sharp flexure in the intestine from the downward displacement of the stomach or a portion of the intestine it- self; the pressure of neoplasms attached to the outer wall of INTESTINAL OBSTRUCTION 673 the gut, or to some neighboring structure ; and the pressure of displaced organs, such as the kidney (especially the right one), the liver, uterus, ovaries, etc. 4. Obturation by gall stones, intestinal concretions {enter- oliths), accumulations of zvornis, foreign bodies which have Fig. 82. — Intussusception of the jejunum; a, internal; b, intermediate; c, external cylinder; d, mesentery. — (From " Klinik der Verdauungs- krankheiten, " von Prof. Dr. C. A. Ewald.) been swallowed, masses of hardened feces, polypi growing from the intestinal mucosa, and exceptionally other benign tumors inside the bowel. 5. Strictures or stenoses which may result from the scars 6/4 THE GASTRO-INTESTINAL CLINIC of ulcers — peptic, syphilitic, tubercular, dysenteric, or catar- rhal — and from carcinoma, which last usually causes an an- nular infiltration of the bowel wall, with a gradual thickening of the latter, and a consequent narrowing of the lumen. The conditions described in i and 2 usually develop acute symptoms which may come on very rapidly, though intussus- LOWER FOLD OF '/LEOCeCAL VALVF APPENDIK Fig. 83. — Ileocolic intussusception. A. Point at which invagination began. ception sometimes fails to produce complete occlusion, and may set up a chronic condition, in which there are occasional acute exacerbations. Those described under 3 and 4 may, or may not cause acute obstruction with violent symptoms. The conditions mentioned under 5 — the stenoses and strictures — generally come on gradually, and the symptoms of obstruction are rarely acute till late in the case, after mild disturbances, pain, constipation, etc., slowly increasing, have long given warning. They will, thereiore, be considered under the head of Chronic Obstruction. Intussusception. — The most common cause of mechanical obstruction is intussusception. This may be classified into two chief varieties, enteric and colic. An enteric intussusception is INTESTINAL OBSTRUCTION 6/5 a condition in which one portion of the small intestine has pro- lapsed or telescoped into another part of the same. A colic intussusception presents a similar state of affairs, except that the invagination is limited to the colon, and the small gut plays no part therein. There may also be a mixed variety in which the small bowel prolapses into the larger, producing a subvariety of enteric intussusception. There are two chief forms of this subvariety : viz., ileocolic and ileocecal. By the term ileocolic is meant an intussuscep- tion which begins in the small bowel and protrudes through the ileocecal valve into the colon. This condition is illus- trated in Fig. 82. An ileocecal intussusception might be con- sidered as only a subvariety of the ileocolic, and is one in which the beginning of the intussusception was at the ileo- cecal valve. That is to say, the first part to prolapse is the valve, which drags after it a portion of the ileum. It is prob- able that many cases diagnosed as ileocecal are really not intus- susceptions in which the site of the primary invagination is the ileocecal valVe, but, as has been shown by Corner,^ the original difficulty was located at some point just above the valve in the wall of the ileum, and this primary invagination is lost sight of as it passes through the valve into the colon. In this form the primary invagination may unroll itself as it passes into the cecum. Many intussusceptions are double, /. e., the first intussusccptum and intussiiscipiens together form a new intussiisceptiim for a second invagination. Corner be- lieves that about 80 per cent, of all intussusceptions are double, and an analysis of his observations tends to confirm his con- clusions. It is easy, for instance, to overlook a primary en- teric invagination, beginning close to the valve and unrolling itself into the cecum as it progresses. This fault in observa- tion would greatly decrease the number of double intussuscep- tions reported. The table of the varieties of intussusception given by Corner is well worth study, and is here reproduced in full: ' Brit. Med. Jour., October, 1903. 6^6 THE GASTRO-INTESTINAL CLINIC Variety Probable Frequency- Definition Single. I. Enteric . Uncommon. Small gut into small gut. 2. Ileocolic . Rare by itself. Enteric through valve. 3- Ileocecal. Uncommon. Originates at valve. 4- Colic . . Probably most common single intussusception. Large gut into large gut. Double. I. D ouble- enteric . Rare. Enteric into small gut. 2. Ileocolic- Most common of all. Ileocolic "impacted" in valve^ colic . cecum invaginated into colon. 3- E nteric- Very rare. Double enteric with one part ileocolic . prolapsed through valve. 4- Enteric- Second most frequent Enteric pushing valve in front ileocecal. variet3^ of it. 5- Ileocecal- colic . . Very rare. Colic into large gut. 6. D o uble- colic . . Rare. Colic into large gut. 7- Colic -ileo- Fairly common. Caput coli or cecum invagi- cecal . . nated iirst blocking the valve, this causing ileocecal intussusception. Intussusceptions of the appendix are, of course, to be classed with those beginning in the caput coH and are probably quite rare. The only case in which any cause for an invagination of the appendix could be found was reported by Rolleston, and is quoted in Corner's paper. In this case there was a prolapse evidently started by a concretion present in the appendix. This had probably caused an exaggerated peristalsis. Intussusception of Meckel's Diverticulum This is of rare occurrence, and some of its varieties might very properly be classified with hernias. Accordingly as the diverticulum is or is not connected with the umbilicus, there will be possible two quite distinct accidents. If the diverticulum is attached only to the bowel, it may become invaginated into the ileum in very much the same manner as the appendix is inverted into the cecum. This accident is only rarely possible because Meckel's diverticulum, when present, is nearly always attached to surrounding structures, a circumstance which would en- tirely prevent its invagination into the ileum. The cases in which this variety of intussusception has occurred usually INTESTINAL OBSTRUCTION ^77 o-ave histories of subacute disturbances followed by an acute attack, which last was due to an acute secondary intussuscep- tion of the ileum caused by the small gut grasping the inverted Fig. 84. — Invaginated Meckel's diverticul-um, with stenosis and perforation of the small intestine; a, cicatricial contraction with perforation; b, mesentery of the diverticulum which has been in part retracted into the latter; (^) diverticulum after it has been everted (" evaginated ") and opened with a longitudinal incision. Length, 9cm.; circumference, 7.5 cm. Diameter of intestine above the stenosis, 14.5 cm.; below, 5cm. (From " Krankheiten des Darms u. des Bauchfells," von Prof. Dr. C. A. Ewald.) diverticulum and thus invaginating its own wall. In a few in- stances the process was acute from the start. In either case, an accurate diagnosis is impossible. The mode in which this ac- 678 THE GASTRO-INTESTINAL CLINIC cident happens is shown by the accompanying diagram. Fig. 85 (a) and (b). The secondary intussusception of the ileum will be produced by dragging on the inverted diverticulum, and, from the fact Fig. 85. — {a) Ileum with Meckel's diverticulum before invagination. /mmmmmmmmmm/ Fig. 85. — (d) Meckel's diverticulum invaginated into the ileum. Dotted line shows position of invagination. Arrows indicate direction of peristalsis. tfiat the pull is exerted on one side of the ileum only, the ring surrounding this secondary intussusception will be obliquely disposed with regard to the circumference of the bowel. This is best explained by the annexed diagram (Fig. 86). In the cases in which the process is connected with the um- l)ilicus, the intussusception takes place in the opposite direc- tion toward the umbilicus. Under these circumstances, there are three different accidents which may occur: (i) The di- verticulum may be telescoped into its own lumen, as is shown in the figure below (Fig. 87). After a time the posterior wall of the ileum (at C) may be drawn into the grasp of the diverticulum and a double in- tussusception produced, as in the annexed figure (Fig. 88). INTESTINAL OBSTRUCTION 679 Under the conditions illustrated in Fig. 88 there would be an umbilical tumor, from the center of which feces would be extruded. (2) The second case, illustrated in Fig. 89 (a) and (b), is one in which the first part of the prolapse is the posterior wall Fig. 86. — Secondary intussusception of ileum due to invaginated divertic- ulum, B. Place where wall of bowel is pulled in, forming the oblique constriction ring A, B. of the ileum and when this intussusception has proceeded far enough the diverticulum may telescope into its own lumen, producing a final result similar to that in which the starting VMB/L/CUS r^y^y///////^^^^^^^^^^^^^^^^^^ ABDOMINAL WALL ■if/y£ffr/cuL (JA/ '(^///////////////////ym/y/ym, Fig. 87. — Meckel's diverticulum invaginated into its own lumen. The con- stricting line is showing at ^, B. point was in the wall of the patulous process and the posterior part of the ileum was pulled in afterward. (3) The third accident which may occur (shown in Fig. 90) is that an invagination may begin in the bowel above the di- verticulum, and, instead of passing down toward the ileocecal valve, finds its way to the umbilicus by way of the open Meckel's diverticulum. 68o THE GASTRO-INTESTINAL CLINIC It will readily be seen that, under these conditions, there will be at first a few bowel movements, and later none at all, be- cause all the feces will be sidetracked in the direction of the arrow A, and will escape at the umbilicus from the center of UMB/UCUff Fig. 88. — Meckel's diverticulum invaginated into its own lumen and pos- terior surface of ileum also invaginated into the same. The line A, B, shows the lower limit of the intussuscipiens. C, Point on posterior surface being drawn into the diverticulum. the tumor. As in other instances, this intussusception may- remain single, or a second one may take place, implicating the walls of the diverticulum. Clinically pathologic states of Meckel's diverticulum are not frequently encountered ; but a patulous condition of the process is found in nearly two per cent, of all bodies in the dissecting room. A weak constitution with flabby muscles, as well as the presence of benign tumors or polypi in the intestine, predispose to the production of intussusception. The symptoms of intussusception include those common to UKjst forms of acute obstruction already described, and when the obstruction is complete, as in the more marked invagina- tions, you will observe the symptoms which always follow a strangulation of a portion of intestine from any cause. The patient is suddenly seized with severe pain in the abdomen referred generally to the region of the umbilicus, or when the INTESTINAL OBSTRUCTION 68 1 trouble is in the colon, it may be localized at first at the site of the obstruction. Almost simultaneously with the pain there occurs vomiting which is a reflex from the traumatism, OMB/L/C/C/S' ABDOM/A/AL WALL III ,, WZ^TZl Fig. Sg {a).— First stage. A, Point on posterior wall of ileum where in- vagination begins. Fig. 89 (b).— Second stage. A, Point on posterior wall of ileum which is now protruding from the umbilicus. and thus differs from that which results later in the disease from an accumulation of ingesta and secretions in the ali- mentary canal above the obstruction. There are usually evi- dences of shock in the rapid, feeble pulse, clammy skin, and 682 THE GASTRO-INTESTINAL CLINIC anxious facies. Distention of the intestines above develops more rapidly than in obturation, obstruction, or even in peri- tisnitis. In intussusception there is often tenesmus, and in 80 per cent, of all cases frequent non-fecal evacuations containing a little blood, with also generally small amounts of mucus, or SBOWEL PROTfiUO/NG fROM aMBILfCUS ABDOMINAL WALL Fig. 90. — Invagination beginning above the diverticulum. Arrow, C, shows direction of intussusception; A, B, line of constriction. more frequently merely blood-tinged mucus. A sausage- shaped tumor can nearly always be felt, and marked indi- canuria is generally present, especially when the small intestine is involved. Invaginations of the colon, which, like those in other parts of the bowel, are most frecjuent in children, are more easily diagnosed, as well as treated, than those of the small intestine. Leaving aside those which begin at or near the ileocecal valve, they are usually single. They most commonly contrast with those of the small bowel by presenting less violent symptoms, though this is not invariably the case. The places at which the invagination usually happens are the cecum and the ascending and descending colon. The symptoms do not, in other respects, differ from those characteristic of the disease in the small in- testine, except that indicanuria is much less pronounced, as a rule. The prolapsed bowel may possibly be felt in the rectum. The treatment of intussusception which cannot be reached by INTESTINAL OBSTRUCTION 683 inflation through the rectum is purely surgical, and it is safe to say that it is impossible without operation to treat success- fully any intussusception involving the ileocecal valve, or which is located above it. The treatment of the colic form of intussusception should include the withholding of all food by the mouth, and the ad- ministration of enough opiates to inhibit peristalsis. The sim- plest method of reduction is to inflate the colon with filtered air or some other inert gas. To do this, before the patient is aneesthetized, the colon is flushM with about a gallon of water. The patient is then anaesthetized and held with the feet up and the head down in as nearly as possible an inverted position. Inflation with the gas is then done by the rectum and will fre- quently reduce the intussusception in recent cases in which the difficulty lies entirely below the ileocecal valve. It is not al- ways safe to assume that it is so situated when the ascending colon is implicated, since many colic intussusceptions are sec- ondary to enteric invaginations. If, after this method has had a reasonable trial, reduction is not effected, laparotomy should be done without delay. Efforts at reduction made through the incision may then often be successful. If not, either an in- testinal anastomosis, an enterostomy, or a colostomy should be performed. After the abdomen has been opened, reduction by manual traction may be assisted by maintaining the inflation of the colon. Volvulus is due to the twisting of a segment of intestine upon itself or around a neighboring coil, and can occur only in individuals with an abnormally long or relaxed mesentery. It involves most frequently the sigmoid flexure — in over half of all cases. The symptoms of volvulus are those common to other me- chanical forms of intestinal obstruction dependent upon stran- gulation. A sign which is held by Wahl to be pathognomonic of volvulus is the presence, during the first day, of a circum- scribed area of tympany which occurs in the affected segment of the bowel. This is caused by distention with gas. After the 684 THE GASTRO-INTESTINAL CLINIC first twenty-four hours this sign is difificult to recognize, be- cause the whole abdomen will then be distended and tym- *panitic. The treatment of volvulus is an immediate laparotomy. The affected loop may be readily untwisted in recent cases ; but if the bowel shows evidences of beginning gangrene, the loop should be excised and an intestinal anastomosis performed. It is frequently well to take a tuck in the mesentery to obviate the return of the volvulus. Hernia. — An extended discussion of hernias is out of place here ; but since any of them may lead to intestinal obstruc- tion, I will enumerate the varieties, with special reference to the locations in which you should seek for such a cause in any obscure case. The chief varieties are : 1. Diaphragmatic, in which the viscus is protruded through the diaphragm, usually at one of the weak points, such as the crura or just behind the sternum where the costal portion joins the sternal. 2. Umbilical, in which there will usually be an umbilical tumor. A hernia into a patulous Meckel's diverticulum is a subvariety of this class, and has already been described. 3. Retroperitoneal. — This form of hernia occurs in the fol- lowing places : (a) Through the foramen of Winslow passing into the lesser sac. (b) Into the phrenico-hepatic fossa located near the left lobe of the liver, (c) A series of three fossae which have been described in relation with the ascending limb of the duodenum and duodeno-jejunal angle (fossa of Treitz). (d) An intersigmoid. (e) Iliaco-subfascialis, a recess in relation with the left psoas minor muscle. (/) Three fossae in the neighborhood of the cecum. 4. Through slits in the mesentery. 5. Inguinal, escaping through the inguinal canal to present at the external abdominal ring. This variety occurs most fre- quently in males. 6. Femoral, which passes along the femoral canal to the INTESTINAL OBSTRUCTION 685 inner side of the femoral vessels and presents on the thigh through the cribriform fascia. This hernia occurs most often in women. 7. Obturator. — In this rather uncommon form of hernia, the gut protrudes through the obturator or thyroid foramen of the. ileum. In its passage through the foramen the hernia will press upon the obturator nerve which goes to supply the mus- cles and integument of the inner side of the thigh as far as the knee. This distribution of the obturator nerve explains the peculiar symptom of this hernia ; /. e., pain at the inner side of the knee. 8. Sacrosciatic, a rare variety in which the viscus pro- trudes through the sacrosciatic foramen. The symptoms of hernial obstructions are those typical of strangulation from other causes which are described below. Strangulation of the Intestines by Knotting, etc. — The bands of adhesion produced by peritonitis may cause obstruc- tion by a fixed kinking or knotting, or in other ways lead to strangulation of loops of the bowel. Such bands are frequently long, and it is not strange that, dur- ing active peristalsis, a loop of intestine sometimes becomes tied or otherwise constricted by one of them, with the result of stop- ping at once both the passages of feces and gases, and the local cir- culation in the part. A loop of intestine may become strangulated similarly by being caught behind the appendix or a fallopian tube, when the free end of these has been attached to a neighboring organ by adhesive inflammation. The Symptoms of Strangulation Ileus. — In such accidents the symptoms are likely to come on abruptly, and with unusual violence. They have been so graphically described by Tu- FiG. 91. — Knotting of loops of the ileum, — (Leichtenstern,) 686 THE GASTRO-INTESTINAL CLINIC holske^ that I cannot do better than to reproduce here his ac- count of them : " Having in a given case ehminated the probabihty of paralytic ileus, and decided that we are dealing with a mechan- ical obstruction not congenital, the question of strangulation or obturation presents itself. The paradigm, as mentioned above, Fig. 92. — Constriction of a loop of small intestine by an adhesion at- tached to the omentum at both ends. (From " Krankheiten, des Darms u. des Bauchfells," von Prof. Dr. C. A. Ewald.) of a strangulation is the strangulated external hernia, or a strangulation of the bowel and its mesentery. The picture of strangulation is a striking one. A person, apparently in good health, is suddenly taken with a violent pain in the abdomen, accompanied by collapse, nausea, and vomiting. To this is very soon added the urgent desire to relieve the bowel of feces and flatus. There is at once the feeling of serious illness, of 1 Loc. cit. INTESTINAL OBSTRUCTION 68/ great anxiety and restlessness. Unrelieved, these symptoms are joined by that of intestinal distention. " The pain generally felt about the navel is not significant of locality; it is infinitely more severe in the thin, highly in- nervated small intestine than in the large. The initial vomit- ing with singultus is reflex and begins with the occurrence of strangulation, and with it also come the signs of collapse, the incarceration collapse, and almost anuria from reduction of the arterial pressure. The vomiting in later stages is due to distention and gas accumulation, the stercorsemia to toxic absorption or septic infection after permeability of the intesti- nal wall has become established. " After a few hours, perhaps eight to twelve, the results of the circulatory interference become noticeable; the strangu- lated section of bowel becomes distended, fixed, and paralyzed, and in favorable subjects, seen early, produces asymmetry of the abdomen and can be made out by inspection and palpation. The afferent loop is not yet appreciably distended ; peristalsis may be present. All symptoms increase in severity. To the distention of the strangulated part distention of the proximal loops is added and general greater distention. The efferent intestine has been emptied of fluid and gaseous contents and remains collapsed. To the initial shock, the incarceration shock, after the second day are added symptoms of permea- bility, due to a changed condition of the gut at the point of strangulation, and symptoms of general peritonitis develop; the vomiting increases in frequency, and the putrid feculent intestinal contents are emitted by regurgitation. The abdo- men is tense and tender on pressure, peristalsis everywhere absent ; to the signs of stercorsemia are added those of septic infection. " With the occurrence of gangrene the pain grows less, and tlie patient enters the stage of lethal collapse. The occurrence of perforation may somewhat modify the latter symptoms. If we add to these local symptoms those of the general condi- tion, the rapid, feeble, compressible pulse, the anxious expres- 688 THE GASTRO-INTESTINAL CLINIC sion of countenance, the pale or cyanotic color, the sunken eye, the pointed nose, the skin cold, clammy, and empty of blood, we get the appalling picture characteristic of the result of sudden strangulation." Treatment of Strangulation Ileus. — In the great majority of these cases surgical intervention is absolutely necessary, and Fig. q3. — Various forms of constriction by a club-shaped diverticulum. (After Regnault-Beclard and Treves.) the sooner it is resorted to the better the chances of a favorable result. The mortality from abdominal operations is enor- mously increased by every day's delay, and in doubtful cases you should have a competent laparotomist in consultation with you at the start. In hernias, even when strangulated, there is often a possi- bility of reduction by taxis and the inverted position, but the former is itself really a surgical procedure. It needs to be carried out with skill as well as the utmost gentleness, and should not be prolonged beyond ten minutes, as a rule, when it fails within that time to relieve the strangulated portion of in- testine. Above all do not administer a cathartic by the mouth in this, or indeed, any other form of serious intestinal obstruc- tion, except when there is a probability that it depends upon a fecal stasis. No food should be given by the mouth (and this INTESTINAL OBSTRUCTION 689 rule, too, holds for all such cases) and the patient should be confined strictly to bed. Morphine should be administered in sufficient doses to control the pain and effect the utmost pos- sible relaxation. Anaesthesia by ether or chloroform will often greatly assist manual replacement, but, as a rule, should not be produced until a surgeon is at hand to open the belly if found necessary. An ice bag should be applied locally over the af- fected region, or, in some instances, a hot poultice or hot wet compress will be better. The detailed directions for carrying out taxis will be found in all the works on general surgery, and would be out of place here. External Tumors, Displaced Organs, etc. — Cancers and sarcomas, as well as the benign tumors which are rare in these parts, may obstruct the bowel, whether they are attached to the inside or outside of the intestinal wall, or to adjacent viscera but near enough to encroach upon the lumen by pressure. Tu- mors within the bowel are considered under Obturator Obstruc- tion. The obstruction produced by tumors regardless of their situation develops comparatively slowly, and by the time it is serious, the tumor can generally be felt on palpation. Cancer is the commonest tumor of the intestines, and it most fre- quently causes obstruction by a gradual infiltration of the bowel wall in an annular form ; but such carcinomatous stric- tures are discussed under Chronic Intestinal Obstruction. Displaced organs may occasionally produce obstruction similar in character to that caused by tumors pressing from without, or gall stones lodged in the common duct may do the same by their pressure upon the intestine. The organs chiefly at fault in this respect are the uterus and kidneys. Retrodisplacements of the uterus which are frequently associ- ated with enlargement may cause sufficient pressure upon the lower bowel to occasion a stubborn constipation, and excep- tionally, such a condition may simulate obstruction. Asso- ciated with a displaced uterus, there is sometimes found an. ovary which has prolapsed into the pouch of Douglas. Such 690 THE GASTRO-INTESTINAL CLINIC ovaries are usually abnormally tender, and sometimes give rise to almost absolute obstruction by reason of the pain which is caused by every effort to move the bowels. Movable kidneys quite frequently interfere with the onward passage of the feces by a direct pressure upon a loop of intes- tine, but such pressure is likely to be intermittent rather than constant, so that constipation, rather than permanent obstruc- tion, results as a rule. A peculiar form of chronic constipation dependent upon conditions affecting .the right kidney has been investigated by W. Arbuthnot Lane.^ He says, " my attention was directed to this diminution of the lumen, particularly of the hepatic flexure, by the close resemblance of the symptoms in these cases to those 'of renal troubles, whether of calculus or of exces- sive mobility." Upon operating, nothing but bands of ad- hesions between the colon and kidneys, and a kink at the he- patic flexure of the colon, were found. However, when these were separated the cases were greatly, improved. The patients who did not improve were women in poor physical condition, whose intestines were flaccid and plastic. In Lane's opinion the cause of these adhesions is an overloaded and distended cecum and colon which sets up enough irritation to produce the bands which bind together the colon and kidney. This author advises an anastomosis between the ileum and sigmoid flexure, because adhesions may re-form, and because the cecum and colon may fail to regain tone in spite of massage, electricity, and other treatment. Symptoms of Ohstniction from External Tumors, Displaced Organs, etc. — In the cases of ileus coming under this class, the symptoms generally develop slowly, except when a heavy organ by its sudden displacement abruptly and completely shuts off the lumen of the intestine, compressing at the same time, pos- sibly, its mesentery so that the local circulation, as well as the passage of feces and gases, is interrupted. In these latter ac- cidents the symptoms may be acute. Malignant growths ' The Lancet, January 2, 1904. INTESTINAL OBSTRUCTION 69 1 usually cause their own localized pain, which may complicate the clinical picture. Otherwise these will appear with a gradually increasing severity, as in the case of tumors encroaching upon the bowel, or intermittently, as occurs more frequently in the case of pres- sure from displaced viscera, such symptoms as pain from gaseous distention, excessive eructations, vomiting of ingesta, with finally, in the severer cases which are not relieved, the vomiting of fecal matter and other distressing features of a stubborn mechanical obstruction. The treatment of the forms of ileus just described must be in the main surgical, though position and certain mechanical measures may do much for the relief of obstruction due to pressure from displaced organs. A rest cure has often re- lieved, and doubtless sometimes permanently cured, such cases by the prolonged change from the vertical to a horizontal po- sition of the trunk ; and other changes of position may suggest themselves to you as likely to relieve individual cases of pres- sure from such a cause. In Lecture XL. you will find descriptions of a method by which movable kidneys and other displaced abdominal organs can usually be raised up and held in place with the help of straps of adhesive plaster. Obturator Obstruction. Gall Stones, Enteroliths, etc. — Obstruction caused by enteroliths, gall stones, and other for- eign bodies impacted in the bowel is rarely complete in the be- ginning, and the circulation is less injured. Enterdliths are ordinarily larger than gall stones. The nucleus of them is usually a gall stone around which the con- cretion is built up in successive layers. Gall stones too large to pass through the gall duct some- times ulcerate through into the intestine. They may cause i-ntestinal obstruction in several ways. ( i ) Their presence in the gall bladder may set up inflammatory processes with the production of bands and adhesions which press upon and obstruct the intestine. (2) They may diminish the lumen of 692 THE GASTRO-INTESTINAL CLINIC the bowel by direct pressure on the duodenum, when large stones become lodged in the common duct. (3) They may fotm a mechanical obturator after they have escaped from the common duct into the lumen of the bowel. The Murphy button has sometimes caused obstruction in the same way, and so have frequently various foreign bodies, such as buttons, coins, false teeth, etc., which have been swallowed. Obstruction by zvorms, hardened feces, etc., belong under the head of obturation. Masses of dead worms killed by a vermi- fuge may produce serious obstruction, especially when there has been a previous stricture of the gut at any point. It is rare, except under similar circumstances, that fecal tumors cause such complete obstruction as to be followed by alarming symptoms, though they may often temporarily interfere with bowel movements before they can be softened by repeated doses of physic or by irrigation of the colon. They are especially likely to do this in cases of spastic constipation. (See Lec- ture LXIX.) Polypi, and exceptionally sarcomas in the intestine, may also cause obstruction by plugging the lumen ; besides, they often aid in the production of intussusception. The symptoms of obturation ileus are in general much milder than those of the other forms of mechanical obstruc- tion — at least in the beginning. Even when the occlusion is complete, there is very much less interference with the circu- lation in the walls of the gut, and none at all, as a rule, with that of the mesentery. There is also comparatively little shock, and in consequence the initial reflex vomiting, which is such a distressing feature in the forms of ileus due to the various forms of strangulation, may be absent altogether, or if present, is less severe. The initial pain may also be slight. When the bowel is completely plugged, the accumulation of its contents, together with the gases from fermentation, soon produces dis- tention with consequent pain, which is likely to be paroxysmal or constant with frequent exacerbations, and vomiting, which finally in unrelieved cases becomes feculent. INTESTINAL OBSTRUCTION 693 The Pathology o£ Intestinal Obstruction. — AMiatever the cause of the obstruction, the important pathologic changes in the intestine will comprise a great distention and dilata- tion of the tube above and its collapse below, while the affected segment will show first a stasis of the circulation, followed shortly by an intense degree of inflammation with often ulcer- ation, which may perforate, thus leading to a secondary peri- tonitis. In the beginning the peristaltic movements are markedly exaggerated in the intestine above the obstruction, but the overaction is soon succeeded by exhaustion and paral- ysis. The dilatation, when the occluded segment is in the ileum or higher, will usually affect all of the afferent intestine and the stomach as well. When it is in the colon the dilata- tion will at first be limited by the ileocecal valve, but will eventually pass beyond this and involve the small intestines. Differential Diagnosis of Acute Ileus. — It is generally com- paratively easy to decide that your patient is suffering from acute obstruction. The clinical picture already described is too striking to admit of any mistake, and a leucocytosis of 18,000 or over by the end of twenty- four hours will confirm the diagnosis. It is exceedingly difficult, however, in many cases to determine which of the various causes has produced the trouble, and in just what part of the bowel it is situated. To arrive at such a pathologic and anatomic diagnosis would not be important if there were any hopeful medical treatment ap- propriate to all the different varieties, or if it were the approved practice to operate at once in every case, regardless of the cause. But neither of these propositions is true. Suppose you have been called to a case of acute obstruction within the first few hours and find the usual symptoms of pain, vomiting, obstipation, and beginning tympanites. You will at once examine most carefully and note whether there be anywhere a special loop of intestine or region of the abdomen which is particularly inflated. Such a finding would point, first of all, to volvulus, especially if it were in the situation of the sigmoid, but might mean intussusception or strangula- 694 THE GASTRO-INTESTINAL CLINIC tion from any cause, particularly if the onset had been very sudden. If an invagination had occurred, you would usually be able to feel a sausage-shaped tumor just below the dis- tended loop. If no such tumor were palpable, and no external hernia were discoverable, you would think of strangulation by a band or diverticulum. If the onset had been sudden and severe, including early vomiting as well as pain, and within the first five to ten hours the abdomen were already becoming exquisitely tender, showing peritonitis to be developing, you would have reason for strongly suspecting the perforation of an ulcer into the peritoneal cavity, and that a dynamic obstruc- tion had resulted. If tenderness were present over all or part of the abdomen, and this and pain had for some time preceded the vomiting, you would think of a peritonitis produced by some infection, such as an extension from a diseased appendix or fallopian tube, or the gradual leakage of pus from an abscess. In acute peritonitis an abnormally high temperature, in the rectum at least, is only very exceptionally absent, though it may be in some very grave cases in which there is great exhaustion. If the patient should be a child under ten, or even twenty years, intussusception would be the most probable cause of a suddenly developed ileus, and next after this, in likelihood, would be hernia or obstruction by worms. Twists, kinkings, displacements, and strangulation under attached diverticula or peritoneal bands are comparatively rare in childhood. In older patients, the more sudden and violent the onset of ileus the greater the probability that the cause is hernia, or else volvulus or some other form of strangulation not remediable except by surgery. It could, however, be due to an in- tussusception in the colon which might possibly be reduced by inversion and inflation from below. If so, there would likely be tenesmus, and you would probably find blood-tinged mucus in the evacuations. If no tumor could be felt and no external hernia be found, you should infer that the cause was probably one of those conditions requiring surgical intervention. INTESTINAL OBSTRUCTION 695 Indeed, in so far as regards the more threatening cases which have had a sudden and violent onset, exchiding those dependent upon perforation ah'eady referred to as weh as in- carcerated or strangulated external hernias, which can gener- ally be recognized and sometimes relieved by taxis, etc., the only probable condition in which, as a rule, anything of practical advantage can be gained by determining the locality of the lesion in the bowel is intussusception. When the usual sau- sage-shaped tumor characteristic of such a lesion can be felt, you can usually decide readily whether it is in the colon, af- fording then some encouragement for a trial of non-surgical measures, or in the small intestines, in which case, if the in- verted position should fail to accomplish anything, there would be virtually no remedy left except laparotomy. Together with a palpable tumor, frequent evacuations containing only a little blood and mucus and passed usually with much straining, would be diagnostic of intussusception when present with the symptoms of acute obstruction ; and as to localizing the in- vagination, besides the situation of the tumor, the amount of warm water which could be injected and retained for even a few minutes in the colon would indicate approximately how far up in it the obstruction was. In the obturator forms of ileus it is important to make the setiologic, pathologic, and anatomic diagnosis, and as soon as possible. Many such cases can be remedied without an ab- dominal section, and the results of operative intervention are very much better when done very early. Obstruction due to plugging by gall stones, enteroliths, foreign bodies, hard fecal masses, etc., is seldom complete at first, and for this reason as well as because of the fact that no violence has been done to the mesentery, and the interference with the local circulation of the part in the beginning is but slight, there is a mildness of the early symptoms in marked contrast to those of the forms dependent upon strangulation. The pain is usually much less intense, and is not accompanied by vomiting at first. Some gas, and often even a part of the feces, may pass the obstruc- 6q6 the gastro-intestinal clinic tion, and in consequence marked distention is much later in developing. When a gall stone is the obturator, whether or not it has been enlarged by successive accretions into an enterolith, the patient will generally have had previous attacks of hepatic colic accompanied, as a rule, by jaundice, bile-stained urine, fever, etc. There will also be often a persisting tenderness in the region of the gall bladder. In the case of foreign bodies, there will generally be a history showing that something of the kind has been swal- lowed, and if they are metallic the x-rays will reveal their sit- uation. When a fecal mass is the- offender, there will be a history usually of a long-standing constipation and symptoms similar to, but still milder, as a rule, than those that may follow obturation by gall stones, foreign bodies, etc. The symptom vomiting in obturation ileus calls for special consideration. It is here generally a late manifestation, but when it appears, more speedily becomes fecal than in the other forms. The reason for this is that, in the more violent forms due to strangulation and characterized by initial emesis, the contents of the stomach and bowel above the obstruction are so completely emptied before the time when fecal vomiting would usually set in, that no feces have been made and there remains little out of \vhich they can be made. Moreover, in the severer forms, death often occurs before there has been time for the development of stercoraceous vomiting. The pain in the obturation ileus is not only less violent, but also much less continuous. In fact it is usually rather inter- mittent, resembling somewhat labor pains, being intensified at every contraction of the afferent part of the intestine. There is rarely any such profound shock with collapse as generally ac- companies strangulation ileus. The following table, contributed by R. Fitz to the Transac- tions of the Congress of Physicians and Surgeons, vol. i., 1888, shows the percentage of each of the more prominent INTESTINAL OBSTRUCTION 697 symptoms which occurred in the several varieties of ileus in a series of 295 cases of acute intestinal obstruction : Strangu- lation Per cent. Intussus- ception Per cent. Twist Per cent. Gall Stones Per cent. Stricture or Tumor Per cent. Pain Nausea and vomiting Fecal vomiting , . . . Tympanites .... Tumor Visible coils .... 82 69 47 56 10 II 70 75 13 33 69 60 37 15 55 7 83 74 61 56 13 60 80 33 66 27 20 Ewald makes much account of the information obtainable by an inflation of the colon with air or any inert gas or the injection of water. Digital examinations per rectum and vaginam, as well as the most painstaking palpation of the abdomen, will help to locate obstructing tumors or displaced organs, fecal masses, twists, intussusceptions, etc. Finally the finding of marked indicanuria will point to the small intestines as the probable seat of the obstruction, though there is likely to be a moderate excess of indican present in the urine, even when the trouble is in the cecum or colon. The Prognosis of Acute Ileus. — Complete occlusion of the intestines is a very serious affection, and a very large propor- tion of all the cases prove fatal. The milder cases of dynamic ileus, some of which scarcely amount to acute obstruction, may be temporary in character, and do not warrant so bad a prog- nosis, and the cases due to a local peritonitis are very generally rather amenable to treatment, either medical or surgical. Even the severer cases, like the external hernias and the invagina- tions in which the diagnosis can usually be made early, can often be rescued by prompt surgical intervention, but too often, unfortunately, either the attending physician or the family in- sist upon waiting until it is too late. In the internal hernias, twists, and other obscure strangulations, the danger is greatly increased by the obscurity and difficulty in making a certain ,a)-r" c J* S ^ M to- • 0) (fl o CJ (D w *-• r-< ::! ^ -p -t-> .. bo oJ o 'p a,' o o bO g -O g a tn ;:! C m 2 3 S""^ "^ "^ n .r; - -. C ii (U ■U g 3 T! <) bo Mh (U (1) a rn 3 3 Oh > d ^o; 5^'.^ uj Ojn *-i • c ' "J • O sii ^ o' 3 3 "Poj'^oif.-'U 5-1 « S -M S !«> OJ CI. aiOWt«o*-'r'_ -M^O!-i<^a3.5G C/2 > O^Jr-l-W O ^ M G R C ^3 « ^ O "P „ c a> .;: c t- i-i ^, oj 5 S a. G -u oi 03 > S o ?5 ^ a 05 o y ^H OJ ^ Oh a bo^ 'O'X. oi H "3 > •Sg Oi ^ 3 o bOcn o3 ^ a> bo a ^ 03 JH - XI G-" "tj ^ o3 (u uj oi — ., (U O C >^o 'u (U G G"^ G .n 3 O ei ^ y 0* 03 0313 t3 ^o •^ c G o3 <+-i . (D O [fi rt I" 3 ^ OS CJ o cr 4) b03 y-g ?3 G saa .X^ G O ^- "5 03 ™ 03 g 3 a bo 03 oS ?— ' o3 G o ti «^ C «3 "^ .- (D (D G ^ ^-d G-Sy 2a .2 =" 4:1 -^ s 3 N O ° .— • 03 OS !- o ■d .-1 Oi 03 &i ■-' _ o! (iT-G in !-i oS • in " O c -^ 4) ™ I ^- P I -1-1 S 5) oi G r/; - 3^2— > '-' 03 O C X OS a! Ph OS a • • G * o3 cxm t/l 0) Oh fH 0. ^ 3 G . 0( H-.^ d) =^?o . ^ !-i f>l > a^ 03 O tn INTESTINAL OBSTRUCTION 699 diagnosis at the only time — in the early stages — when imme- diate laparotomy affords the only hope of cure. Obturation ileus has generally a much better prognosis than any other of the mechanical forms. The onset and symptoms until complete occlusion occurs being milder and the course much more gradual, there is a better opportunity for bringing to bear effective treatment at an early stage. The Treatment of Acute Intestinal Obstruction. — In pre- vious sections of this lecture I have told you of such methods of medical treatment as give some promise of favorable re- sults in certain varieties of acute obstruction, with occasionally a reference to the surgical operations which have yielded the best results. It is not intended in this work to instruct you in the technique of any such operations. Those of you who do your own abdominal surgery will naturally refer to treatises upon that subject, and the others should call in a competent laparotomist early in every case of acute ileus. It remains to be said concerning the medical treatment of acute obstruction that the patient should be put to bed, and as perfect rest as possible secured for the whole body, and for the functions of the alimentary canal in particular. Allow no food, drink, or medicines to be taken into the stomach ; but small bits of ice may be dissolved in the mouth as often as desired, provided the water be not swallowed. The mouth and tongue may be moistened as often as necessary by a pledget of cotton or sponge wet in ice water. When the obstruction is in the small intestines, half-pint enemas of warm (or tepid) water may be, from time to time, allowed to flow into the bowel from a fountain syringe, placed not more than a foot or two above the patient. When such enemas cannot be re- tained, fluid must be supplied to the system by injecting a weak saline solution, either subcutaneously or into a vein. In prolonged cases, provided the obstruction be not in the colon, small nutritive enemas may be given several times a day. As to the use of drugs: in the first place, purgatives must 700 THE GASTRO-INTESTINAL CLINIC not be administered either by mouth or rectum, unless other forms of obstruction than those from fecal concretions or mcisses can be pretty certainly excluded. They may pro- duce a fatal aggravation. They are useful in fecal obstruc- tion — dangerous in nearly all other cases. Narcotic medicines are indispensable when the pain is very severe, and are useful also to quiet excessive and harmful peri- stalsis. Opium, or some one of its active principles, will need to be administered, either by suppository or hypodermically in most cases. After an initial dose of morphine hypodermi- cally, extract of opium, with extract of belladonna by the rectum, is usually sufficient. Atropine will often prove a most valuable adjunct to the opium, and has a still more powerful influence in the relaxation of spasm. With every 1-4 grain of morphine injected there should be, in these cases, at least 1-60 grain of atropine, and some bold therapeutists claim to have obtained brilliant results without harmful ef- fects from such extreme doses as 1-12 grain. When supposi- tories are administered, you may combine, with advantage. 1-2 grain of extract of belladonna with every grain of extract of opium. No doubtful case of acute obstruction should be given up as hopeless until the effects of full doses of bella- donna or atropine have been noted. \\'ashing out the stomach with a warm saline solution is a safe procedure in nearly all cases of ileus, and will, at least, lessen the vomiting by removing the contents of the viscus all at once. Sometimes it is reported to have effected almost magical cures ; but my own experience with it in such cases has been exactly like that of Ewald. I have seen it improve all the symjitoms for a time, but never effect by itself a cure. The administration of niefallic mercury is no longer to be recommended. It very seldom effects any good results, and in certain cases could easily do great harm by increasing an invagination, twist, or strangulation. In the cases of fecal obstruction in which only it could be of service, we have better remedies in atropine and castor oil, or the saline laxatives. INTESTINAL OBSTRUCTION /OI In by far the largest number of all cases of acute obstruc- tion, laparotomy is the only hopeful remedy, and little time should be wasted in other measures in very severe or threaten- ing cases. CHRONIC INTESTINAL OBSTRUCTION— STENOSES Most of the causes of ileus above described may at times produce incomplete occlusion only, and then the clinical pic- ture is likely to be rather that of chronic than of acute ob- struction. Chronic Intussusception. — Invaginations do not always close the lumen of the gut completely and then assume a chronic form with occasional acute exacerbations. Such a condition is rather misleading, and has been often overlooked. In such cases the bowels may move regularly, with or without the help of aperients, and are often loose. There is much pain which is usually paroxysmal, occurring once or oftener daily, though sometimes only at much longer intervals. Vomiting is rare, but the typical evacuations of blood-tinged mucus will be passed at times, especially during the acute ex- acerbations, and during the latter, too, there may be tenesmus. The intussusception is oftenest found in the lowest part of the ileum (ileocolic), but any part of the large or small intestine may be involved. The usual sausage-shaped tumor can be felt in over half the cases. Strictures from Healed Ulcers and Carcinoma. — A ma- jority of cases of intestinal stenosis are probably produced by the cicatrices of the various kinds of ulcers. These are dis- cussed with sufficient fullness in Lectures LV. and LVIII. Carcinoma produces stenoses in various ways, but chiefly by an annular infiltration of the gut which gradually thickens the wall by an infiltration of all the layers, and thus lessens the lumen. Tumor masses ma}^ also project within the bowel and lead to the same result. The symptoms of carcinomatous stenoses include the pain characteristic of malignant growths, which in most cases is 702 THE GASTRO-INTESTINAL CLINIC Fig. 94.— Tuberculous stricture of the ileum. Upper figure shows hyper- trophy and atrophy of intestine above and below stricture. Lower figure shows parts removed from section in same case; a, ulcer at site of rent in colon made during operation; b, fistula bimucosa between ileum and sigmoid flexure; c, ileocecal valve; d, mesenteric band. (From a paper on Enterostomy for Tuberculous Stricture of the Intestine, by f. M. Caird, F. R. C. S., in ScoL Med. and Surg-, four., vol. xiv., No. i,; INTESTINAL OBSTRUCTION 703 rather persistent, though rarely very severe, and may be ab- sent. In addition there are, as a rule, the other symptoms of Fig. 95. — Colloid cancer and tubercle. Figure to right, posterior view of cecum, etc., a, ileocecal valve; b, appendix. Upper left figure from same case, portion of small intestine with patch of colloid cancer. Lower left figure, the same in section. (From a paper on Enterostomy for Tuberculous Stricture of the Intestine, by F. M. Caird, F. R. C. S. , in Scot. Med. and Surg, four., vol. xiv., No. i.) such a growth — anaemia and generally in time a cachexia, debility, emaciation, and disturbances of the digestion. As a 704 THE GASTRO-INTESTINAL CLINIC Pig. 96.— Tuberculous stricture of the ileum. Upper left figure shows great dilatation above stricture and tuberculous deposits tending to form strictures. Lower left figure from same case. Remote lower stricture. Figure to right from another case, marked dilatation of part above stricture. (From a paper on Enterostomy for Tuberculous Stricture of the Intestines, by F. M. Caird, F. R. C. S., in Scot. Med. and Surg. Jour., vol. xiv., No. 2,) INTESTINAL OBSTRUCTION 705 result of both the decreasing motihty of the intestinal muscle above the affected part, and. of the slowly narrowing stric- ture, constipation and meteorism gradually develop. Finally, especially when the stricture is in the lower part of the canal, some time before the tumor has shut off entirely the lumen of the bowel, feces accumulate in the dilated loop above and set up the symptoms of acute obstruction. Such acute attacks may be overcome and recur repeatedly before the lethal end comes, except when there has been surgical intervention. Tubercular Ulcers and Growths as Causes o£ Chronic Ob- struction. — Tuberculosis may obstruct the intestines both by the contraction of the scars of healed tubercular ulcers, and by the formation of tumor-like masses within and around them, through a process of infiltration, or fibrous hyperplasia. An- nular constrictions similar to those of cancer also occur. The cecum and lower ileum are most frequently involved. In six out of eleven cases reported by Caird^ the ileocecal valve and cecum were affected, and the appendix was com- pletely hidden in the mass of proliferated tissue. In four of the same series of cases, the small intestine only was impli- cated. (See illustrations on pages 702-704.) In Caird's cases the symptoms had been little marked at first, as in nearly all instances of intestinal stenosis from a cause which only gradually develops, though generally he has been able to obtain a personal and family history of tubercle. There is usually a history of failing health for years, with in- digestion, colicky pain, tenderness on pressure, and constipa- tion. Vomiting is frequent and generally relieves the pain, but no blood is brought up. Caird particularly calls attention to the presence in nearly all the cases of loud borborygmi. He has been able to palpate a tumor in the ileocecal cases, and re- ports that he has not often noted complete obstruction, except when the stricture has been blocked by some foreign body. As in other strictures of the intestine, serious symptoms of ' Scot. Med. and Surg. Jour., vol. xiv., No. 2. 706 THE GASTRO-INTESTINAL CLINIC increasing meteorism, pain, emaciation, exhaustion, etc., de- velop finally, even before the stricture has caused complete occlusion. As to treatment, surgery affords the only effective resource, and Caird reports that out of his eleven cases, seven were cured by enterectomy. LECTURE LXV ACUTE CATARRH OF THE INTESTINES (ENTERITIS ACUTA) This is deemed by some authors the most frequent disease of the bowels ; but the chronic form of intestinal catarrh, in- volving the small intestine and having constipation as its main symptom, is probably still more prevalent, though very often overlooked. Acute enteric catarrh may affect the entire gut at once, or be limited to any part of it. When its chief seat is the upper part of the small intestine (especially the duodenum), catarrh of the stomach almost always coexists, and vice versa. The colon alone, or any part of it, may be affected, especially the cecum or the rectum, without the involvement of the small intestine, but, according to Nothnagel, it is very unusual for the ileum to be the seat of a catarrhal process without the colon's being also to some extent implicated. .ffitiology — A most important light has been shed upon intestinal diseases through the recent exact studies of the di- gestive system. It has been shown that the secretion of HCl in the stomach is very frequently excessive, and it is probable that when this continues in high degree for a long time, the mucous membrane of the upper intestine, that of the duodenum especially, may become irritated and finally involved in a catarrhal process. It has been noted, too, by many observers, that long-standing cases of hyperchlorhydria are often asso- ciated with constipation, which seems to be a result, being often relieved when the HCl excess has been overcome. And constipation is a frequent cause of enteric catarrh in both its acute and chronic form. It has been observed also, by Allen 707 708 THE GASTRO-INTESTINAL CLINIC Jones and others, that a very low or absent gastric secretion is o^ten apparently a direct cause of diarrhea. In stubborn in- testinal catarrhs, therefore, it is very important to know the state of the gastric secretion, and to correct it when abnormal. Acute enteritis is sometimes caused by corrosive poisons, es- pecially overdoses, or the too frequent repetition of purga- tives. In persons predisposed to such attacks, cold may be the cause; especially prolonged exposure to wet and cold. Drink- ing freely of ice water sometimes excites an attack, but by far the most common causes of the affection are infection from spoiled or decomposed food and the irritation from indigest- ible, or at least undigested, aliments. This may result from an improper kind of food, as well as from too hot or too cold ingesta, or an excess of proper food ; also from eating when, on account of either great fatigue, overheating, or powerful emotions, the usual digestive processes are interfered with. Burns over the abdomen may also set up a catarrh, or even acute ulceration in the intestines. Malarial infection, tuber- culosis, typhoid fever, and other diseases may be accompanied by a secondary acute enteritis. Pathology. — Acute enteritis may pathologically assume at least three different forms — mucous, mucopurulent or purulent, and pseudomembranous. There are redness, either diffused or in patches, swelling of the mucosa, — in severer cases, of the submucosa also, — and increased secretion which is usually mucoid, but when the inflammation is very high, may become purulent. The membrane is covered with slimy mucus, and the blood-vessels are injected — dilated. The solitary follicles in certain of the cases are swollen and prominent, projecting above the level of the mucosa. In other cases patches of the mucosa become loosened and des- quamate. In the intenser types there is a large emigration of leuco- cytes, and the surface of the mucosa may be covered with pus. Extravasations of blood may also occur in places. A round- cell infiltration takes place in the mucosa and submucosa. ACUTE CATARRH OF THE INTESTINES /OQ Follicular ulceration often develops from the swelling and bursting of the solitary follicles. In the pseudomembranous type, the mucus exuded is of a tougher and more plastic nature, so that patches, strings, or large masses form — sometimes true casts of portions of the intestine. The latter cases are usually characterized by con- stipation instead of diarrhea, as in the ordinary acute catarrhal cases. Membranous enteritis does not often occur in an acute form, but is generally a subacute or chronic process. See Lecture LXXIII. on Membranous Catarrh of the Intestines. Symptomatology.— Diarrhea is the predominant symptom of acute intestinal catarrh, and probably occurs in all cases, with the exception of those in which the process affects the stomach and duodenum only. It usually comes on suddenly, the stools to the number of three to six, or even exceptionally ten to twenty in the twenty-four hours, being at first semi- solid, then mushy, and later gruel-like, dark, offensive, and mixed with firmer masses or scybala, but still later almost odorless, of a pale yellow or grayish color, and containing considerable cjuantities of mucus. In young infants the stools are often green. Pains in the bowels, often severe and colicky, generally precede the attack, and often recur with each stool. Tenesmus points to involvem.ent of the rectum. In typical cases there are gaseous rumblings, a vague sense of general discomfort, and very frequently nausea at first, which may go on to vomiting, especially when the attack has been due to im- prudence in diet with an overloading of the stomach ; also when the appendix is involved in the acute catarrhal process. Early in an attack, or even after several days in cases wrongly treated by astringents and opiates before a thorough emptying of the bowel, percussion may reveal accumulations of feces in the cecum, flexures of the colon, the prolapsed center of the transverse colon, or in the sigmoid flexure, and nearby or above such obstructing accumulations, areas of tym- pany may be found. Sudden tapping with the finger tips in the same region often 7IO THE GASTRO-IXTESTIXAL CLIXIC causes high-pitched splashing sounds due to the presence of liquid feces and gases. Digital exploration may discover hard fecal masses in the rectum, especially in cases where neglected constipation has been a cause of the enteritis. Deep palpation frequently produces pain over the course of the colon, when this part of the bowel is much involved. This sign, together with a larger amount of free mucus with the stools, will help you to differentiate a colitis from inflammation of the small intestine only. Boas is authority for the statement that, in colitis, bilirubin cannot be recognized in the stools, having been con- verted into urobilin. AMien the stools contain much undigested matter with com- parativeh' little mucus, and this finely divided as well as in- timately mixed with the feces, the catarrh aft'ects the small intestine mainly. In the same condition the microscope will reveal many undigested muscle fi-bers, fat globules, and starch granules. The chemical reaction of the feces in enteritis varies widely. At present it affords no certain trustworthy guide, except that when there is excessive acidity alkaline astringents, such as the preparations of lime, should be included among the remedies prescribed. Some rise of temperature is a usual accompaniment in marked cases, especially those due to infection. Fever is nearly always present when the patient is an infant or young child, but is less constantly seen in older patients. Various degrees of exhaustion and nervous derangement may result, the form and severity of such phenomena depending upon the age, tem- perament, and previous strength of the patient. The urine becomes scanty, high-colored, and often loaded with indican. Albumin and even hyalin and blood casts may also appear in the urine during the attack, disappearing after convalescence. Diagnosis. — Primary acute enteritis does not closely re- semble any other affection. Cholera morbus and cholera in- fantum, which may be considered as merely violent forms of acute gastro-enteritis, produced by an uncommonly severe in- ACUTE CATARRH OF THE INTESTINES 7 II fection, are easily differentiated by the early and severe gastric symptoms, their more rapid and violent course, including the earlv serious prostration, and wasting and pronounced and very painful cramps. It would not be possible to diegnosti- cate from simple acute enteritis the precursory diarrhea of Asiatic cholera, but later the rice-water stools containing the comma bacillus would be decisive. Serous diarrhea from nervous causes is recognizable by the character of the stools and the absence of all inflammatory symptoms, including mucus in the stools and tender spots over the abdomen. Prognosis. — Uncomplicated acute intestinal catarrh is rarely fatal, except in infants under three years, and even in the latter is nearly always curable, provided the child can be kept under the best possible hygienic conditions, removed to the seashore or mountains, when the attack occurs in hot weather, and have a suitable diet, including good breast milk for those not yet weaned, or fresh cow's or goat's milk, properly modi- fied and combined, for the older ones. In very old or debilitated persons, too, the affection is some- times fatal, but generally because of incurable disease in the stomach, heart, liver, lungs, or kidneys, of which it is merely a complication. Treatment. — In no acute disease is the proper treatment simpler or more uniformly successful than in acute enteritis in adults or in children over three or four years old ; and yet probably none is oftener wrongly treated. The indications are first to remove promptly and thoroughly the noxious cause, instead of waiting for nature's slow efforts to accomplish this by diarrhea, and next to give as complete rest as possible to the temporarily crippled digestive system. When you have se- cured these two conditions, nature will quickly effect a cure in the great majority of cases without other aid. Elimina- tion and functional rest then constitute the keynote of the treatment; and in febrile cases, rest in bed should be en- forced. The emptying of the alimentary canal can generally 712 THE GASTRO-INTESTINAL CLINIC best be accomplished by some gentle laxative, though if the symptoms are urgent, as when there is high fever or convul- sions, or other serious nervous complications, pointing to grave auto-intoxication, you should also cleanse the colon at once by a copious irrigation with a warm saline solution to which some antiseptic may be added. For the laxative, a saline or castor oil in not too large a dose (say one to four teaspoonfuls of the latter) usually proves efficient, but no single remedy acts so magically as a mild mercurial purge, preferably calomel in the dose of 1-20 to 1-6 of a grain, according to the age, mixed with a grain of sugar of milk and repeated every half hour, until a favorable change of color appears in the stools. Not more than six to ten doses should be needed to restore the normal dark yellow color, or at least a rich golden yellow showing an increased content of bile, and at the same time to remove in a few hours all the worst symptoms. I will not at- tempt here to answer the objections which have been urged against this remedy, nor to speculate as to how small doses of calomel accomplish such strikingly good results. It is suf- ficient to emphasize the often observed clinical fact that the remedy will cure rapidly, pleasantly, and harmlessly in most of these cases, provided at the same time the digestive system is allowed to rest, the food being either wholly stopped for a day or two, or (when this is impracticable) limited to the lightest possible articles, such as a few spoonfuls at a time of toast water, egg water, or rice water'' in babies, and very small feedings in adults of wine whey or the weakest broths. If by the second day, with such a treatment, the patient is not well, or so nearly so that manifestly nothing further is needed beyond a day or two more of functional rest through a severely restricted diet, you may administer one-half the former dose of calomel every two or three hours for one day longer. If there should then be still a tendency toward diarrhea, it would indicate either an exceptionally severe infection, or that there had been ])reviously a chronic catarrh, involving portions of the intestines, and often the stomach as well. This chronic ACUTE CATARRH OF THE INTESTINES 713 process after the subsidence of the acute attack would prevent an early return to normal conditions and demand further treat- ment. Some one of the bismuth preparations, given in a simple mixture of mint water and limewater after every stool, should then prove efficient in controlling the remains of the diarrhea. The following formula usually does well : I^ Bismuth subnitrat 3 i" Tannalbin 3 v Mist, cretse, q. s. ad f § iv ■ M. Sig. : One-half to two teapoonfuls, according to age, after every loose stool. When much pain or frecjuent loose movements persist, as will very rarely happen if the above-mentioned plan is carried out in its entirety, the foregoing prescription may prove more rapidly effective with a few drops of paregoric or deodorized tincture of opium added to each dose. ■ Another good formula for stubborn cases is the following: I^ Ichthalbin ) aa '^ ii Tannalbin ) M. et ft. chart No. XV. Sig.: One to two powders in milk or water upon arising, at bed- time, and after each loose stool. Remember especially that during. the first day or two the important thing is to assist nature in clearing out the alimen- tary canal, and to spare the digestive organs by allowing the smallest possible' amount of nutriment. To give an astrin- gent before the bowels have been thoroughly emptied is never useful or justifiable, but always harmful and sometimes dis- astrous. The early use of opiates should be equally avoided, except in the presence of intolerable pain, and even then a further gentle use of laxatives in addition to antacids, com- bined if need be with an antispasmodic, such as the annexed prescription calls for, is generally all-sufficient and far safer: IJ Tr. Cardam. comp ^ f 3 iv Sps. ammon. arom f 3 m Sps. chloroform, q. s. ad f 3 xii M. Sig.: Teaspoonful in half-glass of hot water every hour or two till relief. 714 THE GASTRO-INTESTINAL CLINIC When the colon is solely or chiefly involved, cleansing from below by irrigations with saline, soothing, and antiseptic solu- tions sometimes offers advantages, especially in proctitis, though in chronic colitis these local measures play a more im- portant role than in the acute form. In simple acute, non- dysenteric colitis, rest of the whole body by confinement to bed and rest, especially of the digestive organs, with elimina- tion by laxatives, will usually cure within a few days. The diet for the exceptional cases that linger on longer, in spite of the treatment above laid down, should comprise, mainly, thoroughly fresh milk boiled and mixed with lime- water or peptonized and, in the case of children, properly di- luted and modified to approximate it to human milk, fresh beef juice pressed out of a broiled steak, soft-boiled or poached eggs, or egg water for children, Eskay's Food, or Plasmon, Bovinine, whey, kumyss, and later chopped beef, toasted bread, zwieback, boiled rice, and the best of the various biscuits (crackers) on the market, provided they are fresh. The bis- cuits sold in the shops are often many months old. All the vegetables and fruits should be avoided. Should the gastric juice be found defi^::;nt, HCl and pepsin may be given, es- pecially when the diet is increased. In the cases in which there is an absence of gastric secretion, with atrophy of the glands, the preparations of pancreas may be administered hopefully with or after food. When the HCl secretion is excessive, on the other hand, the preparations of chalk and bismuth should be administered with nitrate of silver and, if need be, bella- donna, but, as a rule, not opium, which tends usually to increase the secretion. Let me repeat in closing, ( i ) that in the early stages of any acute inflammatory or infectious diarrhea, astringents are al- ways, and opiates generally, useless and harmful; and (2) that with the proper treatment by rest and elimination in the first stage, there will rarely ever be any second stage to treat. LECTURE LXVI CHRONIC CATARRH OF THE INTES- TINES (ENTERITIS CHRONICA) Probably no disease affecting the digestive system, except the derangements of gastric secretion, is more prevalent than the chronic form of intestinal catarrh. It is very often over- looked, the victims being treated for the associated neuras- thenia, which in some cases may be the cause, and in many others is certainly a consequence. The only symptoms of certain mild cases are often nervous derangements, and in the earlier stages of the less severe cases there may be absolutely no symptoms, except usually some sluggishness of the bowels. .ffitiology. — Some of the causes which provoke acute catarrh of the intestines also tend to produce the chronic form. These include improper diet, and especially overeating, insufficient exercise of the abdominal muscles, enteroptosis, constipation, the abuse of purgatives, and a prolonged excessive secretion of the gastric juice (hyperchlorhydria) among other setiologic factors. It is probable that in persons with an inherited tend- ency to it, lithemia, as well as neurasthenia due to excessive mental work or overstrain of the nervous system in any way, especially sexual excesses or irregularities, may stand in a causal relation to chronic enteric catarrh, as also to various other derangements and diseases of the digestive system. The most frequent sequence of events in these cases is, according to my experience, as follows : (i) An inherited neurotic tendency; (2) overstrain or other injury to the nervous system with deficient exercise and excessive eating, often provoked by tonics; (3) a resulting de- rangement of the digestion either gastric or intestinal, or both, and most commonly some aberration of the gastric secretion, 715 /l6 THE GASTRO-INTESTINAL CLINIC especially hyperchlorhyclria ; (4) deranged defecation — con- stipation or diarrhea; (5) auto-intoxication from the absorp- tion of the toxic products of a perverted metabolism; and (6) enteritis, which is often acute at first, recurring frequently enough to set up finally a chronic inflammatory process, though it may be in many instances chronic from the beginning. In all the persistent cases, of course, a vicious circle becomes es- tablished, and then the catarrhal process and auto-intoxication are each increased by the other. The disease may result secondarily from morbid growths in or adjacent to the in- testines, and from certain affections of the heart, kidneys, stomach, liver, tuberculosis of the lungs or the bowels, as well as from organic disease in other parts of the body, including, of course, typhoid fever, and sometimes malaria. Influenza is perhaps the most frecpent acute cause of the disease, and the recent large increase in the prevalence of appendicitis is possibly a direct result of repeated attacks of grippe involving the intestines. A slowing of the circulation, in consequence of cardiac or hepatic disease, is often also a predisposing cause of chronic enteritis. Pathology. — In chronic intestinal catarrh there are present the usual changes in the mucous membrane which character- ize the same process elsewhere. The mucosa becomes at first gradually swollen and thickened. Its color is grayish or pale reddish, with dark or black pigment in places. As in the acute form the blood-vessels are enlarged, distended, and often tortuous; the secretion is increased, and the surface of the mucosa is covered with a layer of viscid mucus. Chronic enteritis may be hyperplastic, with increase of the glandular elements, a marked infiltration of round cells, and often proliferation of the connective tissue, or atrophic with, in the end, a shrinking of all the structures. In the latter type, which is a late development of the ordinary catarrhal en- teritis, the glands themselves undergo atrophy, and both the mucosa and sul)mucosa become thinner. Ulcers and erosions are frequently present in this form or stage of the inflamma- CHRONIC CATARRH OF THE INTESTINES JlJ tion. As in inflammation of the gastric mucosa, there is also a form of chronic enteritis in which proHferation of the connective tissue is the predominant feature, and then the glands secondarily atrophy as a result of the pressure of the surrounding hyperplastic structures. Symptomatology. — Though there may be no marked symptoms at first, yet even in the lightest case the patient com- monly shows some falling off in nerve tone, and in both mental and physical vigor, or is at least more easily tired than usual. There are likely to be felt also, quite early in any pronounced case, uncomfortable sensations, referred to some part of the lower abdomen. These come on two to four hours, or even longer, after a meal, and consist usually of a feeling of pressure, fullness, or distention from gases which often cause rumbling and gurgling sounds — borborygmi. These flatu- lent symptoms frequently constitute the only discomfort ex- perienced, the bowel movements continuing for a time ap- parently normal, though generally there is either constipation or diarrhea, or first one and then the other. When such an alternation exists, the underlying condition is really one of con- stipation, the recurring attacks of diarrhea being due to the irritation provoked by retained masses of feces. When the catarrh involves the colon, the acme of symptoms generally occurs shortly before the stool. In cases of chronic colitis, in which there are only one or two stools daily, and these in the morning, the patient is likely to be awakened early by the ac- cumulation of gases, with the resulting discomfort or pains. In duodenal catarrh the stomach is nearly always more or less involved. Exceptionally then, and sometimes when the catarrh affects only other parts- of the gut, there may be nausea, vomiting, and loss of appetite. Anorexia is indeed a very common symptom in all the severer forms. Pain or discom- fort within an hour or two after taking food is often ex- perienced in duodenal catarrh, and in these cases, also, even with no demonstrable implication of the stomach, there is likely to be much eructation of gas, coming on soon after be- yiS THE GASTRO-IXTESTINAL CLINIC ginning to eat. The same phenomenon 3-011 may observe after a thorough lavage. This seemed to me difficult of explanation until I reflected that the opening of the pylorus for the down- ward passage of the licjuid in the stomach would permit an upward rush of the gases which were distending the bowel. Vertigo, headache, anorexia, and jaundice, or at least a very muddy color of the skin, are much more frequently en- countered in catarrh of the duodenum than when this most im- portant part of the digestive tube is not involved. A\'hen the rectum shares in the catarrhal process, the patient will usually complain much of tenesmus after the evacuations. There may be no really painful straining, but instead only a feeling that the stools are not complete — as though some feces remain which cannot be expelled. In severe or advanced cases of catarrh in any part of the bowels, there is alwa3's much self-poisoning from the absorp- tion of the products of faulty metabolism, and you may expect to find many of the typical symptoms of lithsemia and nerve exhaustion, including especially palpitation of the heart with cold extremities, more or less anaemia, insomnia, either mental depression or great irritability, impaired memory, physical debility, etc. In bad cases which do not respond to treatment, you will be likely to observe also a more or less progressive emaciation and loss of strength, as well as a gradual aggrava- tion of all the symptoms, including especially a stubborn diarrhea in advanced cases which involve a large portion of the bowel. Boas^ calls attention to the great variability of different cases of chronic enteric catarrh, some running an almost latent course, while others are marked by very troublesome symp- toms. He has found the general condition of the patients in cases characterized by constipation to be usually little altered, while in chronic enteritis accompanied by copious diarrhea, especially if it involve predominantly the upper bowel, the con- dition of the patient is much more serious. This one would ' " Diagnostik u. Therapie d. Darmkrankheiten," Leipzig, 1899, p. 222. CHRONIC CATARRH OF THE INTESTINES 7^9 naturally expect, since chronic enteritis with diarrhea, which persists, is usually either complicated by ulceration, or else considerable portions of both the small and large intestines are involved. Moreover, very much more poison is absorbed from liquid feces than from those that remain dry or formed. The objective symptoms of intestinal catarrh have to do mainly with the character of the stools, as well as with signs to be elicited by palpation and by succussion or clapotage (tap- ping the abdomen with the finger tips to produce splashing sounds). Inspection of the uncovered abdomen may also afford information, by showing tympanitic swellings over either the whole lower abdomen, or over the cecum or other portions of the intestines. These would render probable the existence of a spastic condition or irregular contractions of the circular fibers of the bowel, though not diagnostic of such a complication. In any well-marked case of enteric catarrh palpation will generally reveal tender areas corresponding to the locality of the part of the intestine involved, especially when this is the colon, and these will be most readily demonstrated when hard feces are present. Such areas are most commonly found over the cecum, sigmoid flexure, or the middle portion of the trans- verse colon. If the disease has continued long, you will often be able to detect by deep and careful palpation the appendix, thickened by a catarrhal inflammation and more or less sensi- tive to pressure. In such cases considerably more muscular resistance will be felt in palpating over the right than over the left iliac fossa. In cases in which there is much catarrh of the cecum, you will likely be able to elicit a splashing sound over that region at almost any time when there is diarrhea, and often in the constipated cases as well, especially a few hours after much fluid has been taken, though this sign may signify merely dilatation of the cecum. The splash may often be ob- tained over other parts of an atonic colon at a suitable time after taking food or drink. Palpation may also reveal masses of hardened feces in any part of the colon. 720 THE GASTRO-INTESTINAL CLINIC All kinds of stools may be observed in chronic enteritis, from thin watery ones passed three to ten times, or even much oftener in the twenty-four hours, to those apparently normal in all respects. Usually, however, more or less mucus will be found with the evacuations — intimately mixed through them, as a rule, when the trouble is mainly in the upper intestine, and smeared over the outside of formed stools when the colon only or chiefly is affected. A close inspection of the stools, even macroscopically, will often enable you to distinguish particles of undigested food, and by the aid of the microscope you can detect, in most cases of catarrh, undigested muscle fibers, starch granules, lumps of casein, fat globules, etc. Neither blood nor pus is usually to be met with in uncomplicated enteric catarrh of moderate in- tensity, and when present in considerable quantity would point to complications. Even the entire absence of mucus for long periods does not exclude chronic enteritis, since there may be atrophy of the mucous membrane, or the mucus may be retained in pockets for considerable periods before being passed. Diagnosis. — Well-marked chronic intestinal catarrh you will easily recognize by the description above given; but the atypical cases may well bother any physician until they have been for some time under observation. The chief distinguish- ing features are at least a slight, and sometimes very marked, impairment of the general health in connection with pain or discomfort in the bowels, and tender areas over them, irregu- larity in the character or number of the stools, and usually the frequent or occasional presence of mucus in them. There is also nearly always an excessive formation of gases in the in- testines, much of which, however, when the disease is in the upper intestine, may escape upward into the stomach and be eructated. The greatest complaints from bloating or gaseous distention will naturally be made in those cases complicated with constipation. An important confirmatory sign is the presence in the urine of indican or aromatic sulphates, or both, CHRONIC CATARRH OF THE INTESTINES 721 in excessive quantities, though these may be found also in cancer, tuberculosis, intestinal obstruction, intestinal indiges- tion, etc., and may, exceptionally, be absent in mild or mod- erate cases of chronic enteritis. The greatest difficulty you are likely to encounter will be in differentiating chronic enteric catarrh from nervous forms of diarrhea, resulting from vaso-motor paresis. Boas holds that in some instances the diagnosis between these can scarcely be made. But in genuine nervous diarrhea there is no mucus, and rarely any pain; the stools are not fetid, no indicanuria nor excess of the aromatic sulphates is likely to appear in the urine, and the attacks are usually transient, as well as coinci- dent with an increase in the other neurasthenic or hysteric symptoms. If such diarrheal attacks recur often, and particu- larly if they incline to linger for days at a time, it may well be suspected that a catarrhal process has been set up. Constipa- tion from stricture, tumors, etc., is to be differentiated also; but when this persists long, a catarrhal process nearly always results. Above all, do not forget that intestinal catarrh is by no means synonymous with diarrhea, the majority of the cases being accompanied at first, at least, by constipation. Prognosis. — This is one of the most difficult of all non- malignant diseases to cure. Yet it is always curable by ap- propriate treatment in the earlier stages, and generally in the later ones, provided the patients can afford the necessary out- lay of time and money with, often, prolonged rest from an in- jurious occupation, and especially if they are willing to change, radicalh^ and permanently, the faulty habits as to diet and ex- ercise (often dress as well) which you will usually find to have been prominent in the causation. Even when the ap- pendix has become involved in the catarrhal process, as hap- pens ultimately in a large proportion of prolonged cases, a cure without operative intervention may sometimes reward your persistent efforts ; but in the more stubborn cases re- moval of the appendix is usually desirable, and, in persons 722 THE GASTRO-INTESTINAL CLINIC not able to afford a long course of treatment, is often indis- pensable, especially when there occur occasionally acute attacks. Treatment. — The dietetic is the most difficult part of the treatment, and the most important. An almost exclusive diet of meat, with a very free use of hot water — the pulp of lean beef, or finely hashed beef or mutton, with just enough of lettuce or celery to act as a relish, and a slice or two of stale bread and butter daily — kept up for a few weeks, will often accomplish brilliant results in controlling catarrh, either gas- tric or intestinal; but there are important contra-indications to such a regimen. When a dilated stomach, or one with a very poor motor power, coexists, as often happens, the large amounts of water will disagree, unless given one glass at a time, and sometimes even then. When there is a very feeble heart, the superabundance of fluid involves dangers, and when the heart is enfeebled by gouty conditions, that is, overtaxed by forcing the blood through arterioles contracted by the alloxuric bases or other poisons produced in lithsemia, there is the added danger that the overplus of meat will aggravate. Moreover, in patients having rheumatism or arteriosclerosis, as in the case of so many elderly ones, the meat diet often proves harmful. But even in persons in whom no such contra-indications appear, it is not always safe. I once saw a young lady become insane, as a result apparently of such a diet after a few weeks' use of it; and in any case, it can scarcely be continued in a strict form longer than three or four weeks. An occasional fast of five to ten days will sometimes effect a cure when the cause was an overtaxed liver and digestive glands. Rest is one of our very best remedies for any diseased organ. When the meat diet does not suit, or when the intestinal catarrh persists, after trying it for a sufficient length of time, your best reliance will be upon good stale white or whole wheat bread (not very coarse bran or brown bread) and butter, together with some of the well-baked cereal foods in a dry CHRONIC CATARRH OF THE INTESTINES 723 form, so as to require thorough mastication and insahvation. Thoroughly cooked rice and gluten preparations are allowable. Eggs, except fried, can also be eaten once or twice daily, and good fresh lean fish may be taken. Fresh milk, preferably boiled or sterilized, and a small or even moderate amount of cream are generally well borne, though there are cases in which they wholly disagree, and Boas tabooes milk entirely in this affection. Scraped or hashed meat once or twice a day is de- sirable in most cases, and sometimes steak, chops, or even tender broiled ham in small quantities, well chewed, agree per- fectly. Sugar and the fruits always aggravate in the severer cases, and when there is diarrhea, especially, should be rigor- ously prohibited. The vegetables are nearly as bad, and though a little celery, lettuce, asparagus tops, or even baked white potato may not always seem at once to disturb, much of them at one time usually does, and the potato especially is likely to increase the fermentation. Summer squash, pumpkin, egg plant, etc., may be cautiously tried in the lighter cases with constipation. All vegetables agree best in purees. Most of them are positively hurtful in well-marked cases of intestinal catarrh. As to beverages, alcohol should be generally avoided, but tea and coffee may be allowed in moderation, provided the patient be not lithsemic. Chocolate and cocoa generally disa- gree on account of their accompanying sugar and large con- tent of fat, but I have recently been seeing good results in patients who partook moderately of a preparation called Plas- mon-Cocoa, which contains no sugar, and yet is fairly pala- table and very nourishing. Cereal coffee and hot water flavored with milk, or otherwise, to suit the taste are safe drinks, and in Europe a little claret is often allowed when the gastric juice is deficient. Iced drinks are injurious. As to the other parts of the treatment, it is impossible to outline any definite course which will cure all cases. Indeed, in no field are experience, diagnostic acumen, an intimate knowledge of all the remedial measures, good judgment, and especially patience, so indispensable. 724 THE GASTRO-INTESTINAL CLINIC The fundamental requirements are to bring up the nerve tone and improve the circulation in the intestines by whatever means will best succeed. The most practicable and effective are, in general, the milder forms of outdoor exercise, includ- ing golfing, rowing, and horseback riding, together with massage (except when there is hyperchlorhydria, or a spastic condition of the bowels), electricity and hydriatic procedures, such as colonic flushing with mild antiseptic or astringent so- lutions, and wet packs and jet douches to the abdomen. An equally important thing is to secure good drainage — perfect elimination through the bowels, kidneys, and skin. This, can often be accomplished by the above-named measures, and drinking freely — even copiously sometimes — of pure water, when this is not otherwise contra-indicated. In some cases, however, a cautious use of the gentler and least irritating laxatives, such as olive oil, by mouth or enema, Purpetrol, a highly purified preparation made from a Russian coal oil, cas- cara sagrada, sulphur, or the salines (especially the phosphate or sulphate of sodium) will best effect this object. It is nearly always indispensable that there should be one complete evacua- tion every day, or at least every other day, but, if possible, this should not be loose — never watery. Even in the cases in which constant diarrhea has become established, flushing the colon with a normal salt solution, followed by injections of antisep- tics, and when necessary also an astringent, such as a teaspoon- ful of bismuth to the pint of tepid water, nearly always gives better results than opiates and astringents by the mouth. These last are rarely necessary, even temporarily, and used long al- ways do harm. Dr. Deardorff of San Francisco recommends in chronic colitis the injection every other evening of several quarts of a normal salt solution, and on the alternate evenings the following: Ac. carbol 3 iss Glycerin f 1 iii Listerin q. s. ad f ^ vi M. Sig. : Add two tablespoonfuls to two quarts of cool or tepid water and inject every other evening. CHRONIC CATARRH OF THE INTESTINES 72 5 I have used this in numerous cases with excellent results in nearly all, but have found that carbolic acid, given by the bowel, will aggravate any coexisting hyperchlorhydria almost as quickly as when taken by the mouth. Recently I have seen a very stubborn case of chronic colitis cured by injections of bismuth with cotton-seed oil. When there is persistent diarrhea, the massage should be light, or omitted, and so also when there is constipation of spastic origin. The milder astringents, such as bismuth, ichthalbin, tannalbin, and tannigen, may also be given by the mouth in 5- to lo-grain doses after every stool, when the bowels are per- sistently loose. In all stubborn cases the stomach should be tested by washing out or extracting the contents, four to six hours after a meal, to ascertain the degree of gastric motor power and the character of the chyme being delivered into the in- testines — whether or not well digested, and whether irritat- ing from an excess of either free HCl or organic acids result- ing from fermentation. When in this way you find the stom- ach contents excessively irritating from a too high acidity, you will naturally need to remove such a cause of the intestinal trouble, before you can hope to effect a cure. The appropriate treatment of the gastric disease will need to be instituted, and if there be much stagnation, gastric lavage, for a time, will be indispensable. Supposing the cause or causes to have been removed, the remedies already mentioned will rarely fail to control the symptoms, except in the severest cases. When one or two loose stools recur every morning, I have seen very small doses of podophyllin — grain i-ioo every three to four hours — act most happily in restraining it (see Lecture XXXIV.). Sometimes I- 10 grain doses of calomel every two to four hours prove the most efficient means of stopping the offensive diarrhea which results as a complication from taking cold, or more often from some imprudence in diet. The same small doses of calomel given for one or two days in each week, or until bile- T2^ THE GASTRO-INTESTINAL CLINIC tinged stools result, are frequently a useful adjuvant in chronic intestinal catarrh. Various spring waters have been recommended for this af- fection, including especially those of Carlsbad. Plombieres, and Vichy in Europe, and those of Saratoga (N. Y.) and Bed- ford (Pa.), and they often exert a curative influence; but pa- tients possibly profit as much by the rest from business or social cares, and change of scene at such resorts, as from the medication. The sulphate of sodium, dissolved in hot water, and sometimes combined with a little bicarbonate or chloride of sodium, will usually prove nearly as useful as the imported spring waters taken at home. In the severe cases having diarrhea, and those in which constipation is complicated with serious nervous exhaustion, rest in bed, for two to four weeks at least, should be insisted upon. This not only secures needed physical and mental rest, but insures better nursing and a closer study of the patient's case by the physician. In all the cases in which the strength is not seriously re- duced, the gymnastic exercises for the abdominal muscles de- scribed in Lecture XXIII. , or other ecjually efficient ones, should be practiced daily to increase the tonicity of the mus- culature, and improve the circulation in the parts. This should not be neglected, even when massage is regularly applied, unless the patient is unecjual to any active exercise. In the more obstinate forms of the disease, a valuable method of treatment to supplement the dietetic and other meas- ures already described, is that introduced by Doumer.^ It consists of the passage, by means of large flat electrodes, of as full doses of galvanism as can be borne through the abdo- men from one iliac fossa to the other. Very large doses can safely be applied in this way. Doumer runs the current gradu- ally up to 70 or even 80 ma. Once a minute he reduces it to 40 ma., and the current having been reversed to produce a momentary shock, the dose is again slowly increased to the 1 Gaz. des Hop., October 27, 1900. CHRONIC CATARRH OF THE INTESTINES ^2^ former limit. He begins with a ten-minute sitting daily, and later lessens it to three times a week. This is kept up for from four to six weeks. Other extraordinary methods applicable in stubborn chronic catarrhs of the colon especially, include that by means of hy- droelectric applications, which you will find described in Lec- ture XXVI. and Turck's method by lavage of the colon de- scribed in Lecture XXVIL ; also the injection of carbon dioxide (COJ, recommended by Dr. A. Rose and described in Lecture XXVIL Applications of the static wave current over the lower abdomen have proved useful in my experience for such cases. To sum up : the most useful measures in my hands have been ( i ) a bland, easily digestible and at the same time very nourishing diet; (2) keeping the bowels regularly open by the mildest means, avoiding purgative drugs so far as possible and relying largely upon enemas of olive oil; and (3) the use three times a week of electricity in the form of the continuous cur- rent applied according to the Doumer method described on the preceding page, or by passing doses of 25 to 30 M. A. through the body from the sacrum (positive pole) to the middle of the lower abdomen in front (negative pole), the seances to last ten to fifteen minutes each. In the cases associated with much nervous debility the patient will progress better if kept at rest recumbent and given passive exercise only by means of massage and general faradization. The French physicians seem to consider most cases of chronic enteritis as mucomembranous and recommend the more stubborn ones either to bathe in the waters of Plombieres and take colon douches of them at the same time, or to drink the waters at Chatel-Guyon . I have known some cases to be cured at Plombieres and one patient to be so seriously depressed by the treatment there, that after waiting three weeks for the promised secondary gain, he was only rescued by a course at Kissengen from what threatened to become a disastrous con- dition. LECTURE LXVII APPENDICITIS, ITS SYMPTOMS, DIAGNO- SIS, ETC. Inflammation in the cecal region formerly classed as typhlitis, perityphlitis, or paratyphlitis, is, in accordance with a newer pathology, now called appendicitis. It is believed nearly always to originate in the appendix vermiformis and ex- tend later in a certain proportion of the cases to the surround- ing tissues. There is doubtless in most cases a previously existing catarrhal process in the colon, which involves the cecum in a more or less obscure way, not often provoking active or serious symptoms there. Finally, when the process extends to the narrow piece of gut known as the appendix vermifonnis, and has produced enough swelling of the mucous membrane of that structure to interfere with free drainage of its contents into the large bowel, threatening symptoms begin. But it simplifies matters to regard the place where the serious symptoms generally arise as the source of the mischief and name the disease accordingly. Very exceptionally, the attack is merely a typhlitis or inflammation of the cecum from first to last, no other structure being involved; but such cases are admittedly rare. The Different Forms of Appendicitis. — Numerous varieties of appendicitis have been described, and the subject thus quite unnecessarily complicated. For example, the following classes have been named: (i) appendicular colic; (2) simple acute catarrhal appendicitis; (3) chronic catarrhal appendicitis, (a) oblitcrative and (b) persistent; (4) interstitial appendicitis; (5) ulcerative appendicitis; (6) purulent appendicitis without perforation or any periappendicitis; (7) purulent appendi- 728 APPENDICITIS 729 citis with leaking of pus into the peritoneal cavity through a small perforation or otherwise, producing local peritonitis and a limited walled-off abscess; (8) purulent appendicitis with extraperitoneal, retrocecal abscess from the escape of pus through a perforation into the connective tissue behind the cecum; (9) purulent appendicitis, with large escape of pus through a perforation into the peritoneal cavity and the production of general peritonitis; (10) gangrenous appen- dicitis. All the foregoing are possible forms of the disease, or pos- sible developments of an attack which began as a simple catar- rhal inflammation of the appendix, or at least extended to it from a similar process in the cecum, which produced no note- worthy symptoms until it invaded the narrower tube, the swelling of whose mucous membrane caused obstruction of its lumen. You should know that what is apparently a simple catarrhal inflammation of the appendix may result in an abscess, or exceptionally take any of the above-mentioned forms, and it is also important to understand clearly that the latter are all merely manifestations of one disease process. A better classification is based virtually upon the degree of vir- ulency of the infecting germs and divides the disease into two forms: (i) the simple catarrhal, and (2) the severe form which is likely to result in the rapid formation of pus, with perforation and possibly gangrene following in a considerable proportion of the cases. The so-called appendicular colic prob- ably never occurs except in an appendix already the site of a catarrhal process ; and the ulcerative form may develop from any severe or prolonged case of catarrhal appendicitis. In all the forms there is more or less involvement of the interstitial connective tissue, but in some cases this tissue is predominantly affected. .ffitiology. — The aetiology of appendicitis has been much disputed. The former view was that the disease is always due to the lodging of fruit seeds, other foreign bodies, or fecal concretions in the appendix. A large number of autop- 730 THE GASTRO-INTESTINAL CLINIC sies have proved that this, though one of the possible causes, is by no means the most frequent one. Different series of au- topsies have revealed foreign bodies or concretions of some kind (mostly fecal) in from one-twentieth to somewhat more than one-third the total number of cases studied. The cause in other cases is traumatism, twisting of the appendix from over- distention of the cecum or ileum, but is most generally in all probability an extension of an inflammatory catarrhal process from the cecum to the mucous membrane of the appendix itself. Both pus cocci and the bacillus coli communis are be- lieved to be able to set up the process, but the latter is by far the most frequent infecting agent. A. O. J. Kelly of Philadelphia has written the most rational and lucid explanation of the origin and development of ap- pendicitis which has yet appeared anywhere. It forms a part of Deaver's " Treatise on Appendicitis," third edition. Kelly has made a thorough investigation of the subject based upon a careful study of 577 appendices, all but 21 of which were ex- amined microscopically. Calculi, even when found in the appendix, are considered by him to have been the consequence, not the cause, of the inflammation of the mucosa. The swelling of the latter produces frequent occlusion of the tube, as happens in the case of all similar narrow structures lined by a mucous membrane. The occlusion leads to stagnation of the contents, with, as a consequence, increased virulency of the colon bacilli or other germs thus imprisoned. The pathology is now sufficiently well understood. The in- flammation attacks first the mucous membrane of the appendix (swelling and erosion) and then involves in succession the submucous and muscular layers, and, in cases not previously arrested, finally extends to the serous coat, producing a local peritonitis. At a comparatively early stage of the process the swollen membrane may close completely the opening into the cecum, and portions of feces with the secretions of the part may thus be retained and undergo decomposition within the appendix. In favorable cases, especially when the colon is APPENDICITIS 731 regularly emptied every day by a sufficient bowel movement, this swelling subsides enough to allow the contents to be ex- pelled, this occurring often after an attack of severe colic (appendicular colic). In less fortunate cases in which the infection is greater, or the recuperative powers of the patient less, and feeding by the mouth not prevented, the occlusion persists, the contents of the appendix become purulent, and we have then established a collection of pus in the appendix which, however, may still possibly find a safe vent spontaneously. Under favorable conditions, even after this stage has been reached, the opening into the bowel is sometimes re-established, and the pus drains harmlessly away. Under less fortunate conditions the walls of the appendix are infiltrated with in- flammatory exudate, the adjacent coils of the intestines become agglutinated to the diseased structures, and with or without the escape of a small amount of pus from within the appendix, a true abscess cavity is established which, as a rule, when absolute rest of the parts has been maintained, is completely walled off from the rest of the peritoneal cavity. Such an abscess may rupture into the peritoneum with rapidly fatal results, or into some part of the intestine, into the rectum, vagina, .bladder, or any other neighboring viscus which may happen to become attached to the wall of the abscess by ad- hesive inflammation. Some such opening is the most frequent result in these localized forms of acute appendicitis going on to suppuration, unless complete rest of the body as well as of the gastro-intestinal functions has been maintained by strict confinement to bed and no food allowed except by enemas. \\'ith such an opening, except it be into the bladder, peritoneal cavity, or pleural cavity, the result may be favorable and con- valescence ensue. When, however, the abscess opens by a large opening into the peritoneal cavity, general peritonitis results, and very often (in one-third to one-half the cases), even in spite of immediate operation, the patient dies. If it should open into the bladder or pleural cavity, the danger of fatal in- fection is also great. In a large proportion of cases no abscess 732 THE GASTRO-INTESTINAL CLINIC forms, the inflammatory process resulting from a true infec- tipn involves the various layers of the appendix, including often the peritoneum, and we have developed a mild local peri- tonitis, which, under appropriate treatment with absolute rest, may terminate favorably in a resolution of the process. In the severer cases the cure is rarely complete, but there is usually left behind a focus of disease in the appendix which, in a ma- jority of instances, is likely to be lighted up again into an acute inflammation at any time later upon a sufficient provocation, such as persistent constipation, prolonged exposure to cold and dampness, etc. When the infection is particularly virulent, or from any cause there is obstruction of the circulation in the part, the in- flammation may take on a gangrenous form and prove rapidly fatal. But in a certain, though probably very small propor- tion of even the suppurative cases, the cure may be complete. In some of these which go on to abscess formation, the ap- pendix sloughs away and is thus totally destroyed, or an ob- literative inflammation may destroy the lumen of the little piece of gut, the sides being agglutinated and a solid struc- ture formed. In still other cases, especially those in which the inflammation does not progress beyond the catarrhal stage, the recovery proves permanent, the infiltrated tissues having un- dergone resolution, and there is never any recurrence of the attack. This may result from a persistence with appropriate treatment of the constipation and catarrh of the cecum which have been the causes of the disease, and from following thence- forth a more hygienic mode of living as to diet, physical ex- ercise, etc. Symptoms. — The mildest cases of appendicitis give no symptoms ordinarily beyond a brief spell of colic, or even of a slight dull pain with constipation, or sometimes diarrhea, preceding it. These are now often called appendicular colic. There is little doubt that many of the cases of so-called bilious colic which all of you have seen in practice, and cured rapidly with the help of hot mush poultices and other simple meas- APPENDICITIS 733 ures, were mild cases of subacute catarrhal inflammation of the appendix, with temporary obstruction of the opening. In somewhat more marked cases of acute appendicitis there will generally be present obvious fever, or at least an increased rectal temperature, and also both severe pain and localized tenderness in the right iliac fossa, with constipation or some- times diarrhea, and usually at the outset one or more attacks of vomiting. You should bear in mind, however, that the pain and tenderness are not always in the right iliac fossa, since the appendix may occupy an abnormal position to the left of the median line, or far below or above its usual site ; and even with the appendix in its normal position, the pain at first is often diffused and referred to different parts of the abdomen. In all cases, therefore, of pain and tenderness, in any part of the abdomen, you should think of appendicitis as a possibility. The pain and tenderness are likely to be greatest at what is known as McBurney's point, which is usually midway of a line drawn from the umbilicus to the anterior superior spine of the ileum. To be more exact, this point of greatest tender- ness should be about two inches (5.08 cm.) from the iliac spine, toward the umbilicus in the line just described. In addition to pain and tenderness in this region you will find muscular rigidity, so that palpation of the parts beneath the surface will be very difficult. The right rectus muscle will at least be more rigid than the left. One well skilled in the art of palpation, and especially one accustomed to examine many appendices, can generally make out, in the early stages of acute appendi- citis as well as in the chronic forms, an indistinct and often somewhat ill-defined swelling or tumor corresponding to the enlarged appendix with, in severe cases, the infiltrated tissues surrounding it. The symptom fever may or may not be ushered in by chills, and is by no means always present. In the very mildest, as well as in some of the gravest, forms of the disease, there may be no fever, — at least no rise of the surface temperature or of that in the mouth. Generally, however, there will be an in- 734 THE GASTRO-INTESTINAL CLINIC crease of temperature, which in the milder cases is not likely toigo above ioo° or lOO 1-2°, but may rise as high as 103 1-2° or 104° — or even, in very severe cases with general peritonitis, 105° or 106° — in the rectum. According to Tiffany, nhe temperature in appendicitis should always be taken in the rectum, with the thermometer placed as high up as possible. Considerable fever will often be shown in. this way when the temperature taken in axilla, or even in the mouth, may be normal. Tiffany insists further that a difference of several degrees between the temperature in the mouth and that obtained high up in the rectum is indicative always of peritonitis. In the mildest cases of catarrhal appendicitis the pulse may vary little from the normal, but even in these is likely to be somewhat accelerated. In other cases it is generally more rapid than the increase in temperature would lead one to ex- pect. In the severer cases it is nearly always above 100, and may reach 130, 140, or even higher wdien general peritonitis exists. In all advanced cases there is dorsal decubitus, with the right knee, or sometimes both knees, flexed. Perforation occurring in an attack of acute appendicitis may lead to merely a slight limited extravasation, with the formation of a local abscess and only a gradual intensifying of the symptoms, or may produce at once grave and threatening symptoms. In many cases there develop suddenly a high rectal temperature, and very acute, often violent pain which may go on to profound collapse when the extravasation is general. The skin then is cold and clammy, and the pulse small and thready, becoming frequently so rapid that it cannot be counted. When general peritonitis has resulted, the ab- domen may be either very tympanitic or extremely rigid. Constipation is complete and urination scanty with the onset of general peritonitis, and there develop only too often all the signs of impending dissolution, including cold hands and feet, feeble respiration, and gradually failing circulation. Intellec- 1 Wood's " Reference Hand-book," last edition; article on Appendicitis, APPENDICITIS 7^35 tion is generally clear, and consciousness in fatal cases per- sists even to the last. Diagnosis. — A pronounced case of acute suppurative ap- pendicitis may easily be recognized by even a tyro in medicine, but there are mild and irregular forms of the disease which present many difficulties. It may resemble somewhat a mod- erate attack of typhoid fever, but the mode of onset and different course of the fever should render the differentiation easy. In the purulent and peritoneal forms there is leuco- cytosis in appendicitis, but never in typhoid fever. Obstruc- tion of the bowel, strangulated inguinal hernia, movable right kidney, stone in the right ureter or kidney, extra-uterine pregnancy on the right side, the twisted pedicle of an ovarian cyst, or hepatic colic may any of them produce symptoms similar in some respects to those of appendicitis. These, ex- cept the last, are devoid of fever ordinarily, and though appendi- citis may exceptionally pursue an afebrile course, careful observation should, within a short time enable the experienced diagnostician to differentiate them. Subacute perforation of a duodenal ulcer is often mistaken for acute appendicitis, and occasionally the same has hap- pened in the case of a gastric ulcer, situated at or near the py- lorus. Moynihan, quoted by Gibbon,^ is authority for the state- ment that of forty-nine cases of perforated duodenal ulcer, a diagnosis of appendicitis was made in eighteen. This could not easily occur in a case previously under the care of an expert diagnostician unless the ulcer had been a latent one. If the ulcer had ilni its course without the usual symptoms, and the perforation had led to an accumulation of fluid and local peritonitis in the right lower abdomen, it would be im- possible, without an exploratory incision, to make the diagnosis from appendicitis. Pus in the gall bladder, perinephritic abscess, acute tuber- cular peritonitis, acute hemorrhagic pancreatitis, local peritoni- tis in women in the region of the right ovary or tube, and right 1 A7ft. Med., December 19, 1903. 71^ THE GASTRO-INTESTINAL CLINIC hip-joint disease at an early stage, are usually characterized by f^ver as well as pain referred vaguely to the right side of the abdomen, and might possibly in some cases mislead you; but in these the pain would rarely, and the seat of tenderness never, be found at McBurney's point, except possibly in tuber- culosis of the cecum, while the mode of onset and other fea- tures would generally be very different. However, you should always think of these different causes when there is pain in the right hypochondriac region, and be able to exclude them before making a positive diagnosis of ap- pendicitis. In case of doubt you should call in consultation a medical expert trained in the diagnosis of abdominal diseases, one capable of giving an authoritative and unbiased opinion as to the need of operative intervention, and it is a wise precau- tion to have an abdominal surgeon in readiness at least, and, preferably, actually associated in the case from the beginning of the disease. Physical Signs. — A small tender swelling can generally be made out in the region of McBurney's point at an early stage by gentle but deep and firm pressure, though the extreme ten- sion of the right rectus muscle may prevent, and this marked tension is itself a valuable diagnostic sign. Later, in severe cases with much infiltration or oedema of the surrounding parts, a large doughy mass can nearly always be felt. Examination with the finger per rectum, or in women per vaginam, with bimanual palpation will help to make the diagnosis, especially when the pain is referred to the pelvis and external palpation does not afford conclusive information. Percussion may give a dull note over the tumor when this is very superficial, though more frequently there is tympany from portions of the in- testines lying above it. The pulse is usually from 90 to 100 in the catarrhal cases, but much higher in the purulent and peritoneal ones, frequently running up to 120 or 130, even in the absence of perforation. Clinical Course. — Appendicitis may exceptionally be slow and gradual in onset, but generally b€gins abruptly and, in the APPENDICITIS 737 severe cases, often with a chill followed by fever. In the milder catarrhal cases the pain is only moderate and is re- lieved by appropriate treatment. Improvement under favor- able conditions sets in soon and goes on to recovery. In the fulminating cases all the symptoms — pain, tender- ness, fever, and vomiting — are likely to be severe from the start, and, except the last, which may be wanting altogether, increase in intensity as the disease progresses. Sudden cessa- tion of pain and of surface fever is a bad sign, pointing to gangrene or perforation and general infection of the perito- neal cavity. In other cases general peritonitis may develop insidiously, with no such marked change in the symptoms. There may be a rise or little change in the temperature, and almost the only sign of the serious turn in the case may be a gradually ex- tending area of acute tenderness on palpation, with increased tympany, and a more anxious expression of the face. With such a development, whether it be sudden or gradual in its manifestations, the patients in a large proportion of cases, under the usual methods of treatment, grow steadily worse until death closes the scene. When a gangrenous condition of the appendix superv^enes the more alarming symptoms, including especially fever and pain, often abate, and unless you are on your guard the ap- parently favorable change may mislead you and cause you to relax your vigilance. Then a sudden rupture of the abscess, collapse, and speedy death threaten the patient unless operative intervention, or a strict persistence with rest in bed and the absolute withholding of food, drink, and disturbing medicines ])y the mouth, according to the method of Ochsner,^ succeeds in averting the danger. Chronic Catarrhal Appendicitis. — In a considerable pro- portion of the cases of apparent recovery from acute catarrhal appendicitis, and usually when the suppurative cases pursue a favorable course without operation, there is left behind a dis- 1 In/. Med. Mag., November, igor. 738 THE GASTRO-INTESTINAL CLINIC eased mucosa in the appendix, Avhich is prone to exacerbations and recurrent acute attacks depending upon the occlusion of the opening by infiltration and inflammatory swelling. Such a condition is called chronic catarrhal appendicitis. The same condition in mild form probably nearly always precedes the first acute attack (except when the latter results from trau- matism or the lodging of a foreign body), and there are good reasons for believing that it exists unrecognized for months, and sometimes years, in large numbers of persons. Many of these latent cases under favorable conditions recover sponta- neously. The disease can very generally be held in abeyance, ■and in the majority of cases be gradually improved, a cure finally resulting in the more fortunate ones ; but taking men ai.d women as they are, prone to be careless in diet, the disease is very likely to return. Some writers insist that there is a natural tendency with advancing years for the lumen of the appendix to be obliter- ated by atrophy and that, therefore, after thirty years of age the danger of developing acute appendicitis steadily lessens. According to these, nearly 70 per cent, of all persons over sixty-five have the lumen of their appendices permanently closed, so that they could not have an attack of appendicitis un- der any circumstances. It is well known^ at all events, that the disease is much more frequent in children and young per- sons, than in older persons, though no age can be said to be immune. The gourmands should not consider themselves safe in being too reckless in their diet even after sixty-five. In this form of appendicitis there may be no symptoms at all for a long time, the disease running an entirely latent course, except that often it may be noticed by the patient or his friends that he is less vigorous or enduring than pre- viously, or has a less ruddy color. Usually, however, there are manifold disturbances of the digestive and nervous sys- tems, including constipation, which sometimes alternates with diarrhea, intestinal flatulence, which is often very trouble- some indeed, dull headaches, impaired sleep, and in short all APPENDICITIS 739 the symptoms generally described as characteristic of neuras- thenia. It is often associated as a consequence, according to Edebohls, with a movable right kidney, and in the earlier stages of such cases there is generally hyperchlorhydria. The diagnosis of chronic catarrhal appendicitis requires an unusual degree of skill in palpation. It is difficult, except in very thin persons, to make out the normal appendix, but one which is swollen by catarrhal inflammation should generally be felt by an adept in palpation, except when the abdominal wall is very thick or the cecum is loaded with feces, or the surrounding tissues much infiltrated, as occurs after a recent acute attack. Edebohls and others have laid down elaborate directions for palpating the appendix, but the matter may be summed up in a few words and arranged under these three heads : ( i ) Have the sense of touch in your finger ends highly educated; (2) get the patient to relax the abdominal muscles completely, which is usually best accomplished by having him lie on the back with the knees flexed over a pillow, and making a few gentle stroking motions upon the abdomen, but some- times relaxation can only be caused by putting the patient in a warm bath; (3) stand on the patient's right side, and with one hand applied flatly against the abdomen, press the finger tips downward steadily, but gently at first so as not to excite contractions, and while you engage the patient in conversation so as to divert his attention as much as possible from what you are doing, press them firmly on down until finally you can feel the structures on the back wall of the abdomen. Then, if you will draw the fingers slowly from the umbilicus toward the anterior superior spine of the ileum on the right side, you should be able to distinguish an enlarged appendix as a little- finger-shaped resisting body which, whenever pressed upon, is likely to be extremely sensitive, whereas the normal appendix is not at all sensitive. There is sometimes an advantage in pressing with tlie left hand over the right or palpating hand. When the appendix is even slightly affected, the right rectus muscle is always very tense. Finding a very sensitive spot at 740 THE GASTRO-IXTESTIXAL CLINIC or near McBiirney's point is not diagnostic of appendicitis, because this may be found in catarrh of the cecum merely, and especially in such a condition complicated by ulceration. Neither will the failure either to feel the appendix thickened, or to find a sensitive spot in its normal site enable you to ex- clude the possibility of chronic appendicitis, since it may be displaced to some other part of the abdomen, or be behind a cecum which is full of soft feces. Prognosis. — The question as to the prognosis of appendi- citis has been greatly complicated by the controversy long waged as to when surgery should be invoked. Keen and White give the mortality of " appendicitis and the attending peri- typhlitis and paratyphlitis " as 12.5 to 14 per cent, (one out of seven to eight cases) ^ and various other estimates have been given, all of those covering large series of cases referring to patients treated in hospitals. In private practice the mortality including all the forms of the disease, the lighter catarrhal cases as well as the severer ones, is very much less. Ewald has put himself on record (" Twentieth Century Practice ") as believing that at least 90 per cent, of all cases recover under medical treatment alone. Hemmeter- cites Hertzog as reporting 285 cases treated by medical means onl}- with an average mortality of 14 per cent. ; 240 of these were circumscribed perityphlitis with a mortality of only 1.6 per cent, and 36 cases of diffuse perityphlitis with a death rate of 100 per cent., there having been no recoveries. Hemmeter has collected 32 cases of appendicitis occurring in private practice between 1899 ^^"^1 1901, without any deaths, 27, of these ha\'ing received medical treatment only. Two of the latter relapsed within five years, but the relapses were re- covered from without operation. Richardson, cited by Da Costa,^ made an elaborate study of 750 cases from which there was shown in operated cases a ' "Am. Text-book of Surgen'," 4th ed., Philadelphia, 1903, p. 839. ' " Disease of the Intestines," Philadelphia, 1902, p. 389. ^ " Modern Surgery," Philadelphia, 1900, p. 793. m APPENDICITIS 741 mortality of 18 per cent.; while the same surgeon, in a later paper/ reports 520 acute cases observed by him with a mortality of 16.4 per cent, under medical treatment, and 21.75 P^^ cent. among those operated on. Richardson, in* a recent lecture,- re- ports that at the Massachusetts General Hospital during 1901 there were 185 operations for acute appendicitis, with 30 deaths, or 16.18 per cent. ; 41 of these operations were in cases complicated with general peritonitis, with 25 deaths — 60 per cent. But in the operations for chronic appendicitis, interval operations, etc., 52 in all, there were no deaths. The foregoing figures, however, are altogether too high for present conditions. Deaver, who operates in nearly all cases, and with a skill unsurpassed, has recently reported^' 377 acute cases exclusive of those having general peritonitis, with a mortality of less than 7 per cent., and both his and Richard- son's last large series of operations in chronic cases (interval operations) were wholly without deaths. Ochsner of Chicago, who practically never operates after the disease has extended beyond the appendix itself until the attack is over (except to open a circumscribed abscess), but relies upon non-operative methods of treatment during the acute stage after the first day or two, treated in the Augustana Hospital during the calendar year 1902, 192 acute cases with 6 deaths, about 3 per cent.* Fuller statistics of the mortality in this disease under operative and non-operative measures are given in the. succeeding lecture on Treatment. \\"hen an appendiceal abscess opens into the peritoneal cavity, the pleural cavity, or the bladder, the peril to life is great, and a very large proportion of such cases under the methods hitherto in vogue, whether with or w^ithout operative inter- vention, have proved fatal, though Ochsner has reported one large series of perforative and gangrenous cases treated by ' Am. Jour. Med. Set'., December, 1899. '^ Old Doininion Jour7ial, January, 1903. ^ Am. Afed., October 17, 1903. •* Med. News, Philadelphia and New York, May, 1903. 742 THE GASTRO-INTESTINAL CLINIC his new method with only 5 per cent, mortahty.^ Every re- currence of appendicitis increases the danger of a fatal ter- mination. Removal of the appendix during the first thirty- six hours, or before the disease has extended beyond that structure itself, involves a very small risk, the mortality in good hands now not exceeding 2 or 3 per cent., and in the best hands in well-equipped hospitals is generally much less — scarcely i per cent. Under appropriate medical treatment alone, catarrhal ap- pendicitis nearly always gets well — or, at least, the attacks are recovered from. A considerable proportion of the patients do not have any further trouble, and it is probable that few of them would relapse if the best possible treatment were strictly followed afterward, including proper diet; but unfortunately this can seldom be insured. AA'oods Hutchinson quotes the late Fenger, one of the most brilliant surgeons this countr}^ has produced, as stating that " alx)Ut one-third of the severer type of cases recovering from one attack would probably never have another." "^ hit. Med. Mag., November, 1901. LECTURE LXVIII THE TREATMENT OF APPENDICITIS The treatment of appendicitis is one of the earnestly dis- cussed questions of the day in the medical circles both of Eu- rope and the United States. In this country, where its true nature was first clearly pointed out, by Fitz of Boston in 1886, the disease is treated with a greater degree of success than any- where else in the world, because in part, no doubt, of its un- usual prevalence here. Three different views as to the treatment' are now advocated, and there is no reason to doubt that the champions of each ar-; equally honest and conscientious. These are as follows : 1. The Radical Surgical Method. — This is ably championed and very successfully carried out in practice by Deaver, Price, and others of Philadelphia, as well as by Morris of New York, and Murphy of Chicago, among others. They hold that ap- pendicitis is exclusively a surgical disease, and that to delay operation and depend upon any kind of non-operative meas- ures at any stage is nearly always only a waste of time which endangers the patient. They would, as a rule, operate in any stage of any form or grade of the disease in the majority of instances, except when the patient is moribund or so near it that the shock of the operation must inevitably prove fatal. They believe that the promptest possible operation is in nearly all cases the truest conservatism. i 2. The Conservative Surgical Method. — This* seems to be favored by a majority of all the well-known surgeons of the United States and of the world, including Richardson of Boston, Wyeth of New York, Park of Buffalo, and in Phila- delphia the following authors of works on surgery or gyne- cology: Keen, White, Martin, Willard, Montgomery, and Da 743 744 THE GASTRO-INTESTINAL CLINIC Costa, and a long list of others, besides prominent surgeons, too numerous to mention, in all the large cities. This method differs from the radical one mainly in de- ferring operation under certain conditions — especially in most cases not seen early — until after the acute attack has ended, and then doing in most instances the very much safer interval operation. The conditions which should lead to a postponement of operation, and a dependence for the time upon other measures, vary considerably with the different surgeons. Most of them agree in not advising operation dur- ing the acute stage after the second day, or rather after the disease has progressed beyond the appendix itself, unless there is a walled-off abscess, or unless perforation or gangrene has resulted. Many of them, also, prefer to trust to nature and non-operative methods of treatment in the milder catarrhal cases, even when these are seen early. When they withhold the knife, the numerous conservative surgeons differ again considerably in their therapeutic meas- ures, but most of them keep the bowels open by means of calomel or salines, and feed lightly with liquid diet, though Richardson seems to have adopted, for cases in which opera- tion must be deferred, the Ochsner practice of washing out the stomach, prohibiting ph3^sic, and allowing no food by the mouth. Probably some of the others have recently modified their methods in like manner. Nearly all employ emollient or revulsive local applications including poultices or wet compresses as hot as can be borne, or, in the more severe cases, rely upon ice locally. Most advise only a very sparing use of opiates, when necessary for severe pain. 3. The Ochsner Plan, or Surgico- Starvation Method, is radically surgical in the main, but combines the practice of the so-called conservative surgeons in some respects, along with a most rigorous withholding from the upper gastro-in- testinal tract of anything, either food or medicine, which could produce peristaltic action. Ochsner of Chicago first began TREATMENT OF APPENDICITIS 745 putting it systematically into effect about the year 1898, and it has already attracted wide attention. He is a believer in the doctrine that every case of appendicitis should be operated at some time, but holds that it makes a vast difference in the results at what stage of a case the operation is done. He in- sists that every case, no matter how mild, should be operated when the opportunity is afforded to do this during the first thirty-six hours, or at least before the disease has progressed beyond the appendix itself, but that when this cannot be done, it is best to wait until the attack has entirely passed over, unless during the acute stage there should be developed a circumscribed abscess, when this may be opened and emptied. When gangrene or perforation has occurred, he particularly objects to operation, believing this to be more dangerous then than waiting, provided his rest and starvation method is strictly carried out. Acting on the theory that the danger in appendicitis is chiefly in the spread of the infection to the entire peritoneal cavity with the result of a general diffused peritonitis, which often follows an operation in an advanced case of acute ap- pendicitis, Ochsner enforces absolute rest of the body, and of the gastro-intestinal functions in particular, by first washing out the stomach with plain water or normal salt solution, to remove any remains of a previous meal, and then prohibiting absolutely all food by the mouth as well as the administra- tion of any remedies such as cathartics, which could excite peristaltic action. It will be obviously fairer to him to let him describe his method in his own words, and I therefore quote the following from his latest paper :^ Ochsner's Description of His Method. — " In every case of acute appendicitis entering the hospital, all food by mouth and all cathartics were prohibited. In case the patient suffered from nausea or vomiting, gastric lavage was at once employed. In the milder cases the patient was permitted to rinse the ' Med. News, May 2, 1903. 746 THE GASTRO-INTESTINAL CLINIC mouth with cold water and to drink small sips of very hot water at short intervals. In the severer cases the patient was pe!tmitted to rinse the mouth with cold water, but was not per mitted to drink either hot or cold water for the first few days until the acute attack had subsided, when the use of small sips of hot water was begun. If the nausea persisted, gastric lav- age was repeated once or twice at intervals of two to four hours, in order to remove any substance which had regurgi- tated into the stomach from the small intestines. " The patient was supported by nutrient enemata consist- ing of an ounce of one of the concentrated predigested liquid foods in the market, dissolved in three ounces of warm normal salt solution introduced through a catheter, which was in- serted a distance of two and one-half to three inches. In case this gave rise to pain or irritation or nausea, it was interrupted for twelve to twenty- four hours at a time. In cases in which no water was given by the mouth, an enema of eight ounces of normal salt solution was given four to six times a day, in ad- dition to the nutrient enemata. In cases operated during the acute attack, this treatment was continued for several days after the operation. " After the patient had been free from pain, and otherwise practically normal for four days, he was first given from one to four ounces of weak beef tea, preferably prepared from commercial beef extract, every two hours. In a few days one of the commercial predigested foods, dissolved in water, was substituted; still later, equal parts of milk and limewatcr; then general licjuids ; then light diet, and finally, after the patient had fully recovered, full diet was given. The commercial extract of beef was chosen because it contains only soluble material, which will usually be absorbed from the stomach without giving rise to peristalsis. The rectal feeding was continued in the mean time. By following this plan the patient is sat- isfied, and one is less likely to do harm with this than any other form of food. Of course, the benefit to the patient is chiefly imaginary. TREATMENT OF APPENDICITIS 747 " So far, nothing has been said of the operative treatment, intentionally, because the treatment I have just described was applied to all cases of acute appendicitis, without regard to the severity of the case or the stage at which the patient was ad- mitted to the hospital. Moreover, because this is the part of the treatment which is responsible for the enormous reduction in the mortality. " Operative Treatment. — The rule which was followed as regards the time of operation varied with the individual cases. In any given case, the operation was performed at the time the patient entered the hospital, or, if this occurred at night, on the following morning, provided it seemed clear from the condition of the patient that he would recover if the operation were performed at once, judging from my own experience in similar cases treated in the past. This could usually be ex- pected in severe cases admitted before the end of thirty-six hours from the beginning of the attack, and in the milder cases during a longer period. " In all cases in which the recovery seemed at all doubtful, the operation was postponed and the patient was placed under the treatment described above, until the acute condition had subsided. In some of these cases it became necessary to open a circumscribed abscess, and later to make a second opera- tion for the removal of the appendix. In other cases the in- flammation became circumscribed, and the appendix could be safely removed, the pus sponged out of the circumscribed ab- scess, the abdominal wound could be closed, a drain being in- troduced through a small incision two inches externally to the abdominal incision." The foregoing is a plain and fair statement of the different methods practiced, and of the points at issue between them. The latter ought to be decided in an entirely dispassionate way, the same as any other purely scientific question, without the slightest regard to any consideration except the interests of the patients whose lives are at stake. I have given the matter much thought and study, feeling that the words of an 748 THE GASTRO-INTESTINAL CLINIC author upon any such important subject should be very care- fully weighed. Murphy's Method — Since the earlier editions of this book appeared, Dr. John B. Murphy of Chicago has written for Keen's Surgery an article on Appendicitis, in which, while agreeing with most other abdominal surgeons as to the advis- ability of early operati\'e intervention in this disease, he ad- vocates operating in a somewhat novel way in the suppura- tive cases complicated by acute general peritonitis. He holds to the familiar doctrine that the most favorable time for operating is in the first thirty-two hours, before perforation with infection of the periappendical tissues. On this head he says: "The danger of intervention in the early stage is scarcely more than that of an exploratory laparotomy. The time required for the convalescence is not more than two and a half to three weeks. * ^= * The patient would be relieved of his appendicitis without hazard, without prolonged illness, without danger of unpleasant sequelae, and without the pos- sibility of recurrence by the timely operation." When perforation has already occurred, Murphy, unlike the more conservative surgeons, advises operative intervention, but with certain precautions which render it much safer than it was formerly under such circumstances. He insists that the intestines should then be all walled off with gauze packing, that the agglutinations of the abscess wall " be separated with the fingers, sufficient pus removed to permit inspection of the cavity, and, if easily recognized, or if not more than four days have elapsed since the onset of the disease, the appendix should be searched for and removed." In general suppurative peritonitis due to a perforation of the appendix or rupture of a circumscribed appendical abscess into the free peritoneal cavity, Murphy still advocates operation, but in a most careful and cautious manner thus de- scribed : He opens the abdomen as in primary appendicitis, and amputates the appendix to prevent further leakage. Then he inserts a rubber drain to the stump and another to the base TREATMENT OF APPENDICITIS 749 of the vesico-rectal or Douglas pouch, but avoids all manipula- tion of the intestine and sponging or flushing of the perito- neum for the removal of the pus, and closes the abdominal in- cision, often with pints of pus remaining in the cavity. The operation, then, must be the shortest possible, rarely needing to exceed ten minutes. He then puts the patient in the extreme Fowler's (sitting) position, and institutes proctoclysis by in- jecting into the rectum every two hours one and a half pints of the normal salt solution together with a pint and a half of a calcium chloride solution, one dram to the pint. In the severely septic cases he advocates the addition to the treatment of 20 c.c. of streptolytic serum, particularly in the cases having a low leucocytosis, repeating this twice in twenty-four hours till the symptoms subside. The proctoclysis, detailed direc- tions for which are given in Keen's Surgery, page 788, is generally continued for three days, and exceptionally for five or six days. Murphy reports 40 consecutive cases of peri- tonitis treated on this plan with only two deaths, an ex- traordinary improvement over the results formerly obtained by even the most skilled operators. The Results Must Decide. — Obviously the decision as to which of various methods of treatment is best in any disease, must depend upon the relative results achieved under each of them. So it must be in deciding what method of treating ap- pendicitis is to be preferred. That one which will save the largest proportion of lives will, of course, be finally accepted. Though it is true that figures can sometimes be made to lie, the statistics as to the results in a sufficiently large aggregate of cases must ultimately decide all such questions. In addition to the figures given under the head of Prognosis, in the preceding lecture, the following, embracing the results of several prominent surgeons who dififer in their views re- garding the time to operate in appendicitis, will shed some light upon the subject : Richardson's Results in 1903. — Dr. M. H. Richardson of Boston, who is one of the most eminent of those surgeons 750 THE GASTRO-INTESTINAL CLINIC whom I have classed above as " conservative," has, in answer to an inc|uiry from me, submitted the following report under (?ate of January 7, 1904: Total number of cases operated on in 1903 149 Acute 44 Chronic 105 " In the 44 acute cases there were two deaths, both from general peritonitis. In these cases recovery was not expected." He added that he could not say how many cases of general peritonitis there were, but had never in his experience known a fully developed case of the kind to recover. Dr. Richardson's mortality rate in acute cases figured out 4.54 per cent. ; in chronic cases o. Dr. W. Wayne Babcock, the Surgeon-in-Chief of the Sa- maritan Hospital, Philadelphia, wrote me a personal com- munication under date of December 17, 1903, embodying a report of his results in operations for appendicitis. Up to that time he had had no deaths in either interval operations or in those done during the first forty-eight hours — none, in fact, except in the cases complicated by general peritonitis, which then was very generally fatal. The following further statistics covering the work of Deaver in the year ended September i, 1903, and Ochsner's last 566 cases previous to December, 1903, are of great inter- est, not only as demonstrating the extraordinary advances made in lessening the mortality of appendicitis by the chief exponents of two different methods of treating it, but also as showing the comparative results of these different methods — the one depending on non-operative measures in most cases during the serious stage, and even in the gravest complications, and the other relying upon the aseptic knife and deft fingers of the expert surgeon, operating nearly always, early if ])Ossible, but if not, then operating anyway, as a rule (to which he makes some exceptions), in accordance with the view that this affords the patient the best chance of recovery. Deaver's Recent Work — Dr. Deaver, in a paper entitled TREATMENT OF APPENDICITIS 75 I One Year's Work in Appendicitis/ reported his operations from September i, 1902, to September 1, 1903, as follows: 16 cases with general peritonitis with 5 deaths ; mortality 31 per cent. 183 acute cases with abscess, 22 deaths ; " . . . .12 " " 194 acute cases without abscess, 3 deaths ; " 1| " " 173 cases of chronic appendicitis, o deaths ; " .... o " " In a personal note to the author, written May 17, 1910, Dr. Deaver reports that in the previous six years he had operated upon 3824 cases of appendicitis with a mortality of 43/2 per cent. In chronic cases his mortality during the same .period was 0.3 per cent. Ochsner's Last 566 Cases. — Ochsner, in response to a re- quest for his latest statistics, wrote me under date of December 5, 1903, that the results of treatment in the last 566 cases treated by him in the Augustana Hospital, Chicago, up to that date, were as follows : Number of cases of appendicitis with general peritonitis, 15 ; recovered, 9 ; died, 6. ; mortality 40 per cent. Number of cases of acute appendicitis with abscess. 81 ; recovered, 80 ; died, 1 ; mortality 1^ per cent. Number of cases of acute appendicitis without abscess, 173 ; recovered, 170 ; died, 3 ; mortality if per cent. Number of chronic and interval cases, 297 ; recovered, 295 ; died, 2 ; mortality f per cent. Under date of May 21, 1910, he writes: "My hospital statistics during the past year show a trifle less than 2 per cent, mortality in all of the cases of perforated, gangrene, and sup- purative peritonitis; no mortality in cases which come under treatment before the end of 36 hours from the beginning of an acute attack, and no mortality in cases of interval opera- tions." Deductions from the Foregoing Statistics. — From the above array of statistics a few very interesting and highly important inferences are clearly deducible : I. The most expert abdominal surgeons, when surrounded by the assistants and appliances of their own hospitals, can ^Am. Med., October 17, 1903, 752 THE GASTRO-INTESTINAL CLINIC Operate hopefully upon almost any case of appendicitis at any stage. In the chronic form of the disease they very rarely now lose a case. In any acute case operated during the first thirty-six hours their mortality is extremely low — next to none — and even at a later stage of the ordinary acute cases, when general peritonitis has not developed, the figures are still very favorable. Deaver's 194 simple acute cases, with only 3 deaths — 1.5 per cent — make a remarkable showing. Though in a much smaller number of cases, Babcock's total absence of mortality, in all cases except those complicated by general peri- tonitis, was exceedingly creditable. The latest figures reported up to May, 19 10, by both Deaver and Ochsner can only be characterized as extraordinary. 2. Regarding perforative or gangrenous appendicitis, and those cases in which general peritonitis exists, the statistics so far reported leave some doubt whether the generally accepted surgical plan of operating at the earliest possible moment after the discovery of the condition is able to save as large a pro- portion of lives as can be saved by the Ochsner method already described, even when the operation can be done under the ex- ceptionally favorable conditions above mentioned, and with the improved technique recommended by Murphy. When the operation must be done, if at all, by a surgeon not indubitably of the very highest skill, or under conditions unfavorable in any other respect additionally to the serious form of the dis- ease, there can be no question that the Ochsner method would promise best, especially if the previous treatment had not in- volved the administration of food by the mouth. The judgment and experience of at least one eminent surgeon — and numerous other able surgeons now agree with him — have come to reinforce the matured views of most hygienists and conservative internists to the effect that a little fasting now and then can help save life at critical junctures, when the sys- tem has neither the energy to digest and assimilate food nor to excrete it undigested. It is a fair inference that perfect rest and the starvation 1 TREATMENT OF APPENDICITIS 753 plan will rescue a larger proportion of the more dangerous forms of the acute cases after the first 48 hours, or after the peritoneum has become infected, than operation, by even the very best abdominal surgeons. At least this seems to be true as regards the latest statistics of the two methods which are obtainable ; but the surgeons are constantly improving their technique and lowering the mortality rate, and it is by no means impossible that the statistics for some future year may tell a different story. 3. The belief that almost any sort of surgery is safer in acute appendicitis than the very best possible non-operative treatment is no longer defensible. It has been gaining ground rapidly of late, both in the medical profession and among the laity. I do not think it was ever quite true. In the country districts, and everywhere remote from the larger cities, where alone really skilled and experienced abdominal surgeons are to be found, as a rule, the Ochsner method should clearly be pre- ferred, operation being deferred — in all cases, at least, in which an operation cannot be done during the first two days — until after full convalescence, when an operator of even ordinary ability and experience could, with reasonable safety, undertake the task of removing the appendix, provided he had mastered the technique of abdominal sections. 4. The most obvious and important inference to be made from the foregoing statistics is that no' patient threatened with acute appendicitis, or with any disease resembling it, should be given even the slightest amount of food by the mouth till all danger of suppuration has passed, and no pur- gative or laxative medicine, except when the patient is seen early enough to admit of the bowels' being cleared out safely before pus could have had time to form in the appendix. This would be a safe rule for all such cases, regardless of what the after-treatment might be. Even if operative inter- vention were to be resorted to later, the patient's chances would be improved by such a preliminary treatment, and if a skilled surgeon could not be obtained in time, a life that might other- 754 THE GASTRO-INTESTINAL CLINIC wise have been sacrificed would probably then be saved by- continuing strictly the Ochsner method. A Symposium on Appendicitis. — As editor of the Interna- tional Medical Magazine I arranged for a symposium on ap- pendicitis in that journal for November, 1901, and received papers or answers to questions upon the subject from sixteen prominent authorities. Ten of them, viz., Wyeth, Park, Morris, Ochsner, Murphy, Willard, Martin, Richardson, Turck, and Stockton, nine of whom, including all but the last named, were surgeons, answered specifically the following question : " Generally speaking, what mode of treatment do you advise during the first two days of a mild or moderately severe attack of appendicitis ? " Of these ten answers, three unqualifiedly favored operation under the conditions named, these coming from Morris, Murphy, and Ochsner. The last named, while advocating operative intervention in the first two days in all cases when a competent surgeon can be obtained, opposed operation in perforation or gangrene. His answer as to the preferable treatment in an acute case, after the beginning of the third day, was as follows : " Exclusive rectal feeding, no nourishment of any kind nor cathartics by the mouth ; gastric lavage. If this is done, the condition will not gTow worse." Seven of the answers above mentioned, all but one from men who have had experience in making abdominal sections, ad- vocated relying upon some form of non-operative treatment during the first two days of a mild or moderately severe attack of appendicitis, though several of them spoke of being in readiness to operate in the event of threatening symptoms. Including Ochsner, then, eight of the ten writers who an- swered the questions favored a reliance upon medical meas- ures either during the first stage of a mild attack, or during the acute stage after the first two days, whenever there are in- dications that the infection has extended beyond the appendix itself. Richardson's Conservative View. — Richardson, in the quite TREATMENT OF APPENDICITIS 755 recent lecture by him already cited, says : " My own views briefly are that operation is indicated in most, if not all severe cases [italics ours] when first seen, unless the symptoms are unquestionably improving, or unless the patient is hopelessly moribund. In many cases of moderate severity I wait for complete subsidence of the infection, as in the present case, before opening the abdomen." Again, in the same lecture, he says : " When it is clear that operation will take away the only chance that the patient has, I refrain from intervention, trust- ing to gastric lavage and rectal feeding, as suggested by Ochsner." The champion of absolute rest for both the body generally and the peristaltic apparatus in particular, from the very beginning of the treatment, might reply to the last sen- tence above quoted, that cases which have been regularly fed by the mouth from the outset, and purged freely in addition, could hardly be saved by the adoption of his method at the last, after their condition has become too desperate for operation. The Treatment of Acute Catarrhal Appendicitis. — The treatment which I have found successful in acute catarrhal appendicitis consists of rest in bed, and when possible, in a cheerful, well-lighted, and well-ventilated room, the application of hot mush or flax-seed meal poultices over the affected re- gion, every two or three hours, or oftener when the oain is very severe, and the administration of calomel in i-io grain doses every two hours, night and day, till the bowels respond by one or two soft yellow stools — not until it produces free purgation, and not followed by saline cathartics to effect such a result. The calomel given in this way has always seemed to assist markedly in removing all symptoms of the disease, and the cures thus effected have comparatively infrequently in my experience been followed by any return of the trouble. In view of Ochsner's extraordinary results I should ndw advise the utmost caution in the employment of even the small doses of calomel above mentioned, and limit the use of the remedy to the earliest stage of the milder cases not likely to develop 75^ THE GASTRO-INTESTINAL CLINIC suppuration, or to the very beginning of severe ones. As to diet, my own experience in this class of cases has been with a very restricted and simple diet consisting of small quantities of broth or beef juice, or whites of eggs, and a little milk or gruel. Again profiting by Ochsner's experience, and in view of the fact that even the milder catarrhal cases may excep- tionally take on later a severe form, I now advise feeding by the rectum exclusively in all cases of appendicitis until the danger is entirely over, since there is no difficulty in maintain- ing nutrition by this method for the short period necessary, especially in the case of a person strictly confined to bed, and nothing is then put into the upper part of the alimentary canal to provoke peristalsis. It is furthermore a valuable precaution to wash out the stomach at the start so as to prevent danger from the food previously taken. In the beginning of the attack, and especially when there has been constipation previously, the colon should be unloaded by flushing with either a normal salt solution or soapy water, or what is safer whenever the temperature is at all high and suppuration is to be feared, by repeated injections of olive or cotton-seed oil, which will usually effect the object almost as surely, if not C[uite so promptly, and without irritation. At the same time i-ioo to 1-50 grain of atropine may be injected hypodermically, and be repeated cautiously till its constitu- tional effects have been obtained, when necessary to relax spasm and promote evacuation, especially in case the dif- ficulty of procuring a stool seems due to a spastic condition. Large disturbing enemas as a means of emptying the colon should not be employed, in my opinion, whenever there are evidences of peritonitis, either local or general, since only harm can result from opposing in any manner nature's con- servative efforts to prevent peristalsis in such conditions. When the above-mentioned milder injections fail, though it be apparently in an early stage only of the attack, and no peri- tonitis is believed to have yet developed, do not try to force bowel movements by stronger or more irritating ones lest TREATMENT OF APPENDICITIS 757 peritonitis should have begun, even though not yet demon- strable. I still remember very vividly my appendicitis cases of twenty to twenty-five years ago, then called typhlitis or perityphlitis, and especially how every attempt to force bowel movements even by enemas aggravated the inflammation and fever, turning the scale against the patient sometimes, when before things were progressing favorably. In cases more severe with a temperature running up to 102° or higher, and acute tenderness over a larger area, ice bags or an ice coil may prove more efifective than hot applica- tions-and a little opium may be found necessary to blunt the pain, but the latter remedy should never be pushed to the point of complete narcosis, since this would greatly obscure the progress of the case, and add to the dangers of the patient. When such marked symptoms occur early — within the first thirty-six hours — they raise the suspicion that the attack is to be more than a simple catarrhal one, and would warrant your calling a surgeon in consultation to consider the propriety of an operation while yet the disease is limited to the appendix — or at least to a circumscribed abscess. Much better than a free use of any opiate is a reliance in part upon belladonna or atropine, which possesses valuable antispasmodic properties, and should be particularly effective in relieving pain due to the spasmodic closure of the appendix at its cecal end, or to complicating colics in other parts of the intestines resulting from like spastic conditions. Treatment of the Severer Forms of Acute Appendicitis. — In cases which begin in a severe and threatening way (ful- minant cases) operation during the first thirty-six, and pos- sibly during the first forty-eight hours, promises better results than any medical measures, always provided that a thoroughly expert laparotomist can be had, and that in other respects the conditions are such that a perfectly aseptic operation can be done. If the patient occupies a dirty room far from any hospital, and cannot command the services of both a skilled surgeon and trained surgical nurse, the advantages of opera- 758 THE GASTRO-INTESTINAL CLINIC tion during the height of the attack compared with rest in bed^ abstinence from food and drink by the mouth, as well as from purgative medicines, and the help of other appropriate measures, would be more than doubtful. In any case not diagnosticated until after the first thirty-six hours, you will, as a general rule, to which there are few exceptions, be safe to advise against operation until after the subsidence of the acute stage, provided the method by enforcing complete absti- nence from stomach feeding and purgatives be strictly carried out. One of the few exceptions would be cases in which a circumscribed abscess has formed, which can be opened easily without danger. But in every severe case of acute appendicitis it is a wise precaution to have a surgeon in consultation until the danger point has been passed. Whatever views one may hold as to the time for operation in these cases when suppuration exists or is threatened, it must be admitted that non-operative treatment is often the only kind practicable, for the reason that the patient refuses to have the operation done, or because it is impossible to ob- tain, in time, a surgeon possessed of sufficient skill and ex- perience to do it with the prospect of any more favorable re- sults than would follow the best medical treatment. Further- more, when the diagnosis has not been made or the consent of the patient and family obtained to an operation until after the second day, and a circumscribed tumor has not yet been formed, non-operative measures are to be preferred till the acute stage has passed, or a walling in of the abscess been fully accomplished. Under these circumstances you should pursue the same course advised already for the mild catarrhal form, except that under no circumstances should anything, either food, drink, or medicines, be given by the mouth which could tend to excite peristalsis — i. e., no stomach feeding, no drinking, and no cathartics or laxatives at all. Dr. R. G. Curtin of Philadelphia reports excellent results from the ap- plication of a blister over the cecum in the beginning of acute appendicitis. TREATMENT OF APPENDICITIS 759 The Treatment of Chronic Catarrhal Appendicitis. — Here again, I must take issue with the more radical of the surgeons, as well as with Ochsner, and advise against the hard and fast rule that all cases without exception which have shown indica- tions of a slight involvement of the appendix in a catarrhal process should be operated. I have seen such cases get ap- parently well under medical treatment, and the easily palpated, thickened appendix subside to its normal size while its tender- ness on palpation disappeared. It is granted that other cases not under strict treatment recur again and again, and often finally in a serious form which proves fatal, when in the in- terval an operation might have been performed with less than I per cent, of risk in expert hands. Indeed, Richardson reported 500 such cases up to November, 1902, which all recovered,^ and the latest statistics of Deaver, Ochsner, and other expert surgeons are almost equally good. This is certainly a powerful argument in favor of having all such cases operated at a time, and under circumstances; which would be most favorable to success. While explain- ing that a prolonged medical treatment and strict diet may cure finally, I should always acquaint patients with the above remarkable figures, and as a rule advise the operation when the best conditions can be fulfilled. In the following in- stances, I think, the operation should be strongly urged : ( i ) in all subjects of the disease who have had at least one acute attack and in whom the catarrhal process is not steadily im- proving under appropriate treatment; (2) in all such persons who, by reason of their occupation, social position, or temper- ament, cannot be kept for months or, exceptionally possibly, for years under suitable treatment for the catarrhal condition. This treatment must include a more or less stricL diet which many patients simply will not adhere to, and therefore, in their cases, as well as in the cases of those who have not the time nor money to devote to the tedious task of getting well by non-operative means, operation is clearly the preferable ' Loc. cit. 760 THE GASTRO-INTESTINAL CLINIC method. In those patients who have never had an acute at- tack, or only one very mild one, who will submit to a long medical treatment with a regulated diet, there is much less rea- son for insisting upon the operation. Under the head of Chronic Catarrh of the Intestines, I have described in Lecture LXVI. the dietetic, mechanical, and me- dicinal treatment which is indicated in chronic appendicitis whenever operative intervention is declined. Frequent coun- ter-irritation over the diseased appendix should be especially insisted on. It should not be forgotten, also, that even when the appendix is removed, the associated catarrh in the cecum, as well as often in other parts of the colon, is not by any means always thereby cured, though it sometimes is. There remains the catarrhal state in the larger bowel with its in- jurious effect on the general health, and the same treatment which this then requires, if skillfully and persistently carried out without the operation, might possibly have cured the chronic appendicitis as well. Report of Author's Case. — A report of my o\yn experience with chronic appendicitis will help to illustrate the foregoing account of the disease. In the summer of 1900, when 58 years old, I took cold by bathing in a lake and afterward rowing in a wet bathing suit some distance to a bathhouse. There resulted a subacute colitis which only slowly yielded to treat- ment and left behind a slight constipation, with an occasional feeling of discomfort in the region of the cecum. After a time I was able to make out, by palpation, a marked sensitive- ness and some thickening of the appendix. This condition was later confirmed by examinations made by my friends Drs. John B. Deaver, De Forest Willard, AV. J. Hearn, and other expert surgeons of Philadelphia. I had been previously some- what neurasthenic and found my nerve tone now distinctly more lowered. There was much intestinal flatulence and im- paired sleep toward morning. Early the following summer I took a long vacation, and re- turned much improved in health, but still with a slightly sore appendix. The treatment pursued consisted mainly of diet, systematic exercises, automassage of the abdomen, and elec- TREATMENT OF APPENDICITIS 761 tricity, the last taken very irregularly. A medical man makes a bad patient, especially when he is his own doctor. The summer of 1902 was spent in part in the Adirondack woods, where the coldness and dampness of an exceptionally cold, damp summer aggravated my intestinal trouble. All autotoxccinic nephritis had meanwhile developed. Small amounts of albumen, with hyaline casts, were almost constantly demonstrable in the urine for the greater part of the time, for a year or longer. For this complication, after the failure of other means, I took the static wave current, as described in my recently published paper entitled The Influence of the Sec- ondary Static Currents in Removing Albumin and Casts from the Urine.^ This treatment, persisted in faithfully for several months continuously, not only did away with all the renal symptoms with the help of diet and a greater attention to physical exercise, but also seemed to assist much in relieving all the symptoms and signs referable to the appendix. As a result of all these means, my health greatly improved. During the past summer (1903) I stayed at home, attended to a larger practice than usual, and worked hard also in preparing the material for this book. I could no longer feel my appendix, had no pain or discomfort there, and believed it practically well. There is little room for doubt that had I continued my careful hygienic way of liv- ing, I should have had no more trouble from it, and that a lessening of confining work, with a persistence in treatment, would have effected a cure. But, unfortunately for me, matters finally assumed such a shape that work on the book had to be pushed at a rate that left me no time for rest or exercise out of doors, and much overtaxed my energies. After several months of such un- hygienic living, some grumblings began to recur in the cecal region, and finally I could again feel, at times, a slightly thick- ened and sensitive appendix. There was again a very abnor- mal amount of intestinal flatus, and much impairment of sleep. A very slight attack of subacute catarrhal appendicitis then developed under peculiar circumstances. November 29 some dull pain and tenderness on pressure, or on bending the body, were experienced in the right loin and side. At the same time a little twinge was occasionally felt ' Am. Med., November 28, 1903. 762 THE GASTRO-INTESTINAL CLINIC in the region of the appendix, but the pain and discomfort were predominantly in the back and right side, just below the site of the kidney. Muscular rheumatism was at first sus- pected, and later the possibility of a large stone in the pelvis of the kidney trying to enter the ureter. On the morning of the 30th the discomfort in the whole right side and loin was marked, but the temperature reached only 99.8 at the highest, which was on the . evening of that day, and there was no nausea, while the intestinal flatulence from which I had been suffering was almost entirely absent during the two days. In consequence, I enjoyed a greater feeling of well-being than before, and continued with my practice and writing as usual. On the morning of December i Dr. John B. Deaver examined me and found a subacute appendicitis — nothing else demon- strable — whereupon I decided to have the pperation of ap- pendectomy done at once, as the shorter and surer way to a complete cure, and the only way for one unable or unwilling to give up hard work and carry out strictly the necessary line of medical treatment. My improved feeling of well-being, in spite of a con- gested appendix, was probably because its outlet had swol- len shut and there was no more leakage of septic matter from it. The operation was done December 2, at the Samaritan Hos- pital, by Dr. Deaver, assisted by Dr. W. Wayne Babcock, sur- geon to the hospital, and the resident staff of that institution. The appendix was found swollen to nearly double the normal thickness, considerably infiltrated, and the vessels much in- jected. The mucosa presented the usual signs of catarrhal inflammation, and there was a slight narrowing of the lumen at the cecal end. My convalescence was uneventful. On the fifth day the stitches were removed by Dr. Babcock, and on the beginning of the eleventh day I was able to leave the hospital. A thorough examination of my urine, made shortly after the operation, revealed no trace of either albumin or casts. Further Considerations Regarding the Management of Ap- pendicitis. — In few fields have the triumphs of surgery been more notable than in that of the appendix. The general belief is that, unlike the ovary or kidney, it is not only either a vital or very useful organ, but a positively dangerous one, or at least TREATMENT OF APPENDICITIS 763 one likely to become a source of danger at any time. The ap- pendix has hitherto, at all events, been considered practically useless. A recent English writer, however, maintains that it normally performs an important function and that its loss by operation or otherwise causes some impairment of the health. But for the considerable inconvenience and at least slight risk of the operation, many persons would have it removed while well. When the organ becomes diseased in whatsoever degree or form, the reasons for wishing to be rid of it alto- gether are greatly increased. Supposing a patient attacked with acute appendicitis to be so situated or so constituted temperamentally that he would prefer the operation of appendectomy, done under the best possible conditions, to the risks of future acute attacks, or the tedious- ness and expense of a prolonged medical campaign against the chronic disease which usually follows, the practical cjuestion arises. How can he most safely effect his purpose? If the at- tack has come while he is in any of the larger cities, he will be reasonably sure of a prompt diagnosis, and could have an early operation done with such skill and care as to involve not very much more risk than attends what is called the interval operation, for which the time, place, and surgeon can all be carefully chosen beforehand. Unfavorable Conditions for Operation. — But suppose, in- stead, he is on a sea voyage, a gunning trip, or camping in the woods hundreds of miles from any town, when the acute attack comes? Or for that matter, suppose it finds him in some remote country village, where the only medical man ob- tainable may have never even seen a laparotomy. Then the only alternative would be to call the nearest abdominal sur- geon, who would most frequently arrive late, and have to do the always dangerous late operation with probably much less skill than that of a Deaver or Richardson, and might possibly be a bungler with a very faulty technique, and*unable to afford him as much hope of recovery as he would have Under the most ordinary medical treatment. 764 THE GASTRO-INTESTINAL CLINIC On the other hand, it is claimed that under the rest and starvation treatment of acute appendicitis vigorously adhered to from the beginning, even the gravest cases may usually be carried through to an interval when an operation, which would be practically devoid of risk, could be done by almost any fairly competent surgeon, though there would then be op- portunity for the selection of a convenient time, a suitable place, and an expert laparotomist, if desired. Under these circumstances it seems to me the very height of unwisdom to teach general practitioners and the laity that an operation is the only remedy in acute appendicitis. Such a doctrine, if fully accepted, means that any half -trained sur- geon, no matter how clumsy, inexperienced, or dirty, should be permitted in an emergency to open the belly of an appendi- citis patient. Even if Ochsner and his starvation-anticathartic method, with its extraordinary small death rate, had never been heard of, it would still be safer not to operate, except under reasonably favorable conditions, since the old Alonzo Clark method of treating attacks of so-called local peritonitis, which were really in most cases appendicitis, saved a very large majority of cases — doubtless, too, because it prevented peri- stalsis and the spread of the infection.^ Then, let me again urge upon you that you adopt the safe rule of withholding food and cathartics in all doubtful attacks beginning with fever and pain in the abdomen anywhere, until you can exclude the possibility of appendicitis. When the suspicion of this affection is strong, and especially if there be nausea, or any symptom of a laboring stomach, wash the 1 Fiertz in the Correspondettz-Blatt f. Schweizer Aerzte oi March 10, 1910, abstracted in the y^. A. M. A., of April 23, 1910, p. 1416, reports hav- ing cured promptly 51 cases of acute appendicitis by a novel treatment in spite of the fact that in 12 of them perforation occurred The patients were kept still in bed and given two or three times a day a rectal injec- tion of a glass of a I in 1000 solution of salicylic acid mixed with a glass of oil, the receptacle held as high as possible ; then a quart of the salicylic solution allowed to flow in slowly, the patient meanwhile kept perfectly motionless. Presumably . the patients were not given either food or cathartics. TREATMENT OF APPENDICITIS 765 latter out, so as to begin the fight without any handicap upon the patient. If, then, the disease proves to be something else, no harm will have been done, but, on the contrary, good. Virtually, all the forms of disease with which appendicitis is likely to be confounded will be the better for such a conservative begin- ning of the treatment. After this good start, if you find a severe type of appendi- citis to be developing, call a consultation, including always as one consultant the best obtainable abdominal surgeon, and whatever may be subsequently done, you will have nothing to regret. One reason urged in some quarters for avoiding a laparot- omy in the milder attacks of appendicitis, especially in the catarrhal form when the symptoms are not threatening, is the fact that adhesions so frequently result from operative inter- vention and give rise then to annoying, as well as, sometimes, dangerous complications afterward. Ford of Utica, N. Y., long ago advised that in catarrhal appendicitis, whether treated by operation or without, the bowels after the attack be kept well filled with some kind of pulpy food and regularly opened by salines — that is, kept active instead of at rest — in order to prevent the adhesions which rest and opiates tend to favor. When adhesions have already formed, he recommended deep massage and large doses of galvanism locally as a means of stretching or dissolving them. Ford's method of after treatment, while probably safe in the milder cases for which he advised it, should not be risked until all danger of peritonitis or abscess has passed. However, in summing up all the evidence for and against early operative treatment in appendicitis, there is a decided preponderance in favor of operating during the first thirty-six, and, possibly, the first forty-eight, hours in all cases, before perforation of the appendix or rupture of an abscess has oc- curred — in all cases at least which are not certainly catarrhal merely — provided a competent surgeon caii be obtained. LECTURE LXIX CONSTIPATION Constipation may best be defined as an imperfect empty- ing of tlie bowels. It is a morbid condition which may result from many different diseases. Though only a symptom of some pathologic state, either in the innervation or muscular apparatus of the intestines, or of disease elsewhere in the body, it is exceedingly prevalent in civilized communities, and in its chronic form is almost never cured by the administration of medicines alone, nor by any directly opening measures, whether in the form of laxative drugs, per os or per rectum, or by colon douches, or even the usual routine massage. Etiology. — To enumerate all the diseases which seem often to stand in a causal relation to constipation w^ould almost ex- haust the list of important known maladies. Prominent among those which nearly always produce constipation (and many of them complete obstruction) are meningitis, brain tumors, among other cerebral and spinal affections, lead poisoning, volvulus, invagination of the intestines, hernia, peritonitis, ap- pendicitis, abdominal and pelvic tumors, etc. Tumors, however, sometimes cause diarrhea. Constipation may also be a result of blood impoverishment, and of most depressing diseases of the nervous system, inflammation of the stomach or upper intestines, ulcer or tumor of the same, and stricture of the bowel ; also, of abnormalities in the gastric secretion, especially hyperchlorhyd- ria, many diseases of the liver and pancreas, hemorrhoids or fissure of the anus, and particularly ptoses of the viscera, backward displacement of the uterus and other diseases of the pelvic organs. Prolapse of the right kidney (movable kidney), which is exceedingly common in women, is often a 766 CONSTIPATION 767 factor in the production of constipation by obstructing at times the lumen of the duodenum, and the agglutination of folds of intestine to each other or to neighboring structures may seriously impede the onward propulsion of the feces. (See Lecture LXIV.) The most prolific causes of chronic habitual constipation, and those most amenable to non-operative treatment, are to be found in either one of two opposite conditions involving both the nervous and the muscular apparatus of the gastro-m- testinal tract, and recjuiring cjuite different methods of treat- ment. These are atony and spasm. Atony of the stomach walls, whether amounting to dilatation or only to motor in- sufficiency with delayed emptying, results generally in a de- ranged intestinal peristalsis showing itself usually, at first, in the form of constipation. Atony in any part of the intestine must manifestly produce a like result. A spastic state of the pylorus or of the muscles of the in- testines, leading to irregular local tonic contractions of the circular fibers, is a common and often unrecognized cause of constipation. In hysteria, and in certain forms of neuras- thenia, such localized spasms are perhaps almost as frecjuently responsible for difficult defecation as muscular atony, and much more frequently than any other single cause. It is probable, also, that the deranged digestion, both gastric and intestinal, which so often accompanies neurasthenia, by producing fer- mentation and abnormally acid conditions in the alimentary canal, conduces powerfully to the spasmodic action; and it is likely that portions of the bowel, the mucous membrane of which is in a state of chronic catarrhal inflammation, have an increased tendency to spastic contractions. Authorities differ widely as to the relative importance of various factors in the causation of both atonic and spastic constipation. Glenard considered displacements of the stom- ach and intestines as chiefly responsible, while Emminghaus traces habitual constipation to degenerative changes in the splanchnics, and Dunin thinks it attributable mainly to central ^68 THE GASTRO-IXTESTIXAL CLIXIC functional anomalies in the nervous system. Boas^ finds it difficult either to deny or confirm these theories ; but points out that in any fully developed case of neurasthenia with consti- pation there may be found a vicious circle, and he thus aptly illustrates his idea by describing a supposed case such as we all often see : " A previously healthy woman begins to suffer with consti- pation and requires aperients. Gradually these become in- efficient; defecation is more and more difficult and imperfect. At the same time, there is taken a decreased amount of nour- ishment, either in consequence of a misuse of purgatives, or as a therapeutic measure ('easily digestible food'), or as a re- sult of a bad general condition, or from anaemia or gastric derangements, c. g., atony. Naturally, then, follow emacia- tion, dropping of the abdominal viscera, and, with these, in- crease of the constipation, and finally, as a capstone to all these symptoms, the picture of well-marked neurasthenia. Here, as every experienced physician must concede, the enteroptosis is not the cause, but the consequence, of the habitual constipa- tion, and the same holds good also for the neurasthenia. But, on the other hand, the loss of flesh from whatever cause can lead to the development of visceral displacements, and so pro- duce constipation, or, perhaps more correctly, favor its develop- ment, as also, in like manner, genuine neurasthenia (according to Dunin's view) may prove the basis for the development often of even very stubborn forms of constipation." An insufficient amount of food or drink, or long-continued overeating, a too bland diet lacking in refuse matters, or a too predominantly nitrogenous diet, sedentary occupations, defi- cient exercise, and a want of regularity in going to stool are further important causes of chronic atonic constipation. Symptomatology. — It has been denied that auto-intoxica- tion can be caused by dry feces, no matter how long retained, and in Gennany the resulting phenomena are more generally considered to be reflex ; but, however accounted for, some of ' " Diagnostik u. Therapie der Darmkrankheiten," Leipzig, 1899. CONSTIPATION 769 the following symptoms may be constantly observed as a result of constipation : Dizziness, headache, insomnia, mental hebe- . tude or depression. Other frec^uent symptoms, which usually disappear more or less cjuickly after overcoming the constipa- tion, are nausea, furred tongue, offensive breath, excessive flatulency, colics, failing appetite, as well as other indications of impaired digestion, urticaria, and various other affections of the skin, and objectively ascertained, often deranged gastric secretion (especially excessive HCl) and probably lowered gastric motility, as well as indicanuria and excess of the aro- matic sulphates, and of the total acids in the urine. Other ob- jective signs are dry, hard stools, lumpy or made up of agglutinated balls of different color and consistency, or hard globular feces of various sizes, from that of hazelnuts up, or in spastic cases, as well as in cases of organic stricture, un- usually small cylinders like lead-pencils. Periodic transient attacks of diarrhea, with usually mingled lumps and hquid feces, which are often exceedingly offensive, may be considered as a symptom of chronic constipation. In these cases there is irritation of both the mucous membrane and musculature of the intestines by the long-continued press- ure of the hard fecal masses and distention from the im- prisoned gases, and probably a catarrhal process is also set up in places, through infection from the enormously multiplied bacteria in the stagnant feces, with abundant formation of or- ganic acids from fermentation. It is a serious mistake to treat such diarrheal attacks by opiates and astringents, or even by antiseptics alone, when nature has so clearly pointed the way to a prompt clearing out of the intestines. Recurrent diarrheas, with either nc stools or insufficient stools between, are signs of chronic atonic con- stipation, or else of a mild chronic enteritis, and need to be treated accordingly. The Differential Diagnosis between Atonic and Spastic Constipation. — It will be of chief practical importance to dif- ferentiate the atonic and spastic forms of constipation from 770 THE GASTRO-INTESTINAL CLINIC each other, and both of these from the organic changes which may impede defecation. Westphalen ^ of St. Petersburg has written elaborate papers concerning both the atonic and spastic forms of constipation, and has pointed out the differences be- tween the two very clearly. Numerous authors, including Nothnagel, Boas, Flick, Fleiner, and others, in Germany es- pecially, have mentioned the spastic as a possible form of con- stipation, but with a few exceptions do not lay much stress upon it. 3vlany cases of this affection, which were seen in my own earlier practice, were not recognized as such. They were often given abdominal massage, not only without benefit, but with the result of increasing the constipation. These were patients suffering from neurasthenia in connection with gastro- intestinal derangements, and many of them showed spastically contracted abdominal muscles and excessive knee jerks. I do not now prescribe the usual vigorous abdominal massage for such patients, though I sometimes find them to be benefited by light stroking — effleurage; but try to cure them by general roborant measures, trusting to diet, special exercises, oil en- emas, etc., to keep their bowels open. Besides the fact that spastic constipation occurs in nervous, excitable patients with heightened reflexes, Westphalen points out that in such cases the stools, though usually complete, are passed with the greatest difficulty, and often only after much straining and long delay. Afterward there is left behind an unsatisfactory feel- ing, as though the rectum had not been perfectly emptied, e^■en when an examination would show that no feces remained there. This sensation he considers to be due to an irritated condition of the nerve-endings in the rectum. A like hyper- sesthesia of the mucous membrane of the bowel is supposed to play a part in producing the irregular contractions of the cir- cular muscles which hinder the onward progress of the feces. A contrary group of symptoms obtains in uncomplicated atonic constipation. Here the amount of feces passed daily is too ' Archiv f. Verdauungskrankhezteft, vol. vi., No. 2, and vol. vii., Nos. I and 2. CONSTIPATION 7/1 small, not at all in proportion to the quantity of food taken, and yet the patient may pass them with little straining or effort and feel afterward as though he had had a thorough evacuation. He may also be neurasthenic, but will not likely have such exaggerated reflexes. His abdominal muscles will not be so rigid upon palpation, and a finger introduced into the rectum will not be so tightly grasped. The Stools in Atonic and Spastic Constipation. — With re- gard to the appearance of the stools in the two forms, all agree that slender ones of lead-pencil or little-finger size, whether long or short, mean a spastic contraction of some por- tion of the bowel, when an organic stricture can be excluded, except in cases of semi-starvation, especially in cancer, as a result of which the lumen of the intestine may become greatly lessened. These slender stools may be canaliculated. I may add, as an important diagnostic point observed by myself, that spastic conditions are almost never constant, but the patients will at some time, under favorable conditions, however in- duced (often as a i-esult of nerve sedatives), pass stools of normal caliber, whereas, when there is a permanent stricture, the stools are always in either a slender form or fluid. West- phalen also lays some stress upon the consistency of the stools, insisting that, while they are very hard and dry, and often covered with a thin layer of mucus in the atonic form, those passed in the spastic form contain no mucus outside or inside, but have usually a larger percentage of water, and are tougher, more sticky, and of a more glistening appearance — gUinzend. The latter* also contain less gas, so that they will not float in water, as normal feces or those from a case of atonic constipation usually will. ^ Careful palpation and percussion over the abdomen will show differences between the atonic and spastic types of con- stipation. In the former, a more general tympany should be demonstrable, with possibly masses of hard feces to be felt in tlie cecum or flexures of the colon ; while, in the latter type, one , may often feel portions of the intestine contracted like a cord 772 THE GASTRO-INTESTINAL CLINIC under the finger. Then, in the spastic form, too, there are more frequently very sensitive spots in various part of the abdo- men, especially in the region of the umbilicus, and there are portions over which marked tympany contrasts sharply with the duller note of adjoining regions, showing imprisoned gas. Ta- betic patients in an early stage are likely to present the phenom- ena of spastic constipation. Judging from my observation, it is highly probable that most neurasthenic patients who suffer excessively from intestinal flatulence which accumulates in places to their great discomfort, finally passing with bor- borygmi through evidently narrowed coils of intestine, while the feces themselves are retained, have the spastic form of con- stipation, however complicated with other conditions. Finally, you may find both forms in the same case, since it is quite possible for atonic constipation to be complicated at times by a spastic condition. Constipation, from Strictures or Other Organic Obstructions. — From the constipation or obstruction dependent upon serious organic disease, such as strictures, tumors, inflammatory af- fections, etc., both the atonic and spastic form of impeded de- fecation can generally be differentiated by thorough and pains- taking examinations, with the help of our modern exact methods. Other serious conditions which must be differen- tiated from the simpler forms of constipation are adhesions of intestinal loops to each other or to adjacent structures follow- ing operations or peritonitis, partial twists of the bowel (vol- vulus), and chronic forms of intussusception. Some of these it is impossijjle at times to diagnosticate, except by exclusion, liut intussusception in a chronic form should be suspected whenever there are recurrent colics accompanied by the pas- sage of a little blood or mucus or both. The above-mentioned hint as to the constant smallness of the stools in organic stricture should be helpful in making a di- agnosis. Filling the stomach with gas, and again with liquid, and afterward, if necessary, treating the colon in the same way, will often reveal latent tumors and their attachment, and CONSTIPATION 773 a thorough douching of the colon with warm water will usually demonstrate a chronic enteritis by the amount of mucus brought away. You should be careful not to mistake for morbid growths the masses of hardened feces which can often be felt in chronic constipation, especially in the cecum, flexures of the colon, sigmoid, and rectum. Indeed, before making a final diagnosis in any case of suspected abdominal tumors, the bowels should be thoroughly emptied by repeated enemas of oil, followed, if necessary, by flushing the colon with a warm saline solution after the administration of a full dose of belladonna or atropine to relax any spasmodic con- tractions. Areas of dullness over parts of the colon are generally due to a spastic contraction of such parts, since in atonic con- stipation, even when the bowel is loaded with retained feces, the percussion note is usually tympanitic. Constipation can not only result from many different causes, but its possible evil consequences are quite as numerous and varied. A very large proportion of the chronic diseases which afflict mankind and greatly shorten life, as well as some very serious acute forms of disease, result, in the main, directly or indirectly from prolonged constipation, and the dietetic faults upon which it chiefly depends. Such diseases include nearly all the affections of the gastro-intestinal tract not due to entozoa or poisons from without the body, except cancer (and possibly that also, since excessive meat-eaters, who are generally constipated, are believed by some careful observers to be particularly prone to malignant disease) ; many skin dis- eases, arteriosclerosis with its involvement of the heart, arteries and kidneys directly, as well as indirectly the brain and nervous system generally; and so On through an almost endless list, including acute intestinal obstruction, apoplexy, etc. Do not let patients continue indefinitely with laxatives. Our duty is to ascertain the exact cause of the constipation, and then to cure it, as is possible in a large majority of cases. LECTURE LXX CONSTIPATION, CONTINUED— PROGNOSIS AND TREATMENT Constipation is curable when its cause can be cured or re- moved. If the cause be some functional nervous affection, a displacement of the stomach or liver, chronic catarrh of the stomach or small intestine, excessively acid or deficient gastric juice, gastric or intestinal atony, or spastic contractions of the pylorus or of parts of the intestines, the condition is gen- erally remediable by some one or more of the hygienic, hydri- atic, mechanical, and medical measures which we have at com- mand. Even gastric ulcer, movable kidneys, and displacements or kinks of the intestines, you may often be able to overcome by a combination of several of these non-surgical measures, and thus cure the resulting constipation. Serious cases of obstruction, whether due to any of the above-mentioned causes or to hernia, volvulus, adhesions from former attacks of appendicitis, or from local peritonitis else- where, usually respond to surgical intervention when invoked sufficiently early, now that abdominal surgery has become so Avonderfully developed and perfected. When a tumor inter- feres with defecation, the prognosis depends upon its charac- ter, location, and size, and the ability of the patient to bear the necessary operation. The chronic organic diseases of the nerve centres being generally incurable, the prognosis of the constipation dependent upon them is necessarily bad. Most pelvic causes of constipation can be remedied in some way nowadays, except malignant growths, and even these will sometimes yield to prompt surgery or the Massey method — see page 928. 774 CONSTIPATION 775 Treatment. — Chronic habitual constipation, resulting from any of the above-mentioned diseases, can only be overcome, of course, by a successful treatment of such diseases. Many of these have already been discussed in previous lectures, and others will be later. It remains to consider especially the two principal types of constipation, the atonic and the spastic. These are not only the types most frequently encountered, but, though generally sec- ondary to other affections, they both depend much more than other forms of constipation upon a diseased condition in the nerve supply or muscular apparatus of the intestines them- selves. This is particularly true of the atonic form. Impaired gastric motility or a faulty secretion on the part of the liver, peptic or pancreatic glands, or a weak, depressed nervous sys- tem, as well as numerous other maladies, often conduces greatly to this type of constipation, and there is perhaps always some such predisposing factor in the causation. Yet a sed- entary life, with lack of exercise leading to lowered vigor of the intestinal muscles, abuse 'of purgatives (one of the crying evils of the times for which we doctors are, I fear, in large part responsible), and also a too concentrated diet, are all causes which may set up atonic constipation by a direct action upon the intestines themselves. To cure this condition, you will need, therefore, to impress upon your patients, first of all, that even the mildest laxative drugs must be abandoned, or taken only in the smallest possi- ble effective doses when, and so long as, they are indispensable, which they rarely are; that exercise, especially of the trunk muscles, must be practiced every day to the end that both tliese and the muscles involved in the peristalsis may be grad- ually strengthened up to the normal — a process which may require many months to accomplish — and you must strenu- ously insist also upon such a modification of the diet as shall afford refuse matter enough in bulk to effect the necessary distention and stimulation of the intestines. Of course you will see numerous patients in whom all this 7/6 THE GASTRO-IXTESTIXAL CLINIC cannot be easily done. There are many cases of constipation complicated with, or dependent upon, catarrh of the stomach or' small intestine, and the process may also involve a part or all of the colon. In these, before you can cure the con- stipation, you must first get rid of the catarrhal process by the help of an unirritating and often somewhat constipating diet, meanwhile securing sufficient bowel evacuations by the least disturbing methods that will effect the object. This will rarely be pills or any of the resinous laxatives in any form. Olive oil by the mouth, with plenty of drinking water, will sometimes suffice. Enemas of olive oil or cotton-seed oil, or, in some cases, of a tepid or cold saline solution, will usually prove less irritating than any aperients by the mouth, and the former will seldom fail when skillfully used. In all cases, when not otherwise contra-indicated, the special exercises for the abdominal muscles described in Lecture XXIII. should be practiced daily in a well-ventilated room. Massage of the ab- domen will assist in curing the catarrhal process as well as in directly overcoming the constipation, except when there is a spastic complication. The constant electric current (galvan- ism) applied to the abdomen and lower spine, or the inter- rupted current (faradism), static-wave, static-induced, or sinu- soidal current, or vibratory stimulation within the rectum will often proA"e curative. In the catarrhal conditions, whether they are primarily causative or only complications, actual curative results may often be obtained from small doses of the saline laxatives, such as the natural Carlsbad (Sprudel) ^^■ater, the Rubinat Condal water, or artificial solutions of sodium sul- phate or phosphate, and sometimes the bitter waters (mag- nesium sulphate natural waters or solutions), and in cases not too depressed or debilitated you will be justified in making a trial of them for the double purpose of helping to remove the catarrhal process, thus obviating one chief obstacle to the cure of the constipation, and keeping the bowels open meanwhile. In the more asthenic cases, however, especially those with deficient gastric secretion, the alkaline waters and drugs will CONSTIPATION 'J^'J be likely to disagree and the more tonic sodium chloride waters, such as those of Kissingen and Homburg, will then agree better. In any case when a teaspoonful of Carlsbad salt or of sodium sulphate, or a mixture containing sodii bicarb., 5^ to oss.; sod. sulph., oss. to 5j, and sod. phos., oss. to oj ; all dis- solved in a glass of hot water, or an equivalent dose of the nat- ural waters, fails to keep the bowels open with the hygienic and mechanical helps mentioned, it will not be desirable to admin- ister large doses of them for long periods, even in the presence of catarrhal complications. You should, then, instead, continue them in the same small dose, provided they agree ( not produc- ing irritation) ; and as auxiliaries, besides plenty of drinking water, give the oil or saline enemas already mentioned. Then, if need be, give one of the forms of local stimulation above re- ferred to, of which the simplest and most effective is vibration applied within the rectum for two minutes daily. The milder the case of an associated chronic intestinal catarrh, the more nearly the treatment may approach to that required for simple atonic constipation, from which it doubt- less may sometimes result ; but in the pronounced catarrhal cases, the diet must be blander and more concentrated, includ- ing more lean beef and avoiding all coarse, irritating articles. For further details as to the diet and other treatment ap- propriate to catarrhs of the alimentary canal, see the previous lectures devoted to those diseases. Do not overlook the fact, in prescribing remedies for one part of the alimentary canal, that they may act injuriously upon another part. For example, such drugs as belladonna and Carlsbad salts, as well as some of the foods, such as sugar and the fats or oils, which are useful for their laxative effect (not to mention the value of Carlsbad water or salt also for their alterative effect in catarrhal affections), have a very positively depressing effect upon gastric secretion, lessening the quantity and strength of the gastric juice. These effects have been confirmed repeatedly. In fact, any physician who does not "jy^ THE GASTRO-INTESTINAL CLINIC test the stomachs of his chronic invahd patients occasionally, as to their secretory work, should avoid drugs as much as possible afld depend mainly upon hygienic measures. Even then his dietetic prescriptions may often disagree with the stomach in a way that could have been foreseen and prevented. In cases of atonic constipation without any inflammatory complication, or after curing a previously existing catarrh, you should usually devote your first and your chief attention to the diet, reducing the excess of meat and other nitrogenous foods which most constipated persons allow themselves. This nitrogenous overplus does harm in various ways when long continued, but what concerns the present discussion mainly is that, when taken in the form of meat or eggs, as is usually the case, it does not leave enough residue in the intestines to afford the necessary distention and mechanical stimulation to provoke an adequate peristalsis. A considerable proportion of cel- lulose, found largely in the grains, vegetables, and in many fruits, is absolutely necessary to induce regular and complete evacuations of the bowels, unless one is to depend upon physic. Some of the less acid fruits, such as figs and prunes, have proved in my experience particularly effective in overcoming constipation, even in the cases very often of the spastic form complicated with considerable atony. When stewed without sugar, the prunes, especially, agree well with most patients, even taken liberally, though they may increase somewhat the flatulence in large eaters. Penzoldt's Diet for Atonic Constipation. — The subjoined diet table for uncomplicated atonic constipation was originally prescribed by Penzoldt and is also recommended by Boas : 7 A. M. — One glass of water. 8 A. M. — A generous breakfast with sweetened coffee, much butter, honey and Graham bread or brown bread (pumper- nickel). Thereafter an attempt to have a stool. I P. M. — Dinner of meat, much vegetables, salads, stewed fruit (compot), farinaceous preparations (mehlspeise), one- half bottle of light wine — Moselle — or cider. CONSTIPATION 7^9 7 P. M. — Meat with much butter, Graham bread, stewed fruit, and beer. lo P. M. — Before going to sleep, fresh or stewed fruit. The alcohohc beverages inchided in the above hst are not indispensable, since an equivalent amount of fruit juice would be equally effective in promoting bowel movements. You should also bear in mind that in numerous diseases which are often associated with constipation both the decidedly sweet and sour articles of such a typical laxative diet, as well as the excessive amount of indigestible material in the form of cellulose as in many of the vegetables and raw fruits, are likely to aggravate and are, therefore, positively contra-indicated. Boas calls attention to this himself and mentions among the diseases in which such a diet is contra-indicated the following: diabetes mellitus," obesity, atony or dilatation of the stomach, hyperacidity, gastric ulcer, cancer of the stomach or intestines, and excessive flatulence. My own experience fully bears out the statement of Boas as to the unsuitableness of the diet scheme above given in the presence of the diseases just named as well as in pronounced catarrhal inflammation of any part of the alimentary canal and in ulceration of the intestines. The ultra adherents of the meat-and-hot-water regimen, which often proves efficient during short periods in the treat- ment of chronic catarrhal inflammations of the alimentary canal, have preached constantly against starch and led thus to a popularization of the foolish notion that starchy foods are to be carefully avoided in all the derangements of the digestive system. On the contrary, except in the catarrhal cases (when for a few weeks at a time the starches and sugar may be greatly restricted), there are few such derangements in which a mixed diet, with a due proportion of the carbohydrates, is not prefer- able in the long run. It is necessary, as not only promoting more thorough elimination through the bowels, but also as better supplying the needs of nutrition. When not otherwise contra-indicated or found to disagree, the fats in the form of ySO THE GASTRO-INTESTINAL CLINIC fresh cream, butter or olive oil, and also sugar, especially sugar of milk, if taken rather liberally by constipated persons, will greatly conduce to freer stools. Many patients can drink coffee with apparent impunity,, and it often exerts a slight laxative effect. Tea, chocolate, cocoa and milk, and claret tend to increase constipation, as a rule, to which there are occasional exceptions. Cold water, taken one or two tumbler- f uls several times a day — upon arising, at bedtime, and between meals — often helps to overcome atonic constipation. The ad- dition of five to ten grains of table salt to each tumblerful of water increases its efficacy, except in hyperchlorhydria, when soda or some other alkali should replace the salt. Next in importance after the diet comes exercise in the open air. Patients who have been stubbornly constipated while leading sedentary lives, often recover spontaneously after en- gaging in outdoor occupations, or through spending several hours daily in such recreations as horseback riding, rowing, golfing, or lawn-tennis, though prolonged and excessive horse- back-riding, as in the case of cavalrymen, has been observed to produce constipation. Bicycling sometimes effects a cure, but less frequently. Changes of climate involving, as they usually do, rest from mental or nervous strain, and especially when prudent sea- bathing or mountain climbing is added, often promptly relieve constipation. When these things are not practicable, good results may usually be obtained from systematic movements of the trunk muscles and a course of hydriatic treatment carefully adapted to the case. Reference has already been made to the exercises that may be practiced by patients in a well-venti- lated bedroom; and the douches or sponge baths with tepid or cold water, that may be taken in any bathroom, will frequently prove effective in connection with appropriate diet. Cold affusions or douches do not suit well in the spastic cases; and the same may be said of abdominal massage, which, though it aggravates the spastic form, may be a very useful factor in the treatment of atonic constipation, given by the physician him- CONSTIPATION 781 self (when he is competent to give it), or by a thoroughly expert masseur under his personal supervision. But massage of the abdomen, like gymnastics, can only very gradually overcome even atonic constipation by develop- ing and strengthening the muscles involved in the' act of defecation. Except, therefore, in the cases in which the diet, with a liberal use of drinking water, effects a speedy improve- ment, this form of constipation recjuires time to cure — nearly always months and sometimes a year or more. For the small proportion of incurable cases of constipation in which enemas of some bland oil do not procure sufficient evacuations, the best laxative drugs are cascara, aloes, senna, and sulphur, in their smallest efficient doses. Phenolphthalein in doses of one to three or four grains daily has been lately proved of value in atonic constipation. The treatment of the spastic form resolves itself mainly into the cure of the neurasthenia or hysteria upon which it depends. When this is severe in type, the usual method by rest, seclusion, and generous feeding is applicable, except that massage of the abdomen must be omitted, and that the milk diet disagrees when there is much dilatation or even marked atony of the stomach. Notwithstanding the excessive irritability of the intestines, a bulky diet, including a liberal allowance of vegetables and fruit, is usually helpful here as in the atonic form, when not otherwise contra-indicated. Not only is massage of the ab- domen to be avoided in the spastic type, but stimulating af- fusions or jet douches of cold water to the same part are likely to aggravate, and our German confreres generally insist that purgatives are equally harmful. My own experience con- firms all these observations. Good results may be expected from the usual building-up measures, including systematic ex- ercises and tonics, except that possibly iron may increase the constipation, and even strychnine and the other tetanizers may have a like effect in this form unless given in small doses. Warm jet douches to the abdomen are recommended by West- 782 THE GASTRO-INTESTINAL CLINIC phalen, who also insists that opium and belladonna in these cases will often produce more copious evacuations than purga- tives. The same author advises bromides, with small doses of chloral, for more prolonged use, to overcome the irregular intestinal contractions. With regard to belladonna and atropine, there are numerous observations attesting their ef- ficacy in various forms of constipation, and even in ob- struction from irregular spasmodic muscular action, intestinal cramps of different degrees of severity; but it needs to be constantly borne in mind that in overcoming by these rem- edies a spastic constipation associated with hypopepsia — dys- pepsia from deficient gastric juice — the latter condition will necessarily suffer an aggravation that may be serious, though this result might be avoided by administering HCl and pep- sin after meals at the same time. In cases of spastic con- stipation with persistently excessive contraction of the anal sphincter, the latter should be dilated either quickly under ansesthesia, or gradually by dilators. Olive oil, both by the mouth and by enema (especially the latter), is a safe and generally efficient resource in stubborn cases of the spastic form. I have recently seen curative results in cases of constipation from the use of various preparations made from coal oil such as vaselin, albolene, Purpetrol given internally. Teaspoonful to tablespoonful doses of either, taken once or twice a day, often succeed in mild cases; but these petroleum preparations seem to depress the heart a little in some cases when used long, and even Purpetrol, the purest of them all, will bear watching. In the spastic, even more than in the atonic, form of con- stipation, the greatest help may be derived from changes of climate and an out-of-door life, except in the case of the worst neurasthenics and hysterics, who require rest at first. Then, as in all nervous affections, every case needs to be studied by itself. There is no class of diseases in which routine methods are more likely to fail. The best progress will be made when the state of the gastric CONSTIPATION 783 function, both secretory and motor, is carefully studied. The cases with markedly deficient peptonization will often gain as much by the administration of HCl and pepsin after meals as the opposite class of cases are sure to be injured and ag- gravated by such a line of medication. Great regularity in observing fixed times for eating and for defecation is extremely important. Various observers have noted the clinical fact that lavage will sometimes cure constipation. Spivak has recently called attention anew to this and claims priority for the original observation. He has found lavage useful ( i ) in constipation due to excessive acidity; (2) in the same due to gastric atony; (3) in diarrhea from excessive mucus in the stomach, and (4) in obstruction of the intestines, from whatever cause. I have employed lavage coincidently with other measures in a great many cases of constipation from various causes, and have occasionally seen the latter symptom relieved by it. Flushing the colon with large quantities of water or aqueous solutions of drugs may be useful for short periods, but as a means of emptying the bowels regularly in stubborn cases of chronic constipation, which have proved refractory to curative treatment, is to be condemned. It is sure in time to aggravate the disease, causing a gradually increasing paresis and dilata- tion of the colon, even more surely than a dependence on the daily use of a laxative medicine. In spastic constipation Abrams advises stimulation by a strong sinusoidal current or by concussion (performed by a succession of blows with a little hammer called a concussor) of the spine of the eleventh dorsal vertebra; in atonic con- stipation he treats in the same way the first three lumbar verte- brae, but in this form finds concussion the more effective. See page 311.^ See Lecture XXVII. for details of the technique of various forms of local treatment of the colon by injections of oil, medi- cated aqueous solutions, etc. ^Spondylotherapy. Philopolis Press, San Francisco, 1910, LECTURE LXXI DIARRHEA Etiology. — The symptom diarrhea is most frequently a consequence of catarrhal inflammation of the mucosa in some portion of the bowel, but may result from constipation both through the direct irritation of the mucous and the muscular coats of the intestines by the retained and hardened fecal masses, and by the irritating influence upon the same of the gases which are caused by decomposition in such feces. Diar- rheas thus produced soon develop into true inflammation — enteritis — after frequent recurrences, especially when neglected, or treated, as so often happens, by astringents and opiates. Frequent loose stools may also depend upon poisons, etc., in the blood, as in uraemia, lithsemia, malaria, and various acute diseases. They often owe their origin to fermentation in the stomach in consequence of the absence or deficiency of HCl, as in chronic gastritis, especially the atrophic form with achyha, and of the digestive ferments in the gastric juice. They occur usually in the later stages of morbid growths in or adjacent to the intestines, though sometimes in fhese cases constipation persists almost to the end. Diarrhea occasionally seems to have no other cause than a nervous derangement in- volving the peristaltic apparatus. The feces are then propelled so rapidly that they do not have time to harden by the absorp- tion of their liquid contents. The loose movements may also depend u\)C)n either an increased secretion or diminished power of absorption, both of which conditions may result from faulty innervation as well as from other causes. Diarrhea is an almost constant accompaniment of tuberculous, syphilitic, and 784 DIARRHEA 783 simple ulceration of the bowels, especially when the colon is affected. Chronic catarrhal inflammation involving the appendix alone, or with only a slight and occasional implication of other portions of the gut, is probably responsible for many otherwise inexplicable recurrent attacks of bowel looseness. I have often observed such attacks in persons presenting signs of a thickened and somewhat tender appendix, but without evidences, in the intervals, of enteritis elsewhere, and sometimes no such evidences appeared even during the attacks; and the latter could not be traced to any of the ordinary causes. It is well known that bacteria grown in closed cavities are likely to be excessively virulent, and it is probable that the colon bacilli, which are from time to time forcibly expelled into the cecum through the stenosed orifice of a catarrhal ap- pendix, may be virulent enough to set up a decided irritation of the colon with or without the production of a catarrhal process there. Chronic enteritis, involving a portion at least of the colon, and often much of the small intestine as well, is, however, with sometimes ulceration as a complication, the most frequent cause of a persistent diarrhea. When enteritis exists, you will be able to find at times mucus in the stools, either coating the occasional formed portions on the outside, showing its origin low down in the colon or rectum, or more commonly mixed with the feces more or less intimately, coming then from higher up in the bowel. . Usually, too, by deep palpation gently made, you will find sensitive regions over the course of the colon, especially over the transverse portion and the cecum. The treatment of diarrhea divides itself naturally into dietetic, mechanical, and medicinal, and the medicines useful in the disease include eliminants, alkalies, and antiseptics, with sometimes sedatives and astringents. In an acute attack of loose bowels, or one which has existed only a few days, it is usually not necessary to do anything ex- 786 THE GASTRO-INTESTINAL CLINIC cept to insist upon rest, and either abstinence from food or a limitation to the smallest quantities of the blandest possible nourishment, such as fresh meat juice or boiled milk with boiled rice, though the remedies to be first administered in a doubtful chronic case, as recommended below, will often hasten the cure. To give you the most practical instruction in the clearest manner, I will advise you how one may best proceed in a case of diarrhea which has persisted a number of da3^s, or weeks, or longer, in a patient not tuberculous nor syphilitic, not acutely ill in any way, and not having a palpable tumor in the abdo- men. If the stools are very offensive (or if they contain scybala, with or without mucus), begin with a moderate or small dose of some gently acting laxative, preferably a tea- spoonful to a tablespoonful of castor oil, but an equivalent dose of rhubarb or a saline will answer the purpose. When the tongue is foul and the breath bad, follow with grain 1-20 to 1-6 of calomel, given every hour or two till the stools be- come less offensive and of a yellow color. If there should be nausea or an irritable stomach, it would be better to omit the oil and begin at once with the smallest mentioned doses of calomel, given every hour at first, and later every two or three hours. This is usually the better plan, in the case of children especially. These will, in a few days, often control both the gastric and intestinal trouble without any other measures ex- cept rest and diet, as advised above for an acute or recent attack. Should the laxati<\'es not have removed all fetor, scybala, and undigested pieces of food from the stools by the end of two days, it will usually be desirable to give oil or rhubarb a second time, unless there should be pain or other signs of ir- ritation produced by the remedies, which rarely happens, except when excessive doses have been administered. In the event of such irritation, give, instead of more laxatives, ,5- to 20-grain doses of bismuth subnitrate after every loose stool ; and a day or two later, if all the symptoms have not been DIARRHEA • 787 removed, repeat the laxative and continue cautiously this method of elimination with the addition of bismuth after stools, and opium if needed for severe pain, until by careful inspection of the evacuations and deep palpation over the colon, you have determined that all stagnant and decomposing re- mains of food or feces have been removed. In the great majority of cases, including usually all those dependent upon an underlying condition of constipation, which has led to accumulations of hardened feces, with often patches of inflammation of the mucosa, such a course of laxatives con- tinued for a few days with a little bismuth at the last, com- bined with chalk wdien the stools are very acid, will, without any opium or active astringent, be found to have controlled the diarrhea. You will need then to apply yourselves to the more difiicult task of overcoming the underlying condition of constipation, for which, besides diet and special exercises, massage and electricity will serve you best, as I have de- scribed in Lecture LXX. The cases in which constipation has gone on to the development of a persistent diarrhea, will usu- ally present more or less intestinal catarrh, and both the constipation and its resultant diarrhea w^ill then be best treated by remedies addressed to the pathologic change. In certain cases the bowels can be emptied better by a thor- ough flushing of the colon from below than by purgatives, and, generally speaking, the more strictly the disease is limited to the large intestine, and the longer the accumulation of feces has been going on, the greater the advantages of this method of removing the cause, provided it be not continued too long. Complicating Conditions. — But in a certain proportion of these cases, even after the intestines have been cleared of fecal masses, decomposing ingesta, irritating secretions, etc., fre- quent thin stools will persist. In such cases, you should test the stomach contents to see whether the gastric juice is sufficiently active, and proceed to remedy any deficiency discovered. You should also study the urine carefully, to detennine 788 THE GASTRO-INTESTINAL CLINIC whether the uratic diathesis or some other toxsemic state is not answerable for the persistent flux. You may find that a latent nephritis is at the bottom of the trouble, the kidneys failing to do their excretory work thoroughly, thus imposing more upon the bowels; and in all these self-poisoning cases you will readily see what mischief must be wrought by the cus- tomary method (which fortunately generally fails) of trying to check diarrhea with opium and astringents. The Appendix Often Involved in Diarrhea. — You will also examine thoroughly to see that there is not a tender, swollen appendix sending out its colonies of virulent colon bacilli, or a cirrhotic liver, or feeble, laboring heart causing an obstructed circulation in the abdominal vessels, or that widely prevalent affection in women especially, a downward displacement of one or more of the abdominal viscera, which has been the dis- turbing cause, producing at first, as such conditions usually do, constipation, followed by its very frecjuent sequel — diarrhea. Any such factor in the causation will, of course, need to re- ceive a large share of attention in the treatment ; and nearly always some one of them can be found, if searched for with the necessary care and skill. AMiatever else may be wrong, the liver is generally embarrassed in chronic diarrhea, and a use- ful addition to other appropriate remedies will be very small alterative doses of podophyllin — grain 1-200 to grain i-ioo every three to four hours — too small a dosage to increase peri- stalsis, in adults at least, and yet seemingly enough to exert a curative influence upon many cases of diarrhea with profuse, thin stools. It is particularly effective in the so-called morning diarrhea, in which there are one or more loose and usually painless stools every morning, with no further trouble during the day. (See Lecture XXXIV.) I have controlled numerous previously stubborn cases of this kind l)y i-120-grain doses of podophyllin, assisted only by a bland, digestible diet ; but when this alone does not prove promptly effective, I am accustomed to prescribe in addition for any chronic form of looseness, de- pendent upon excessive secretion, or an irritated intestinal DIARRHEA 789 mucosa from fermentation, some such combination as the following : B Bismuth subnit. vel. salicylat. \ Ichthalbin |- , aa 3 ii Cretae preparat. ) M. et ft. chart. No. XII. Sig. One in water after every loose stool. But before prescribing the above, or any astringent, clear out the bowel by a mild physic. When the looseness depends upon a pronounced chronic colitis, the remedies can often be applied to the best advantage per rectum. Once a day at first, and later every other day until the flux ceases, place the patient upon the back, or first upon the left side for a few minutes, and after that upon the right side, with the hips a little raised, and after a preliminary cleansing of the colon by introducing a normal salt solution, or a weak solution of sodium bicarbonate ( 3 i to Oii) at a temperature of about 100 to 105° F., a quart at a time, repeated until it comes away without the color or odor of feces, inject a pint of water at 90° containing a dram of bismuth in suspen- sion, and let it remain as long as it will. In bad cases it is well to supplement this by injecting, two or three times a week, some decided astringent, such as nitrate of silver (grain iii to Oi) ; or an antiseptic solution such as one and a half drams of strong carbolic acid dissolved in three ounces each of glycerin, and glycothymoline or listerine, of which an ounce is then added to two quarts of tepid or warm water for one clyster. (See Lecture LXVI.) When the bowel will not tolerate enemas well, but con- tracts at once spasmodically, there is often some morbid con- dition discoverable in the rectum or prostate gland, or, in the case of women, in the internal genitals, which should be sought for and remedied. In such cases the treatment can generally be carried out in spite of the difficulty, by placing the fountain syringe or other reservoir containing the solution not more than one or two feet above the patient, so as to lessen the 790 THE GASTRO-INTESTINAL CLINIC pressure, and in addition, when necessary, by raising some- what the temperature of the hquid. Such medicated clysters often help much in the cure of an intestinal catarrh, but should never be continued long as a routine method of evacuating the bowels in stubborn constipation. The diet in chronic diarrhea needs to be most carefully studied, for it is a difficult problem often to nourish the patient sufficiently w^ithout permitting a greater variety of aliment than can be taken without aggravating the disease. Milk in some of its forms can usually be made to agree, and we may allow well-cooked rice, freshly toasted bread, zwieback (if not too hard), or other partly dextrinized starch food, though sometimes good home-made stale bread agrees even better. In many cases soft-boiled or raw eggs are borne well, and in nearly all, the whites of eggs. Baked white potatoes and some of the vegetable purees may be cautiously tried in the less severe cases, and often buttered stale bread can be added. In certain cases in which there is very excessive fermentation, beginning in the stomach, and yet sufficient gastric juice, or the possibility of supplementing it well enough by administering HCl and pepsin, the most satisfactory basis of the diet at first — for, say, three or four weeks — is finely chopped beef, with a free use of hot water still further to stimulate the secretion of the digestive glands. Give with these only two or three slices of stale or toasted bread daily, and a very small amount of as- paragus tips, spinach, or a leaf or two of lettuce merely as a relish, gradually adding more carbohydrates and fats as they are found to be tolerated. In some of the worst cases the diet may have to be limited for a while to peptonized milk or other predigested foods, such as Eskay's Food, etc., and in others, Plasmon, with the help of some one of the meat powders, answers best. Boiled rice with boiled milk makes a good combination for some severe cases. The foods which are most likely to aggravate diarrhea are first of all the raw fruits, and the sourer the worse, next the DIARRHEA 79 1 cooked fruits, especially when sweetened, and third the crude succulent vegetables. In some cases no vegetables can be made to agree. Sugar in any form, as well as hot or fresh yeast bread, and the shell fish, are badly borne as a rule. Milk, which usually suits best, will occasionally increase diarrhea, though it is less likely to do so if boiled, sterilized, or pepton- ized, and even soft-boiled eggs are not always well digested by these patients. The suitability of a diet must be judged by its effects upon the frequency of the stools and the amount of fermentation as shown by the stomach contents and feces, as well as by the amount of indican and aromatic sulphates in the urine. In the diarrheas resulting from chronic catarrh of the ap- pendix, the same treatment applies as in those from other forms of intestinal catarrh, except that it is even more im- portant in them to keep the colon, especially the cecum, free of fecal accumulations and as aseptic as may be. Counter-irrita- tion, by iodine or otherwise, over the appendix is helpful, and small alterative doses of calomel can be advantageously con- tinued during two days of each week, for a month at a time, provided there be one or two complete (but not necessarily loose) evacuations daily. Moderate doses of galvanism (15 to 30 ma.) may also be applied locally through the cecum from side to side. • For persons thus affected who are not able or willing to diet strictly and persist faithfully with the above-outlined treat- ment, the operation of appendectomy should be performed. In the comparatively infrequent diarrheas dependent upon other causes than indigestion, constipation, intestinal catarrhs, and toxaemias, opium and astringents may at times be needed ; but great caution should be exercised not to resort to them until the latter varieties of the affection, requiring generally the opposite method — elimination — can be positively excluded, and such mild antiseptics and astringents as bismuth should al- ways first be tried. Finally, in all the forms of chronic diarrhea, the general 792 THE GASTRO-INTESTINAL CLINIC health should be built up in all possible ways, by an abundance of outdoor air, changes of climate at times, proper clothing, and a judicious use of water locally. It is a very debilitating disease, and other debilitating conditions aggravate it. To cure obstinate cases, the mode of life must be- hygienic in all respects. The Nervous Forms of Diarrhea following grief, fright, or any intense emotion, or from any nervous derangement, are usually transient in duration, but chronic cases do occur. These demand, in addition to the general treatment of neu- rasthenia, nerve sedatives with, in the more stubborn cases, bismuth, or even the stronger astringents, and sometimes some one of the opiates. When fermentation in the stomach or small intestine causes excessive acidity, the cure of the resulting or complicating diar- rhea will usually be promoted by adding to the other treatment 5- to 20-grain doses of prepared chalk several times a day. The addition of lime water to the milk given as part of the diet, helps in the same way and also makes the milk agree better. LECTURE LXXII DYSENTERY Definition. — The term dysentery signifies an inflammatory condition of the large, and sometimes also of the small, in- testine accompanied by tenesmus and the frequent passage of small mucous and blood-stained stools. It is generally con- sidered an epidemic disease, but may occur sporadically. .Etiology. — Each variety of dysentery has a cause peculiar to itself; all forms, however, have certain aetiologic factors in common. Dysentery is most prevalent in the tropics, although it oc- curs both epidemically and endemically in the temperate zone, where it exists more frecjuently at the end of summer and in the autumn. In the tropical districts it is more fatal than cholera, and has caused more deaths in armies than actual warfare. Striimpel states that in the Anglo-Indian army the mortality due to dysentery is 30 per cent, of all deaths. The high death-rate of this disease in the past has largely been due to bad hygiene and the lack of proper sanitary regulations. Attention has been called by Manson to the tendency of dys- entery to occur in malarial districts. The manner of infec- tion has not been positively determined ; evidence, however, tends to point to the water-supply, flies, and the fecal dejec- tions of either the sick or of healthy bacilli-carriers, as the prin- cipal sources of the specific germ. Constipation, and gastro-intestinal disturbances brought about by the ingestion of bad food, especially unripe fruit, predispose to dysentery. 793 794 THE GASTRO-INTESTINAL CLINIC This disease occurs at any age and in either sex. There is no race immunity, although Kieffer/ from an extended ex- perience with troops, believes that the American negro is relatively immune to amoebic and bacillary dysentery. A classification of dysentery into the following varieties has been found convenient : catarrhal, bacillary, amoebic, and chronic, though now authorities are inclined to condense all these into two main classes — bacillary and amoebic. CATARRHAL DYSENTERY (SPORADIC DYSENTERY)^ This is an acute form which occurs commonly in the tem- perate zone. Etiology. — Catarrhal dysentery may acco npany the spe- cific intestinal lesions of tuberculosis and typhoid fever, and is sometimes associated with the acute exanthems. Simple irritants, such as the eating of green fruit or other unwholesome food, and exposure to a chilly night air after a hot day, or sleeping on damp ground may cause the disease. Until recently no specific organism was associated with this type of dysentery, but in an epidemic at Hartwick, N. Y., Curtis was able to isolate the bacillus pyocyaneus in large numbers in the stools, and both he and Kiefifer now consider this micro-organism as an important setiologic factor. Catar- rhal dysentery occurs in children as the so-called enterocolitis of the summer months. It was in the dejecta of such cases that Duval and Vedder^ found the bacillus of Shiga. If their researches can be confirmed, catarrhal dysentery will here- after be classed as a form of bacillary dysentery. Pathology. — The morbid process is usually limited to the colon, although occasionally the lower part of the ileum is invoh'ed. The mucosa is covered with a bloody mucus, the "^ Phil a. Med. Joiir., January 31, 1903. 2 Recent observations make it probable that most cases hitherto classed as catarrhal or sporadic dysentery owe their origin to some one of either the Shiga-Kruse or Flexner group of bacilli. See note on p. 808. ^Jour. Exper. Med., February 5, 1902. DYSENTERY 795 blood-vessels are injected, and the solitary follicles have un- dergone hyperplasia. The mucosa is eroded and the seat of superficial ulcers. Symptoms. — A prodromal stage lasting a day or two may exist, during which there occur slight abdominal pain, ano- rexia, and a mild diarrhea; or the onset may be sudden. At first there is a copious and painless diarrhea ; soon the evacua- tions become more frequent and smaller in size ; the stools are streaked with mucus and blood, and their passage is accom- panied by colicky pains (tormina) and straining (tenesmus) . When the disease is fully established, the amount of the evacu- ations seldom exceeds a tablespoonful. They consist of a clear gelatinous mucus, streaked or tinged with blood. Pus may occasionally be present in them. The number of stools varies in mild cases from five to ten, and in severe cases from thirty to one hundred in twenty-four hours. The colicky pain may come on spontaneously, or after the ingestion of food, or even upon moving about in bed. The straining is a most distressing symptom ; the anus becomes inflamed and is the seat of intense pain, and the bowel may be prolapsed. There may be tenderness upon pressure along the course of the colon. The disease rarely begins with a chill. The temperature at the onset is generally slight, but may range between 102° and 104° F. The tongue is coated, at first moist, then dry, and at last it may become red and glazed. The skin is dry, except during the attacks of tormina, when it may temporarily be moist. The pulse may be normal in the mild cases, but in the severe types it is small and rapid. There are anorexia and excessive thirst. Sometimes vomiting and attacks of hiccough occur. In severe cases there are great prostration and wasting ; the evacuations become almost constant or involuntary ; ulcers form in the mouth and sordes collect on the teeth ; delirium develops, which later in- creases to stupor and from that tO' coma. The urine is scanty and of high specific gravity, with an excess of urea and uric acid and a diminution of the chlo- ■ rides ; albumin, blood, and bile may be present in it. 79^ THE GASTRO-INTESTINAL CLINIC Microscopic examination sliows the dysenteric discharge to consist of red and white blood cells, and large round or oval epithelioid cells containing fat-globules, vacuoles, and putre- factive micro-organisms. Occasionally the cercomonas intes- tinalis is found in large numbers. The specific germs which have been found are the bacillus pyocyaneus and the bacillus of Shiga. Diagnosis. — This is rarely difficult, except in atypical cases. The fever, frequent small stools containing blood and mucus, with occasionally shreds of tissue and the other intestinal symp- toms, are sufficiently characteristic. Prognosis. — Catarrhal dysentery is often curable in three or four.days, but, as usually treated, lasts on the average in the mild cases about eight or nine days. The duration depends largely upon the plan of treatment followed, as well as upon the grade of the case. The severer cases often continue a month, especially when unskillfully treated in the beginning. Recovery nearly always occurs in the temperate zone, except in persons whose strength has been reduced by previous illness or chronic disease. In infancy and extreme old age the prog- nosis is much less favorable. Occasionally it becomes chronic. Treatment. — Mild cases of catarrhal dysentery can often be checked in the very beginning — when the first mucous stools appear — by repeated small doses of castor oil, calomel, or any saline laxative. It was a cause of surprise and no little morti- fication to me, during my first year or two in practice, to find that the old women could do more for dysentery by even one or two moderate doses of castor oil than it was possible to ac- complish by either ipecac or any combination of opium and astringents upon which I had been taught to rely. But it was not until after many years of experience with astringent mixtures and hard-fought battles with numerous stubborn cases, which only yielded at the end of ten to fourteen days of extreme suffering, and the supervention in some cases of com- plete exhaustion, that I learned the magic efficacy of the treat- ment by repeated small doses of one of the saline laxatives. DYSENTERY 79/ Either Epsom or Rochelle salt is employed by me as a rule, and I have the patient take one or more doses, large enough at first to produce feculent stools, instead of the small dysen- teric evacuations of mucus and blood, and this is generally to be effected in the case of adults by a teaspoonful dissolved in a goblet of moderately hot water, and repeated once or twice at intervals of three or four hours. In the milder cases this slight purgation may abort the attack completely. If not, as soon as the typical dysenteric stools, voided with pain and tenesmus, have been thus changed to feculent ones, passed with little or no pain, you may direct the dose of the saline to be reduced to one of lo to 20 grains, and taken in half a goblet of water, flavored if necessary, every three hours. If this should act too much as a physic, the dose must be reduced, and if, on the other hand, there should occur any tendency to a return of the small stools containing only a few teaspoonfuls of bloody mucus, shreds, etc., with straining and pain, the dose must be again increased. Hot poultices or compresses will also promote the cure. With this plan of treatment and a diet of milk, or better, milk with one-third limewater, taken not more than a tumbler- ful at a time, once in three or four hours, I have seen numerous cases of catarrhal dysentery completely cured in three days, in- stead of the eight, ten, or more usually required when the treat- ment is that by astringents and opium. If, at the end of three days of such a treatment, the feculent stools should not show a tendency to cease, 5- to lo-grain doses of bismuth subnitrate, given after each, are usually all that is needed to stop them. If not, I add i grain of Dover's powder to each dose, and if an examination shows any ulcera- tion or persistent catarrhal inflammation in the rectum or sig- moid flexure, enemas of bismuth, a dram to the pint, or later, if necessary, enemas of one of the stronger astringents men- tioned under the head of the treatment of bacillary dysentery, should prove effective. Special topical applications to slug- gish rectal ulcers may be necessary in some exceptional cases, ■ and a very convenient and effective remedy for such lingering 798 THE GASTRO-INTESTINAL CLINIC trouble in the rectum or sigmoid is a suppository containing 3 fo 5 grains of ichthyol, one of which may be inserted after the morning stool and one at bedtime. BACILLARY DYSENTERY Definition. — Bacillary dysentery is a serious form of the disease and runs a more protracted course than the others. It is accompanied by necrosis and ulceration of the mucosa of the colon, and the formation of croupous exudate or pseudo- membrane. It occurs in epidemics with a mortality-rate some- times as high as 45 per cent. It is especially liable to occur in armies, asylums, prisons, and the like. Bacillary dysentery is also known as epidemic, specific, and diphtheritic dysentery. Pathology. — In the mild cases the characteristic lesion is a thin, grayish-yelloAv false membrane, covering the folds of the colon. In the severe form, there is a diphtheritic infiltration of all the coats of the large intestines, which undergo coagula- tion necrosis. Considerable sloughing occurs, leaving exten- sive ulceration of the bowel. The disease process, may be con- fined to the rectum and the sigmoid flexure ; occasionally, how- ever, it extends to the ileocecal valve, and even into the ileum. .Etiology. — The specific cause of this type of dysentery is the bacillus dy scut cr ice discovered by Shiga^ during the Japa- nese epidemics. Flexner and Barker found the same bacillus causing dysentery in the Philippines. The bacillus dysen- terise belongs to the typhocolon group, midway between the bacillus coli communis and the bacillus typhosus. It resembles closely the typhoid bacillus, but Flexner found that it is not in- fluenced by the blood-serum of typhoid patients, but does re- spond to the serum from dysenteric cases, by which the bacillus typhosus remains uninfluenced. This micro-organism is a slender rod, i to 3 microns long, occurs in small groups, singly or in pairs, and grows upon all the ordinary media. It is stained by all the common aniline dyes, but is not stained by ' Centralhl. f. Bakt. tc. Parasitenk, 1898, xxiv., No. 22-24. •DYSENTERY 799 Gram's method. It is slightly motile and possesses flagella which surround its body. Symptoms. — The symptoms are usually those of the catar- rhal form, but exhibit an unusual intensity from the onset. It ma)^ begin with a chill or a rapidly rising temperature. There are early prostration and delirium. The abdomen is tender and may simulate typhoid fever. The abdominal pains are very severe. The stools usually contain more blood than in the catarrhal form. Other elements in the dejecta are membra- nous shreds, thin black sloughs, pus, and mucus. The stools are dark brown in color and often of very fetid odor; or at' times may be odorless. Secondary Diphtheritic Dysentery. — This is a name given by some authorities to a mild form of bacillary dysentery. It occurs as a complication of many acute and chronic diseases, It may be the terminal event in chronic nephritis, chronic car- diac disease, pulmonary tuberculosis, and in various cachexias, as well as in certain acute ailments, such as typhoid fever and pneumonia. The -symptoms consist of three or four loose bowel movements daily, containing a little blood and mucus. Tormina and tenesmus may be wholly absent, or, if present, be very slight. Diagnosis of Bacillary Dysentery. — The diagnosis is posi- tively made by finding the specific germ in the stools, and by means of the agglutination reaction. The technique of the latter is identical with that of the Widal test and serves to dis- tinguish dysentery from all other infections. Additional aids in the recognition of this disease are the intestinal symptoms, the odor of the stools, and the presence in the latter of false membranes. The occurrence of bacillary dysentery in epi- demics is also of diagnostic value. Complications and Sequels. — Hemorrhage and perforation may occur in the same manner as in typhoid fever. Peritonitis may develop either through perforation, or by extension of the inflammation from the walls of the intestines. Other compli- cations are gastro-intestinal catarrh, acute bronchitis, pleurisy, 80O THE GASTRO-INTESTINAL CLINIC pleuropneumonia, endocarditis, pericarditis, phlebitis, ascites, anasarca, meningitis, cerebral embolism, ulcer of the cornea, ^d nephritis. Abscess of the liver, which is commonly held to be the most frequent of all the complications of amoebic dysen- tery, except when it occurs in epidemic form, is rare in the bacillary type. Bacillary dysentery has a tendency to relapse, one infection increasing the patient's susceptibility to another attack. It may be followed by a chronic dysentery or diarrhea, paralysis, rectitis, and stricture of the bowel. A septic arthritis of the larger joints may supervene, the so-called " rheumatic dysen- tery of Sydenham." Treatment. — First of all, in the treatment of bacillary dys- entery, absolute rest is imperative. The patient should be con- fined to bed and the use of a bed-pan insisted upon. It is even recommended that to obtain local rest, a large, thick, and firm pad be applied to the abdomen and retained there by a broad, tight binder. The medicinal treatment should be begun with a dose of castor oil or a saline purge, which tends to deplete the mucosa. In the later stages of the bacillary form purgatives are harmful. Ipecacuanha has long been considered almost specific in its management, and is best given in large doses, though some authorities prefer small and fre- quent doses of the drug. The following is the classic method of prescribing it : Nourishment of every description is with- held for three or four hours. Then 15 to 25 drops of the tinc- ture of opium are administered. In from twenty to thirty minutes, when the opium begins to take effect, from 30 to 60 grains of ipecac are administered in powdered form, stirred up in one or two ounces of water. The patient should be kept as quiet as possible; the slightest exertion or disturbance may bring on an attack of vomiting. If the drug is vomited within an hour, repeat the dose as soon as nausea subsides. If the ipecac is retained two hours or more, sufficient has been ab- sorbed to produce the desired effect. The continuance of the ipecacuanha will depend upon the character of the stools. One DYSENTERY 80I dose may bring about a feculent stool, but failing improve- ment, the drug should be continued twice a day in lo-grain doses for several consecutive days. After the administra- tion of this drug no food or drink is allowed, except the suck- ing of a little ice, for at least three hours, when small and fre- quent feedings may be begun. As the dysenteric patient may also be infected with malaria, it is well, in case the ipecac fails, to give quinine in 5-grain doses every six hours for two days. Besides the ipecac, other drugs are often indicated in the treat- ment of bacillary dysentery. Opium is the most valuable means of allaying pain, restlessness, or undue peristalsis. Morphine is the best form of it, and should be administered hypodermically. A 2-grain opium suppository, or 30 minims of the deodorized tincture by enema, may relieve the tenesmus. After the more intense symptoms have subsided, bismuth, and especially betanapthol bismuth, is a valuable preparation. An- ders recommends the continued use of Dover's powder, bis- muth subnitrate, and salol. The bichloride of mercury in i-ioo- grain dose, every two hours, has given good results. Stengel^ recommends the employment of sulphur. Weisenberg" also reports excellent results from the drinking of the water of a sulphur spring by the dysenteric patients in Manila. Tyson advises the use of iodoform in 1-2- to 3-grain doses in capsule or pill. In the tropics simaruba bark, monsonia orata, and the as- tringent juice of the unripe guava fruit are popular, and, it is claimed, effective remedies which, however, are not much em- ployed in the temperate zone. Opinions differ as to the local treatment of acute dysentery by means of enemas. Some believe this to be the rational method, while others condemn it. Usually the bowel is so ir- ritable that this mode of medication is difficult. To relieve the irritability, cocain, either in solution or in suppository, or a laudanum enema is useful. The most valuable agents are 1 Proc. Phila. County Med. Soc, 1902. ^ Phila. Med. Jour., March 14, 1903. 802 THE GASTRO-INTESTINAL CLINIC silver nitrate (grn. ss. to f^i), 1-2 to i per cent, tannic acid, I to 2 per cent, salicylic acid, or mercuric chloride solution (t-6000). Lukewarm injections of potassium permanganate solution (1-4000), twice daily, have given good results in the hands of some clinicians. Shiga has produced a serum from goats by means of which he was able, in an epidemic in Japan, to reduce the death-rate from 34.7 to 9.6 per cent. Excellent results have been reported from the use of this serum in doses of about 20 c.c. conjointly with local injections of germicides. The diet in the acute initial stage should consist of rice water, weak chicken broth, whey, very weak tea, barley water, or koumiss. Later a pure milk diet is indicated. The stools must be watched to determine whether the food is expelled un- digested, and if so the diet must be decreased in amount, al- tered in quality, or what is sometimes better, predigested. AMCEBIC DYSENTERY Etiology.— This form of dysentery is due to the amoeba coli, which was discovered by Lambl in 1859. Kartulis,' however, was the first observer to claim it to be the specific cause of tropical dysentery. Since then this micro-organism has been found constantly present, not only in the stools, but also in the coats of the large intestine and in the liver abscesses secondary to this form of dysentery. If a small fleck of the flocculent mucus of a dysenteric stool, immediately after being passed, is placed on a warm (100" F.) microscope stage, the amoeba may be recognized. The amoeba coli is about five times the size of a red blood cell ; it is colorless, or very faintly greenish in hue, and consists of a granular endosarc, with a narrow zone of clear colorless ectosarc. It contains a nucleus and one or more vacuoles. When recently voided, it is in constant char- acteristic motion. This parasite is sometimes found in very great numbers. Then again only a few may be present. The number of amcebse present seems to bear very little, if any, ' Massenhafte Entwickelung von Amoeben in Dickdarra, Virchow's Archiv, 65, 1875. DYSENTERY 803 relation to the severity of the disease. If the pus from a Hver abscess shows no amoebae, a gauze swab should be twisted, with considerable pressure, against the broken-down liver tissue forming the abscess wall; in this manner one obtains a mass of liver cells and leucocytes, among which, in all proba- bility, the amcebse will be found. The specific germ probably Fig. 97. — Amoeba dysenteriie. (After Roos.) enters the body through the drinking water. (See annexed illustration of the amcebse.) Pathology. — There is cedematous swelling of the intestinal wall and a cellular infiltration of the submucosa. The surface of the mucous membrane presents circumscribed thickenings of various size, in which there are cavities filled with a gelat- inous mass. The openings to these cavities or ulcers are very small in comparison with the extent of destroyed tissue under- neath the mucosa. The latter sloughs away, leaving extensive irregular ulcers; these may be connected with each other by fistulous channels beneath the mucosa. This ulcerative process usually involves only certain parts of the colon, like the hepatic and sigmoid flexures, but occasionally the entire large in- testine is affected. If the disease is well advanced, healing may be found more or less extensive ; contraction of the scar tissue causes irregularities in the surface of the mucous membrane and occasionally results in the formation of strictures. Mi- 804 THE GASTRO-INTESTINAL CLINIC croscopic examination of the infiltrate shows the absence of pus and a prohferation of the fixed connective-tissue cells. Amoebse are found in the walls, the base of the ulcers, in the lymph channels, and rarely in the blood-vessels. Symptoms. — Amoebic dysentery may begin gradually or suddenly. It usually comes on insidiously with a moderate and painless diarrhea, alternating with short periods of consti- pation. Whether sudden or gradual in onset, there are irregu- lar periods of intermission (from one day to three weeks) antl of exacerbation (one to ten days). There is usually a slight fever, which may be entirely absent ; nausea and vomiting are uncommon, and abdominal griping and tenesmus are present only at the beginning. The stools are at first mucous and bloody; later they become fluid and yellowish gray in color, containing mucus and, at times, blood; they vary in number from six to twelve in twenty-four hours. Active amoebae are found in the dejecta. This disease is usually accompanied by a progressive loss of flesh and strength and a marked ansemia. Complications. — Hepatic abscess is the most frecjuent and serious complication. It is liable to develop in from four to twelve weeks. From 20 to 25 per cent, of amoebic dysenteries cause liver abscess. The latter may be single or multiple ; the single abscesses are usually situated in the right lobe of the liver, near its convexity. The multiple abscesses are dissemi- nated. They may be the size of a pigeon's egg, or as large as a cocoanut, or even larger. The pus found in such an abscess is thick, reddish-brown or chocolate-brown in color. Micro- scopically it contains necrotic liver tissue, pus cells, amoebse, elastic tissue, and blood. The liver may also be the seat of circumscribed necrosis, scattered throughout the organ, caused by the action of the amceb?e. Perforation of the intestinal wall because of ulcera- tion may lead to peritonitis; if this occurs in the rectum, a periproctitis results, or, if in the cecum, a perityphlitis occurs. Diagnosis. — The presence of the other dysenteric symptoms DYSENTERY 805 above described, with the amoeba coli in the stools, estabHshes the diagnosis. Prognosis. — Favorable cases of amoebic dysenter}^ last from six to twelve weeks. The mortality is much higher than in the catarrhal form. In some epidemics the death rate may reach 70 to 80 per cent. ; in sporadic cases, the rate is much lower, averaging about 5 per cent. This disease shows a tendency to relapse, and the convalescence is prolonged because of the anfemia and debility. Treatment. — In severe cases the patient should be kept at rest in bed, but in the milder forms may be allowed to be up and about for a short time daily and directed to take slight ex- ercise in the open air. The food must be highly nutritious and easily assimilable. The medicinal treatment should include, as a rule, that already described above as applicable to the treat- ment of bacillary dysenter)^ The most satisfactory single remedy, however, for this variety of dysentery has been found to be rectal injections of a warm solution of quinine (1 to 5000, I to 2500, or I to 1000). CHRONIC DYSENTERY Chronic dysentery usually succeeds acute dysentery, al- though it may be a subacute or chronic process from the be- ginning in amoebic cases. The amoeba coli is the cause of most cases of chronic tropical dysentery. Pathology. — The lesions found are similar to those described in the other varieties of dysentery. Ulceration may be present or absent. Some of the ulcers show no signs of healing, while, in others, a process of repair is going on. In some areas the healing is completed and the mucosa presents a rough, irregu- lar, puckered appearance. All of the coats of the bowels are thickened. The mucous membrane presents black or slate- gray patches, due to the extravasation and disintegration of the blood. The glandular elements may be the seat of cystic degeneration. "Symptoms. — The symptoms are not especially characteristic. 8o6 THE GASTRO-IXTESTINAL CLINIC The stools vary from four to twelve in twenty-four hours, may be fluid, frothy, or semifluid, yellowish or brown ; occasionally the}'- contain mucus, undigested food, rarely blood, pus, or ne- crotic shreds. Constipation may alternate with diarrhea, in which case the bowel movements are apt to be scybalous, and each separate fecal mass is covered with tenacious mucus. The amoeba coli is constantly present in the amoebic form, but, in the bacillary form, the Shiga bacillus disappears as the dis- ease becomes chronic, particularly when there is marked ul- ceration. Acute exacerbations are not tincommon. Tormina and te- nesmus are rarely present, except during the exacerbations. Pressure in the left iliac fossa over the sigmoid flexure, and sometimes in the right iliac fossa over the cecum, elicits pain ; the sigmoid flexure may be felt to be indurated, enlarged, and tender. Flatulence may cause considerable distress. The tongue is red and glazed or dry and fissured. The appetite is impaired and digestion poor. Anaemia is usually present, and the emaciation may be extreme. Complications. — The complications are those of the acute form. Because of extreme debility the patient is very subject to intercurrent disease, such as pneumonia, cardiac failure, or tuberculosis. It is claimed that ulceration of the cornea may be a complication. Persistent indigestion and irritability of the bowels may follow chronic dysentery. Diagnosis. — The history of an antecedent acute attack, the occurrence of exacerbations, together with the characteristic dysenteric stools, serve to distinguish this disease from chronic diarrhea. It is differentiated from tuberculous ulceration by the absence of a family history of tul^erculosis or of tubercu- lous disease in other parts of the body. Prognosis.^ — This depends upon the severity of the symp- toms, the- duration of the disease, and the extent to which the health of the patient has been compromised. It may be pro- longed over a period of months, or even years. Treatment. — Internal medication is considered by many DYSENTERY 807 writers as of little value in chronic dysentery, but benefit has been reported from the use of the following: 5 to 10 grns. of zinc oxide, three times a day; salol, alone or in combination with bismuth; sulphur in lo-grn. capsules, three or four times a da}^ with sufficient opium to overcome the laxative effect. Mercuric chloride (corrosive sublimate) in i-ioo grn. doses every two hours has been employed with marked success in this disease. In my earlier practice I encountered a number of previously stubborn cases in which it proved markedly suc- cessful with the help of an exclusive milk diet. (See Phila- delphia Medical Times of 1879.) One such case which had yielded to the treatment, but relapsed several times in conse- quence of the fact that the patient, who was a sailor, could not, when on a cruise, follow the diet prescribed, was finally cured completely by a toxic dose of litharge — about a teaspoonful — which the patient took on the advice of some lay friend. He suffered for several days afterward from violent lead colic and came near dying, but, after convalescing from the effects of the remedy, remained afterward free of dysentery. The local treatment is of special importance in the manage- ment of chronic dysentery. The remedy of greatest value is silver nitrate. A solution of this preparation is made by dis- solving 10 to 20 grains in a pint of water; of this one-half to one pint may be carefully injected every other day, and some bold authorities advise the use of three to four pints in the same way. Before administering the silver enema, the bowel should be irrigated with a weak solution of sodium bicarbo- nate, and care should be exercised that nearly all the former solution escapes again. The days on which no silver enema is given, the patient should receive rectal injections of antiseptic solutions, such as mercuric chloride (i to 6000) or i to 2 per cent, salicylic acid. Other preparations useful in injections are creolin, copper sulphate, zinc sulphate, alum, iodide, car- bolic acid, and chlorine water. During acute exacerbations these injections must not be given, but the patient is to be treated as in acute dysentery. 8o8 THE GASTRO-INTESTINAL CLINIC The dietary should follow the same lines as in acute dysen- tery, but be more nourishing. Milk is usually the best food. Changes of climate and sea voyages are often beneficial. As a last resort in chronic and apparently hopeless cases, operative treatment may be instituted. The object is to put the colon at rest, and also to facilitate through-and-through ir- rigation. The colon is brought up and fastened to the edges of an incision in the right side of the abdomen, and is irri- gated directly through this opening. This procedure has, in some cases, cured chronic dysentery. Note. — Dr. A. Ruffer of Alexandria, in discussing dysentery before the i6th Internat. Med. Congress in September, 1909, stated as a result of the study of over 400 cases annually among returning pilgrims at El Tor, Egypt, that two main typesare encountered, theamoebic and the bacillary, and not infrequently a mixed form. Only two per cent gave a serum re- action with the Shiga-Kruse bacillus. The Flexner bacillus and also the so called pseudo-dysenteric bacilli A and D were sometimes found. To another entirely distinct the name Tor bacillus was given. At least nine different micro-organisms including six bacilli were recognized as causes of dysentery seen among the pilgrims. In those due to the Shiga-Kruse bacilli brilliant results were obtained from serotherapy, while in the Tor cases this had no effect. Various others have also reported good results with the anti-dysenteric serum in the Shiga-Kruse forms and its useless- ness in other forms. Professor Wm. A. Edwards of Los Angeles tells me that he sees many cases of dysentery including generally manageable ones of the Flexner form as well as some of the Shiga-Kruse type which are much more fatal. Among adults the disease is apparently rare on the Pacific coast. During my practice for a period of over four years in the Los Angeles region I have seen one case only and that once in consultation. The patient had resided in Cliina a number of years and since returning had been under Christian science till nearly dead. It was an amoebic case. LECTURE LXXIII MEMBRANOUS CATARRH OF THE INTES- TINES (COLICA MUCOSA, MYXONEURO- SIS INTESTINALIS MEMBRANACEA) This affection is doubtless rather more prevalent in the United States than in Europe, and was studied by various American writers before it had attracted special attention abroad. The late Dr. J. M. Da Costa was probably the first to publish a full and thorough scientific paper concerning it.^ Various theories have been held regarding its aetiology and pathology, the prevailing view at present being that the abun- dant secretion of viscid mucus which characterizes the affection is due to a disturbance of the innervation of the intestine — es- pecially of the colon, where the excessive mucus is chiefly formed — or, in other words, that it is a neurosis. There is much to be said in favor of this explanation of it, and von Noorden, especially, has very ably championed it in his recent monograph on the subject,^ the American edition of which was edited by me. But it is generally admitted that a certain proportion of the cases presenting the symptom mucous colic are associated with a true enteritis. While some observations have apparently shown that in certain cases of the affection no catarrhal inflammation ex- isted, it does not seem to me satisfactorily demonstrated that there may not be. in even the cases classed as neurotic, a slight degree of enteritis, and I prefer, therefore, not to include this lecture upon the subject among the neuroses of the intestines. Nevertheless, it cannot be denied that in most if not all in- ' Am. Jour. Med. Sciences, October, 1871. "^ " Membranous Catarrh of the Intestines," New York, E. B, Treat & Co., 1903. 809 8lO THE GASTRO-INTESTINAL CLINIC stances, the patients are hysteric or neurasthenic, and that the nervous constitution is a strongly predisposing cause. Von Noorden himself says : " The scanty anatomic material at our disposal, therefore, teaches us, on the one hand, that colica mucosa may be one of the symptoms of genuine enteritis, and, on the other hand, that this affection may also occur without any essential anatomic lesion of the mucous lining of the in- testine, or even without any anatomic lesions whatever." Nothnagel holds to the view that there are two distinct diseases, one a true enteritis, complicated by the discharge of membranes, etc., from the bowel, and often by colic, and the other a strictly neurotic affection in which the latter symp- toms are independent of any inflammatory process. Ewald enunciated the same opinion in a recent noteworthy paper.^ He calls the neurotic form of the affection " Myxoneurosis In- testinalis Membranacea." .ffitiology. — All are agreed that nervous persons are most af- flicted with this disease, that hysteria and neurasthenia are de- cidedly predisposing conditions. So, also, are displacements of the stomach, colon, or kidneys. Peritoneal adhesions and eye- strain, according to Morris of New York, are other causes of the intestinal neuroses, including possibly mucous colic." Careful studies have been made relative to associated gas- tric conditions, but no particular fault in the stomach, except displacements of it, has been found to be especially provoca- tive of colica mucosa. It occurs with excessive, as well as with deficient gastric motility, and with both the extremes of gas- tric secretion, but von Noorden, in seventy-six cases, found four only suffering from achylia gastrica, while " in the others there was comparatively frequently a condition of hyper- acidity." by which he undoubtedly means hyperchlorhydria. Ewald includes the climacteric among predisposing conditions. Prolonged constipation, and especially constipation de- pendent upon a long-standing chronic intestinal catarrh of ■■ Anier. Med., February, IQ04. ' N. V. Med. Record, December 26, 1903. MEMBRANOUS CATARRH OF THE INTESTINES 8X1 the ordinary form; though of mild degree, is probably one of the most common causes of membranous catarrh of the in- testines. Uric acid or the uratic diathesis, and especially such results of an imperfect metabolism as the xanthin bases, are believed to be capable also of causing the disease now under consideration. Symptoms. — Colic is usually given as one of the most promi- nent symptoms, and this is true, as a rule, of the worst types ; but I very often encounter cases in which nervous persons dis- charge much mucus from the bowel, including membranous pieces, shreds, strings, etc., without suffering at all from the colicky pain described as typical of the affection. The pieces of membrane thrown off are of various sizes and may be in long stringy pieces, or perfect casts of portions of the colon. The frequent passage of such membranes and the abnormali- ties in defecation, usually constipation, constitute with the marked nervous tendency the only constant distinctive symp- toms of the disease. In typical cases the colic is a very conspicuous feature, and is usually most marked when the bowel movements have been most deficient. The pain is often severe, and continues, as a rule, until a complete evacuation, not only of the feces, but also of the retained masses of mucus, can be obtained. After such an evacuation the colic and all pain disappear, not to return until there has been a re-accumulation of the mucus. Patients thus afflicted generally learn the great importance of keeping their bowels freely open, and, therefore, try tO' avoid letting them become confined. Though a colicky pain relieved by the passage of a cjuantity of mucoid membranes or masses will be observed in the se- verer cases, in the milder ones there will be, instead, often merely a dull discomfort in the bowels which increases toward evening and disturbs the sleep at night. For the rest, more or fewer of the symptoms constantly ob- served in hysteria or neurasthenia, as well as those seen in chronic indigestion, will be present. 8l2 THE GASTRO-INTESTINAL CLINIC The most constant and conspicuous of these to be noted are constipation and intestinal flatulence, impaired sleep, irritable temper, and a dirty pallor of the skin. Diagnosis. — In most instances you- could have no difficulty in recognizing a case of membranous catarrh of the intestines by the peculiar stringy or membraniform pieces of mucus passed with or without the admixture of feces and accom- panied usually by colicky pain. In case of doubt, a micro- scopic examination of such pieces would show their mucous character and differentiate them from skins or pulpy portions of fruit, etc. It is important to distinguish, when possible, the cases in which a true colitis of sufficient extent to demand attention in the treatment is complicated by the formation and passage of membranes accompanied by colic, since for these the diet and therapy generally need to be modified. This cannot always be done; usually, however, when there exists a decided colitis, there will be tenderness o\"er the portions of the bowel in- volved and more or less discomfort, or at times even pain in the colon at some part of every day, especially for several hours preceding an evacuation, or when constipation is unre- lieved, most of the time. But in a case of membranous colonic catarrh, in which there is either no true inflammation or only a very slight degree of it, not sufficient to interfere with the success of the treatment described below, there is not likely to be sensitiveness to pressure or palpation, and an attack having ended with a free opening of the bowels and the passage of the accumulated membranes or masses of mucus, the patient may feel well and have no discomfort in the intestines for. days or weeks. Pathology. — In those forms of membranous catarrh asso- ciated with a true enteritis or colitis, a swelling or thickening and serous infiltration of the mucosa exist w^ith usually pro- liferation of the connective tissue, as in the ordinary types of such chronic inflammations. In the other forms which by many writers are held to be dependent entirely upon a neu- MEMBRANOUS CATARRH OF THE INTESTINES 813 rosis, the liypersecretion of mucus resulting from some unknown disturbance of the innervation, no inflammatory lesion, as a rule, can be made out during life by any means at our com- mand, and in a very few well-observed cases which have after- ward come to autopsy, it is said that no evidences of inflamma- tion in the mucosa could be demonstrated. Boas considers the far greater number of cases of so-called colica mucosa, which at autopsy showed definite lesions of enteritis, as " without doubt of much greater importance than any negative," while von Xoorden maintains, on the contrary, that even the occasional observation of such a clinical case, which reveals a perfectly normal condition of the intestinal mucosa on autopsy, is far more significant. The mucus may be in bands, strings, pieces of membrane of reticulated structure, or in the form of a cast of the bowel. There is no sufficient proof that it differs essentially from the mucus in other forms of enteritis, except that it is tougher and more sticky in consistence, which is doubtless a result of in- spissation, since constipation is nearly always present in these cases, and the mucus thus is longer retained. Ewald, in the paper already cited, describes as follows the mucous masses which make up much of the stools which are found in both forms of colica mucosa : " They are composed of tenacious mucinous bodies, plus fibrin in small amount, nucleo-albumin, and globulin. The mucin can be differentiated from the fibrin by using triacid stain. The histologic peculiarities of these slime masses have been studied by Wolf, Ewald, Nothnagel, A. Schmidt, West- phalen, and others. They consist of a homogeneous, somewhat opaque ground substance which is interspersed with cell detritus. This detritus is composed of nuclei which are recog- nized because of their strong refractile properties, cell-elements, epithelial and round cells, as well as peculiar shining flakes which are thought to be due to hyaline degeneration or an imbibition of soap. The epithelial cells usually show granular degeneration, are without demonstrable nucleus, vacuolated 8 14 THE GASTRO-INTESTINAL CLINIC and frequently broken up. Besides these, there are cholesterln crystals, needles of the fatty acids, triple phosphate crystals, particles of undigested food, bacteria, and occasional red and white blood cells. It sometimes happens that there are sand- like concretions which resemble ground white pepper and are easily mistaken for the seeds of strawberries or currants, but their character can be proven by the addition of acetic acid, in which they are soluble." Prognosis. — Membranous catarrh of the intestines is rarely fatal, except indirectly, when long neglected, but under the forms of treatment hitherto generally in vogue, has proved rather difficult to cure thoroughly. The usual course has been slow improvement, and when after prolonged treatment an ap- parent cure has resulted, there would be a strong tendency to relapses from slight causes. Von Noorden, however, w'ho treats the disease in an original manner, as will be described below, reports a recoveiy in sixty out of seventy-six cases, of which thirty-eight remained well a year after the termination of the treatment, and the majority of the cured patients re- mained well after many years. Treatment. — Since von Noorden has been so extraordinarily successful in the cure of colica mucosa, 1 have recently adopted his method of treatment in the main, for the neurotic cases not demonstrably complicated by colitis or enteritis, with results which are decidedly better than those previously obtained. I will, therefore, give you a condensed account of the method as described in his monograph already cited. Symptomatic Treatment. — It is obviously desirable to ter- minate a typical acute attack of mucous colic as soon as possible, and, at the same time, to relieve promptly the pain from which the patieni suffers. Both these objects are best achieved by putting tl'.e patient to bed, applying hot applications such as flaxseed-meal poultices or hot wet compresses over the abdo- men, the administration of anodynes, and flushing the colon to remove the accumulation of mucus. The anodyne should con- sist of either morphine and atropine hypodermically, or the same MEMBRANOUS CATARRH OF THE INTESTINES 815 in larger doses by suppository. Von Noorden recommends 4 cgr. {2-^ grn.) each of ext. opii and ext. belladonnse in sup- pository. Such a combination, aided by the hot apphcations and repeated in a few hours if necessary; relaxes the spasm and fa- cilitates the evacuation of the spastically contracted bowel, thus giving prompt relief and cjuickly ending the attack. In the ab- sence of the narcotic, the colon douche would probably irritate, especially if any such an excitant as soap or glycerin were added. Von Noorden includes salt in the same category with irritants, but most of us have found that when salt is dissolved in water at the temperature of the body, in a strength of not more than a dram to the quart, the result is a more soothing mixture than plain water. One to two hours after the first water enema, you may inject half a pint to a pint of sweet oil or cotton-seed oil to insure the thorough softening and removal of any remains of hardened and adherent mucus. Causal Treat incut. — Formerly, the chief attention in these cases was g'iven to the treatment of the hysteria or neu- rasthenia in the always neurotic patients — generally young or middle-aged women — who suffered from this affection. Von Noorden believes that, while not neglecting this predisposing factor in such cases, we should earnestly combat the constipa- tion which excites the attacks. Dietetic treatment will accomplish most. The usual pre- scription of a bland, non-irritating diet, which leaves too little residue to overcome the constipation is condemned, and instead the patient is required to take, beside a large amount of milk and cream for the fat they contain, a very coarse laxative diet including the grains, legumens, and the other vegetables which have in them much cellulose; also plentifully of the seedy fruits such as figs and the 1)erries — especially currants, goose- berries, etc. — just the sort of diet which is certainly contra-in- dicated in any case in which a decided enteritis exists. Hence you should be careful to differentiate your cases and exclude from the number treated by this von Noorden method any in which a true colitis is a prominent feature. 8l6 THE GASTRO-INTESTINAL CLINIC In applying the diet rules here prescribed, it is also of the highest importance to study the metabolism of each patient, j!nd vary accordingly the choice and quantities of the different kinds of food ordered. Von Noorden considers the improvement of the general nu- trition the fundamental preliminary condition to be fulfilled if we would effect a permanent cure, and finds that in many of the cases of colica mucosa, this is best accomplished by be- ginning with the familiar rest treatment, including systematic full feeding. And in the other cases, as will be seen from the subjoined detailed directions as to diet, etc., he secures a partial or modified rest treatment. He advises strongly that the cure be carried out in an institution or somewhere away from the pa- tient's home. His failures have been mainly among patients treated at home, and we are all familiar with the difficulties encountered in these cases under such conditions. The average duration of the systematic treatment with extra full feeding, as here laid down and carried out by von Noor- den, is three to six weeks, or on the average four weeks. • While it is impracticable to prescribe any scheme of diet which will suit every case, even of the same disease, and von Noorden deprecates any attempt to do this, he submits the fol- lowing as a general outline of the plan which he has found serviceable in many cases : Von Noorden's Detailed Directions for the Average Case of Membranous Catarrh of the Intestines. — " In the morning in bed, at seven o'clock. — Three-tenths of a liter of milk and cream (two parts of milk and one part of thick sweet cream, ordinarily O. Rademann's sterilized Holstein cream) ; then, usually, a rub with moderately cold water. " At eight o'clock. — One-quarter of a liter of Kissingen (Racoczy) or Homburg Elisabeth water. " At nine o'clock. — Three-tenths of a liter of the milk-cream mixture, or of thin tea or coffee with much cream ; sometimes, too, cocoa prepared with cream or butter and sweetened with sugar of milk. In addition, 50 to 70 grams (i^ to 2^ oz.) MEMBRANOUS CATARRH OF THE INTESTINES 81/ of coarse bread containing much cellulose, and 30 to 50 grams (i to lyi oz.) of butter. " At ten-thirty. — If necessary, a massage of the intestine, or hydrotherapeutic treatments of different kinds ; sometimes electrization of the colon. " At eleven o'clock. — Soup made from leguminous plants boiled with bacon or Westphalia sausages ; in addition, Graham bread with plenty of butter. Aho a glass of break- fast wine or a small glass of brandy. " At one o'clock. — Some meat dish, as much as w^anted. In addition vegetables of different kinds, boiled or baked potato with butter. Fruit with coarse skins and large seeds, as cur- rants, gooseberries, cranberries boiled, or a pound of grapes. One-half a bottle of light Moselle wine. After eating, rest in bed for an hour and a half, with hot applications to the abdomen. " At four o'clock. — A light lunch similar to the breakfast at nine o'clock. Then a walk of one and one-half to two hours. " At seven o'clock. — Supper like the dinner ; sometimes, too, junket or fruit soup. In addition, 50 to 70 grams (i^ to 2^ oz.) of Graham bread, with plenty of butter. " At nine o'clock. — Three-tenths of a liter of the milk- cream mixture as in the morning. " On the first and the third day of the treatment, an oil clyster is usually given in the evening in order to prevent all disturbances that might possibly arise. It is rarely necessary to repeat this later on. " The average cjuantity of cream consumed amounted in our cases to one-half a liter a day; this amount containing 150 grams (4^ oz.) of pure butter-fat (the manufacturers of the sterilized cream, mentioned above, guarantee a percentage of 30 per cent, of butter-fat). The daily average of butter equaled 230 grams (7^ oz.). Of this quantity about two- thirds were eaten as pure butter with bread and potato, or with vegetables and fish. The rest was taken cooked with the food. 8l8 THE GASTRO-INTESTINAL CLINIC " The average quantity of Graham bread was 200 to 250 grams (6^ to 8 oz.). We usually give the bread sold by O. Rademann (Frankfurt-am-Main) under the trade-mark * D-K.' " According to our experience, mild disturbances occur under this regime. It is well to prepare the patients for this invadvance. In order to counteract these disturbances, it is a good plan to keep the patients in bed for the first few days; in addition, hot compresses, or possibly suppositories of three- fifths cgr. (i-io grn.) of extr. belladonnae, and the oil clysters mentioned above, may be given (this on the first and third days of the treatment). After the first two to four days, the stools that are evacuated assume a normal consistency and a normal appearance. As soon as this occurs all the disturbances usually disappear ; in particular, all painful sensations. Mucus, however, is passed for some time longer. This mucus, to judge from its appearance, is freshly secreted. This demonstrates that the hyperirritability of the mucus-secreting apparatus is not allayed at once. At the same time the mucus no longer ac- cumulates and the quantities passed are very insignificant. If the cure takes a normal course, the secretion of mucus does not continue for longer than a week. In at least one-half of the cases the secretion of mucus ceases at once, as soon as soft motions are evacuated, and never returns thereafter." Comments on the von Noorden Method. — It will be ob- served that the above-described plan includes the administra- tion every morning of one-quarter of a liter (about a goblet- ful) of one of the natural chloride-of-sodium waters, which exert a very slight laxative action on many sensitive patients, and a curative influence on the intestinal mucosa. In my ear- lier attempts to efifect cures in these cases, as well as in others in which constipation was a marked symptom, by resorting to a coarse laxative, as various German authors advise, I failed often, and doubtless because the saline water was omitted. The oil enemas, too, are most valuable adjuvants in all such cases, and. are still more useful — even indispensable — in the treat- MEMBRANOUS CATARRH OF THE INTESTINES 819 ment of constipation, associated with the famihar types of chronic enteritis or cohtis. The fact that the Carlsbad and other alkahne waters are strictly contra-indicated in the affection under consideration, as well as in all gastro-intestinal derangements accompanying or dependent upon nervous or depressed conditions, is insisted upon by most writers, and is mentioned also by the author above quoted. The latter insists further upon massage of the large intestine, especially over the sigmoid flexure, as a most valuable adjunct in the treatment of these cases, not- withstanding that it is generally contra-indicated in spastic cases. His view is that, with the usual bland diet, massage does aggravate all forms of spastic constipation, including that occurring in colica mucosa; but when his full laxative diet is adhered to, he finds that massage agrees perfectly well, and promotes complete evacuations. The After-Treatment. — When the three to six weeks of special treatment with full or partial rest, massage, electricity, etc., and very full feeding on an exceptionally coarse laxative diet are over, the after-treatment is highly important. The mechanical measures, saline water, oil enemas (when the last need to be employed), are now to be omitted, and the patient is required gradually to resume an ordinary but rational diet appropriate to his circumstances and place of residence. It is customary after most of the special cures at German springs or bathing places, to send the patient to some invigo- rating climate for a few weeks, but von Noorden cautions against ordering patients who have pursued the above-pre- scribed course for colica mucosa to either the seashore or to any high altitude. He does not know why these localities dis- agree with convalescents from the affection under considera- tion, but experience has taught him that they do. He prefers that such patients should go to some wooded country at a moderate altitude, and there take frequent short walks — not overtaxing their strength. The educational process of adaptation to an ordinary diet 820 THE GASTRO-IXTESTIXAL CLINIC may be finished in a few weeks, or exceptionally, may take several months. If the patient too soon goes back to a less bulky diet before the habit of daily spontaneous and sufficient bowel movements has been acquired, and especially if there is a return to any objectionable habits of eating, there is likely to be a relapse ; but once the normal habit is fuily restored, and a rational mode of living is thenceforward followed, the cure remains a permanent one. Treatment of Colica Mucosa in True Enteritis. — In those membranous catarrhs of the intestines which are nervous com- plications of a well-marked and decided enteritis, the coarse diet and forced feeding will rarely succeed. The diet will need to be blander and less irritating in all cases in which an in- flamed condition of the mucosa is a prominent feature, though there are doubtless numerous cases in which, while there ex- ists a true enteritis, it is mild, recent, and a result merely of the irritation produced by retained masses of hardened feces, and in these whatever diet or other remedies will best overcome the constipation may prove effective for the cure of the entire symp- tom-complex. V\'hen there is a chronically inflamed mucosa of a stubborn character, complicated by mucous colic, you wnll need to rely upon the very carefully regulated diet advised for chronic enteritis in Lecture LXVL, and combat the constipa- tion or diarrhea by the therapeutic measures recommended in the lectures upon those subjects. Nearly always there will be constipation, and the most successful single remed}^ for it will usually be olive, linseed, or cotton-seed oil, injected at bedtime in doses of one to eight ounces and retained till morning. When more decided laxative drugs are needed, cascara sa- grada, sulphur, senna, dandelion, or tamarinds in the smallest doses that will empty the lower bowel every day without lique- fying the stools will succeed best. A complete or partial rest cure will prove the most effectual remedy for the neurotic symptoms, including the excessive secretion of mucus and ac- companying pain, and should be supplemented by electricity — especially general faradization or some of the static modalities MEMBRANOUS CATARRH OF THE INTESTINES 821 for their systemic effect, and large doses of galvanism for their local alterative effect upon the diseased intestinal mucosa as described in Lecture LXVI. (See also Lectures XXV., XXVL, and XXVIL) Massage of the body generally is in- dispensable as passive exercise for the patients who are in bed, but in the presence of spastic complications, such as are almost invariably associated with colica mucosa, there should be no deep kneading or other irritating procedures over the abdomen. Light stroking or surface friction will be all the manipulations which can then exert a favorable action in that region. In this connection it should be again emphasized as strongly as possible that all neurasthenic patients, including those suf- fering from, colica mucosa, whether with or without a pro- nounced enteritis, need to have rest, partial or complete, plenty of sleep, and at least an adequate supply of nourishing food to maintain nutrition at its proper level. LECTURE LXXIV EXCESSIVE ERUCTATIONS AND GASTRO- INTESTINAL FLATULENCY IN GENERAL Flatulency, or the eructation of gases from the stomach, is the most common of all gastric symptoms in the various con- ditions usually grouped under the vague term, indigestion or dyspepsia. And those who have made a special study of the numerous diseases of the digestive system, from the standpoint of aetiology and pathology, should be prepared to djscuss them from the clinical side as well. Such an important and obtrusive symptom as flatulency needs to be elucidated and traced to its possible causes in language easily intelligible to every practi- tioner of medicine. Gases eructated from the stomach most often result from fermentation or putrefaction somewhere in the alimentary tract. The small quantities that may be swal- lowed ordinarily, and the little carbonic dioxide taken some- times with effervescent drinks or disengaged from the carbon- ates, are not important; and the rare cases generally classed under the head of nervous eructations are only the exceptions which prove the rule. In thirty-two years of practice I have seen a very few cases only in which there were excessive eructations of apparently swallowed air, and yet in that time thousands of cases of di- gestive disorders characterized by much flatulency have been under my observation. Even a cursory study of these has been very interesting. Full detailed reports and an exhaustive analysis of even the more noteworthy of them would require more space than could be spared here ; but an attempt has been made to classify them according to their causes, relations, and complications. They include cases of (i) fermentation of sugar and starch due either to hyperchlorhydria or acid gastric. 822 EXCESSIVE ERUCTATIONS 823 catarrh (gastritis sthenica), and complicated nearly always with more or less chronic intestinal catarrh; (2) chronic asthenic catarrh of the stomach (gastritis asthenica) ; (3) mus- cular atony of the stomach (myasthenia gastrica), with or without dilatation or prolapse (gastroptosis), but always with delayed emptying and resulting stagnation of the stomach con- tents; (4) pyloric obstruction, with stagnation or retention re- sulting from one of numerous obstructive causes, such as tumors, scars of ulcers, stenosing gastritis, adhesions to ad- jacent organs, spasm of the pylorus in severe hyperchlorhydria, or the pressure of a prolapsed right kidney upon the duo- denum; (5) nervous dyspepsia (neurasthenia gastrica); (6) intestinal indigestion; (7) chronic intestinal catarrh (enteritis chronica) without gastritis; (8) chronic catarrh of the ap- pendix vermiformis (appendicitis catarrhalis chronica), with usually also some involvement of other portions of the intes- tines in the same process; (9) chronic constipation from ob- struction or other cause, apart from the above-named affec- tions; and (10) fermentation in the stomach, dependent upon swallowing mucus and bacteria having their origin in the nose, naso-pharynx, and mouth, including carious teeth. Very exceptionally, also, sufficient air may be swallowed to produce excessive eructations, but I have not for a number of years encountered a single case in which such a cause of eruc- tations was to be suspected, or in which some more tangible cause could not be discovered. There are probably still other causes of gaseous accumula- tions in the stomach which do not now occur tO' me ; but, with two or three possible exceptions, I have never met with any cases of eructations which could not be accounted for as at- tributable to some one of the conditions above mentioned. I have not yet been able to convince myself that large quantities of gases are secreted directly by the cells of the stomach, as has been claimed by some authors. Belched Gas often from the Intestines. — It is quite demon- st-able, however, that the gases so copiously produced by fer- 824 THE G.ASTRO-INTESTINAL CLINIC mentation and putrefaction in the intestines of many dyspep- tics easily invade the stomach through the pylorus. This may take place at any time when the pylorus is relaxed, but es- pecially during digestion, while the chym.e is passing into the duodenum. With the highly distended condition of the intes- tines in these patients, the pressure is great in every direction, and manifestly the pylorus must often be the point of least re- sistance, especially when the gut below is obstructed by ac- cumulations of feces or by spasmodic contractions of its cir- cular muscle. ]\Iost of the causes of flatulency given in the above classification are too obvious to require discussion. As to three of them, however, Xos. i, 8, and lo, a few words may be in place. Hyperchlorhydria, the most frequent cause of indigestion, according to Einhorn's view — which my experience fully con- firms — greatly increases the fermentation of farinaceous foods in the stomach, besides being one of the most potent factors in the production of intestinal derangements, especially gas formation. Chronic Appendicitis as a Source of Flatulency. — Catarrh of the appendix, with more or less occlusion of its open- ing, constantly breeds and sends out into the cecum, from time to time, colonies of highly virulent colon bacilli as described by A. O. J. Kelly.^ As a result, the colon is kept constantly or inter- mittently infected, and even after appropriate measures, such as abdominal massage and antiseptic colon douches, have cured the catarrhal process in the bowel, there is reinfection from the persisting catarrh in the appendix, and this probably often involves the small intestine. The virulent bacteria es- caping frequently from the chronically diseased appendix would greatly increase fermentation and putrefaction in the intestinal contents, and, as explained above, the gaseous accumulations there may, at times, find a vent in the upward direction through the stomach. One evidence that in cases of copious belching the gas may 1 Phila. Med. Jour., November ii, i8, and 25, 1899. EXCESSIVE ERUCTATIONS 825 not come from the stomach but from the intestines, is an ob- servation often made by me. In washing out the stomach of a catarrhal patient afflicted with excessive eructations, it would be noted that after completely emptying the viscus of all food remains and mucus, there would develop, coincidently with the opening of the pylorus to permit the escape of the portion of wash water retained, a spell of active and profuse belching. The stomach having been previously completely emptied, the gas brought up could only have come from the bowel through the pylorus when it opened for the escape of the wash water. Infection of the Alimentary Tract from the Mouth, Nose, and Throat. — In catarrh of the upper air passages, or in any part of the oral cavity, myriads of germs, as well as mucus, are swallowed with the saliva frecjuently, and always washed down copiously by the food and drink. In the case of disease in or about the roots of the teeth, and especially when there are neglected dental cavities, the germs are liable to become very virulent as well as abundant. The swallowed mucus, once in- fected, is as good a culture medium as that produced in situ, and is not easily extruded from even a healthy stomach. Hunter^ has shown that diseased mouths may produce a septic form of gastritis with serious secondary effects, going on even to pernicious anaemia in some cases, and I have recently seen a case in which purulent conditions around the teeth, long neg- lected, coexisted with gastric atrophy which had probably re- sulted from such a gastritis. Reflex Causes of Flatulency. — Robert T. Morris, in a very suggestive paper on Intestinal Fermentation as it Interests the Surgeon,^ refers to the role played by the displacements of the different abdominal viscera, and by adhesions between the lat- ter and adjacent structures in the production of neuroses of the digestive system, including nervous dyspepsia, mucous colic, flatulent conditions, etc. Furthermore, he emphasizes anew his former observation that certain normal involution ■■ Afed. Press and Circular, April 3, 1901. ^ Loc. cit. 826 THE GASTRO-INTESTINAL CLINIC changes in the appendix vermiformis, which result in the re- placement of the lymphoid and mucous layers with connective tissue, cause irritation of the terminal nerve filaments to such Pneumogastric left Ganglion - Pneumogastric right Coronary artery Coronary vein Ganglion Hepatic artery Gastro-epiploic artery Ganglion Gastro-epiploic •_ vein ._.j^ JvomHartnidiiu dnd Cune'o. Fig. 98. — The nerves, blood vessels, and lymphatics of the stomach. (By permission of Dr. W. J. Mayo.) an extent as to set up a train of symptoms generally classified as intestinal fermentation. Morris adds also a strong indorsement of Dr. George M. Gould's view regarding the importance of ocular defects as a cause of these neuroses, testifying that " a very large group of cases of intestinal fermentation is dependent upon eye-strain." He states further on this head : " The ones that I see are sent to the office most often with the request to have the appendix EXCESSIVE ERUCTATIONS 82/ examined because the distention of the cecum is apt to cause more pain than distention of other parts of the bowel, and at- tention is attracted to this region. If there are external evi- dences of eye-strain, these cases are referred to the ophthal- mologist along with my cases of ' nervous dyspepsia ' and ' gas- tric neuralgia,' and some of the most brilliant results that I have observed in any kind of medical practice have come out of the treatment that was instituted." The exceeding richness of the nerve supply of the storhach is shown clearly by the accompanying illustration, Fig. 98. The numerous branches of the vagi and of the ganglionic nervous system ramify to every part of the viscus. No wonder it is so often disturbed reflexly, and so frequently, on the other hand, a cause of reflex derangements in other organs ! The Treatment. — ^The cause of the jflatulency must, of course, first be sought for, and the therapeutic measures then be directed to the underlying pathologic state. In fermentative conditions with chronic gastric catarrh, the diseased process needs to be combated persistently by lavage, diet, massage (in the asthenic cases), and often hydriatic pro- cedures, as well as by HCl and bitter tonics for deficient, and alkalies and sedatives for excessive, gastric secretion, aided by all the practicable roborant measures, including a proper alter- nation of rest and exercise, and especially by those recreations that will keep the patients as much as possible out in the open air without unduly taxing their strength. The intragastric spray may be employed instead of lavage when the latter fails. Intragastric electricity may be made very helpful in chronic gastric catarrh, and in deficient motor power of the gastric muscles ; therefore, of course, in all the fermentative condi- tions resulting therefrom. - Antiseptic drugs have often proved disappointing in my hands, especially when administered by way of the mouth with the idea of controlling fermentation by a direct action. I have seen great good result from even small doses of HCl — 2 to 10 drops of the officinal dilute acid in water after meals — 828 THE GASTRO-INTESTINAL CLINIC in cases of asthenic gastric catarrh with a deficient gastric juice, the secretion of HCl increasing, and the fermentation and flat- ulency being often lessened or stopped, but this gain has seemed to result mainly from a restorative action upon the gastric glands. Furthermore, I have seen in like cases, as well as in others with fermentation dependent merely upon diminished secretion of HCl, marked improvement gradually result from one to two drops of carbolic acid or creosote, or even smaller doses, the improvement coinciding with a gain in the amount and quality of the gastric juice. In both the usual forms of gastric catarrh — whether the HCl be increased or diminished — bismuth, in doses of 5 to 50 grains after meals, has often effected brilliant results, especially in the higher range of doses when combined with alkalies, a milk diet, and absolute rest, in cases of hyperchlorhydria with ulcer, accompanied by much fermentation of starch foods ; but here the good result doubtless comes more from its mechanical, soothing and absorptive effect than from its antiseptic action. Evidence is accumulating, also, as to the efficacy of magnesium salicylate and bismuth sali- cylate, the former when constipation and the. latter when diar- rhea accompanies and complicates the flatulence; also some of the newer combinations of bismuth, particularly betanaph- tol-bismuth (orphol) and tribromphenol-bismuth (xeroform). In cases following operations in the abdomen, and in all others in which there is reason to suspect peritoneal adhesions, surgical aid may be required ; so also when there are dis- placements which have not yielded to other suitable treatment. As in all gastro-intestinal cases, you should carefully see to it that any ocular faults have been properly corrected. The diet appropriate to chronic gastro-intestinal catarrhs and the fermentation dependent upon them I have discussed at length in the lectures devoted to the subject of diet in general. It is unnecessary to say more here than that it is not safe to at- tempt to follow strictly any general rules, since there are so many exceptions. Every case must be studied by itself. I might venture the statement, however, that in the true catar- EXCESSIVE ERUCTATIONS 829 rhal cases much restriction is usually necessary, especially as to the carbohydrates, while in nervous dyspepsia patients often eat too little. It is most unscientific and often very harmful to attack the flatulence symptomatically by means of irritant antiseptics which w^ould aggravate an unsuspected hyperchlorhydria, and perhaps bring on a fatal gastric or duodenal ulcer. And it would be equally disastrous to treat a debilitated, underfed neurasthenic, suffering from nervous dyspepsia, by low diet and stomach washing. ^Vhen the fermentation and eructation do not depend upon catarrhal inflammation in either the stomach or small intes- tine there is usually gastric atony or dilatation, the treatment for which must be carried out as described in the lecture de- voted to that subject, and at the same time lavage with anti- septic solutions as advised for asthenic gastric catarrh may often be practiced with advantage every day, or every other day, to cleanse away fermenting food remains. The diet should, for a few weeks at least, contain as little of the more fermentative carbohydrates as possible. In the cases of nervous eructation, the treatment, in addition to electricity locally, should be that appropriate to the neuras- thenia or hysteria upon which the affection depends. Intragastric applications of the induced electric current (faradism), in connection with cold water locally, regulated physical exercise in the open air, abundant sleep, and all the other measures required for neurasthenia, will rarely fail in these cases, when the eructations do not result from some real lesion, but you should always examine closely into the condition of the intestinal mucosa, w^here will frequently be found a catarrhal inflammation which has caused both the excessive upward rush of gas and the associated so-called neurosis. In the section on meteorism, etc., under the head of Intestinal Neuroses, in Lecture LXXVIIL, I have discussed with suf- ficient fullness the subject of excessive flatulency in the in- testines in all its forms, whether of nervous or other origin. LECTURE LXXV GASTRIC NEUROSES, SECRETORY AND SENSORY Most of the gastric affections having no known anatomic basis are assumed to be of nervous origin, and as to a certain proportion of them, this is probably correct. I shall, therefore, follow the example of the majority of authors in devoting con- siderable attention to the so-called neuroses of the stomach and intestines. They shall be discussed under the three heads, secretory, sensory, and motor, though they are more frequently considered in the reverse order. It is my belief that the ex- cessive acid secretion — hyperchlorhydria — which I have found to be the most prevalent of all gastric derangements, and some degree of gastric hypersesthesia, which frecjuently occurs, are the chief causes of the common motor disturbances, such as spasms of the cardia and pylorus, cramps or colics of the stom- ach, etc. Hence it seems to me appropriate to take up the derangements of secretion first, those of sensation next, and those of motility last. The Nervous Secretory Derangements of the Stomach. — The derangements of gastric secretion dependent upon in- flammatory conditions have been considered already under the heads of Asthenic and Sthenic Gastritis. " Hyperchlorhydria and Hypersecretion" is the title of another lecture (LI.), in which I have discussed Hyperchlorhydria, Reichmann's Disease, and Gastroxynsis, which are due probably, in some cases, to obscure nervous conditions, and in others to gastric or duodenal ulcer, or to reflex causes. In Lecture XLIX., espe- cially, excessive secretion of HCl and the ferments is fully dis- cussed. There is little left to be said about the many derange- 830 GASTRIC NEUROSES 83 1 ments of secretion, which are supposed to be of purely neu- rosal origin. They have no patliology, their aetiology is ob- scure, their symptoms are virtually the same as those of the other forms of abnormal HCl secretion, and the treatment of them must be along the same lines. Whether the secretion is excessive, as is most usual in nervous conditions, or deficient, the chief difference in the therapeutic measures applicable is that, the affection being a complication or direct result of neurasthenia, the measures suitable for that disease must sup- plement the other usual remedies for the deranged secretion. Further on, in Lecture LXXVIL, devoted to the subject of Nervous Dyspepsia (Neurasthenia Gastro-Inte-stinalis), the treatment of this condition will be found somewhat fully con- sidered. Rest, both physical and psychic, as well as all the practicable strengthening measures, are still more important than in the other forms of HCl excess. Nervous Hypochlorhydria or Gastric Subacidity. — You will encounter many cases in practice showing all possible de- grees of HCl deficiency, and in quite a proportion of them no other cause than some nerve derangement can be found. If, after having performed your whole duty in respect of thorough examinations to exclude any other possible lesion, you find no tangible cause excep!: neurasthenia, your proper course will be to build up the system in eveiy practicable way as directed for the management of the nervous forms of hyperacidity, and in addition, to administer small or moderate doses of HCl, with usually pepsin as well, unless the tests have shown a sufficient amount of the latter. But do not prescribe these until, after several examinations, you have become convinced that the deficiency of HCl is more than a passing one, to be followed in a few days by a normal or excessive proportion of- it. Even then, do not continue such remedies at first beyond one week without testing ^again, for in such neurasthenic cases, the glands are usually very impressionable and may sud- denly respond to the stimulation of the HCl and pepsin by a hypersecretion, which is likely to be more injurious, if it per-< 832 THE GASTRO-INTESTINAL CLINIC sists, than the deficiency would be. Indeed, if, for any reason tests of the stomach contents cannot be made at least every week or ten days at first during such a course of treatment, it will be wisest to refrain from prescribing HCl altogether, and depend upon the bitter tonics, especially nux vomica, quassia, and a general roborant treatment. Hyperchlorhydria Mistaken for Hypochlorhydria with a Serious Result. — The point above made is well illustrated by the following case report: M. K., aged thirty-five, a stenographer of delicate nervous temperament, has come to me while I have been writing this lec- ture and gives the following history : Six weeks ago, after a spell of unusual physical weakness, she began to suffer from a hot and uncomfortable feeling in the stomach, coming on an hour or two after eating and persisting often for several hours. She consulted an irregular practitioner, who prescribed tonics, including HCl. The discomfort then steadily increased, and by the end of two weeks later had developed into such severe pain that she was directed to remain in bed and limit herself to liquid diet, to consist of beef tea and milk. The acid was continued some time longer, without the other tonics. Later the diagnosis of gastric ulcer was made, and the acid medication changed to small doses of an alkaline one, but meat extractives were still allowed as part of the diet. No tests of the stomach contents were made. The patient is now able to be about, but still suffers pain after eating, especially after solid food. Examination at my office revealed the usual marked tender spots characteristic of gastric ulcer, and this being still so recent a development I decided to delay, for the present, the in- troduction of a tube for the purpose of getting a sample of the stomach contents. Excluding meat and meat extracts or broths from the diet entirely, and limiting her to milk and Plasmon, at the same time administering alkalies in larger doses, together with full doses of bismuth, have relieved the painfnl symptoms already within a few days. The patient has meanwhile been kept strictly in bed. If the relief had not been so prompt from this regime, 1 should have prescribed rectal feeding for a week or ten days. GASTRIC NEUROSES 833 This patient at first, doubtless, had merely an acid form of dyspepsia, /. c, hyperchlorhydria, instead of hypochlorhydria as the physician supposed. If he had established this fact by a stomach test, and instead of hydrochloric acid and meat ex- tractives (the two most powerful stimulants of the gastric glands), had prescribed alkalies, belladonna, and a very bland unstimulating diet, the patient would have been spared weeks of sufifering, to say nothing of the loss of income through an illness which has already detained her from her occupation nearly two months, and will probably prevent her resuming it for another month or two, even if she should be fortunate enough not to require a laparotomy to bring about a final cure. Nervous Anacidity of the Stomach — Achylia Gastrica Ewald, sixteen years ago, called attention prominently to the fact that, even in the absence of any discoverable disease, there may be a total lack of gastric secretion, or at least achlorhydria with hypopepsia. He named this condition Anadenia Gastrica, and it has been called by Einhorn Achylia Gastrica. Both these names merely imply the condition of a total or nearly total lack of gastric secretion without involving any theory as to the cause. It is convenient to discuss this condi- tion among the neuroses, though it by no means always results from any fault in the nervous system. On the contrary, it is probably most frecjuently either a consequence of organic dis- ease in the stomach, or of a deficient blood supply to that organ due to cardiac asthenia or arteriosclerosis of the gastric vessels. The symptoms of anadenia or achylia gastrica depend upon the cause. When there exists a true atrophy of the glands there is likely to be much impairment of the health with anaemia, debility, etc., from a lack of nutrition; especially when, at the same time, there is a failure of the intestinal di- gestion, or what would amount to the same thing, a lack of propulsive power in the stomach so that its contents cannot be extruded into the duodenum in time. It is rare, however, that a failure of gastric motility coincides with atrophy. 834 THE GASTRO-INTESTINAL CLINIC Certain writers have assumed that achyha, or rather a com- plete atrophy of the gastric glands, is the most frequent cause of pernicious anaemia ; but this theory has not been proved. I have seen several cases of achylia in which the patient was well nourished and complained of no indigestion, except after some marked imprudence in eating or drinking. Achylia is itself ohly a symptom — the absence of gastric secretion — and may be associated with various diseases, or be found in conditions of apparent health. The diagnosis can only be made from a test of the stomach contents, and finding not merely a total absence of HCl, both free and combined, but also of the rennet ferment and its xymogen as well as the inability of the gastric juice to digest albumin even when 0.2 per cent, of HCl has been added to the mixture, showing thus absence of pepsin. The total acidity will not be over 10 or 12 in a case in which the failure of se- cretion is complete, and is often less. The treatment must be directed to the primary disease, whatever that may be. When it is neurasthenia, the remedies advised in Lecture LXXVII., on Nervous Dyspepsia (Gastro- intestinal Neurasthenia), may be hopefully followed, and in addition it is often well to add a mixture containing small or moderate doses of dilute HCl combined with some efficient preparation of pepsin. I have observed numerous cases in which for months or even years at a time there was an absence of all the- elements of the gastric juice, and yet finally a moderate secretion was re-established as a result of such a course of treatment. In a large proportion of these it is bighly probable that the sup- pression of the secretion was due to some nerve fault ; but in one of them, at least, the cause was doubtless the prolonged ad- ministration of bicarbonate of sodium. By the advice of a physician who did not make a practice of testing the stomach contents, this patient, a lady aged about thirty, took regularly moderate doses of the soda preparation daily for a period of several years, both in this country and during an absence in GASTRIC NEUROSES 835 Europe, and when she came under my care, there was neither free nor combined HCl and no rennet ferment. She took by my advice HCl and pepsin for some eight months before the secretion was fully restored. In several cases of achylia in elderly persons, I had reason to believe that there was atrophy of the glands, and in some of them this diagnosis was con- firmed by the failure of even HCl and pepsin persevered with for several years (because of their good effects in a palliative way) to restore the secretion. In others again, in which the achylia may have been due to nervous causes alone, there was finally a return of the secretion under the course of treatment which included 5 to 10 minims of dilute HCl with 15 to 30 minims of a good glycerol of pepsin after each meal, along with a generally tonic regimen. In cases of undoubted atrophy it is not, as a rule, useful to administer HCl as a remedy. Better results have usually, in my experience, followed the abandonment of all attempts to re-establish the gastric secretion and the prescription of full doses of an active preparation of pancreas ; but whenever there is the slightest doubt on this point, I believe it is well to push the administration of small doses of the HCl with pepsin at intervals, if not persistently, for at least one year, provided it agrees well, since after an even longer time than this the se- cretion has sometimes returned. Cases are on record in which there has been a restoration of the secretion after as long a time as five years, but in these cases HCl could not have been administered perseveringly as a remedy, since it is unquestion- ably the most powerful stimulant we have for the gastric glands, so effective, indeed, that if it is to bring back the se- cretion at all, this result could scarcely be postponed so long. SENSORY DISTURBANCES OF THE STOMACH: GAS- TRALGIA, GASTRIC HYPER./ESTHESIA, ETC. True gastralgia or neuralgia of the stomach is not very often encountered. You will likely see many more cases of acute gastric pain due to hyperchlorhydria, at least an equal 836 THE GASTRO-INTESTINAL CLINIC number attributable to spasm of the pylorus or gastric cramps, and nearly as many in which the cause is ulcer or cancer. The name gastralgia should be applied to those acute stom- ach pains only which occur paroxysmally without regard to the character or amount of food taken, and are caused by a true affection of the nerves of the stomach, or of the centers from which they arise, and not to any of the numerous similar pains which may result from a diseased condition of some of the other structures of the viscus. The Aitiology of Gastralgia. — The affection can arise from any of the causes that are likely to produce neuralgia in nerves elsewhere. These include malaria, syphilis, gout, anaemia, hysteria, neurasthenia, and systemic poisoning by tobacco, lead, mercury, or other of the metals. According to some authors the pains that may be produced in the stomach by perigastritis and organic diseases of the stomach itself, as well as by the reflex gastric pains from displacements of any of the viscera or various diseases in distant parts as in the genito-urinary organs of either sex, etc., are classed among the gastralgias; but I cannot see that any useful purpose is subserved by giving to the word gastralgia so broad a significance. Call the other gastric pains of obscure origin by the name of gastrodynia if you will, but let us keep the word gastralgia to describe a true neuralgia of the stomach nerves. Various diseases of the central nervous system can produce gastralgia. Cerebral af- fections are exceptionally the cause of it, but those of the spinal cord more often, including certain forms of mye- litis, and tabes dorsalis produces a comparatively frequent manifestation of gastralgia, known familiarly as gastric crises. The syiupfonis of Gastralgia are much the same as those of other forms of neuralgia. The pain comes on in paroxysms lasting from half an hour to several hours, and is generally severe, often intolerable, so that relief by hypodermics of mor- phine is urgently demanded. It may be shooting, boring, tear- ing, or burning in character. Unlike most other gastric pains GASTRIC NEUROSES 837 it is usually relieved, to some extent at least, by firm pressure upon the epigastrium, though there are often very sensitive spots in the middle line over the sympathetic nerve plexuses. The pain may radiate in any direction, but especially toward the spine or downward into the hypochondria. Attacks of gastralgia do not recur with any regularity, nor can they often be traced to any special provocation, though sometimes mental strain or excitement precedes them. In the severer ones the patient suffers acutely ; the face is contorted, the coun- tenance expressing great suffering, and cold sweat may appear upon the skin. The diagnosis of Gastralgia is not always easy, and can often be made only by exclusion. In the absence of the symp- toms and signs of ulcer, chemical findings showing hyper- chlorhydria or other form of HCl excess, paroxysms of vio- lent pain in the stomach occurring irregularly, independently of the digestive periods, and leaving the patient entirely free of any discomfort in the intervals, may be set down as probably due to gastralgia. Carcinoma of the stomach may possibly produce spells of similar pain, but is much less likely to do so than the other affections named, and there would not then, as a rule, be such entire freedom from discomfort between times. Gall-stones cause extremely violent pains in the region of the gall bladder, and may be confounded with gastralgia, but the pains are usually referred to a point much further to the right than those of gastralgia and are not relieved in the least by pressure. Moreover they are generally accom- panied by symptoms of obstruction of the bile duct — jaundice, high-colored urine, pale clay-colored stools — and usually also by a swelling in the region of the gall bladder, as well as by more or less fever, though this may often be wanting. Atypi- cal cases of biliary colic may be impossible to differentiate from gastralgia, and you must then decide by the results of the treatment for the latter. The diagnosis from hyper- chlorhydria, ulcer, and cancer will readily be made by compar- ing the symptoms and signs of those diseases as described in 838 THE GASTRO-INTESTINAL CLINIC previous lectures. In hyperchlorhydria the pain is relieved by more food ; in ulcer, increased by food ; but in gastralgia, has no relation at all to food. Muscular rheumatism could scarcely be confounded with gastralgia, since the pain is not paroxys- mal nor violent. Intercostal neuralgia may cause a similar kind of pain, but in such cases the affected nerve will be sensi- tive to superficial pressure, not only at the locality where the pain is felt, but usually at various points all the way around to its spinal origin. The diagnosis from any of the conditions involving excessive secretion of HCl with the acute pains and motor spasms frequently resulting therefrom, can easily be de- termined by examinations of the gastric juice, repeated if necessary. A¥hen for any reason these cannot be made, the makeshifts for determining otherwise approximately the pro- portion of HCl in the gastric juice may be resorted to, and will sometimes help you to decide. (See Lecture IX.) Then, too, the regular recurrence of the pain at the height of diges- tion, relieved by taking more food and passing off entirely as a rule when the digestion has ended, presents a picture in hyperchlorhydria and allied conditions, totally different from that I have just shown you as characteristic of gastralgia. The cramp pains occurring in pyloric spasm usually persist till the stomach has been emptied either through the pylorus, or by vomiting, and recur after the next full meal. Treatment of Gastralgia. — Your chief object in this respect should be to ascertain as certainly as possible the nature of the primary disease, and then so shape the treatment as to re- move or control it. When the attacks are of unusual severity, the pain must of course be relieved in some way — by the ad- ministration of morphine — even hypodermically, if necessary; but, if possible, other less harmful remedies should be first tried. A turpentine stupe or hot mush poultice will generally lessen the pain decidedly, or what is often just as effective and not nearly so troublesome is a very hot, w'et compress, applied so hot that a layer or two of flannel will need to be placed be- tween it and the patient. The whole should then be covered GASTRIC NEUROSES 839 by three or four thicknesses of cloth, inchiding, if practicable, one layer of some impervious material so as to confine the mois- ture and prevent evaporation or a too rapid cooling. Such an application, fastened firmly to the abdomen by a binder passing all the way around the body, will often control an attack of even very severe gastralgia or other abdominal pain as ef- fectually almost as an opiate, without any of the unpleasant effects of the latter. When morphine must be injected, it is best to combine with each ^ grain of the latter i-ioo to 1-80 grain of atropine sulphate, since the combination is likely to disturb the stomach very much less than would morphine alone, and is also more powerfully antispasmodic. The systemic treatment to be pursued between the attacks, depends, of course, very much upon the character of the pri- mary disease. When this has resulted from any specific in- fection, such as malaria, quinine is naturally the very best remedy of all, and it has even been found effective in other forms of gastralgia in which there has been no suspicion of malaria. Syphilis and the metallic poisons call for potassium iodide in full doses. Lithsemia or obscure forms of gout de- mand alkalies and deobstruents with more exercise and less rich food. Anaemia, chlorosis, and the other depressed con- ditions including neurasthenia and hysteria are benefited by iron, arsenic, and often by phosphorus, the hypophosphites or the glycerophosphates. All the other tonic or building-up measures, such as country, mountain, or seashore air (es- pecially the last, which often acts almost magically), well-se- lected hydriatic procedures, and above all, electricity, are par- ticularly indicated in these latter classes of cases. Full doses of galvanism (20 to 30 ma.) applied directly through the 'region of the stomach from the back to the front with the positive pole over the epigastrium, and repeated every other day at least, or better yet, half these doses applied intragas- trically, will usually prove effective, and sometimes will even relieve the paroxysms of pain. For the latter, too, the new method by mechanical vibration, applied with moderate pres- 840 THE GASTRO-INTESTINAL CLINIC sure directly over the seat of pain, is well worth a trial in such cases, since it often proves effective in relieving neuralgic pains, both when applied over the site of the pain and upon that part of the spine from which the structure involved receives its nerve supply. The static sparks and electrostatic currents are often effective here also. When the pain is a reflex from disease in the genito-urinary system, or in any other distant organ, the affected part must receive the chief attention, and naturally any local disease or unhygienic practices which are keeping up irritation must be corrected. Gastric Hyperaesthesia. — In many diseases of the stomach, especially in the different forms of gastric catarrh, in liyper- chlorhydria, etc., pain or discomfort is experienced in the viscus, and the sensory nerve terminals are believed in such cases to be unduly sensitive. There is certainly a wide dif- ference between the complaints of abnormal sensations in some severe cases of the kinds mentioned, and those made by the patients in other like conditions of a far milder degree — not that the complaints in the former are greater, as you would naturally expect them to be, but often markedly less. For ex- ample, I exceptionally encounter cases of acid gastritis with a percentage of free HCl above 0.2 withoiit any symptoms what- ever, and then sometimes see cases in which there is only a very slight catarrhal process and a percentage of free HCl not ever 0.09 per cent., with complaints of burning or other markedly disagreeable sensations during the height of the pe- riod of digestion. Again, in consequence of a long-standing chronic atrophic catarrh, with virtually no gastric juice left in certain cases, there will be complaints of burning sensations after the administration of very moderate doses of HCl, unless it is largely diluted and sipped slowly during the course of an hour or two. Indeed, I have most frequently encountered such a manifest hyperccsthesia, against acids especially, in cases in which there has been complete achylia. Yet, if we were to accept tlie view of gastric hyperaesthesia GASTRIC NEUROSES 84I given by Riegel, all such instances of the condition as are above described would have to be excluded entirely. After accurately defining this affection as " a morbidly increased sensibility of the sensory nerves of the stomach," he goes on to say: " Hypersesthesia is characterized by a variety of ab- normal sensations — a feeling of pressure, fullness, tension, burning, boring, etc., during digestion. As a rule, these sensa- tions persist for some time after digestion. Abnormal sensa- tions of the kind are encountered in the majority of organic diseases of the stomach. These of course we are not discuss- ing in this place. The same abnormal sensations are occa- sionally seen as complications or symptoms of hysteria, neu- rasthenia, and a number of diseases of the central nervous system. In anaemia and chlorosis we also occasionally en- counter hyperccsthesia. In the latter cases we are by no means justified, however, in declaring the hypersesthesia to be a true neurosis of the stomach, for we may only diagnose this con- dition if the stomach is intact, and in chlorosis and anaemia, as we know, we frecjuentl}^ see perversions of gastric secretion, in particular hyperchlorhydria, so that the latter alone may be made responsible for the abnormal sensations, and may even pioduce attacks of cardialgia."' Accepting Riegel's definition of gastric hypersesthesia, " a morbidly increased sensibility of the sensory nerves of the stomach," and it cannot well be improved, it seems logical to include under it all the cases of unduly heightened sensibility of the gastric nerve endings, in which comparatively trivial causes produce an exaggerated amount of sensation, in spite of the fact that there is an associated organic lesion. It is well known and admitted by Riegel himself, elsewhere in his great work on the stomach, that, in a large proportion of the gastric affections which we usually class as nervous, there ex- ists some real lesion which by our present methods we are un- able to discover, but even admitting that there may be cases of hypersesthesia dependent wholly upon a fault in the nerves themselves, whether it be in a nerve center, trunk, or ter- 842 THE GASTRO-INTESTINAL CLINIC minal, we need some term to describe also the numerous symptom groups in which, along with a relatively slight lesion, there is an altogether exaggerated sensibility of the nerves. The diagnosis of gastric hypersesthesia is made from the single symptom that with either no determinable gastric le- sfon, or one of slight or moderate character, there are com- plaints of discomfort or pain after eating, which is apparently causeless, or, if disease be found, out of proportion to the amount of such disease. There is usually some sensitiveness on pressure over all that part of the stomach which is below the ribs, but this is not marked anywhere, and there is lacking especially the acute tenderness over circumscribed spots demon- strable in ulcer. Though considered by some to be closely related to gastralgia, it should be easily differentiated from the latter by the uniform dependence of the pain upon eating, while gastralgia may come on in parox3^sms at any time, re- gardless of meals. Besides, the pain in the latter affection is often intense, severe, while that of hypersesthesia is usually slight — often not more than a decided discomfort. It might be confounded with the dull pain and tenderness often seen in chronic gastritis if no examination of the stomach contents could be made, but the findings, chemic and microscopic, in such an examination would reveal the true condition. Treatment of hypersesthesia should be based mainly upon the nervous element which is always present. Galvanism from the spine to the epigastrium, with a short application addi- tionally to the vagi in the neck, rarely fails to accomplish much. Galvanism or high-tension faradism applied within the stom- ach, by means of the intragastric electrode, is still better for all except the very few who are intolerant of any instrument in that viscus. Spraying with a weak nitrate of silver solution (o.i per cent.), or a menthol solution, and in stubborn cases with a combination of menthol and cocaine, is generally effective. Hot GASTRIC NEUROSES 843 compresses, as advised for gastralgia, may be kept on con- tinuously at night with advantage. The following prescription has often proved very helpful to my patients suffering from this affection : Argent, nitrat. T^ ^ . r aa gr. IV Ext. nuc. vomic. ) ^ Ext. belladon gr. i Ext. taraxaci 3i. — 3ii Bismuth subuit 3 i M. et ft. mass, in pil. No. XX dividend. Sig. One before each meal. In addition to the above-mentioned local remedies, the medi- cines and measures described in Lecture LXXVII. as suitable for nervous dyspepsia (gastro-intestinal neurasthenia) are in- dicated in gastric hypersesthesia. Like the neuroses of the stomach, generally, it might be considered under the head of nervous dyspepsia, but there are reasons already stated for giving to some of them separate consideration. Other Abnormal Sensations in the Stomach. — In health one does not have any sensations in the stomach except the pleas- urable one of a comfortable satiety after a full. meal. In various diseased conditions, especially in neurasthenia, whether there be any pathologic change in the organ or not, unpleasant sensations of one kind or another are frequently experienced. In addition to the various degrees of pain in the stomach described under the heads of Gastralgia and Gastric Hyperccsthesia, and to the pains arising from pathologic states, a symptom frequently described by patients is a feel- ing' of weight or heaviness coming on regularly after eating. This is probably almost invariably due to atony of the stomach walls, whether associated with dilatation of the viscus or not ; ■but it is claimed by some authors that the same sensation is sometimes encountered as the result of a neurosis merely, and I therefore mention it in this connection, though doubtful whether it ever occurs when the gastric motility is entirely normal. Other abnormal sensations which may undoubtedly be of nervous origin are a feeling of heat or cold in the stom- 844 THE GASTRO-IXTESTINAL CLINIC ach after eating, and especially nausea. The latter symptom I have seen so often in women quite independently of any demon- strable gastric lesion that I am convinced it very frequently depends upon a reflex cause, the real lesion being most fre- quentlv in the sexual organs, particularly in women (who nearly monopolize the symptom), or else upon a pure neurosis. Xausea of such a reflex or nervous type never yields to any medicine addressed to the stomach. In a number of women patients afflicted at times with this trouble, I have found the cause to be an irritation of the uterus or ovaries, and it is al- ways much aggravated at the menstrual periods. In some of these cases the particular fault has been a backward displace- ment which, failing the patient's consent to a curative opera- tion, the g}'necologist has tried to keep in place without a pes- sary, and with only partial success. The bromides will some- times relieve temporarily, but all drugs may fail till the cause has been removed. Tonic measures and medicines are usually indicated, as in all the neuroses. Hemicrania or migraine and intercostal neuralgia are other sensory disturbances which Fleiner has considered in this con- nection, because they are frequently dependent upon faulty stomach conditions. But. though these are often due to gastro- intestinal disease, especially migraine, they are more appro- priately considered elsewhere. They no more belong here than epilepsy, neurasthenia, eczema, etc., which often have a gastro- intestinal cause. DERANGEMENTS OF THE APPETITE These may be due to organic lesions or to an excess or de- ficiency of the gastric juice, or be merely dependent upon a disturbed condition of sensation in the stomach. According to my experience, an abnormally large appetite has been most frequently seen in connection with either an increased secre- tion of HCl, or else with an excessive amount of the organic acids resulting from a catarrhal condition, or from a deficient GASTRIC NEUROSES 845 gastric motility ; and anorexia has been rather constantly asso- ciated with a lack of secretion or motility or both, though ex- ceptionally I have seen it coincide with hyperchlorhydria. But there are many cases which we must attribute to nervous causes. Bulimia and Akoria. — Bulimia is an exaggerated or almost unappeasable hunger, sometimes called canine hunger. Akoria is a lack of the normal feeling of satiety after eating an abun- dant meal. The two conditions are closely allied, and when a person habitually eats far too much, it is often impossible to decide whether his excess in this respect is due to the one or the other fault. As a rule the two apparently go together, for it is exceedingly rare that one is impelled to go on eating after a feeling of fullness has been reached. The term bulimia is commonly applied to an abnormally great appetite, one which is out of proportion to the demands of the system, regardless of the cause. Naturally the growing child and youth require more food than the full-grown adult, and the pregnant or nursing woman more than she who does not have to " eat for two." In like manner the convalescent from a fever or other serious disease has a normally in- creased appetite,, and the man who works out in the open air for ten or twelve hours a day, as farmers and laborers often do, not to speak of soldiers on forced marches, needs two to three times the amount of food which will suffice for the idle indoor- dweller. In estimating whether the amount of food taken is excessive, these differences must always be taken into the account. But when a person not in any one of the above-mentioned classes, who is not actively using his muscles for many hours ciaily, eats exceptionally large meals without feeling fully sat- isfied, or if, after a feeling of satiety, within an hour or so again experiences a sharp sensation of hunger which impels him to demand imperatively more food and drink, you may know that the appetite is an abnormal one and should take measures to remedy the diseased condition upon which it 846 THE GASTRO-INTESTINAL CLINIC depends. Most frequently this will be either a simple hyper- chlorhydria, or some one of the various forms of excessive secretion of HCl, which you can, in most cases, easily deter- mine by examining the gastric contents after a test meal. If such a hypersecretion be found, the appropriate treatment — alkalies, sedatives, intragastric electricity with the high-ten- sion farad ic current, etc. — will usually prove effective in curing the bulimia in the same degree that it succeeds in remedying the primary disease. When there is gastritis with either too much HCl or too little of the latter, but then with an excess of the organic acids which unduly irritate the gastric nerve endings and thus cause excessive hunger, the cure will be much helped by washing out the patient's stomach daily or every other day. In other cases the excessive appetite may be due to worms or to diabetes, and then, of course, the first thing to do will be to treat by suitable measures these underlying diseases. When, on the other hand, the bulimia is consequent upon some obscure nervous lesion, as in epilepsy, certain states of defective intelligence, or any fault of the nervous system, the task will be more difficult. In some of these cases a systematic limitation of the amounts of food to be taken is necessary, and all eating between meals must be strictly forbidden ; the ap- petite can thus be gradually trained to correspond more nearly with the normal requirements. In stubborn cases it is ad- visable to apportion not only the kinds of food to be eaten, but precisely the amounts of each kind based upon the tables showing the number of calories or heat units required for a person not actively exercising and the normal proportions of proteids, fats, carbohydrates, and salts needed to maintain nu- trition. (See Lecture XVI.) Meanwhile, of course, any dis- coverable fault or vice of the organism should be combated by appropriate measures. The Buccal Reflex. — Horace Fletcher, a layman, who has made a more profound study of the appetite in relation to mastication, digestion, nutrition, etc., than most physicians, GASTRIC NEUROSES 84/ maintains in a very interesting book recently published^ that the majority of persons eat at least twice as much as they re- quire, and claims to have discovered that the buccal reflex which should guide us in the length of time we chew our food, and the amounts eaten by us, has been lost or perverted in the case of most human beings. He holds that food should be masticated, or in the case of liquid, kept moving about in the mouth, till it has been so thoroughly insalivated as to become alkaline, when only, under normal conditions, the muscies about the fauces will open and permit it to be swallowed. As a result of hasty and excessive eating, with insufficient insaliva- tion supplemented by drinking to wash down the imperfectly insalivated boluses, the natural buccal reflex is lost. To re- store this lost reflex and prevent gluttonous eating, Fletcher advises systematic overmastication of every portion of food, solid or liquid, taken into the mouth, the attention being mean- while concentrated upon the act, and claims that if this be practiced faithfully for from four to six weeks, the lost reflex will be regained, after which there will be neither appetite for more food than the body requires, nor the ability to swallow (without forcing it) any morsel that has not been properly masticated and insalivated. The Proper Food Ration. — Fletcher is an American who has been carrying out scientific investigations and experiments upon this subject in Venice (Italy), and Cambridge University (England), as well as at Yale University (New Haven), in co- operation with a number of prominent physiologic chemists and other medical men. The results demonstrated by these ex- periments, particularly the smallness of the amount of food which could be made to maintain a complete nutritive equili- brium, when overmastication as advised by Fletcher was prac- ticed, are described in Lecture XVI., on Prophylaxis, etc. They are very striking and exceedingly interesting. Fletcher refers also to a similar experiment as to the proper food ration '"The A B-Z of Our Own Nutrition," New York, Frederick A. Stokes Co., 1903, 848 THE GASTRO-INTESTINAL CLINIC recently undertaken at Yale University under the auspices of the United States Government, a number of enlisted members of the Hospital Corps, who volunteered for the purpose, being the subjects. These experiments are highly important, since the conclu- sions of Voit and others, as to the normal food requirements of man, have not finally settled the question. Anorexia and Hyperkoria. — Anorexia is a lack of appetite, and hyperkoria, the opposite of akoria, is the coming on of a feeling of fullness or satiety too soon — after the ingestion of an insufficient quantity of food. As in the opposite conditions, these are often associated, and it may be impossible to tell which predominates in some cases when too little nourishment is regularly taken. Although we would naturally expect a deficient appetite and deficient gastric secretion to go together, we by no means al- ways find them so. \Miile, as a rule, a lack of gastric juice is accompanied by a, lack of appetite, I have seen many cases in which the appetite has been good in spite of a persistent achylia gastrica. So, too, anorexia is generally accompanied by a deficient secretion of the gastric juice, but by no means always. There are many depressed nervous or psychic con- ditions in which tbe patient runs down in health from insuffi- cient food, or can only with great difficulty be induced to eat enough to maintain nutrition, in spite of the fact that the gas- tric secretion is sufficient. I believe, however, that an exami- nation of the stomach contents in all the cases of nervous ano- rexia would show that in most of them the HCl and ferments are almost constantly much below normal, though the fre- quent improvement of such cases, under remedies addressed to the nervous system or mental state alone, might seem to prove the contrary. In these cases both the deficient secretion and deficient appetite are results of the systemic depression, and when this is removed by whatever cause, both the secretory fault and the consequent anorexia are overcome. In addition to the faults in the stomach itself, such as a GASTRIC NEUROSES 849 lack of secretion, lowered motility, chronic gastric catarrh, and cancer, various systemic affections, such as, e. g., tubercu- losis and many other diseases, tend to decrease the appetite. Anorexia is often a consequence, too, of certain little under- stood nervous conditions. As already mentioned, psychic depression from whatever cause may take away all appetite. Grief, worry, anxiety, the fear of pain, and merely overstrain with the resulting profound debility and neurasthenia are quite capable of setting up the condition. The symptoms of nervous anorexia are a marked distaste for food and a steadily increasing debility and emaciation in the absence of any organic affection capable of producing such a lowering of the health. The diagnosis is equally simple and w^ould seem well-nigh unmistakable. When no real lesion is to be found, and the pa- tient persistently refuses to take an adequate amount of food, the cause can only be nervous or psychic. The treat men f, which in the beginning, before the loss of nutrition has gone too far, is nearly always successful, con- sists, first of all, in imperatively requiring the patient to take more food. At the same time, every effort should be made to tempt the appetite with a variety of toothsome dishes, as well as to stimulate it by means of stomachics. For the latter pur- pose I have found a combination of the tincture of nux vomica, or of quassia, with pepsin and HCl the most effective of all the drugs at our command, especially for the great majority of cases in which the cause, whatever it may chance to have been, has lessened the secretion of the gastric juice at the same time that it has taken away the appetite. The majority of authors, it seems to me, have not given sufficient prominence to the very valuable part that HCl and pepsin, as natural remedies which imitate closely the principal elements of the gastric juice, are able to play in restoring appetite, the power to digest food, and finally, in many cases, the normal secretion of that juice itself. \Mien the mental depression is verj^ marked, and the condi- 850 THE GASTRO-IXTESTINAL CLINIC tion has existed so long that complete apathy has resulted, the danger to life is considerable, and forced feeding through a tube — gavage — is sometimes indispensable. In other cases the rest cure proves a most valuable means of restoring the normal state. In bad cases of the kind it is frequently quite useless to attempt to carry out a successful treatment at the patient's home. Treatment in some institution, or seclusion with a skilled nurse, is then the onlv alternative. LECTURE LXXVI THE MOTOR NEUROSES OF THE STOMACH^ Under this head gastrologists have described numerous af- fections, the predominant feature of each of which is an abnormahty of some one or more of the motor functions of the stomach. These inchide the fohowing: irregular or over- persistent contractions (cramps or spasms) either of the gas- tric walls as a whole, or of the sphincter muscles of the cardia or pylorus, and insufficiency of the same with such direct con- sequences of insufficiency of the cardia as rumination, re- gurgitation, and perhaps some of the forms of nervous vomit- ing, as well as nervous belching, pyrosis, etc. ; also hypermo- tility and nervous atony or hypomotility and hyperperistalsis (the peristaltic restlessness of Kussmaul). Spasm of the Entire Stomach (Gastrospasm). — This con- dition occurs very much less frequently than cramp or spasm of the orifices. - Indeed it is exceedingly rare. It may result probably from hyperacidity or from certain derangements in the nen-ous system of obscure origin. The symptoms are acute crampy pain, and often a visible contraction of the stomach into a hard roundish tumor. The treatment for the attack should be hot, wet, and emol- lient applications locally, such as a hot meal poultice or wet compress, with, if necessary, morphine or atropine or both, hypodermically. To combat the tendency employ the measures recommended for gastro-intestinal neurasthenia, under the head of Nervous Dyspepsia, with additionally galvanism or high-tension faradism- locally, preferably with one pole within 1 Some of the motor disturbances of the stomach — notably gastrospasm and pylorospasm — are accompanied by severe pain, and therefore may be said to involve both sensory and motor neuroses ; but the motor fault is here the primary one. 852 THE GASTRO-INTESTINAL CLINIC the stomach. The pneumogastric nerves in the neck, and the second to the fifth dorsal nerves, should also be stimulated mildly at their origin by counter-irritation, galvanism, vibra- tion applied by a mechanical vibrator or otherwise. (See Lec- tures XXV. and XXVIII.) Spasm of the Cardia. — This is a spasmodic contraction of the muscles which close the cardiac orifice. It is less frequent than spasm of the pylorus. It may be provoked by the intro- duction of a stomach tube, by any very hot or cold drinks, or by swallowing unmasticated morsels of hard or tough food. Cardiospasm may also result from overdistention of the stomach with swallowed air, or with gases formed within the viscus, the pylorus then being spasmodically closed at the same time; or from the irritation of an ulcer or cancer in the immediate vicinity of the cardia, wdiether in the stomach or lower end of the esophagus. Gastric hyperacidity or hyper- esthesia is less likely to be an efficient cause of spasm in this part of the stomach than in the pylorus. Doubtless cardio- spasm is also sometimes a consequence of a nervous shock, hysteria, or neurasthenia, — then a pure neurosis. Acute cardiospasm of purely neurosal origin may be re- covered from very quickly, or may last a day or two, the at- tacks recurring meanwhile every time an attempt is made to swallow. When it depends upon some lesion in the vicinity of the cardia, aggravated by hysteria or neurasthenia, it may still possibly be controlled by appropriate treatment, but is likely then to be much more stubborn. The chronic neurosal form, when recent, is usually curable, but the longer the disease has lasted, the less amenable it is to treatment. When secondary to some other disease, the prognosis of the chronic form is that of the primary affection, provided it be treated sufficiently early. The condition sometimes persists for years and then becomes refractory, as a rule, to all therapeutic measures. The symptoms of acute cardiospasm are occasional attacks of dysphagia — either difficulty in swallowing or complete in- ability to swallow from a spasm of the sphincter — and often a regurgitation of food before it has entered the stomach. The MOTOR NEUROSES OF THE STOMACH 853 food thus brought up contains neither HCl nor peptones, nor indeed any of the elements of the gastric juice or of the prod- ucts of peptic digestion. The attempt to pass food through the orifice usually causes severe pain, such as is felt in cancer of the cardia, but in some chronic cases pain is wanting. Acute spasm of the cardia is most likely to occur in nervous persons, and during a meal. It may then be merely transient, passing oft" in a few minutes, but usually recurs frequently in the course of the same meal, and may sometimes be persistent. In the more chronic form swallowing is less acutely painful, but it may be impossible to get any except liquid food into the stomach, and in the worst cases not even liquids will pass, ex- cept after dilatation with a sound or tube. In these cases feed- ing through a tube, or rectal feeding, may need to be resorted to for a time. The stomach then becomes much contracted, and it is generally held that the esophagus becomes dilated. Riegel doubts whether dilatation or diverticulum of the esophagus is not the cause, rather than a consequence, of the cardiospasm when both occur, but we know that an organic stricture, at or above the cardia, causes a pouching in the esophagus, and it is probable that persistent spasmodic stricture may have a like result. Tlic diagnosis of cardiospasm can easily be made from a permanent stricture due to ulcer, cancer, or other cause, by in- troducing a large-sized tube or esophageal sound. This will usually pass with only slight difficulty, encountering only a momentary opposition, when the closure is from spasm, but will fail entirely to go through an organic stricture. Further trials, then, with smaller sizes may succeed. In the latter class of cases a distinct sensation of a hard obstruction finally over- come will often be experienced when the smaller tube or sound passes into the stomach, though when a very small tube is used, no such sensation may be recognized. It is not so easy to distinguish a chronic cardiospasm from a large diverticulum in the esophagus with a consequent dif- ficulty in getting food or a tube to pass into the stomach ; but by 854 THE GASTRO-IXTESTINAL CLINIC a patient persistence with large-sized tubes, one can finally be introduced in the case of a spasm, after first encountering a resistance which is felt to yield, while, when there is a diver- ticulum, the entering is purely a matter of luck ; either a large or small tube or sound will sometimes pass in easily, and at other tipes, being caught in the diverticulum, cannot possibly be made to pass. Then in the spasmodic cases, even when chronic, there are nearly always occasional times when, the patient being in an unusually good condition, the spasm relaxes and all symptoms cease temporarily, whereas, when there is a divertic- ulum or pouching of the esophagus or any organic obstruc- tion, the symptoms never abate, but rather incline to become progressively worse. ■ You should bear in mind especially that in any form of or- ganic disease causing obstruction or stenosis, small sounds or tubes can be introduced more readily than large ones, while, on the contrary, when a spasm of the cardia causes the ob- struction, it is most easily overcome by the largest-sized in- struments. The Treatment of Cardiospasm. — This is in the main that of neurasthenia, which has been mentioned in connection with other gastric neuroses and fully described under the head of Nervous Dyspepsia. Locally, in addition there should be a systematic use of the largest-sized esophageal sounds or firm stomach tubes, one of which should be introduced daily and allowed to remain in position for ten to fifteen — some say thirty — minutes at a time. When there is a coincident gastric catarrh and much fermentation, the thorough washing out of the stomach daily with an antiseptic solution will prove doubly curative, provided a large and firm tube be employed for the purpose. Naturally you will also insist upon a careful, but nourishing diet, which at first should be liquid or soft, and upon a thorough mastication of all food. Indeed, a solid or semi-solid food, fully liquefied by prolonged mastication, is better than liquids, which cannot be chewed. When the spasm has been provoked by an ulcer or erosions near the cardia, the MOTOR NEUROSES OF THE STOMACH 855 frequent passage of a tube or sound would only aggravate, and it is then necessary to pursue the treatment suitable for the primary affection, including rectal feeding, and the latter is required also for the worst cases of cardiospasm dependent upon some neurosis. Einhorn praises large doses of bromides in cardiospasm, and suggests, besides the remedial measures above mentioned, that in the chronic cases the patient after every meal should make a special effort, by an extraordinary pressing action long continued, to force on into the stomach any food lodged in the esophagus, and th^t every evening any remains of food left in the esophagus should be washed out with the help of a tube. Spasm of the Pylorus (Pyloric Cramp, Pylorospasm). — This is probably one of the most prevalent and most pro- ductive of injurious consequences of all the reflex and nervous gastric affections. Pylorospasm consists of a spasmodic con- traction of the circular muscular fibers of the stomach outlet, whereby the latter is kept firmly closed for much longer periods during digestion than normal. The commonest cause of this condition when it is not due to ulcer, is a hyperacidity of the stomach contents, usually an excessive secretion of HCl, — but it can doubtless be caused by an undue amount of the organic acids which result from fermentation. Possibly the ingestion of large amounts of sour fruits, tart wines, beer, vinegar, or other acid food or drink may have a like effect sometimes in neurasthenic pa- tients. Large pieces of tough or hard and indigestible sub- stances, whether ingested as food or otherwise, are probably also capable of setting up a pylorospasm in certain nervous persons, but, as a rule in such cases, the pylorus relaxes sufficiently to let the digested matter pass out, while the undigested pieces are retained often for long periods, as shown by their being brought up during lavage, days or even weeks after they were ingested. The seeds and skin of many kinds of fruit, and the tough pulp of oranges especially, are often detected in the wash 856 THE GASTRO-INTESTINAL CLINIC water when all the other contents of the stomach had passed on into the duodenum. In time, however, even such tough sub- stances, when not too large, will usually make their way through the pylorus, which doubtless finally relaxes to an ex- ceptional extent to permit their passage, except when there is a marked tendency to pylorospasm. It has been assumed that spasm of the pylorus may some- times be a primary disease and result then from nervous causes. This, though difficult to prove, is possible, but, if it exists as a primary affection, without hyperacidity or other reflex cause, it is doubtless extremely rare. The symptoms of pylorospasm in its most severe form are violent and painful contractions of the gastric walls, ending finally in vomiting; except when there is a coincident spasm of the cardia, closing that orifice also. In case of the latter compli- cation the pain and distention of the stomach become very great, and it is then necessary either to empty, the viscus by introducing a tube, or else to administer full doses of some anodyne, especially morphine and atropine hypodermically. But such extreme cases are rare. In the milder ones in which the pylorus seems to remain closed for several hours longer than usual after each meal, the symptoms are merely an un- pleasant feeling of weight or fullness in the epigastrium with generally increased fermentation and eructation of gases. The excessive fermentation and formation of large amounts of acetic, butyric, and sometimes also of lactic, acid may irritate the gastric mucosa, thus adding to the discomfort, besides tending to the development of chronic catarrhal inflammation, hypera^sthesia, etc. Moreover, the augmented amounts of the organic acids doubtless aggravate the pyloric spasm, and thus a vicious circle is produced. The worst feature, however, of the affection is that, when unrelieved, it almost uniformly causes atony of the gastric musculature which ultimately develops into dilatation. Most cases of so-called atonic dilatation of the stomach are probably produced in just this way. There is often also considerable MOTOR NEUROSES OF THE STOMACH 857 tenderness on pressure or even gentle palpation over a spas- modically contracted pylorus. The treatment of pylorospasm is for the most part that of ulcer, that of hyperchlorhydria and that of excessive fermenta- tion and organic hyperacidity, which are considered in the lectures on Sthenic Gastritis, Hyperchlorhydria, Gastric Flatulency, etc. In a few cases, doubtless, the spasm is pri- mary and merely an expression of the neurotic diathesis, the real disease being hysteria, or possibly neurasthenia. The treatment, then, must be that required for the underlying nervous condition and should include the various strengthen- ing remedies and measures to which I have so often referred. Peristaltic Restlessness (Hyperperistalsis). — Following Kussmaul, authors generally describe under the above head a symptom denoting a disturbed innervation of the stomach. This, when severe (which is rare), may occasion a patient much annoyance. It is simply an exaggeration of the normal peristaltic waves or rhythmic contractions of the stomach walls which pass usually every few seconds from the cardia to the pylorus. In the abnormally excited condition these waves, which are not felt in health, are much increased in force and frequency, insomuch that the patient is conscious of them and sometimes much disturbed by them. At times they are re- versed in direction — antiperistalsis. When the stomach is dilated or displaced downward, the contractions are plainly visible below the ribs and can be easily felt upon palpation. The affection may extend beyond the stomach, involving the intestines also. The contractions often produce a loud gurgling noise when both gases and liquid are present in the stomach. The Causation of Peristaltic Unrest. — It is held by some that the trouble always coexists with either spasm or other obstruc- tion of the pylorus and results therefrom, but it is probable that a sufficiently great irritation of the motor nerves of the stomach can cause hyperperistalsis or even antiperistalsis in the absence of any obstruction at the outlet. 858 THE GASTRO-INTESTINAL CLINIC Any powerful stimulation of the gastric mucosa as from hyperacidity, overloading of the stomach with food, or its over- distention with gas, tends to excite the affection in neurotic person?, and hypersesthesia of the mucosa further conduces to it. But pyloric obstruction is certainly a strongly pre- disposing cause, if it be not an indispensable factor in the semiology. The symptoms have already been described above, and the affection cannot well be mistaken for any other when the stom- ach extends below the ribs so that the contractions can be seen and felt. In the rarer cases in which the stomach is of normal size and in its normal position, the trouble may be easily over- looked, if mild, or may then be considered as a form of nervous dyspepsia. In the severer forms, even though the viscus does not extend below the ribs, the affection should be suspected from the conjunction of the peculiar uncomfortable sensa- tions, not often amounting to actual acute pain, with frequent loud gurgling. The disease is then also likely to be compli- cated by excessive eructations and even vomiting. Further- more, the nutrition will suffer, the digestion being impaired as in most excessive aberrations from the normal, and the patient will often lose so much in weight and strength as to awaken the suspicion of malignant disease. The prognosis is good, as a rule, when there is no insuper- able obstruction of the pylorus or other organic disease, pro- vided the patient is able and willing to persevere with the neces- sary therapeutic measures. The treatment demands (i) the removal of any existing cause such as hyperacidity, gastric hypersesthesia, overeating, insufficient mastication, or any curable obstruction of the pylorus, and (2) the cure of the underlying nervous condition by the methods so often described in these lectures. Elec- tricity in the form of galvanism to the spinal centers, and to the vagi in the neck with the positive pole, either over the epi- gastrium or within the stomach, the high-tension faradic current intragastrically applied, or the static wave current MOTOR NEUROSES OF THE STOMACH 859 to the spine and epigastrium alternately is the most efficient remedy. But such patients need, most of all, to live hygienically in every way, avoiding all excesses, especially sexual irregulari- ties and mental overwork. Sedative drugs, such as the bromides, hyoscyamus, etc., may be temporarily necessary, and the nerve and blood tonics can usually be so used as to hasten the cure. Nervous Eructation. — This subject is considered along with the other types of eructation in Lecture LXXIV., on Excessive Eructation and Gastro-Intestinal Flatulency in General. Its importance seems to me to have been somewhat overrated by writers generally, and I shall not take up further space with it here. Nervous and Reflex Vomiting, — The complex act of vomit- ing is produced by a peculiar combination of muscular move- ments, including a contraction of the abdominal muscles and of the pylorus as well as of the gastric walls, and a relaxation of the cardia, besides a shortening and widening of the gullet and a shutting off of the windpipe and nares by the action of the epiglottis and soft palate. It occurs as a symptom of va- rious diseases of the stomach and intestines, especially of ulcer and carcinoma, gastrectasis, pylorospasm, and also insufficiency of the cardia. Again vomiting occurs reflexly as a result of irritation in various remote parts of the body, particularly the genital or- gans, but also of the pharynx, as well as from eye-strain, and especially from inflammation of the peritoneum. When emesis occurs in an apparently causeless manner, without any lesion near or remote being discoverable, it is called nervous vomiting. In hysteria and marked neurasthenia it is doubtless often a pure neurosis, the result of an irritation in the nerve centers or nerves themselves._ The vomiting of the gastric crises in locomotor ataxia is usually so classed. Nervous vomiting in certain of its forms is believed to be due, in part at least, to insufficiency of the cardia, »and possibly 86o THE GASTRO-INTESTINAL CLINIC in most cases of such vomiting a relaxed condition of the car- dia predisposes to it. Authors describe among the forms of nervous vomiting what is called juvenile vomiting, which affects especially school children as an alleged result of overstudy, but more likely of eiye-strain from a faulty arrangement of their desks with re- lation to the position of the windows, or from uncorrected ocular faults. This form of the affection does not seem to have any very distinctive symptoms. It may be known only from the lack of other cause, and is remedied by taking the children out of school, by fitting proper glasses, etc. Stockton, the American editor of Riegel's " Diseases of the Stomach," refers, in a note under Nervous Vomiting, to the " periodic or cyclic vomiting in children," which has been much discussed by pediatrists in this country during the past ten years, but would seem to be a different disease from the juvenile vomiting described by German and American gastrologists, since it appears first at the age of two or three years. It is a serious affection accompanied by great prostration, and often proves fatal. Periodic vomiting is another variety which has been de- scribed by Leyden. It recurs somewhat regularly, like mi- graine, at more or less definite intervals, with sometimes head- ache, which may be severe and from no discoverable cause. This may possibly be merely migraine without the usual in- tensity of headache. In some of the cases there are constipation and symptoms of indigestion in the intervals, but as a rule the patient is well between the attacks. These may last a few hours only or several days. They seem to require the usual treatment of migrainous attacks, to wit: rest, pellets of ice, morphine, belladonna, etc. As in the case of that disease, too, there does not appear to be any line of treatment yet tried which will surely prevent a recurrence of the attacks in all cases. Pos- sibly remedying ocular faults or other causes of reflex disturb- ance might prove more successful. The diagnosis of nervous vomiting can only be made by ex- MOTOR NEUROSES OF THE STOMACH 86 1 elusion — the apparent absence of any sufficient cause. It is generally not preceded by much nausea and is easy in character as compared with that dependent upon indigestion, or other real gastro-intestinal disease, which may signify that there is a relaxed or easily relaxable cardia. In Leyden's periodic form, however, there is often nausea, and the vomiting may be very severe and difficult to control. When the patient is very neurasthenic, or especiallv if hys- teric, attacks of apparently causeless vomiting may be set down as neurotic, when a thorough examination has revealed no lesion in the eyes, digestive tract, or pelvis, and no displace- ment of the kidneys which could have excited it reflexly. In such cases some of the dorsal vertebrae — or to be more exact, the intervertebral spaces on one or the other side of the spine — will often be found tender on pressure. The diagnosis from gastroxynsis is made by determining the absence of any marked excess of HCl. The vomiting not only occurs usually with little straining or discomfort, but produces very little depression. The patients continue, as a. rule, to be well nourished and enjoy compara- tively good health. Then, too, the attacks of vomiting are prone to follow psychic disturbances. Sometimes certain kinds of food will always be vomited in such attacks, while other kinds will regularly be retained. For example, solid foods may be vomited and liquids retained, or vice versa. The treatment of an attack of nervous vomiting should aim to secure rest and sedation. The patient should be placed at complete rest, preferably in bed, and hot, moist applications be made to the epigastrium. In some severe cases sinapisms or turpentine stupes may accomplish still more. The best results will follow the withdrawal of all food by the mouth, and feed- ing, if necessary, by the rectum, though very small quantities of bland liquid food may be tolerated in the milder cases. The following mixture will usually prove effective if any medicine should be required in addition to the measures just men- tioned : 862 THE GASTRO-INTESTINAL CLINIC i^ Bismuthi subuit 3 i Cerii oxalat 3 ss Glycerit. ac. carbol. (1-4) 7;z xx Sps. chloroformi , ^^ ^ ^ .^^ Tr. cardomon. co. f Aquae menth. pip ^ f 3 iv Aquse calcis q. s. ad f 3 ii M. Sig. Teaspoonful in a tablespoonful of water every hour till relieved. Between the attacks, your efforts should be directed to the general condition, and to an improvement of the nerve supply of the stomach as well as of the nervous system in general. A particularly efficacious method of accomplishing these objects is the application of galvanism 3 to 15 ma. — with the negative pole stabile over the epigastrium, in the form of a flat electrode about four to five inches square, and the positive as a small sponge electrode passed over the tender region alongside the spine for from five to ten minutes ever}^ other day. A current of 2 to 5 ma. should also be applied to the vagi in the neck for two or three minutes at each seance. Static sparks over the epigastrium and the static breeze or wave current over the spine will often do as well or better; and very brief applica- tions with a good rigid mechanical vibrator, over the same re- gions, will also prove helpful. In all difficult or stubborn cases, a thorough search should be made for some direct or reflex cause of the trouble. An examination should be made of the pelvic organs, for movable kidney or other ptosis, and for a swelling in the region of the appendix. Not to discover an existing lesion in any of these regions, which had excited the vomiting, would be to meet with failure. You would naturally examine also the vomited matter to see that it did not contain an excess of HCl, pointing to a possible ulcer, gastroxynsis, Reichmann's disease, or even a simple hyperchlorhydria, any one of which might give rise to severe vomiting; and look carefully in the ejecta for l)k)0(l or changed blood, which might have come from a latent ulcer or carcinoma. The finding of any of these things would lead you to shape your treatment accordingly, MOTOR NEUROSES OF THE STOMACH 863 and not only to direct your remedial measures more success- fully, but also enable you to give a more accurate prognosis. Treatment of Reflex Vomiting — Pernicious Vomiting of Pregnancy. — In the treatment of these forms of vomiting, it goes without saying that the main thing is to remove the cause — cure the primary affection. To take up all the possible diseases and special conditions which can cause reflex vomiting, and consider the treatment suitable to each, would far transcend the limits of these lectures. In the case of one of them, however, — the pernicious vomiting of pregnancy, — some consideration of the most approved remedial measures is* desirable, since it is a serious complication which quite un- necessarily destroys many valuable lives. Systematic lavage has cured numerous cases of this affec- tion, but probably those only which were dependent in part upon chronic gastric catarrh or dilatation with excessive fer- mentation. Treatment addressed to the nerv^es supplying the stomach, and measures designed to lessen the reflex irritation near its source, have occasionally proved successful. For strengthening the gastric nerves the mode of applying elec- tricity to the spine, epig'astrium, and vagi in the neck, already described above .as useful in nervous vomiting generally, prom- ises most. Hot, moist applications, or even blisters over the epigastrium, often afford relief. The local treatment should consist first in correcting any ex- isting displacement or other fault. Next after this, the most effective in lessening or diverting into other channels the re- flex irritation has been some decided revulsive application to the OS uteri, and Hirst^ reports that sometimes he has found a simple vaginal examination sufficient to check the vom- iting. Usually a powerful impression must be made upon the uterine nerves to prove curative. An application of Churchill's tincture of iodine will sometimes succeed, but a surer means is one long used successfully by Dr. Jacob Price of West Chester, Pa. It consists of the old-fashioned method of ' " Text-book of Obstetrics," Saunders & Co., Philadelphia, 1903. 864 THE GASTRO-INTESTINAL CLINIC cauterizing the os uteri externally with nitrate of silver in stick form. When this fails, a cautious dilatation of the cervix uteri, under strict aseptic precautions, with a series of gradu- ated bougies, will occasionally stop the vomiting without bring- ing on premature labor. Edgar reports that he has " dilated the internal os in primi- gravidse, curetted the cervical canal, scraped the cervix itself free from erosions, applied pure carbolic acid to the cervix and canal, and obtained a cure without interrupting pregnancy in a number of cases given up as hopeless and sent to the hospital to have labor induced." He adds that " the finger will oc- casionally serve as a dilator, and in early cases the greatest care must be used not to rupture the membranes."^ But such measures should be resorted to only after a con- sultation with another physician, so that if they should fail to accomplish their intended object, and labor should result, the latter could be accepted and welcomed as the proper alternative. When other means are ineffective, the uterus should be emptied as promptly as possible. I have seen very precious lives sacrificed by delaying too long to obey this imperative in- dication, when other measures had failed to stop the vomiting within a reasonable time. The patient's vitality finally became exhausted before the operation was attempted. The induc- tion of premature labor promises little or nothing to an ex- hausted woman, but to rescue her, must be done while she still has a good degree of strength. In very aggravated cases, not more than two weeks at the most should be spent in experimeiiting with palliative or con- servative remedies, and, meanwhile, nutrition should be main- tained by means of rectal feeding. In less serious cases in which the flesh and strength are being but slightly lowered, it may be safe to wait until the end of the third month, when, as a rule, the vomiting tends to cease of itself. If after that, two weeks of further treatment have effected no progress toward a cure, labor should be purposely brought on and the uterus 1 " The Practice of Obstetrics," Blakiston's Son & Co., 1903. MOTOR NEUROSES OF THE STOMACH 865 emptied, provided dilatation of the cervix fails to bring relief or of itself set up uterine action. In all severe cases the patient should be kept in bed, sexual intercourse prohibited, and her strength spared in all possible ways. Drugs usually fail to help much, but the prescription for a sedative mixture which I have given in the former part of this lecture for the treatment of nervous vomiting generally, may sometimes succeed, as will occasionally i-io-grn. doses of calomel given every hour or two till purgation results. Bro- mides, opiates, or hyoscyamus by suppository, or hypoder- mically, occasionally assist in controlling the vomiting. But let me repeat that, in many of the more serious cases, to empty the uterus offers the only hope, and this must not be postponed too long. Nervous Atony of the Stomach. — This is sufficiently dis- cussed in Lecture XXXVI. under the head of Gastric Atony or Myasthenia Gastrica, etc. The. various^ forms of atony, both neurosal and otherwise, are therein considered at much length. The subject is again referred to in this, connection, for the reason that, most authors class Gastric Atony among the neu- roses of the stomach. I think, however, it has been shown in the lecture above mentioned to be predominantly a result of either local inflammatory or mechanical conditions, or depraved constitutional states in which the weakening of the gastric musculature has been produced by a generally lowered nutri- tion, including usually impoverished blood. But the affection is- doubtless sometimes- encountered as a consequence of psychic influences coming on more or less sud- denly during apparent health. When it thus occurs, the ab- sence of any of the more usual aetiologic factors and the history of a shock or other nervous disturbance should enable you to differentiate it. The treatment would then consist of a removal of such cause or the combating by appropriate measures of any depressing influence, and at the same time fortifying the nearly always 866 THE GASTRO-IXTESTIXAL CLIXIC excessively vulnerable nervous system. Persons encloved with a strong constitution and sound nerves are not likely to have their stomachs seriously give out from any mental, nervous, or emotional disturbance. Insufficiency of the Cardia, Rumination, Regurgitation, etc. — It is convenient to assume, as most authors do, that there may be a sort of paresis of the cardia. The habit of rumina- tion — that is, the frequent raising without nausea of ingesta from the stomach into the mouth, then chewing them further and swallowing them again, — or the vers* similar habit of bringing up without effort or nausea food previously swal- lowed, and actually ejecting it — regurgitation — are generally considered to result from an aljnormally relaxed state of the circular muscle which forms the sphincter of the cardia. In- ordinate belching and very frequent as well as quite easy vom- iting are often attributed to the same defect. There is no ab- solute proof, however, that these symptoms result from any such cause, though rumination has been observed in a case afterward shown, at autopsy, to have been one of carcinoma of the gastric walls, including the cardia, wliich was abnormally wide, while there was also cylindric dilatation of the esophagus. Another theory as to the causation of such symptoms is that they are due to an irritated state of the vagus and over- stimulation of the dilator nerve of the cardia. !Much has been written concerning regurgitation and ru- mination, or mer3xism, but when it is carefully sifted, only a few grains of actual reliable information about these habits remain. Owing to the absence of effort or disturbance asso- ciated with the acts, the prevalent belief, that a lack of tone in the sphincter muscle of the cardia is at least a contributory cause, is probably well founded. But extensive obsen-ations by numerous careful investigators prove that neither excessive nor deficient motility nor excessive nor deficient gastric secre- tion plays any part in the ?etiolog}\ Rumination has been shown to result from imitation in sev- eral instances, and 1x)th habits are most frequently seen in MOTOR NEUROSES OF THE STOMACH 86/ hysteric or neurasthenic persons. Insanity, imbecihty, and epi- lepsy still more strongly predispose to them. Rapid and ex- cessive eating and imperfect mastication may unquestionably prove efficient as predisposing causes. Gastritis and other le- sions of the stomach are believed sometimes to produce the affections. Tlie treafjiieiit of regurgitation and rnniiiiatioii will prove successful in most cases if faithfully persevered with, and if the patients have sufficient will-power to do their part. They must be taught to chew all food until it is either liquefied or pulp- efied, and energetically oppose with a strong effort of the will any tendency to let any of it come up. When the habit has been to eject the regurgitated material, the first step must be to retain it in the mouth, when the impulse to raise it cannot be at once controlled, and then, after further chewing, to swallow it again. This converts regurgitation into rumination. Then, by the utmost possible exertion of will-power, aided by the im- perative commands of the physician, the latter practice may often be finally overcome, even without other treatment. But all the oft-advised therapeutic methods useful for neurasthenia, including cold sponge baths, regulated exercises, outdoor life, and especially electricity, may be employed with advantage as adjuvants to the cure. Galvanism or high-tension faradism, externally or within the stomach, will be found generally useful, and the static spark, applied to the region of the cardia, should prove especially effective. Full doses of strychnine have also been highly praised for their curative action in these affections. In all the more stubborn cases, at least, you should test the stomach contents and combat with appropriate remedies any excess or deficiency of HCl. Observations upon one ruminant showed hyperchlorhydria, and he was then quite rapidly cured by the administration of alkalies. This led to the theory that rumination depended upon hyperacidity and could be cured by alkaline treatment. But another obsenxr disproved this theory when he reported a series of cases showing a deficiency of HCl, and responding well to HCl given as a remedy. 868 THE gastro-intEstinal clinic Insufficiency of the Pylorus. — It is well known that the pylorus may lose its power of closing tightly and remain un- duly patulous as a result of certain mechanical causes. Among these is carcinoma or ulcer of the part acting through a process of infiltration of the circular muscular fibers of the pylorus, as a result of which the latter are permanently stiff- ened — rendered incapable of efficient contraction. Obstruction of the duodenum by a stricture from any cause (as carcinoma, round or peptic ulcer, or syphilitic, tuberculous, or simple catar- rhal ulceration), or by the closing of its lumen from the press- ure of a tumor, or a movable kidney, etc., may produce a like condition. Since Ebstein demonstrated a relaxation of the pylorus as a consequence of pressure myelitis, authors have generally as- sumed the possibility of, and described a nervous insufficiency of the pylorus. Riegel, however, has never encountered any case of the kind, and a number of prominent gastrologists seem to lack personal experience with such a condition. Injury of the portion of the cord whence emerge the motor nerves that supply the sphincter muscle of the pylorus may doubtless para- lyze it, but such an injury must be rare, and the possibility of it by no means warrants us in assuming a neurotic incontinence of the pylorus comparable to the neuroses which are familiar phenomena of hysteria or neurasthenia. Ebstein' s case was no doubt a true paralysis of the pyloric sphincter, and in no proper sense a neurosis, ^^'hen pyloric incontinence exists in the absence of any mechanical cause for it, the more plausible explanation seems to be the one championed by Knapp, viz., that the muscle has become exhausted by long overaction. Other cases of apparent pyloric insufficiency, in which no lesion could be discovered in either the pylorus itself or in the duodenum, have been reported by Ebstein, and there is no doubt that such cases do occur. Ewald says on this head : " Unfortunately we have no diagnostic criteria by which we may establish the existence of this condition as dependent upon atony of the pyloric sphincter — /. e., a pure neurosis — MOTOR NEUROSES OF THE STOMACH 869 for an occasional incontinence of the pylorus is a normal phe- nomenon."^ The symptoms of pyloric insufficiency are abnormally rapid emptying of the stomach, a difficulty in inflating it with air or CO2, and the frequent finding of bile in the wash water during lavage. The first symptom has been commonly explained as due to hypermotility or overexcitation of the gastric peristaltic apparatus, but I am now convinced that atony of the pylorus may also cause it. Diarrhea following immediately after the ingestion of very hot or cold or insufficiently masticated pieces of hard or tough food might be due to pyloric incontinence, but would not alone be conclusive. The one sure means of demonstrating the sufficiency of the pylorus is by intubating it according to the Hemmeter method with one of the ingenious instruments devised by Hemmeter and Turck in this country and F. Kuhn of Giessen. With re- gard to the question of priority, it may now be regarded as settled that both Hemmeter and Turck in this country intubated the duodenum through the pylorus before the procedure was at- tempted by Kuhn. Knapp^ insists that insufficiency of the pylorus is quite fre- quent, and that it is the natural result of a prolonged condi- tion of hypertonicity of the part, the overtaxed muscle finally becoming exhausted and weak. He maintains that delayed emptying of the stomach is generally due rather to an over- vigorous contraction of the pylorus (pylorospasm) than to atony of the gastric muscle (which is doubtless often true of the earlier stages of prolonged retention of food in the stom- ach), and conversely that a too rapid emptying of the stomach is evidence rather of an exhausted and relaxed pylorus, than of hypermotility of the gastric walls. From this point of view, the symptoms of pyloric insufficiency, beside the reflux of bile or other duodenal contents into the stomach, are the failure 1 " Diseases of the Stomach," New York, 1892. "^ Jour. Am. Med. Assn., April 16, 1904. 8/0 THE GASTRO-IXTESTIXAL CLINIC to find any gastric contents or the usual quantity of them at the end of an hour after the test breakfast, and it would fol- low further that most of the symptoms of intestinal indiges- tion, such as flatulency, pains in the bowels, constipation, or diarrhea, may be produced or aggravated by pyloric inconti- nence from any cause. The treatment of pyloric insufficiency in not too old patients may be hopefully undertaken when there is no organic lesion in the part or serious chronic debilitating disease elsewhere in the body. The more fermentable foods and drinks, ef- fervescent beverages, and also, generally, coffee and tea must be avoided. Thorough mastication of all food is particularly important. Combinations of an alkali with bitter tonics are often helpful. Nearly all authorities agree in recommending strychnine in full doses, though some recent experiments throw doubt upon the prevalent view that strychnine strengthens muscular fibers. Electricity is praised by those who have had most experience with it. The faradic current applied in- tragastrically will prove the most efficient form of administer- ing it. Static sparks taken directly from the pyloric region are capable of powerfully stimulating the weakened muscle. Mas- sage of the abdomen, vibratory stimulation, and cold affusions to the part are also useful. LECTURE LXXVII NERVOUS DYSPEPSIA (GASTRO-INTES- TINAL NEURASTHENIA) The conceptions of nervous dyspepsia have been almost as various as the authors who have written upon it, and the ail- ments which are given this name by physicians in practice are very often something else — direct or indirect results of patho- logic changes, such as the inflammatory affections, muscular insufhciency, dilatation or displacement of the stomach, dis- placement of one or both kidneys, disease of the pelvic organs, or disease or disorder of some kind in the intestines. In a large proportion of the cases of so-called nervous dyspepsia, the trouble is dependent upon actual disease some- where in the gastro-intestinal tract, though very often such cause is unrecognized and, It may be, unrecognizable. The mythologic deities of antiquity have all disappeared as scientific causes have been discovered for phenomena previously considered supernatural, and in like manner nervous dyspepsia may ultimately cease to be classed as a distinct type of disease when our methods of diagnosis shall have become more perfect. The fewest cases of it are encountered now by the men who are the most expert and painstaking in their examinations. There is no apparent appropriateness in giving this designa- tion to any gastric derangements or symptoms that result from organic changes in other organs, as the heart, lungs, kidneys, or even In the central nervous system. Thus the gastric crises of tabes surely should not be called nervous dyspepsia any more than the vomiting of Bright's disease or of strangulated hernia. Possibly there may be some reason, however, for considering under this head the frequent gastric symptoms of hysteria. The symptoms resulting from abnormalities of secretion by the 871 872 THE GASTRO-INTESTINAL CLINIC gastric glands are classed by some writers under nervous dys- pepsia, but I prefer to limit the term strictly to forms of indi- gestion or gastric symptoms which cannot be traced to any organic lesion, and are not the manifest result of even any well-known so-called functional affection. In general neurasthenia it is usual to find the digestion more or less impaired, and most frecjuently then there is either 1 variable secretion or sometimes a rather persistent increase or diminution of the gastric juice, to which the discomforts pres- ent may be attributed. Then, again, however, you will see cases in which the neurasthenia will seemingly be limited to the stomach and intestines, no complaints being made of any function except those of digestion and defecation. You may be unable to discover a lesion of any kind in any of the organs. It is convenient at present to retain the name nervous dyspep- sia for these as well as possibly for the type of indigestion oc- curring In the course of that form of general neurasthenia in which mental depression, and a marked delicacy or sensitive- ness of the nervous system, with a great variability of symp- toms, exist without any discoverable dependence upon disease having its origin in the intestines, liver, or elsewhere in the digestive system. The term, then, shall be limited here to the apparently causeless dyspepsias, and experience shows that these are found usually associated with neurasthenia. Symptomatology. — Any form or shade of pain or unpleasant sensation referable to the stomach or intestines may be com- plained of. Nausea, vomiting, gaseous distention, sensations of dragging, fullness or weight (though these last generally in- dicate motor insufficiency or a demonstrable weakness of .the stomach walls), heaviness, drowsiness, dizziness, prostration or languor, flatulency, headache, or mental irritability during the digestive period, may be present in nervous dyspepsia. In short, it may mimic almost any of the symptoms of gastric disease, or many of those usually seen in intestinal disorders. The discomfort occurs, as a rule, during the digestive period only, and the patient generally feels well when the stomach is NERVOUS DYSPEPSIA 873 empty. The ganglia presiding over the nerves of the stomach may be presumed to be at fault in some v^ay in these cases. Ewald refers to the investigations by Jiirgens' on the bodies of forty-one patients who had complained of vague dyspeptic dis- turbances during life, showing a complete degeneration of Meissner's and Auerbach's plexuses. However this may be, the innervation of the gastric structures is faulty; and just as in general neurasthenia there is an excessive impressionability and an undue response to all stimuli, so in gastric neurasthenia there may be an excessive secretion of the gastric juice after taking food (especially meat or acids), or a depression of such secretion below the normal with an absence of free HCl, if the patient chance to drink a pint of some alkaline table water or to be taking an alkali or belladonna as a medicine. But when the aberration of secretion is marked enough to have set up a de- cided and persistent hyperchlorhydria, the case could no longer be properly designated as one of mere nervous dyspepsia. Then, any of the symptoms of general neurasthenia may be present, such as mental depression, insomnia, special fears, as of crowds, closed places, elevators, etc., and greatly increased impressionability. One symptom- of importance that is considered characteristic by most authors is a lack of relation between the amount of indigestion and the quality of the food taken. For instance, the true nervous dyspeptic will often complain as much after eating bread and butter or plain beefsteak as after a complicated mixed meal including shell-fish or mince pie. But there are apparent exceptions to this statement. Notwithstanding the fact that with them one food is digested about as well as another and produces usually the same amount of discomfort, gastric neu- rasthenics are prone to fancy great dififerences and to deny themselves one class of foods after another, until at last they attain a condition of subnutrition which amounts to semi-star- vation and seriously aggravates their disorder. When given a diet table they readily abstain from the articles forbidden, but ' Jurgens, Ver handlungen des III, Congress f. inner e Medecin, S., S^S- 8/4 THE GASTRO-INTESTINAL CLINIC neglect to make up the deficiency from the allowed list, and the observant physician soon finds them losing flesh faster than before, merely from a lack of sufficient food. Numerous intestinal symptoms and diseased conditions have been described as frequently accompanying nervous dyspepsia. These may include constipation, diarrhea, gaseous distention, either general or partial (spastic phenomena), tender areas over the colon especially, membranous colitis, etc. These phe- nomena are indeed exceedingly common in association with neurasthenia, both gastric and general, but in many cases are probably the cause rather than result of the nervous condition, or if an inherited nervous dyscrasia was the first link in the chain, a vicious circle has been formed, and the two conditions act and react upon each other in an injurious manner. The skin over the stomach may be unduly sensitive, both before and behind, and on either side of the spine correspond- ing to the origin of the nerves supplying the stomach. Espe- cially over the ganglia of the great sympathetic system, deep pressure will be likely to cause pain. Diagnosis. — This calls for the most thorough examination of the entire body, including the secretions, excretions, and the blood, in order to exclude any organic disease. W^hen all the organs, including those of the alimentary canal, are found to be healthy, and there is complaint of pain, discomfort, or any symptom directly or indirectly referable to the stomach, espe- cially during the period of digestion, it may be attributed to nervous dyspepsia. If it is very fitful and changeable, now here, now there, depending much more upon the mood or asso- ciations and surroundings of the patient than upon the quality or quantity of food ingested, it will tend to confirm the diag- nosis. It is often extremely difficult to exclude positively the existence of a mild form of gastric or intestinal catarrh, or ulcer, not to mention incipient cancer, and it is by no means possible to make the decision after a single examination, how- ever complete and expert, including a single analysis of the gastric contents or feces. Without a resort to the recent exact NERVOUS DYSPEPSIA 875 methods of examination, any diagnosis must be only a more or less shrewd guess. To exclude gastric catarrh you will need to ascertain by lavage either that there is no considerable amount of mucus in the stomach, or, if mucus be found in the wash water, that it comes from the nose, throat, or oesophagus — that it was not secreted in the stomach. In doubtful cases a microscopic ex- amination of portions of the gastric epithelium may be neces- sary to decide. You will be able to exclude hyperchlorhydria and anacidity or hypoacidity of inflammatory or degenerative origin by care- ful analyses of the stomach contents, which may have to be made more than once. If you find as a constant condition dur- ing digestion a large excess of HCl, the case will be either one of hyperchlorhydria or acid gastric catarrh, unless there should be also an excess during a fasting period, when the trouble would be Reichmann's disease, or unless there should be pro- nounced tenderness on pressure over the region of the stomach, hemorrhage, or the peculiar aggravation of pain from taking food, which is characteristic of gastric or duodenal ulcer, in which case that disease should be strongly suspected. A slightly diminished secretion, or marked variability of secre- tion, would not be inconsistent with a diagnosis of nervous dys- pepsia, but when there is constantly found a very marked defi- ciency of HCl, the diagnosis should be hypochlorhydria, and when there is an absence of secretion the disease should be called anadenia gastrica or achylia gastrica. Lessened secretion with the microscopic findings of chronic asthenic gastritis would point to that disease, unless there should be a palpable tumor or, with a very marked cachexia or hemorrhages, the Boas-Oppler bacillus should be found in the wash water, when the more probable diagnosis w^ould be carcinoma, complicated, as it usuall}^ is, by gastritis. The presence of a decided percent- age of lactic acid would also tend to confirm the diagnosis of cancer, though not incompatible with an aggravated form of chronic catarrh of the stomach. Such a careful and painstaking 876 THE GASTRO-INTESTINAL CLINIC exclusion of possible gastric diseases is necessary, because the depressed nervous condition which is characteristic of nervous dyspepsia, and even the complete symptom-complex of neuras- thenia, are frequently present in hypochlorhydria as well as in both cancer and chronic asthenic gastritis especially, and may be in ulcer or hyperchlorhydria, particularly when these have been of long standing. Chronic intestinal catarrh with consti- pation is probably one of the most frecjuent causes of dyspeptic symptoms which are constantly diagnosed as nervous dyspep- sia. Derangements of the liver, catarrh of the bile-ducts, etc., are other very common causes of such symptoms, and when not accompanied by jaundice are often overlooked. Then, the various diseases of the pancreas, which have only recently been studied with any thoroughness or promising results, are doubt- less responsible, in part at least, for a large amount of the dis- tress which is labeled nervous dyspepsia. Prognosis. — Nervous dyspepsia is generally curable and, if uncomplicated, should never prove fatal. But when there is a strong inherited tendency to neurasthenia, the cure may be very difficult and prolonged. In such cases, too, it is often an in- dispensable condition that the patient shall be in a position to have a complete rest from injurious pursuits or excessive activity of any kind, if not actual rest in bed for a few weeks; or at least a change from a sedentary or professional occupation to an outdoor life, and, temporarily at least, from a residence in a city or large town to one in the country, mountains, or at the seashore. Treatment. — If the case has been correctly diagnosticated, and is very severe or of long standing, it is well to begin with some modification of the Weir Mitchell rest treatment, espe- cially when the patient is a woman. Rest in bed and seclusion, with full regulated feeding, massage and electricity for four to eight weeks, followed by gradually increased exercise in some healthy climate out of doors, will of itself go far toward curing many cases. But when, instead of true nervous dys- pepsia, the case is one of neurasthenia complicated with or NERVOUS DYSPEPSIA 877 resulting from gastric catarrh, and especially if there be a con- siderable displacement or dilatation of the stomach, as is so exceedingly common in neurasthenic women, the rest cure, if carried out without regard to the gastric trouble, is usually not very successful, and sometimes even aggravates. In gastric dilatation it is contra-indicated, unless considerably modified, since the liquid diet then disagrees from the start. Men need to be given a long vacation from business and kept out in the open air. A hunting or camping trip of several weeks, or a long sea voyage, often accomplishes wonders. And afterward there should be such a complete reform of the patient's mode of life as to insure more hours for recreation and sleep and a less strain upon the nervous system. Depressing or injurious habits of all kinds must of course be abandoned. Spending regularly an hour or two daily out of doors during the remainder of life, on horseback, or walking, or driving (or on a wheel, provided care be used not to over- exert), will usually complete the cure and render it permanent. As to diet, while very indigestible dishes are better avoided, there is need of full nutritious feeding, and there should be such a variety of well-prepared viands as to tempt the appetite, since in the majority of these cases too little food is taken. Both central galvanisation and general faradization are help- ful and static electricity sometimes accomplishes still more. Abdominal, or better yet, full general, massage nearly always effects good results — indeed may cure of itself — that is, pro- vided the disease is nervous dyspepsia and nothing else. If there is hyperchlorhydria or acid gastric catarrh, instead, as in a certain proportion of the cases so classed, abdominal massage vigorously given will do harm decidedly. In the cases as- sociated with a spastic condition of the intestinal musculature resulting in constipation and painful collections of gas confined in knuckles of the bowels, the massage over that region, if any at all is given, needs to be very gentle and soothing, without any percussion, slapping, hacking, or other exciting procedures. It should not include even deep kneading. 878 THE GASTRO-INTESTINAL CLINIC Tlic drug treatment, when any drugs are necessary, should be much the same as that for neurasthenia generally — nerve tonics and tissue builders mainly," such as iron, arsenic, gold, the hypophosphites and especially the glycerophosphates. Especially useful in my hands has been a combination of so- dium glycerophosphates with strychnine. In a majority of cases, however, little or no medication will be recjuired, pro- vided the hygienic and dietetic treatment already outlined is properly carried out.^ When the gastric juice is deficient — as it so often is in such cases — you will nearly always obtain good results from ad- ministering HCl and some active preparation of pepsin, but for some cases one of the preparations of papain may be equally effective. Constipation should be overcome, if pos- sible, by diet, massag"e, electricity, or vibration, and gymnastics with the help of enemas of olive or cotton-seed oil (though, during the rest treatment, aloes or cascara is often necessary), and riding horseback is a good adjuvant. (See Lecture on Constipation.) In the .cases in which there is a decided tendency to '^a excessive secretion of HCl, calcined magnesia or sodium sulphate usually suits better than the bitter tonic laxatives. For the worst cases a permanent abandonment of sedentary, or a too engrossing professional occupation is necessary, and a change from the city to the country or shore usually conduces to a cure. 1 A too prolonged course of any of the active tonic medicines often does harm in neiirasthenia of whatever form by overstimulating and further exhausting the nervous system — inciting to greater exertion vi'hen rest is the real need. LECTURE LXXVIII NEUROSES OF THE INTESTINES Most of the affections generally considered under the above head are of either complicated or obscure origin. The subdivision Secretory Neuroses is often made to include Mem- branous Catarrh (Colica Mucosa), and under either this or Motor Neuroses are classified Constipation and* Diarrhea. There doubtless are nervous forms of all these diseases. But they are large and many-sided subjects, which require a broad and general consideration in all their phases. Constipation, for example, is as much a secretory as a motor neurosis, and is a symptom of many organic diseases. I have deemed it best, therefore, to refer briefly to the unimportant nervous forms of diarrhea, along with the other types of the same disease, in a separate lecture, and to devote an entire lecture also to con- stipation, as well as to the interesting subject of Membranous Catarrh of the Intestines, under which head both the neurotic and^the inflammatory type of that disease are considered. Intestinal colic, which most authors exclude from the neu- roses altogether, seems to me to be an especially complex neu- rosis involving both the motor and sensory nerves of the bowel surely, and possibly also the secretory. Meteorism, or an excessive amount of flatus in the intestines, may be partial, caused then by obstruction of one or more coils through dis- placement, kinking or otherwise, or may be general, in which case it is manifestly due chiefly to atony of the bowel, along with possibly a derangement of the absorptive function of the intestinal mucosa, the former .of which is clearly neurosal, and the latter of which may be. The neuroses of the intestines which are not discussed in special separate lectures shall, therefore, be here grouped as 879 880 THE GASTRO-INTESTINAL CLINIC their aetiology and relations suggest, without attempting to classify them under the separate subheads Secretory, Sensory, and Motor. ENTERALGIA, INTESTINAL COLIC, ENTEROSPASM, AND METEORISM Enteralgia may exist by itself as a sensory neurosis of the intestines — or at least of the corresponding nerve plexus of the sympathetic — a neuralgia then pure and simple. With it there is often associated, though not necessarily, a spasmodic contraction of the intestinal muscles showing an irritation of the motor nerves also. This combination constitutes intesti- nal colic, which, however, may also have other causes. When _ there are irregular contractions of both the longitudinal and circular muscular fibers of the intestines at once without pain, there results enterospasm, and some would include under the head enterospasm cases of prolonged tonic spasm of the bowel with. pain, while admitting that the latter cannot be differen- tiated from colic. In enterospasm the abdomen is likely to be either flat or boat-shaped (retracted), when the larger part of the intestine, and especially when the entire intestine, is in- volved, as in lead poisoning or basilar meningitis, particularly the tubercular form. In metcorism or tympanites there is primary or secondary paresis of some part or all of the intestines, with a resulting distention of the latter, and often great swelling of the belly. The secondary forms may result from any of the various causes of obstruction. These different affections are all closely related, and involve primarily or secondarily derangements of one or more of the sets of nerves supplying the intestines. All are accompanied by constipation, more or less obstinate. Indeed, spastic consti- pation is a very troublesome condition which may result di- rectly from an enterospasm in some part of the bowel. Grouping these allied disorders facilitates an understanding of their causes, relations, and the therapeutic methods re- NEUROSES OF THE INTESTINES 88 1 quired. After describing them separately I shall consider the treatment of the entire group. Enteralgia. — In certain conditions of the system, especially in lithsemia, or what the French call arthritism, as well as in malaria, gout, and syphilis, you may possibly encounter neu- ralgia in any nerve of the body, including, of course, those of the stomach and in any part of the intestines. The different plexuses of the abdominal sympathetic are often thus affected, and Max Buch^ maintains that so-called enteralgia is really always situated in some one of these. The pain may be very acute and severe, or merely a dull, wearying ache, which in- terferes with the patient's sleep. Acute pain in any part of the abdomen may be attributed to neuralgia, when there is no fever or other sign of inflammation, no tumor, and no accumu- lation of flatus as in colic. While, in the latter, pressure most commonly relieves the pain somewhat, there will usually be in enteralgia some tenderness on deep pressure, especially over the position of whichever nerve plexus is involved; but the diag- nosis between a pure enteralgia and colic cannot always be made. You should avoid mistaking for enteralgia especially malignant growths in which pain is likely to be rather constant, while that of the former is usually paroxysmal; also chronic appendicitis in which the tenderness is commonly located in or near the cecal region and is nearly always accompanied by an unusual tension in the right rectus muscle. In hepatic colic there is usually at least beginning jaundice with pale feces and high-colored bile-stained urine, while the pain is situated in the region of the gall bladder. In renal colic, the pain shoots down along the course of the ureter and is nearly al- ways accompanied by a frequent desire to urinate. In movable kidney there may be attacks of acute pain, but the situation of the pain is then below the liver, in front (more likely there- fore to be confounded with that of gall-stone colic), and with a little practice you may easily palpate the kidney in its abnormal position. Besides, when a displaced kidney is painful, it will usually be tender as well as somewhat swollen. 1 Arch, d. Verdauungskrankh., ix, 4 and 5. 882 THE GASTRO-INTESTINAL CLINIC Intestinal Colic. — This disease is so often seen by every practitioner as scarcely to need description. The conjunction of violent paroxysmal pain, with a manifest accumulation of gas and constipation, following as a rule some indiscretion in diet, is a familiar picture. The pain is intense, and may usually be relieved somewhat by pressure over the abdomen. Colic or cramp pains, whether in the stomach or bowels, are caused by some irritant. This may be in severe cases any cause of obstruction as hardened feces, gall stones, worms, etc., but is most frequently indigestible food or an excessive amount of acid, either the HCl of the gastric juice (which is very often the irritant) or the organic acids resulting from fermentation. As a result of such irritation there ensue, in- stead of the normal relaxation of one part of the gut while the part immediately above contracts, irregular contractions which do not yield to the peristaltic waves. In consequence, the pro- pulsive efforts are greatly inoreased in force and frequency. The bowel contents are violently driven on into the narrowed part, thus giving rise to intense pains. The absence of fever differentiates intestinal colic at once from the more serious inflammatory affections, and the dif- ferential diagnosis from the more frequent non-inflammia- tory causes of abdominal pain is much the same as in the case of enteralgia. From lead colic it can be easily distinguished by the absence of any tympany as well as by the presence usually of a blue line on the gums in the latter. Enterospasm involving either all the intestines, or all except the colon, is very rare except as a result of basilar meningitis or lead poisoning. In the latter there is usually a particularly severe colic, as well as a blue line at the junction of the gums with the teeth, so that this form of the malady should be easily recognized. In enterospasm dependent upon meningitis, there is nearly always at least a slight rise of temperature, which should help you to differentiate it. There will be also a pe- culiar hypersemia of the skin in most cases, so that when the finger, or especially the finger nail, is drawn quickly over the NEUROSES OF THE INTESTINES 883 surface of the body, a red streak remains for some seconds along its course. The typical retraction of the abdomen with marked depression in its center, called " boat belly," is seen most perfectly in enterospasm resulting from meningitis, though it is often also well marked in lead poisoning. In the exceedingly rare cases of supposed enterospasm described in medical literature which were not dependent upon either of these two diseases, there does not seem to have been a marked general contraction of the abdomen. In enterospasm, there is, as a rule, very obstinate constipation — obstipation — ^but in the partial or milder types of the affection which form the basis of chronic spastic constipation, there may be bowel movements of a peculiar character, either very small and slender — lead- pencil-sized stools — or little hardened balls like bullets or marbles. You will rarely, if ever, meet with a case of enterospasm from purely nervous causes, not a result of either meningitis or lead poisoning, but such have been observed by Ewald and by Hemmeter, among others. Some of the reported cases, however, were complicated with spasmodic pain and could be classified under Intestinal Colic, except that there was retrac- tion of the abdomen instead of tympany, as is usual in colic. In any such case we cannot positively exclude lead colic, since the blue line on the gums is often wanting in persons — plum- bic patients — who take good care of their teeth, while the other signs of lead poisoning may often fail us, and there may be nothing in the most carefully developed history to suggest that origin in some of the worst cases of such poisoning. Lo- calized spasm in some one or more parts of the bowel pro- duces spastic constipation without any marked appearance of abdominal retraction. Meteorism, Tympanites, or Flatulency Colic might have been described as enteralgia or pain in the bowels plus a gaseous distention of them, and the commoner forms of meteorism may be defined as a gaseous distention without the violent paroxysmal pain which is characteristic of colic. Still 884 THE GASTRO-INTESTINAL CLINIC there is usually much discomfort or dull pain in meteorism, and when the condition is due to inflammatory causes as appendi- citis, peritonitis, etc., the pain may be severe. The cause of meteorism may be : 1. A local obstruction, such as a twist or displacement in- VQlving a kinking of some portion of the intestine, intussus- ception or invagination, a contraction with narrowing of the lumen from the cicatrix of an ulcer, the pressure of a tum.or or displaced kidney, inflammatory adhesions attaching one coil of intestine to another coil or to some other organ, a blocking of the bowel by a large gall stone or by a mass of hardened feces, or hernia, appendicitis, peritonitis, typhoid fever, etc., spastic contractions producing constipation, or constipation from any cause. 2. The excessive formation of gas in either the stomach or in- testine through fermentation or putrefaction, with the addition of the gas in any effervescent beverages ingested, and increased possibly in some cases to a certain extent by swallowed air. The suggestion that air sucked in through the rectum may be responsible for some cases of excessive distention of the intestine seems too ridiculous for serious consideration. 3. An unquestionably important factor in the aetiology of meteorism in many cases, if not the chief cause, is atony of the bowel wall, which allows even the normally small amount of gas formation to produce an undue distention, and at the same time retards the onward propulsion of the bowel contents. 4. Deficient absorption of gases through some defect in the mucosa may be a cause of excessive tympany, though it is dif- ficult to prove this beyond question. The symptoms of meteorism include constipation, marked distention of the abdomen, which in severe cases becomes bar- rel-shaped, and, in its worst forms, pain which is usually dull and constant rather than paroxysmal. When the distention is extreme the stomach and diaphragm are pushed upward against the heart, and there is then often vomiting as well as NEUROSES OF THE INTESTINES 885 possibly palpitation, dyspnea, and sometimes even faintness or collapse. Diagnosis. — Percussion gives a loud tympanitic note all over the abdomen, including the sides, where in ascites there would be dullness instead. Then in the middle line the abdomen is high and rounded instead of flattened there with prominent bulging at the sides, as there would be in ascites. Furthermore, in tympanites no wave of licjuid can be driven across from one side to the other by a tap from one hand, so as to be felt as an impact by the other hand while palpating on the opposite side. It must not be forgotten, however, that in peritonitis, especially when it results from the escape of the gastric contents through a perforated ulcer, liquid may be demonstrated in the ab- dominal cavity on one or both sides, the tympanites being then only one symptom of a serious complicated condition. In simple meteorism, not a result of perforation with escape of gas into the peritoneal cavity, the liver may be pushed upward so that its zone of dullness is higher than normal, but the latter is rarely entirely obliterated, as it is when there has been perforation of the stomach or intestines. Absence of the usual liver dullness may be produced also by the displacement upward of a much distended colon, so that too much importance should not be attributed to this sign. PERISTALTIC UNREST; ATONY AND PARALYSIS OF THE INTESTINES Peristaltic unrest of the intestines is in all respects analo- gous to peristaltic unrest of the stomach. When a mere neu- rosis it affects predominantly the same class of persons — those possessing an unstable nervous system — but may be en- countered also in strong persons as a result of inflammatory disease or any mechanical cause of obstruction to the onward propulsion of the feces. As in the stomach, peristaltic restlessness in the intestines consists of excessive or exaggerated peristaltic movements, 886 THE GASTRO-INTESTINAL CLINIC which in thin persons can often be seen or felt by the palpat- ing hand. The cetiology can be various. The affection is generally classed among the neuroses, and nervous causes are supposed to be sufficient alone to produce it; but it is a curious fact that, though the essence of the trouble is excessive peristalsis, it is only exceptionally seen in diarrhea, when the exciting cause of the latter doubtless produces it, but, on the contrary, is nearly always associated with constipation, which it is sup- posed to cause. I hope not to be condemned as hopelessly heterodox if I venture to suggest that the constipation may be the primary condition — the cause — and the neurasthenic state and associated peristaltic unrest may be results. In addition to the nervous cases, it is well understood that any of the numerous forms of intestinal obstruction which have been already discussed may be, and usually are, accompanied by peristaltic unrest. The symptoms in the milder cases include merely the con- sciousness of excessive movements in the intestines, or actual discomfort produced by them, together with the gurgling and rumblings which are audible both by the patient and others. As a rule, the trouble is not persistent, but occurs in recurrent attacks which may last for variable lengths of time, but usually for a few hours only. In some cases the discomfort of the un- usual movements increases to actual pain, and severe cases of this kind are scarcely to be diagnosed from intestinal colic, es- pecially when some tympanites is also present. Most authors have observed that the affection occurs chiefly in nervous per- sons, especially in women, and in the latter is worse at the monthly periods as well as during pregnancy. The diagnosis can only be made from the above-mentioned symptoms, especially by seeing or feeling the exaggerated movements. The neurotic form may be distinguished from those cases due to intestinal obstruction by the comparative mildness of the symptoms, and especially by the fact that they do not persist right along as do the latter, but have periods of NEUROSES OF THE INTESTINES 887 remission, and usually cease whenever the patient's attention is diverted by spirited conversation or any engrossing occu- pation. Paralysis of the Intestines. — This disease may be a neu- rosis, but, as most frequently encountered, is a consequence of certain anatomic lesions, mostly surgical affections. For the sake of convenience the whole subject shall be here briefly considered. Complete paralysis of the intestines generally is rare, and is a result either of diffuse peritonitis, or of some central nervous disease, such as tumors of the brain or cord, meningitis, loco- motor ataxia, myelitis, hysteria, melancholia, etc. Exception- ally it may result reflexly from traumatism in some of the more sensitive sexual organs — ovaries or testicles — through operation or accidental injury. Paralysis of a single coil or small part of the intestines is often seen and may result from a local peritonitis, abscess, severe enteritis, appendicitis, replacement of a hernia, an ac- cumulation of hardened feces, volvulus, intussusception, dis- placement of almost any of the viscera (especially when kink- ing is thus produced), tumors, obturation by a large gall stone, and In short any -of the mechanical or other causes which can obstruct the lumen of the intestines when such a cause per- sists long. The symptoms are extreme meteorism, obstipation, eventu- ally vomiting (often of fecal matter), pain, great restlessness, cardiac palpitation, weakness, and, unless relief can be af- forded, collapse and death. The diagnosis of intestinal paralysis can be made when ex- treme meteorism exists in the absence of any discoverable cause of obstruction, or persists for many days in spite of the removal of the obstruction. Indeed, since obstruction of the bowel can finally lead to paralysis, this condition may be in- ferred when a high degree of meteorism persists long, because of the non-removal of the obstruction. Prognosis. — Paralysis of the intestines, or any part of them, 888 THE GASTRO-INTESTINAL CLINIC can usually be cured when the cause can be completely removed within a short time — a few days. But when the primary disease or mechanical obstruction is irremediable, there can naturally be no hope. When the cause has persisted very long, even its removal will not be likely to be followed by a return of power to the intestinal muscles. ^ The Treatment of the Intestinal Neuroses. — In all of the true neuroses, however manifested, the primary indication must be to strengthen in every way the weakened nervous system. You must treat the neurasthenia or hysteria which is the fundamental disease. The most efficient therapeutic meas- ures and medicines for this purpose have already been fre- quently discussed in this series of lectures, especially under the heading of the Treatment of Nervous Dyspepsia, but the sub- ject is so important that the principal remedies will be here again summarized. The therapeutic means which are of universal application in all such cases are : 1. All enlivening and encouraging psychic influences. 2. A generous and nourishing diet, as abundant and varied as the patient's digestive powers and purse will permit. 3. The inhalation of as much of a pure, bracing, outdoor air (outside of cities when practicable) as can be taken into the lungs, though in the worst cases of neurasthenia it needs often to- be inspired while the patient is resting in a recumbent po- sition, rather than exercising. 4. A full or even extra-large amount of sleep, not forced by hypnotics, though the use of nerve tonics or even the cautious administration of the milder stimulants to favor this is often permissible, or even advisable, since the former especially may assist in other ways the work of improving the lowered nerve tone. In addition to a general tonic treatment, enteralgia, colic, enterospasm, and cases of meteorism or flatulency, not de- pendent upon any serious form of obstruction, all call for com- bined sedative and aperient remedies. In the first three af- I NEUROSES OF THE INTESTINES 889 fections in all of which pain is the predominant symptom, and often the cause of intense suffering, an efficient close of some powerful anodyne, preferably in most cases morphine and atro- pine (grn. Ya of the former with grn. 1-80 of the latter), should be promptly administered hypodermically in cases in which the pain is violent, and repeated in twenty to thirty minutes if there has been no relief. Then it is often desirable to order further amounts of the same remedies in doses twice as large, to be administered in the form of suppositories by the rectum. This is more efficient in intestinal pains than cor- responding (half) doses by the mouth, and is much less likely to disturb the stomach. I have often been obliged in severe colics to inject hypo- dermically 1/4 grn. of morphine combined with atropine as above described, before the pain could be controlled. But until you have tested the tolerance of a patient for the drug, it is best not to give over >4 gi'i^- of morphine at a dose, and it is not wise in any case to inject more than y2 grn. at a time. While the pain is thus being relieved, it is necessary in most cases to administer remedies designed to unload the bowels. When there is no nausea or vomiting, castor oil, or some such disguised preparation of it as Laxol, will succeed best given in doses of fo ss. to foi ; or you may prescribe instead some agree- ably flavored saline, such as a pint bottle of the familiar effer- vescent solution of magnesia, taken gradually to avoid nausea, or the following prescription : "S, Magnesiae sulph § ii Succi limonis f §i Aq. menth. pip q. s. ad f § iv M. Sig. Teaspoonful in water (preferably carbonated) every half-hour till it acts. One or two compound cathartic pills may answer instead of the purgatives mentioned, though they must often be repeated, and are too slow in acting for the worst cases. In the latter the quickest and most efficient means of emptying the colon is by copious enemas of hot normal salt solution or warm soap 890 THE GASTRO-INTESTINAL CLINIC suds alternated with enemas of olive, linseed, or cotton-seed oil, fsiv to fovi, injected preferably through a long flexible tube, though the ordinary apparatus will answer, if the patient lies first on the left side with the hips raised, and after a few minutes is directed to lie on the right side, while the colon is kneaded in the reverse direction to carry the liquid over into the cecum. A very soothing and helpful adjuvant in all the^e cases char- acterized by either pain alone, or pain, spasm, and constipa- tion, is the application of hot mush or flaxseed-meal poultices, or hot wet compresses over the entire abdomen, changed as soon as they become cool. To prevent the recurrence of such attacks, besides the al- ways indispensable tonic measures addressed to the nen^ous system, great attention should bei given to securing regular and sufficient bowel movements by diet and exercise — active or passive, or both according to the strength of the patient — aided when necessary by oil enemas, and when not otherwise contra- indicated, by massage, electricity, and hydrotherapeutics. (See lectures on Constipation.) When either colic or meteorism is due to obstruction of the bowel, this primary affection must receive the chief atten- tion. (See lecture on Intestinal Obstruction.) Treatment of Peristaltic Unrest of the Intestines. — This affection, when it proceeds from nervous causes, neecte the same roborant measures appropriate to other phases of neurasthe- nia, and sometimes in addition the milder nerve sedatives, such as the bromides, valerian, Scutellaria, gelsemium, cimicifuga, asafetida, sumbul, etc. The bowels should be kept open by hygienic means as advised above. More serious causes, such as intestinal obstruction, demand the treatment appropriate to the primary affection. Treatment of Paralysis of the Intestines, when partial and due to inflammatory disease or mechanical obstruction, re- quires the measures necessary for the cure or relief of such af- fection. After this has been accomplished, or at once in cases NEUROSES OF THE INTESTINES 89I attributable to general depressing conditions, remedies de- signed to strengthen the intestinal musculature will be in order. Strychnine internally or hypodermically has been gen- erally recommended, and may be tried, though some recent ex- periments failed to show that it can really strengthen muscle fibers ; massage and electricity locally, vibration over the lower spine and the colon, as well as within the rectum, and some- times, though not in very weak patients, cold douches or af- fusions to the abdomen, will be suitable unless contra-indicated for any reason because of the nature of the exciting disease. None of these, except intra-rectal vibration, would suit when the bowels are obstructed by spastic contractions, nor in any acute inflammation. Care must be taken to have the bowels open daily without unduly irritating the weak musculature, preferably by the use of oil enemas, and the diet must be nour- ishing and digestible without being either toO' bland or too dis- turbing. LECTURE LXXIX DISEASES OF THE RECTUM AND ANUS J. It would be impossible, in the limited space allotted to the subject in this book, to attempt a full discussion of those con- ditions of the rectum which are influenced by disturbances of the digestive functions, or which, in turn, affect the nutritive or digestive processes. An attempt will be made to review briefly the more common affections of the rectum and anus as met with in general practice, and to indicate such methods of treatment as have been found of service to the writer, es- pecially methods which can be employed by the general prac- titioner not having access to a hospital with its fully equipped surgical paraphernalia. The accepted methods of operative procedure in given cases will be briefly reviewed, but for the full description of the technique, the reader must be referred to the more complete writings dealing with that special subject. Fortunately, in recent years, more attention has been paid to the important relation the rectum bears to the general gastro- intestinal tract, and it is to be hoped the day will soon be numbered with the past when a long-continued enteritis or colitis will be treated without a careful rectal examination. Should a case present with definite rectal symptoms, a local examination ought to be made before any treatment is insti- tuted. No sensible patient should refuse to have this examina- tion made, and no physician, however strongly convinced of the diagnosis from the symptoms stated, should allow himself to be lulled into a sense of false security and prescribe for that case until, by careful local examination, the diagnosis has been verified. When a patient tells you that he has an attack of the " piles," his diagnosis is of about as much value as that of an old countrywoman who had a bad attack of cystitis, and DISEASES OF THE RECTUM AND ANUS 893 who told her doctor that she had " an awful pain in her stom- ach." The plebeian, but correct term, " piles," may be used to express any rectal condition from a simple fissure to carcinoma, such is the dense ignorance on the part of the average layman as to things rectal. For the sake of brevity a discussion of the anatomy and physiology of the rectum will be omitted, and only such men- tion of the subject will be made as is absolutely necessary for the clear understanding of any particular condition. EXAMINATION OF THE PATIENT When a patient presents himself for treatment it is very im- portant to obtain a clear history of the case. This is best ac- complished by first allowing the patient to give a 'recital of his symptoms in his own words, beginning with the time when he first became aware of any abnormal rectal condition. Do not interrupt by asking any questions, for the man will naturally lay stress upon the .symptoms which appear to him most important, and much valuable information may be gained from hearing the symptoms detailed in this manner. Oft- times a premature cjuestion put by the examiner will force the patient into placing too much importance on some insignificant or misleading symptom. After the patient has completed his story, the time has arrived to ask leading questions so as to arrive as nearly as possible at an accurate diagnosis of the case, but a positive diagnosis is an impossibility without a carefully instituted examination, the history simply indicating what is to be looked for, and helping -one to find obscure conditions which might otherwise be overlooked. The Symptoms and Their Significance. — The most promi- nent symptom usually complained of is pain, for unless this be present the patient rarely consults a physician and it is by re- lieving this one symptom, by correcting or removing the cause, that the professional man earns for himself the gratitude of the sufferer. Unfortunately, recourse is only too often had to the use of opiates, and too often, either from ignorance or a 894 THE GASTRO-INTESTINAL CLINIC mistake in judgment, the foundation is laid for the acquire- ment of the opium or cocain habit. Right here let me say- that the use of opium is hardly ever indicated for the relief of rectal pain. If the cause can be ascertained it can usually be removed by very simple means, and then the mistake is not made, as is often done, of masking very important guiding symptoms. The time, duration, and character of pain are very important. If felt during stool, it would suggest strangulation of anal tissues, hemorrhoids, abscess, or ulceration. If it should begin after stool, it would point to the presence of fissure, while, if it is continuous and of a throbbing character, abscess formation may be suspected. Bleeding, during stool and immediately after, would indicate internal hemorrhoids, ulceration, or malignant disease. Oc- casionally there may be a little bleeding from, a fistulous tract. In children the presence of blood in the stools would suggest the existence of a polyp. Itching, as a symptom, occurs with aggravating frequency. This may be a mild, fleeting, and almost a pleasurable sensa- tion, or it may be present in such an aggravated form as to render the life of the patient almost unbearable. Nearly any rectal condition may produce itching as a reflex symptom, but as a rule the correction of the cause removes the trouble. Un- fortunately, in cases of pruritus ani of the more pronounced type the physician will find that he has a very grave and stub- born condition to deal with. Protrusion from the anus is usually a prolapsed internal hemorrhoid, a polypus, or a prolapse of a portion or all of the rectal coats. Szvellings at the margin of the anus may be due to strangu- lation of an hypertrophied anal margin, thrombotic external piles, anal condylomata, abscesses, fatty tumors, or malignant growths. Constipation, while a symptom, is of such frequent occur- rence, and of such importance, that it has come, in the lay DISEASES OF THE RECTUM AND ANUS 895 mind at least, to be regarded as a distinct disease, or at least an unpleasant abnormality. It is the hobby-horse of the quack, and the stumbling-block of the regular practitioner. Its rectal relations will be dealt with in another portion of this lecture, and the subject of constipation in general is considered in Lec- tures LXIX. and LXX. Diarrhea is also a term loosely applied to discharges from the rectum of undue frecjuency or liquid formation, whether feces, mucus, blood, or pus. If feces, the trouble is rarely of local origin, but mucus, blood, or pus may originate anywhere along the intestinal tract, and the location of the trouble should be diligently searched for. Hemorrhage may follow any ul- cerative condition of the intestine, as in typhoid or tubercular ulceration, or that ulceration taking place in the later stages of malignant disease. If the bleeding be from any point in the small intestine, the discharge will contain clots of blood, mixed with feces, and show evidences of partial digestion. If the clots are large and undigested, the hemorrhage has either been very free, or the bleeding has occurred at some point in the colon or rectum. Should the bleeding be free at stool and contain few clots, the cause is probably to be found in the rectum and is du€ to the conditions mentioned under hemor- rhage. Mucus may result from almost any catarrhal condition of the large or small intestine, from polypoid growths, or simply from a localized rectitis due to local irritation. Pus in the stool may also occur as a result of high ulceration or the rup- ture of an abscess into the bowels, or it may be of local origin, as from ulcerated hemorrhoids, perirectal and ischiorectal abscess, or from carcinoma of the sigmoid or rectum. It is also well to bear in mind such symptoms as cough, rapid loss of weight, skin eruptions, temperature, respiration, and pulse, as they may have a bearing upon the general con- dition of the patient, suggesting phthisis, specific disease, or malignant development. Technique of the Examination. — The most satisfactory 896 THE GASTRO-INTESTINAL CLINIC method of examining patients is to place them on a lounge or operating table in the left lateral posture, with the knees drawn well up, the right knee a little higher than the left, and the but- tocks well over to the edge of the table. The light should be direct, daylight being preferable to artificial light. This posture has the advantage over others that with it there is less exposure of the person, a very important consideration when dealing with a female patient, and also it is a very comfortable position, especially when the examination occupies a consider- able length of time. There are few rectal conditions where any other position for examination is either necessary or desirable. Inspection of the Anus, etc. — Before any examination of the rectum itself is made, a careful inspection should be made of the anus and surrounding tissues. The skin should be ex- amined for abnormalities, such as redness, cracks, swellings caused by thrombi, inflamed anal folds, ulceration, or the open- ings of fistulous tracts. Particular notice should be taken of the anal aperture. Normally the anus should appear as an antero-posterior slit, about one inch in length, and the line only broken by a few normal corrugations. Upon separating the buttocks, should the aperture appear round or funnel-shaped, spasm of the sphincter, due to some irritation, is undoubtedly present. This condition is most pronounced in cases of fissure of the anus. The anal opening may be occluded by a pro- lapsed polypus, or internal hemorrhoids, or the lower extremity of a fissure may be seen. In patients suffering from paresis and locomotor ataxia, there is frecjuently, noted a loss of tone in the sphincter re- flexes. \\nien the flnger is inserted into the rectum the sense of contraction around the finger is very slight, while if a little, lateral pressure is made, the sphincter relaxes easily, allowing the anus to gape open. In the advanced stage of these diseases this relaxation increases until incontinence results. The con- dition seems to be due, possibly, to the diminution of tactile sensation in the internal sphincter, associated with paralysis of the external sphincter. DISEASES OF THE RECTUM AND ANUS 897 The Digital Examination. — After carefully noting all ex- ternal anal conditions, a digital examination should be made. Lubricate the index finger either with petrolatum or other lubricant, introduce it gently into the anus, overcoming the normal resistance by firm but gentle pressure. The finger should never be introduced with undue haste, as uncomfort- able and often painful spasm of the sphincters is produced thereby. In a normal anus the finger should slide in easily, and when at rest, there should be very little sensation of con- striction caused by the rhythmic contraction of the muscle about the finger. By means of tactile sensation, the trained finger can diagnose most of the local diseases affecting the lower portion of the rectum, as for instance, fissure, the in- ternal opening of a fistula, polypoid growths, fibromata, malig- nant neoplasms, stricture, deep ulcerations, foreign bodies and fecal impaction occuring in the rectum, fluctuation, or points of abnormal tenderness. Internal hemorrhoids cannot be ac- curately diagnosed in this manner. It should be borne in mind that the finger is the best instrument for diagnosis, while a speculum .is of chief value only to verify conclusions, to diag- nose internal hemorrhoids, and particularly is it an instrument to assist in local treatment of the rectum. For pathologic con- ditions beyond the reach of the index finger, a speculum is necessary. The More Important Instruments Required — The speculum I find most convenient for routine use is the small conical form designed by Dr. Robert W. Martin. It will be noticed by re- ferring to the accompanying figure that the rectal end is cut off at an angle of 45°. A small wire bead is added to this edge to protect the tissues from injury and also to add to the comfort of the patient while rotating the speculum in the rectal cavity. The angularity of the distal end is for the pur- pose of allowing the side of the rectal wall to prolapse into the aperture, so that a distinct view of the mucosa may be ob- tained. By rotating the speculum, every portion of the rectal mucosa of the lower two inches can be closely inspected. The 898 THE GASTRO-INTESTINAL CLINIC speculum is of course introduced with the obturator in place, and as much care should be used in the introduction as was used in passing the finger into the rectum. There are several Fig. 99. — Martin's conical speculum. good forms of bivalve specula on the market, but while they may be useful in some cases, they have the disadvantage that they cannot be rotated in the anus without great pain and dis- FiG. 100. — Bodenhamer's bivalve speculum. comfort to the patient, but have to be reintroduced every time a new section of the rectal cavity is to be examined. One of the most convenient forms is that designed by Boden- hamer, a cut of which is shown. DISEASES OF THE RECTUM AND ANUS 899 While it must be borne in mind that a large percentage of rectal conditions can be diagnosed simply by digital examina- tion followed by the use of a small speculum, there are other diseases of the upper rectum and sigmoid for the diagnosis of which an extra-long speculum or pneumatic proctoscope is necessary. Dr. Tuttle has kindly permitted me to use the cut of his proctoscope, and I have taken the liberty of cjuoting the excel- FiG. lor. — Tattle's pneumatic proctoscope. — A, obturator; B, plug with glass window closing end of tube; C, handle; D, cords connecting in- strument with battery; E, inflating apparatus; E, main tube of procto- scope. lent description of it given in his book on the " Diseases of the Anus, Rectum, and Pelvic Colon." " This instrument is composed of a large cylinder (F) into one part of the circumference of which is fitted a small metallic tube, closed by a flint-glass bulb at its distal end. The electric lamp is fitted upon a long metallic stem, and carried through 900 THE GASTRO-INTESTINAL CLINIC the small cylinder to the end of the instrument, as is shown in the illustration. " The proctoscope is introduced through the anus with the obturator (A) in position. As soon as the internal sphincter is passed, this obturator is withdrawn and the bayonet-fitting ptug (B), which contains either a plain glass window, or a lens focused to the length of the instrument to be used, is inserted in the proximal end of the instrument. This plug is ground to fit air-tight, and thus closes the instrument perfectly. The plug being inserted in the tube, a very slight pressure upon the hand-bulb will cause inflation of the rectal ampulla to such an extent that the whole rectum can be observed, and the instru- ment can be carried up to the promontory of the sacrum with- out coming in contact with the rectal wall. Further dilata- tion will show the direction of the canal leading into the sig- moid, and by a little care in manipulating the instrument, and keeping the gut well dilated in advance, it can be carried up into this portion of the intestine without the least traumatism of the parts. If any fecal material obscures the light by being massed or smeared over the glass bulb, the plug can be re- moved, and a pledget of .cotton introduced with a long dress- ing-forceps, to wipe this off, so that the plug can be reintro- duced and the examination continued with very slight delay or inconvenience. " The adjustable handle ( C) fits on the rim of the instrument and thus converts it into a Kelly tube. This instrument is oper- ated with an ordinary dry battery of four cells." In the following pages the more frequent rectal diseases will be briefly discussed. It is not intended to review all the ac- cepted operative procedures, but rather to indicate such surgical and medical treatments as may be carried out in the office of the general practitioner or in the patient's home. The methods indicated are such as may be applied to that large class of pa- tients who either will not or cannot be treated in a hospital. DISEASES OF THE RECTUM AND ANUS QOI THE RECTAL RELATIONS OF CONSTIPATION The causes of constipation are either general, depending upon some abnormal state of the digestion, obstruction of the bowel, or disease in some portion of it ; or local, resulting from some anomalous anatomic condition of the rectum, or upon pathologic processes in or about it. The general or digestive conditions causing constipation have been fully discussed in Lectures LXIX. and LXX., so that the local rectal factors only will be considered here. Anatomically, constipation or obstipation may be caused by an abnormal formation of the rectal valves, as pointed out by Martin of Cleveland, who has done much to clear up the aeti- ology of these conditions. A frequent local cause of constipation is an abnormal ir- ritability of the sphincter muscles, causing a loss of the nor- mal relation between the expulsive power of the rectum and the cut-off action of the sphincters. Congestion or inflamma- tion of the rectum or anal tissues causes an increased irrita- bility of the sphincter muscles due to excitation of the nerves supplying those organs ; thus we frequently find constipation as a symptom in cases of internal hemorrhoids, external hemor- rhoids, fissures, abscesses, or ulceration of the rectum. Pros- tatic congestion and hypertrophy are often important factors. Other cases are due to local obstruction, as in benign or ma- lignant stricture, or the presence of tumors or foreign bodies in or about the rectum. In women, the pressure upon the rectal wall of an enlarged uterus, or tumors connected with the uterus, forms a very troublesome complication when we try to relieve this condition. There are also some cases in which the constipation is due to paralysis or loss of tone on the part of the rectal and accessory muscles of defecation. The Operation of Divulsion. — One of the most efficient means of treating these spasmodic cases is the employment of divulsion or rapid dilatation of the sphincter under g-eneral anaesthesia. Rapid divulsion is of value from the fact that 902 THE GASTRO-INTESTINAL CLINIC the nerves supplying the muscles undergo the process of nerve stretching, thereby lessening the irritability and improving the venous and arterial circulation of the muscle. N^ it rolls oxide has many advantages over other anaesthetics for this purpose, as the sphincteric reflexes are retained, thereby furnishing an index as to the amount of force re- quired. The operation can be as readily performed under ethyl chloride anccsthesia, the tubes of ethyl chloride being very convenient to carry in the emergency case. Divulsion should be manual and not instrumental, thereby avoiding the danger of undue laceration of the muscle. . The sphincter should be stretched to its utmost, till the fibers just begin to give way, care being taken not to tear the muscle. This operation need not confine the patient to bed, but may be performed in the office. When any extensive surgical operation is to follow, the divulsion should be performed under the influence of ether or chloroform, bearing in mind that the reflexes are then absent; therefore much more care and time are recjuired in the per- formance of the operation. Under nitrous oxide or ethyl chloride, a good divulsion can be obtained in from thirty to fifty seconds, while under the other anaesthetics several minutes should be consumed in care- fully kneading the muscle until it is thoroughly relaxed, very little force being employed. In about 70 per cent, of cases suffering with rectal troubles and constipation as a symptom, divulsion and appropriate treatment of the local conditions will completely cure the constipation. It may be well to add that the stretching of the muscle in itself will in nearly every case relieve any local pain in or about the rectum, and, from the improvement in the circula- tion, materially hasten the cure in the majority of cases. "Di- vulsion is indicated in all cases where there is marked inflam- mation, strangulation, pain, or hemorrhage of the rectum, the only contra-indications being paralysis of the sphincters and malignant disease situated near the anal orifice. DISEASES OF THE RECTUM AND ANUS 9^3 FECAL IMPACTION Impaction of feces in the rectum may be due to catarrhal conditions of the colon, muscular atony giving rise to sluggish peristalsis, dilatation, and sacculation particularly of the sig- moid and rectum, and arrested foreign bodies in the bowel, such as seeds. Should the feces become stopped at any por- tion of the colon, the watery constituents are absorbed, leaving a firm residue, rich in lime salts, glued together by mucus and the compressing muscular action of the bowel. This mass shows a marked tendency to adhere to the walls of the gut, and may produce considerable local irritation, followed in some cases by ulceration and hemorrhage. The early symptoms are constipation, partial or absolute, followed suddenly by diarrhea. The stools are liquid and fre- quent, with a marked tendency to tenesmus. If the condition is pronounced, there may be considerable auto-intoxication, with flatulence and a sense of abdominal fullness. Should the im- paction be in the sigmoid, palpation may reveal a doughy tumor in the left groin, with tympanites over the colon above. In the rectum, the mass can usually be felt upon digital ex- amination. Pain in the back, rectum, and anus is a frequent symptom. The diarrhea is caused by irritation of the mucous membrane inducing an excessive production of mucus. Added to this, the liquid contents of the bowel above the impaction may insinuate themselves along the side of the fecal mass or, in a few instances, may make a canal directly through it, and thus pass down the alimentary canal. If there is any ulceration, the stool will be tinged with blood. The treatment of impaction consists in the removal of the arrested fecal mass, followed by treatment of the irritation of the mucosa from the unavoidable -traumatism, and finally, the correction of the primary cause, if this be a colitis or atony of the muscular coats of the bowel. Where the feces are lodged in the rectum, a divulsion may be 904 THE GASTRO-IXTESTINAL CLINIC performed, when the mass can be turned out with the fingers or broken up and removed with a rectal scoop. If the collec- tion is in the sigmoid, or is too large^^or too hard to remove through the anus, Tuttle advises an injection of ^ pint of warm water, to which has been added 3 ilof inspissated ox-gall and 3 i of glycerin. This should be retained as long as pos- sible, and repeated four times in tw^enty-four hours. The mass will then usually be soft enough to pass the anus after a large enema, associated, if necessary, with a large dose of castor oil. Dilatation of the rectum and colon with air, either by means of the pneumatic proctoscope or a simple rubber valve syringe, will frequently assist in dislodging the impaction, especially when assisted by gentle massage of the abdomen over the tumor. After the rectum has been emptied, the patient should be given a laxative, preferably castor oil or magnesium sul- phate, followed by the internal administration of such peri- staltic stimulants as eserine or strychnine. The patient should make a daily practice of drinking plenty of water and taking regular exercise. Should any symptoms of constipation again appear, relieve the bowels with a saline laxative. Should there be any local ulceration in the rectum or sig- moid, it will usually yield to a daily irrigation with warm normal salt solution. This injection will often relieve the con- dition of shock which sometimes follows the rapid removal of the retained feces and gas. Internally, ichthyol, grns. 5, three times daily, seems to exert a very soothing effect on irritations in the upper portion of the colon. HEMORRHOIDS Varieties. — Hemorrhoids may be classified as either external or internal, depending upon whether they have their origin below or above the external sphincter. Of the external, there are practically only two varieties, the thrombotic pile, consist- ing of a clot of blood in one of the inferior hemorrhoidal veins. DISEASES OF THE RECTUM AND ANUS QOS or else a clot resulting from the rupture of one of these veins just beneath the skin. These are easily recognized by their purple color and shot-like hardness to the touch. The simplest and most effective treatment for this condition is to inject a few drops of a 2 per cent, solution of cocain, transfix the clot with a curved bistoury, turn it out, stop bleeding by pressure forceps, or by torsion, and pack the cavity with iodoform gauze kept in place by a T bandage. Healing will be complete in a few days. The practice of using sutures in or around the anus and rectum is to be condemned, except under the most ideal aseptic conditions, and, even then, infection along the line of suture is very apt to take place, resulting inevitably in the formation of a fistula. The second variety of external hemorrhoids may be classi- fied as hypertrophies of the anal margin. These may be either inflamed, oedematous, or composed principally of connective tissue. For the inflamed and oedematous varieties, a simple di- vulsion of the sphincters, followed by the application of hot compresses for ten minutes at intervals of two hours, . will usually result in almost immediate relief. The folds rapidly decrease in size, and if necessary they can be scissored off under local anaesthesia at some subsequent period. The con- nective-tissue variety rarely give any trouble, and may be dis- regarded unless they become inflamed, when they should be treated as the preceding. Internal hemorrhoids may be classified under the following five vafieties, thrombotic, being merely a clot in a superior hemorrhoidal vein ; varicose, or. venous, being a varicosity of the primary branches of the superior hemorrhoidal veins ; the arterial, which are relatively rare; the capillary, which are small piles composed of enlarged venous and arterial capil- laries and bleed upon the slightest touch ; and the Hhrous hemor- rhoid, or polypoid pile; this last variety being simply a vari- cose pile which, from repeated attacks of irritation and in- flammation, has hypertrophied, resulting in the deposition of an excess of fibrous tissue. The mucous membrane on the 906 THE GASTRO-INTESTINAL CLINIC surface has, from this irritation, undergone a polypoid degen- eration, and as a result there may be a profuse discharge of mucus from the pile. The symptoms of the thrombotic variety are pain in the rectum coming on suddenly, usually after some straining at stool, accompanied by a sense of fullness or a feeling as of a foreign body in the rectum. Generally there is considerable sphincterismus, accompanied by constipation. The clot can easily be felt upon digital examination, usually just at the upper border of the internal sphincter. The treatment con- sists in divulsion of the sphincter and turning out of the clot after transfixing it with a long, curved bistoury. An applica- tion of stick nitrate of silver will usually stop what little bleed- ing is present, or the cavity may be packed with a small pledget of cotton saturated with adrenaline chloride, i-iooo. The treatment may easily be performed through the small conical speculum and local anaesthesia is rarely necessary, as the rectal mucosa above the sphincter is not very sensitive. A 5-grain iodoform suppository may be used after bowel movements, and one may be inserted at bedtime for a few days. The bowels should be moved every day, with the aid of a mild laxative if necessary. Varicose and capillary hemorrhoids produce, as prominent symptoms, bleeding at stool, a sense of fullness at stool, consti- pation, and, in the more advanced cases of the varicose variety, protrusion of the piles, which may reduce themselves sponta- neously or may have to be replaced manually. Should these hemorrhoids not be replaced immediately, and spasm of the sphincters occur, strangulation is almost sure to follow, at- tended with great pain, swelling, or oedema of the anal margin, and, in some cases, sloughing of the rectal or anal tissues. Some of the more aggravated cases are complicated by the formation of a submucous or marginal abscess. If the pa- tient refuses any cutting operation, by far the cjuickest means of relieving the symptoms is by immediate divulsion under nitrous oxide, followed by the application of hot compresses. DISEASES OF THE RECTUM AND ANUS 90/ The case may subsequently be treated either palhatively or by the injection method. The Injection Treatment of Hemorrhoids This has in the past been brought into disrepute because employed by quacks and physicians unacquainted with the proper techinque and unable to cope with the complications resulting from improper methods. In the experience of the writer, it is not only a safe procedure, but the results obtained earn for it a position as a recognized and satisfactory method of treatment. Its ad- vantages consist in the fact that the patient is not confined to bed, the treatment is practically painless, the complications are few, and the results compare very favorably with those follow- ing other operative methods. Recurrences are rare, and when they do occur it is usually in a segment of the rectum not pre- viously treated. It is always wise, before attempting to inject internal hemorrhoids, to preface the treatment with a thorough divulsion under nitrous oxide, thereby removing any abnormal irritability of the sphincters which may exist. Many of the accidents which have been reported are the result of neglecting this simple procedure. The solution used for injection is a matter of great im- portance. The use of the stronger solutions will, in most instances, be followed by the formation of a slough, causing considerable pain and often resulting in quite serious ulcera- tion, if unrecognized and untreated. The solutions I usually employ are 50 per cent, aqueous so- lutions of Phenol Sodique or Phenol Boboeuf, filtered and freshly prepared. Dr. Tuttle recommends the following formula, which he attributes to Shuford : ^ Ac. carbolic (Calvert's) , 3 ii Ac. salicylici , 3 ss Sodii biborat 3 i Glycerinae (sterile) q. s. ad f i An ordinary all-metal hypodermic syringe, with a three-inch extension barrel, may be used for the injection. The conical speculum should be introduced and the hemor- 908 THE GASTRO-INTESTINAL CLINIC rhoid to be injected prolapsed into it. Firm pressure of the end of the speculum is then made against the lateral wall, thereby limiting the spread of the solution through the sur- rounding tissue. The hemorrhoid is then swabbed off with a 2 per cent, solution of creolin. From three to ten minims of the injection solution should be injected directly into the center of the pile, the amount depending upon the size of' the tumor. The speculum should be withdrawn first, followed by the hypodermic syringe. Insert a 5-grain iodoform suppository. Only one tumor'should be injected at a 'time, and an interval of from five to seven days should be allowed between treat- ' ments. Very little discomfort follows the injection, but if too much fluid is used a slough may be produced. This is usually limited, and should be treated by an application oi stick nitrate of silver, followed by the regular use of iodoform or ichthyol suppositories. No further treatment should be instituted until the slough has healed. The fibrous or pol3^poid hemorrhoid would better be removed by excision, as the injection method usually fails to cure it and only results in sloughing, which later causes the patient considerable discomfort. The pa- tient's bowels should be kept perfectly regular all through the treatment. When a patient will submit to an operation under general anaesthesia the ligation or clamp and cautery method may be resorted to, as the results obtained are very much quicker, al- though I -do not believe they are much superior to those ob- tained by injection, if the latter be skillfully performed under proper antiseptic conditions. The technic|ue of the operative methods may be obtained from any of the standard text-books on rectal diseases. The crushing method for the treatment of hemorrhoids is now rarely employed, as it possesses no advantages over the clamp and cautery or ligature operations. The Whitehead operation of excision of the pile-bearing area, wbile it has given brilliant results in the hands of a few surgeons, has so frequently been followed by stricture, when used by some less DISEASES OF THE RECTUM AND ANUS 909 skillful operator, that the sooner it is relegated to medical liter- ature the better. A Palliative for Bleeding. — Should the patient refuse to have any of the above methods of treatment used, great relief may be given in cases of bleeding by the use of the following suppository : R Pulv. suprarenal. ) Iodoform S • grn.xxxvi Ichthyol i?i xxiv 01. theobrom q. s. M. ft. suppos. No. 12. Sig. One suppository half an hour before bowels are to be moved and one after movement. .The morning evacuation may be rendered more comfortable by the injection of from ^ to i oz. of olive oil into the rectum just before retiring, retaining it overnight. In case there is strangulation, the piles should be replaced as soon as possible. Should there be much difficulty in this, the application of a compress wrung out of very hot water and pressed firmly against the inflamed mass of tumors will usually, in about ten minutes, reduce the congestion enough to allow them to be reduced. FISSURE OF THE ANUS This frequent and painful affection is often a complication of internal hemorrhoids, but may also exist with no other condition. Symptoms. . — The patient presents himself with a history of pain beginning after stool and lasting anywhere from a few minutes to several hours, often so severe as to incapacitate him from business. There may be more or less constipation oc- casioned by the excessive spasm of the sphincters. Bleeding is usually slight, except when complicated by some other condi- tion, such as hemorrhoids or deep ulceration. Examination shows an anus tightly contracted, more from excessive spasm than hypertrophy. At the posterior margin of the anus there is often a small hypertrophied skin tab or sentinel pile, above 910 THE GASTRO-INTESTINAL CLINIC which, Upon separating the buttocks and having the patient bear down, the fissure wih be seen as a small crack in the posterior aspect of the anus. Upon an examination . with a speculum the fissure will prove to be an oval ulcer, sometimes having ragged indurated edges. At times in the upper angle of this ulcer a minute polypoid fold of mucous membrane may be found. Care should be exercised to be sure that there is no sinus in the base of the fissure leading into a submucous ab- scess. Treatment — Immediate relief of the symptoms will be ob- tained by a thorough divulsion of the sphincter. Subsequently, the removal of the sentinel pile and superior sentinel polypoid fold, under local anaesthesia, followed by a few applications of nitrate of silver, will suffice to make a perfect cure. PRURITUS ANI Probably no class of cases gives the physician or specialist so much anxiety and annoyance as do those in which the pre- dominant symptom is an intolerable itching. Beginning as the consequence of rectal or anal lesions, such as external or in- ternal hemorrhoids, or as the result of irritating discharges, the anal skin becomes so changed from irritation and scratch- ing that it takes on a characteristic appearance and pathologic formation, being sometimes even eczematous in type, which persists after the primary cause has been removed. Symptoms — The anal skin in well-advanced cases is much thickened, friable, cracked, and lacking in vitality. It looks leathery and full of creases and has been classically described as a *' washerwoman's " skin. The itching is generally worse at night just after retiring, and the patient often wakes to find that he has been scratching vigorously at his anus. Treatment — In treating these cases careful attention to the diet must be given in those instances where there is an under- lying condition of diabetes mellitus, Bright's disease, or a rheumatic diathesis. The local cause should be removed and DISEASES OF THE RECTUM AND ANUS QH applications should be made to the skin, not only to relieve the itching, but to try to bring the skin back to a normal condition. Applications of nitrate of silver or pure carbolic acid should be applied to the fissured skin, followed by a moderately stim- ulating but not irritating ointment. Adler recommends a dressing of citrine ointment, full strength or diluted as the case may recjuire. Carbolated petrolatum or acetanilid oint- ment, 3 ss. to the ounce, may relieve the itching. Resin cerate will sometimes be found valuable. Where the skin is intoler- ant to ointments a wash of dilute alcohol, lo per cent., or 5 per cent. Labarraque's solution, may be tried. A few cases have been relieved by the following: i^ Menthol gr. xx Alcohol q. s. 01. cadini \ 01. rusci haa .m. x. Ichthyol ) Petrolat q. s. ad §i M. ft. ung. Sig. Apply locallj'-. Internally ichthyol, given over a long period of time, has often brought about a decided improvement. Acetate of potash or sodium bicarbonate in large doses has proved of value. Even in the worst type of pruritus sticking faithfully at it, by both doctor and patient, will nearly always be rewarded by a cure or at least a very gratifying improvement. ABSCESS Varieties. — Abscess in the neighborhood of the anus and rectum is of such frequent occurrence, and early treatment so imperative, that the condition is one of the most important with which we have to deal. The most common varieties are the marginal or subcutaneous abscess of the edge of the anus ; the submucous, found in the rectum and upper portion of the anus ; the perirectal, situated above the sphincter in the cellular tissue surrounding the rectum ; and the ischiorectal^ occupying the ischiorectal fossa. 912 THE GASTR0-INTE3TINAL CLINIC The infection may either start at the skin surface or may have its origin from pyogenic material within the rectum and carried to the point of inflammation by the lymphatics or blood current. Abscess within the rectum frequently follows infec- tion from, strangulated and sloughing hemorrhoids, neglected fissures, ulceration, strictures, both benign and malignant, and perforation by foreign bodies, such as fish bones or pieces of toothpick, that have been carelessly swallowed. The marginal abscess usually follows the infection of ex- ternal hemorrhoids, particularly the , thrombotic variety. The ischiorectal abscess may be produced by traumatism followed by infection from the bowel through the lymphatics. The part which tuberculosis pla3'S in these cases I feel sure has been overestimated, for by far the greater number of cases occur in persons previously healthy, and after cure they regain their previous good health. The symptoms of marginal and ischiorectal abscesses are pain of throbbing character near the anus, localized swelling and redness of the skin, tenderness upon pressure, and indura- tion over the affected area, followed by fluctuation and a dis- charge of pus if the abscess opens spontaneously. There may or may not be a general feeling of malaise, attended with a temperature of septic type. In the ischiorectal variety there may be a rapid loss of weight and strength, leading to a mis- taken diagnosis of tubercular complications. The submucous and perirectal abscesses are attended with pain in the rectum or anus (worse during stool), tenesmus, constipation, and lo- calized tenderness and induration upon digital examination. If the abscess has ruptured into the rectum there is a decided relief from pain, attended with the free discharge of pus at stool. It may he accepted as an axiom that all fistulas in the neigh- borhood of the anus or rectum are the direct result of ab- scesses zuhich have been eitlier neglected or improperly treated. Were these abscesses radically treated, fistulas would rarely occur. DISEASES OF THE RECTUM AND ANUS 9I3 Diagnosis of Ischiorectal Abscesses. — These may be recog- nized by tenderness over the ischiorectal fossa, swelling, in- duration, and redness on either side of the anal margin. If pus be present, fluctuation may be obtained by bimanual pal- pation with one finger introduced into the rectum. The ab- scess may have ruptured spontaneously either upon the skin surface or into the bowel, in which last case the opening will usually be found in the inten^al between the two sphincters. Treatment of Ischiorectal Abscess. — Every ischiorectal ab- scess should be incised immediately to prevent the foiTnation of a fistula. Do not waste time in abortive treatment, incise freely and drain. The method I find most useful is to thor- oughly anaesthetize the area for operation by a hypodermic in- jection of a 2 per cent, solution of cocain, and, with a curved bistoury, transfix the swelling in its long axis, carrying the incision well into the healthy tissue at either end. In the same manner make another incision in the middle of the first, and at right angles to it. With a pair of curved scissors trim off the projecting angles of tissue left by this crossed incision, thus converting the wound into a diamond-shaped cavity. If pos- sible, curette out the necrotic tissue and pack the cavity tightly with iodoform gauze. Over this place a pad of cotton held in place by a T bandage. After forty-eight hours, remove pack- ing and pack loosely with plain gauze or cotton saturated with acetanilid ointment 3 ss. to o'l. Usually, it is not necessary nor desirable to put the patient to bed. The Treatment of Complications. — When there is much spasm of the sphincters they should be divulsed as soon as convenient. Have the bowels moved regularly after the pri- mary dressing has been removed. If excessive granulations develop, they should be cauterized with pure nitrate of silver. Probe the wound carefully at every dressing, and should any sinuses be found, divide them freely under local anaesthesia. Any overhanging edges of skin which persist should be scis- sored off. If the abscess has perforated the bowel, there should be no hesitancy in dividing the overlying tissues, especially if 9^4 THE GASTRO-INTESTINAL CLINIC the external sphincter only be involved. Divide the muscle fibers at right angles, so as to prevent a possible incontinence from a poorly formed cicatrix. Particular attention should be paid to the after-treatment, no case should be discharged until every part of the wound is absolutely healed. If done under general aneesthesia, the primary operation should include a careful dissection of all indurated tissue and the patient should be kept in bed until granulation has become well established. In place of the cocain anaesthesia, Gant uses sterile water injected intradermically. As soon as the skin is thoroughly infiltrated over the line of incision, he makes subcutaneous in- jections until the tissues are fully distended. He claims that the advantages of this method are rapid anaesthesia and free- dom from toxic symptoms, FISTULA IN ANO As mentioned above, the formation of a fistula must be secondary to an abscess. The classification into complete, in- complete, and " horseshoe " fistulas may be accepted for con- venience' sake, and I believe the terms are so gener'ally under- stood as to need no special description. The variety neces- sarily depends upon the direction in which the pus has bur- rowed and at what point the abscess has ruptured. If the ab- scess has only opened on the skin surface, the result will be an incomplete external fistula ; if into the bowel, an incomplete in- ternal fistula; if in both places, a complete fistula; and if the pus has burrowed around the outside of the rectum, the natural consequence would be the formation of the " horseshoe " fistula. Diagnosis — The presence of a fistula may be inferred from the history of an abscess followed by a continuous or an in- termittent discharge of pus from the anus or skin surface. Upon examination a sentinel papilla or button of granulation tissue may be seen near the anus. Slight pressure will cause a drop of pus to be squeezed from the external opening of the DISEASES OF THE RECTUM AND ANUS 915 fistula, which is usually in the center of the papilla. A probe should be gently and carefully passed through this opening and the sinus explored to find if an internal opening exists. The internal opening in the majority of cases may be located in the interval between the external and internal sphincters. After the probe is in place, the finger may be inserted into the rectum, when, by careful palpation, the whole fistula may be out- lined. If the finger is introduced before the probe is in place, the spasm of the sphincter will prevent the probe from passing into the internal opening. The internal incomplete fistulas are usually first located by digital examination, the fistulous tract feeling like a fibrous cord beneath the finger. A bent probe may then be passed through a speculum and into the opening of the sinus. When the fistula has multiple openings and branch sinuses, they should all be carefully outlined before operation. The injection of peroxide of hydrogen or of a colored solution into a fistula will often aid one to find the internal opening. Treatment — The recognized methods for the treatment of fistula are the application of cauterizing agents, the elastic ligature, incision, and excision, followed by suture of the primary wound.. The use of caustics or absorbents has been so universally unsuccessful that it has justly fallen into disrepute. The operation by elastic ligature, aside from being very pain- ful, is only applicable when the fistula has no branch sinuses, and even then the cures are few and far between. Excision of the fistulous tract, with suture of the wound, is only successful under the most perfect aseptic conditions, and because of the difficulty of obtaining these conditions in the neighborhood of the rectum, the wound often becomes reinfected and may take on conditions more serious than existed before the primary operation. One disastrous result will more than- counterbal- ance the time saved over the more conservative method of free incision, with repair by granulation. A Majority of Fistulas Non-tubercular. — Many authors in- sist that a very large percentage of fistulas is of tubercular 91 6 THE GASTRO-INTESTINAL CLINIC origin. While this may be true of cases treated in hospital dispensaries, it is certainly not true in respect to those treated in private practice. The majority of fistulas occur in persons otherwise healthy, while only about 12 per cent, are associated with or followed by tuberculosis of the lungs. It must be borne in mind that a tubercular fistula, and a fistula in a tubercular subject, are two entirely different conditions. The mere pres- ence of phthisis pulmonalis should not deter one from operat- ing upon a fistula, with fair chance of success, except in cases where this fistulous tissue shows localized tubercular infection. In all these cases it is of great advantage to employ local an- aesthesia, thereby avoiding any possible irritation of the lung tissue by the anaesthetic. In most cases where a fistula has existed for any length of time, there will be found an excessive irritability of the sphinc- ters. Where this exists it is well to preface treatment by thor- ough divulsion of the sphincter. After two or three days' rest the skin and tissues over the fistula should be thoroughly an- aesthetized with a 2 per cent, solution of cocain. A grooved director should be passed through the fistula, and the tissues above divided either with a bistoury or sharp scissors. In place of a grooved director, the fistula knife shown in cut will be found very useful. It was designed by Dr. R. W. Martin, and is shaped like a large cataract knife with a flex- FiG. 102. — Martin's fistula knife. ible, probe-pointed beak. The probe can be passed through the fistula, and then, with a -finger introduced into the rectum, the end can be bent and brought out through the anus. The over- lying tissues can then be divided with no danger of slipping. If there are any other sinuses, these should be laid freely open. In dividing the sphincters, be careful to cut the fibers transversely. Stop any bleeding by torsion or compression DISEASES OF THE RECTUM AND ANUS 917 with liemostats, pack the wound tightly with iodoform gauze, and apply a pad of cotton held in p.lace by a T bandage. It is not necessary in most cases to put the patient to bed, but he should keep c[uiet for the first twenty-four hours. At the end of forty-eight hours remove the gauze, clean out the wound, and dress with a light packing of plain gauze or cotton sat- urated with acetanilid ointment 3 i to oi- Too tight a packing will prevent the formation of healthy granulation. Be sure to keep the granulations in check by the application of pure ni- trate of silver every three to five days. Dress the wound daily, and carefully probe it to discover if any sinuses have been over- looked. If any are found, open them freely under local an- esthesia. Incomplete fistulas, either external or internal, may have to be made complete fistulas and freely divided before they will heal. The most important factor in curing a fistula is to obtain free drainage. Do not allow any overhanging edges of skin or undivided sinuses to persist, as they will only offer a field for reinfection. Do not persist in packing a wound with iodoform, as its constant use causes an overstimulation of the granulations, resulting in the formation of a poorly nour- ished hard cicatrix, often showing a pronounced tendency to contract. PROLAPSE OF THE RECTUM By prolapse of the rectum we mean any protrusion of the rectum, including either the mucous membrane or all of the coats of the bowel, through the anal aperture. Procidentia is a term used to describe a prolapse consisting of all the coats of the bowel. A slight eversion of the anal mucous membrane takes place at every stool, which may be considered physiologic. .Etiology — The causes of prolapsus may be summed up as any conditions which produce an abnormal tension on the rectal mucosa, such as straining at stool due to hemorrhoids, polypi, stricture, or tenesmus due to ulceration. It may be produced by any weakness in the natural pelvic supports of the rectum or sigmoid, particularly where there is an elonga- 91 8 THE GASTRO-IXTESTIXAL CLINIC tion of the mesentery. A relaxed condition of the sphincters may be another factor, especially that found in old age, in paralysis, and after operations which have destroyed the sphincteric control. In some very pronounced cases there will be found either an undeveloped internal sphincter or an entire absence of that organ. ' Symptoms. — These cases usually have a history of gradually increasing constipation, followed by a protrusion from the anus, which at first goes back spontaneously. As the mass increases in size the patient finally has to reduce it after every stool. The mucosa, from irritation, becomes enormously hypertrophied, and after the condition has become pronounced, the constipa- tion is followed by a teasing diarrhea containing much mucus, which is sometimes streaked with pus and blood. In exam- ining these patients, unless the mass protrudes spontaneously, a full enema of warm water should be administered, so that the entire prolapse will protrude at stool. The prolapse will then be found to consist of a hemispheric tumor, A-arying in size from that of a walnut to that of a man's fist, depending upon whether the prolapse consists of mucous membrane, or includes all the coats of the bowel. The opening of the bov/el is usually situated about in the center of the tumor, and may appear simply as a slit, or it may be circular in outline. The mucous membrane is thrown into irregular folds which surround the prolapse. The mucosa is greatly -hypertrophied, and is often covered with consider- able mucus. Treatment — After examination the prolapse should be care- fully reduced. The incomplete variety may be successfully treated by injections in the same manner as in treating in- ternal hemorrhoids, care being taken to inject the solution well under the mucous membrane. A T bandage should be used during the first stages of treatment to keep the prolapsed part in place. If a polypoid tumor be present, this should be re- moved before any other treatment is tried. When the prolapse is due to hemorrhoids, a divulsion of the sphincters will often DISEASES OF THE RECTUM AND ANUS 9I9 Stop the protrusion, leaving only the hemorrhoids to be treated. In children, prolapse may frequently be cured by strapping the buttocks together with adhesive plaster. The child should be given an enema of warm water and m.ade to have its bowel movement while lying on its side. Should any protrusion occur, it should be immediately replaced. In adults, the wearing of plugs or compresses to support the anus gives only temporary relief, and eventually aggravates the condition. In bad cases of complete prolapse, nothing but a radical sur-. gical operation will give any permanent result. Among the best operations for this condition may be mentioned rectopexy, or suspension of the rectum on the sacrum; excision; and colo- pexy, which consists in anchoring the sigmoid to the parietal peritoneum and abdominal wall. AMiere the prolapse is not very extensive, the condition may be treated just as in a case of hemorrhoids operated on by the clamp and cautery method. Linear cauterization has been beneficial in some instances, but the results are rarely permanent. For the technique of these operations you are referred to the larger text-books on rectal surgery. They should never be attempted by any but a skilled surgeon. STRICTURE OF THE RECTUM Varieties and Etiology. — Stricture of the rectum may be either hereditary, spasmodic, inflammatory, or malignant. The first two varieties are so rarely seen that the inflammatory kind will be the only one considered. Under this heading may be included those produced by simple inflammatory processes, syphilis, and tubercular ulceration. While it is undoubtedly true that many patients suffering from stricture of the rectum are also afflicted with syphilis,- yet it is rarely that the stricture cambe directly proved to be caused by the specific infection ; more often the beginning of the trouble can be traced to some acute 920 THE GASTRO-INTESTINAL CLINIC or chronic infection involving the deeper coats of the bowel. Inflammation of the mucous membrane alone is not known to be followed by stricture, as it is probably necessary to have the submucous and muscular coats involved before this process is set up. The primary inflammation is followed by a plastic exudate beneath the mucosa which finally becomes organized or transformed into fibrous tissue, and it is the secondary con- traction of this fibrous tissue that produces the stricture. As- sociated with the stricture we nearly always have ulceration of the mucous membrane, usually most pronounced at the upper and lower margins of the stricture, and accompanied by a more or less copious discharge of mucus and pus, with sometimes a trace of blood. If the ulceration is extensive, very serious hemorrhages may be produced. As the result of ulceration, submucous abscesses are often formed, resulting in the produc- tion of one or more fistulas. Symptoms — A patient afflicted with stricture usually gives a history of a preceding rectal inflammation, with more or less pronounced symptoms, such as pain, diarrhea, dysentery, tenes- mus ; with the presence of pus or blood, followed, after the acute symptoms have subsided, by a gradually increasing con- stipation, until finally the patient has to rely on the use of laxa- tives or enemas to obtain any movement of the bowels. Oc- casionally, in place of constipation there may exist a constant teasing diarrhea, with a general feeling, as Tuttle describes it, of " unfinished business." Along with the obstructive symp- toms, there may be associated those of ulceration and sup- puration. Diagnosis — If the stricture is in the lower portion of the rectum, the diagnosis can be made by digital examination, while, if it is in the upper rectum or sigmoid, the use of a rectal bougie or proctoscope maybe necessary to confirm the diagnosis. Care should be used in passing any instrument through the stricture, not to use any force, as the tissue is often very friable, and much damage may result. Treatment — The radical cure of stricture of the rectum is DISEASES OF THE RECTUM AND ANUS 92 1 often so disappointing and unsatisfactory that I believe we are justified in adopting a very conservative course, performing the more extensive operations only after all other expedients have failed. Enemas, especially when used by the patient, frequently in- crease the irritation and ulceration. The persistent use of saline laxatives often increases the local tenderness. By far the most effective and soothing laxative is simple castor oil, and the sooner the patient contracts the habit of using it the better. Many of the symptoms can be relieved by gradual dilatation of the stricture with bougies, especially if the treatment is con- tinued for a long period of time, months or even years. The dilatation should be practiced once or twice a week, and after the ulceration has been controlled, and the stricture well di- lated, the periods between treatments may be increased. The application of pure nitrate of silver to the ulcerated surfaces, followed by an irrigation with warm, normal salt solution is often beneficial. In some cases it is well to paint the whole surface of the stricture with Lugol's solution of iodine (Liq. iodi. comp.). A very satisfactory sound for gradual dilatation of a stric- ture is the Kelly dilator for the female urethra an illustration Fig. 103. — Kelly's dilator for female urethra. of which is shown. Care should be exercised not to. exert much force in passing any sound in the rectum, as it is very easy to perforate or tear the rectal wall. One of the safest instruments for dilatation is a soft rubber Wales bougie. If, in spite of' all treatment the stricture continues to contract, and the obstructive and ulcerative symptoms increase, radical surgical treatment should be advised. Rapid dilatation under anaesthesia often results disastrously from tearing, followed by 922 THE GASTRO-IXTESTINAL CLINIC serious hemorrhage or secondary infection. Simple division of the stricture, or internal proctotomy, is apt to be followed by infection due to insufficient drainage. Fairly good results may be obtained by performing a complete posterior linear proc- totomy, dividing the stricture and carrying the incision through the internal and external sphincters and well back to the tip of the coccyx on the skin surface. Incontinence rarely results, and the danger of infection is very slight. After all of these operations the dilatation must be kept up, as the tendency of the cicatrices to contract persists. Excision of the stricture has so often been followed by a second and much \vorse contrac- tion, that it is a question if the operation is really indicated. Where the obstruction is so great as to endanger the patient's life, permanent coJostoni}' should be immediately performed. In conjunction- with the local treatment the patient's gen- eral health should be kept up. In specific cases, the iodides are to be used as indicated, but they appear to have no effect on the local condition. In tubercular cases, tonics and intestinal antiseptics are indicated. Stricture or obstruction caused by malignant disease will be discussed under that heading. ULCERATIONS OF THE RECTUM Ulcerations of the rectal mucosa are of frequent occurrence, and conform in many instances to the types found throughout the intestinal tract above, especially to those forms involving the colon. Varieties and Etiology. — The most common types are those due to acute catarrhal proctitis, tuberculosis, and dysentery. The ulcerations which are confined more particularly to the rectum are the venereal, the diphtheritic, and the erosions due to stricture. In the hemorrhoidal area quite extensive ulcera- tion may be produced by strangulation or thrombosis of in- ternal hemorrhoids, or from the application or injection of caustic solutions. ^ DISEASES OF THE RECTUM AND ANUS 923 The symptoms of rectal ulceration are rather indefinite, usu- ally assuming the form of vague uneasiness in the rectum, little or no pain, accompanied by a frequent desire to go to stool, es- pecially during the day when the patient is on his feet. If the ulceration is situated near the anal margin, there is usually considerable pain, with marked spasm of the sphincter often associated with constipation, the constipation being probably secondary to the sphincterismus. The stools are often mixed with mucus, pus, and blood. \Mth the aid of the proctoscope, the ulcers should be carefully examined, and either some of the discharge or a scraping from the floor of the ulcer should be ob- tained for bacteriologic examination. The treatment, in conjunction with such internal medication as may be indicated by the systemic condition, should include a daily irrigation of the rectum with antiseptic or soothing solu- tions. A warm, normal salt solution will often be found bene- ficial, or we may employ a solution of boric acid, gr, 5 to oi- Where there is much tenesmus, the injection of olive oil, with or without bismuth subnitrate, or an injection of starch water, will be found ver}^ soothing. The local application of nitrate of silver or iodine to the ulcers will often stimulate them and pro- duce a cure. AVhen there is much pain and sphincterismus a divulsion of the' sphincters will relieve the distressing symp- toms. The introduction of a suppository containing 3 minims of ichthyol, used three or four times a day, is a valuable pro- cedure. BENIGN TUMORS OF THE RECTUM Benign tumors are frequently encountered in the rectum, and may conform to any of the histologic forms found in other portions of the anatomy, such as the mucous, lipomatous, or fibroid variety. The tumor most frequently seen is the polyp, or pedunculated growth, which may be made up of any of the above histologic elements. The mucous polyp is of most fre- quent occurrence, and may be found either in children or adults. These tumors are said to develop from an enlarged or 924 THE GASTRO-INTESTINAL CLINIC hypertrophied solitai-y follicle in the rectum, which, from ir- ritation and traction, has caused an elongation of the mucous membrane, thus forming a distinct pedicle. They usually take their origin at a point from one to four inches above the anal margin, although they may be found located in the sigmoid flexure or above. The symptoms of polyp of the rectum are usually a sense of fullness or of a foreign body in the rectum, a frequent desire to go to stool, attended at times with the passage of consider- able mucus, and an occasional history of repeated hemorrhage. If the pedicle is very long, or the growth situated low down in the rectum, the tumor may protrude at stool. In these cases there is apt to be associated spasm of the sphincters resulting in considerable pain. The diagnosis is easily verified upon digital examination, when a movable growth attached by a pedicle can be readily made out. By pressing the growth firmly against the rectal wall under the index finger, it may frequently be delivered through the anus. If the growth is situated beyond the reach of the finger, it may usually be seen with the aid of a procto- scope, especially after the rectum has been well inflated with air. The treatment of this variety is quite simple, and when the pedicle is small, consists in seizing it with two hemostats, when the whole growth may be removed by slowly twist- ing the distal hemostat while holding the other firmly. If the pedicle is thick, it is safer to ligate first either by a simple liga- ture, or else by transfixing the pedicle and ligating in two halves. If general anaesthesia is used, the pedicle may be seized with a hemorrhoidal clamp, the polyp cut ofT close to the clamp, and the stump cauterized with a Paquelin cautery. The rectum should be irrigated daily for about a week with a mild antiseptic solution, when the stump will usually be found to be healed. When multiple adenomas or large villous tumors are found in the rectum, because of their proneness to be followed by malig- DISEASES OF THE RECTUM AND ANUS 925 nant degeneration, nothing short of the most radical surgery should be thought of, and the case should be at once placed in the hands of a skilled surgeon for operation. For the differ- ential diagnosis of these rarer and more serious forms of tumor, the reader must be referred to the larger text-books bearing on this subject. It is a good plan, after the removal of any tumor from the rectum, benign or otherwise, to have the patient report for a rectal examination at regular intervals of from three to six months. Were this method a routine one, there is no doubt but that the percentage of inoperable cases of malignant dis- ease would be much smaller. MALIGNANT TUMORS The great increase in the past few years of the mortality from malignant disease renders the diagnosis of this condition, when involving the rectum, one of great importance. Again, the uniformly fatal termination of these cases, except when a radical operation has been performed early, renders the neces- sity of making the diagnosis in an early stage of the disease imperative. These tumors may be divided into two great classes, carcinoma of the epithelial type, and sarcoma, or tumors in which the morphologic constituents conform to the connective-tissue type. Varieties. — Of the first class of neoplasms, we recognize four varieties : Epitheliomatous, adenoid, medullary, and scirrhous cancers. The most malignant variety is the medullary, while scirrhus may persist for a long period, months, or even years, before causing death. Epithelioma is most frequently found on the skin surface at the margin of the anus, while scirrhus is usually located in the sigmoid or upper rectum. The remaining two varieties are usually met with in the rectum proper. The aetiology of carcinoma is yet in doubt. Age can hardly be claimed as a markedly predisposing factor, as we fre- quently come in contact with the disease in very early adult 926 THE GASTRO-INTESTINAL CLINIC life. Heredity may be a factor, but, aside from accounting for a lowered power of resistance of tlie tissues to this (probably) special infection, its influence seems problematic. It will likely be found that, as the rectum and sigmoid are more often the seats of irritation, ulceration, inflammation, and trau- matism than any other portions of the intestinal tract, they are more often involved in thi^ disease process. The symptoms of beginning carcinoma of the rectum are vague and uncertain, often resembling those of simple ulcera- tion or of benign stricture. They are constipation, a vague sense of uneasiness in the rectum, pains in the pelvis and thighs, flatulence, followed frequently by a mucous diarrhea, often out of proportion to the apparent conditions, and usually worse in the daytime. Early in the disease there may be no apparent alteration in the general health. As the disease progresses the symptoms increase, with gradual loss of weight and strength, increase of mucus complicated by the presence of pus and blood, and a gradual increase in pain. If the growth is low down, near, or involving the anus, the pain increases rapidly. A\^hen the tumor is high up, as in scirrhus of the sigmoid, the ob- structive symptoms will be more pronounced. Only too often the patient has lulled himself into a sense of false security by taking it for granted that his trouble was all due to piles. Too much stress cannot be laid upon the fact that, when a patient complains of a diarrhea that cannot be checked by medication in a few days, a careful digital and proctoscopic examination of the rectum should be made. The diagnosis of carcinoma in the lower four inches of the rectum can usually be made by digital examination alone. The one thing that impresses the examining finger the most is the sense of resistance or infiltration. The finger feels as if it had come in contact with a stone wall, and all the tissues around feel unyielding. This is probably due to the fact that the mu- cous membrane is not movable over the tumor as it is in the early stages of sarcoma. The growth is often more or less lobulated. In epithelioma of the anus there is also consider- DISEASES OF THE RECTUM AND ANUS 92/ able induration attended with ulceration, presenting a raised base and sharply outlined margins and a tendency to scab over. This scab breaks down repeatedly, each time leaving the ulcer larger than before. \Mien the carcinoma involves the upper rectum or sigmoid, the pneumatic proctoscope will render valuable assistance in making the diagnosis. The growth in most cases causes a''stric- ture in the caliber of the gut, but the surface of the stricture will be found intensely inflamed or ulcerated, while in benign stric- ture of the rectum, the surface of the stricture will be found smooth and glistening, the ulcerations being, as a rule, situated above and below it. Enlargement of the pelvic or inguinal lymphatic glands may or may not be present, while in some cases secondary involve- ment of the liver or abdominal viscera may be found. The growth usually surrounds the whole rectum, yet at times it may only involve a small area. To verify the diag- nosis, it is best, if possible, to remove a small portion of the growth for microscopic examination. Treatment — Once the diagnosis has been established, the question of treatment is a very serious one. The case should at once be examined by a competent surgeon to decide as to the advisability of a radical operation. While the ultimate cures from operation are discouragingly few, yet the condition, if left alone, is so absolutely fatal that it is a question whether it is not justifiable to tell the patient his exact condition and al- low him to choose the few chances of surviving an operation (one to four) with a very remote hope of recovery, or to wait for the inevitable termination of the disease when only pallia- tive measures are employed. Except in scirrhus the patient rarely lives over a year or a year and a half without operation, while, even if the growth returns after operation, he has been relieved of many of his symptoms and has had his life prolonged probably from six months to two years or more. Where the growth is manifestly inoperable, or where the pa- tient refuses operation, much good can be done by careful at- 928 THE GASTRO-INTESTINAL CLINIC tention to the patient's diet, feeding him on partially digested and unirritating foods. The bowels should be kept freely open either by castor oil or the use of non-irritating enemas, and the rectum should be freely irrigated daily with a mild anti- septic solution, such as a 5 per cent, solution of boric acid or a 1-2 per cent, to i per cent, carbolic solution. If bleeding is persistent, the growth m.ay be curetted. Since the x-ray has been used in treating malignant tumors, we may hope to gain some benefit from its employment, but it must be confessed that, so far, the results have not been satis- factory, and sufficient time has not elapsed since the cures re- ported to prove anything as to their permanency. MASSEY'S IONIC METHOD BY CATAPHORESIS IN MALIGNANT DISEASE The treatment of malignant disease by mnc-inercury cata- phoresis deserves mention. The method consists in the inser- tion of mercury-coated zinc electrodes into the tumor to be destroyed. When the electric current is turned on, the zinc and mercury undergo electrolytic changes, uniting with the tissues to form soluble salts of these metals. As the result of this electro-chemic action, the tumor and surrounding tissues become decolorized, the tumor itself softens down, and ulti- mately comes away as a sterile, odorless slough. The sur- rounding tissues, acted upon by these salts, offer a zone of pro- tection against metastasis or spread of infection. Dr. G. Betton Massey has kindly furnished me with a brief outline of his technique which is here quoted : " The patient is anaesthetized in the lithotomy position, lying upon a thick, moist pad, under which is the negative or indifferent pole. This pad should cover the whole dorsum of the patient. The sacral region should be protected by a de- flated Kelly pad to prevent short-circuiting of the current. Care should be exercised that no portion of the indifferent plate comes in direct contact with the patient, or a severe burn will result. After etherization, small pointed electrodes of zinc heavily coated with mercury are inserted directly into the tumor, connected with the positive pole of a constant current apparatus with a voltage of from no to 160 volts, and the I DISEASES OF THE RECTUM AND ANUS 929 current is turned on until about 200 milliamperes for each point used is attained. (See illustration.) " The amperage will vary with the size and position of the growth; in the lower rectum, where six or eight points have Fig. 104. — Short electrodes for external use. been inserted at one time, 1600 milliamperes have been used. In the upper rectum, only one long insulated electrode can be employed, allowing the use of from 250 to 350 milliamperes. (See illustration.) " When the current is connected at the point of one electrode, the temperature will have to be controlled by a stream of cold water used at intervals. About everv half-hour the current Fig. 105. — Long rectal electrode for internal use. must be turned off, and a freshly amalgamated electrode in- serted. " During the hour and a half to two hours usually required to sterilize and destroy a large growth, repeated examinations with the finger and miniature lamp will show a progressive softening of the growth and its gradual change to a whitish- gray color. When all portions are softened the current is 930 THE GASTRO-INTESTINAL CLINIC turned off, the electrodes removed, and the patient put to bed. " The after-treatment is purely expectant. Pain rarely lasts over twenty-four hours, and any odor present disappears en- tirely after the application, the slough remaining odorless for some days. When the odor returns, and the sloughs are ready to separate, mild antiseptic douches should be frequently em- ployed. The granulating surface remaining should be kept clean, and mild antiseptic dressings applied. Should the slight- est sign of recurrence appear, repeat the treatment imme- diately." Sarcoma differs from carcinoma of the rectum, in that it in- volves the deeper coats, and the mucous membrane, early in its development, is movable over the tumor. While the growth is dense in structure, it does not have the sense of hardness to touch noticed in carcinoma. Because the mucous membrane is intact, hemorrhage is absent until late in the disease. The growth is often pedunculated, and is more apt to be sharply cir- cumscribed to one portion of the rectal wall. The disease de- velops rapidly, metastasis takes place early, and a fatal termina- tion may be expected in from six months to a year and a half. The only possible treatment consists in early and complete excision of the whole growth. The application of caustics or the incopiplete removal of the growth results only in increasing the malignancy of the condition. During the six years since the first edition of this book ap- peared, Dr. Massey has been making a large use of his ionic method by cataphoresis, with increasing success. In the Am. Jour, of Surg, for March, 1910, he summarized a part of his results reporting a number of cases which have remained well 5, 8, 9, and even 12 years after treatment. These results seem striking enough to attract wide attention from the profession, especially since a majority of the cases are said to have been found previously inoperable. See page 928 for the author's description of the method. LECTURE LXXX BACTERIA AND ANIMAL PARASITES IN THE GASTRO-INTESTINAL TRACT The presence of bacteria in the gastro-intestinal tract is of double significance. Not only may many of them produce specific lesions and cause disease, but even the saprophytic bacteria may bring about changes in the food stuffs resulting in the elaboration of highly poisonous ptomaines which, when absorbed, give rise to the well-known conditions of auto-intoxi- cation. Indeed, many of the symptoms accompanying gastro- intestinal derangements are due to the effect of these subtle poisans on the nervous system. When it is remembered that the gastro-intestinal mucosa is really an internal cutaneous surface, and, like the skin, forms a barrier to the entrance of micro-organisms, it is not surprising that bacteria may thrive in the normal gastro-intestinal tract without producing any serious harm ; but let there arise an abnormal condition in the mucous membrane, let there occur a locus minoris resistantice, and bacteria hitherto harmless invade the injured mucosa and produce disease. In the case of dilatation, or atony, the stagnation of the food favors the multiplication of putre- factive bacteria and consequent formation of poisonous pto- maines. The constant presence of bacteria in the normal intestines has led some authorities to the conclusion that many of them are concerned in the process of digestion. This view, how- ever, is hardly tenable. Aside from the fact that repeated ex- periments on animals have demonstrated that digestion can be carried on in the absence of micro-organisms, the proposition that bacteria are necessary adjuncts in the process of digestion is contrary to our physiologic conceptions. One might as well 931 932 THE GASTRO-INTESTINAL CLINIC argue that artificial ferments are necessary in health to aid di- gestion ; yet we know that, under normal conditions, the gastro- intestinal ferments digest just as much food as is needful for perfect nutrition, and excess of digestion would tax unduly the absorptive and eliminative organs, and lead to disturbed as- similation. Besides, under normal conditions, the motility of the stomach and small intestines does not give the bacteria time enough to act with sufficient force. Whatever changes in the undigested food the intestinal bacteria may and do pro- duce, such as the formation of indol, skatol, and various gases, such changes are secondary and unessential, and are only toler- ated by the organism to a certain limited extent. The bacteria which invade the gastro-intestinal tract, coming as they do from the outside world, represent the various groups, as cocci, bacilli, spirilla, sarcinse, etc. Many of them cannot be cultivated on any of our artificial media, and our knowledge concerning them is therefore incomplete. In the mouth Miller isolated about 30 species. Of these, Leptothrix innominata. Bacillus buccalis maximus, Leptothrix buccalis maxima, lodococcus vaginatus, Spirillum sputigenum, and Spirochseta dentium are normal inhabitants, though all are non-pathogenic. Of the pathogenic micro-organisms, many occur in the healthy mouth without producing disease. Thus streptococci, staphylococci, pneumococci, micrococcus tetra- genes, and even diphtheria bacilli may be present in the mouths of perfectly healthy individuals. It is noteworthy that the pneumococcus was first isolated by Pasteur from the saliva of a boy suffering from rabies, and by Sternberg from his own sa- liva. The presence of pathogenic bacteria in the mouths of healthy individuals is explained by the assumption that such individuals possess, for the time being, a natural or acquired immunity from the particular affections the specific germs of which happen to gain access. Other micro-organisms pathogenic to animals have been, from time to time, isolated from the saliva, and while not distinctly pathogenic to man, such organisms may produce BACTERIA^ ETC.^ IN THE GASTRO-INTESTINAL TRACT 933 divers affections of the gums and teeth. It is beheved by some investigators that the saHva exerts an antiseptic action on pathogenic bacteria. In the stomach only a few bacteria are found under normal conditions, this, no doubt, being due to the antiseptic action of the gastric juice, aided by the frequent emptying of that viscus. However, certain yeasts and yellow sarcinas are found, and many bacteria, especially those producing acid fermenta- tion, will thrive in the stomach, even in the presence of ex- cessive amounts of HCl. Pathogenic bacteria are more sus- ceptible to the action of HCl, but even they will escape unin- jured, being protected by the bolus of food. Under abnormal conditions, such as deficiency of HCl or stenosis, with de- creased motility and in dilatation, numerous bacteria may be found in the stomach. Many of them cause fermentation and putrefaction, and it is to these changes in the gastric contents that many of the symptoms accompanying these affections are due. The Oppler-Boas bacillus, an unusually long, non-motile micro-organism, is claimed by its discoverers to be constantly present in gastric cancer. Its presence, however, is not path- ognomonic of that affection. In the intestinal tract, B. coli communis, B. lactis erogenes, B. putrificus coli, and Streptococcus coli gracilis are perma- nent inhabitants. B. erogenes capsulatus, B. butyricus, and numerous other micro-organisms may be temporarily present. It is to be remembered, however, that the bile, to some extent, and in all probability the intestinal secretions, exert an anti- septic action on bacteria, and many micro-organisms found in the feces are dead. This, in part, accounts for the failure to cultivate some of the bacteria which are observed in the feces on direct microscopic examination. Of the pathogenic va- rieties, B. typhosus is present early in typhoid fever ; B. tuber- culosis, in intestinal tuberculosis ; B. anthracis, in intestinal an- thrax; B. dysentericus, in dysentery; Spirillum cholerse asi- aticse, in cholera; Spirillum Finkler-Priori possibly, in cholera nostras, and B. botulinus, in meat poisoning. The importance 934 THE GASTRO-INTESTINAL CLINIC of carefully disinfecting the stools in all these affections be- comes self-evident. The bacteria of the gastro-intestinal tract are derived from the air and food. Those from the air are lodged in the mouth and find their way into the stomach and intestines with the saliva and the food. While in this way pathogenic bacteria may gain entrance and set up specific lesions in the stomach or intestines, the much more serious danger lies in the ingestion of pathogenic bacteria contained in food. It is a matter of common experience that typhoid and tubercle bacilli may be transmitted through milk, and the latter micro-organism may be also contained in the meat from tuberculous animals. Milk, on account of its being a most suitable culture medium, is es- pecially prone to contain fermentative as well as pathogenic bacteria. Investigations carried on in New York, Philadel- phia, and other cities disclosed a most deplorable condition of the milk supply of large cities. Aside from pathogenic bac- teria, which such milk may and in many cases does contain, the micro-organisms commonly found in polluted milk are capable of producing synthetic changes in the milk, rendering it injurious to babies and invalids. The pity of it is that pas- teurization does not destroy spores, and boiling changes the character of the milk to such an extent as to- render it some- what less digestible. Meat may contain putrefactive bacteria, tubercle bacilli, or the ova of animal parasites. Uncooked fruit and vegetables may be the carriers of patho- genic and putrefactive bacteria, and it is frequently in this way that disease is contracted. Fish, especially shell fish, may carry' the typhoid bacillus or putrefactive bacteria derived from sewage-polluted beds. Water, when polluted with sewage, may contain the typhoid bacillus, the cholera spirilKuPi (in times of an epidemic of cholera), the bacillus of dysentery, and other micro-organisms still unidentified, which produce digestive disturbances and diarrheal diseases. It is thus seen that the harmful bacteria found in the gastro- BACTERIA, ETC., IN THE GASTRO-INTESTINAL TRACT 935 intestinal tract are derived from food and drink, and it be- hooves us to guard most zealously against contamination of the food taken by the well, and more especially by the sick and feeble. As a corollary to the subject under consideration, the ques- tion of intestinal antiseptics may be taken up. The antiseptics provided by nature are the HCl of the gastric juice, possibly the bile, and probably other secretions, the existence of which we can only suppose a priori. However, as already mentioned,, even these natural antiseptics have their limitations, for the hardier micro-organisms are not affected by them. In the case of the gastric juice, it is only the free and not the combined HCl which exerts any antiseptic action at all. Moreover, natural antiseptics are biologic in nature, and act in minute quantities. How different is the case with arti- ficial chemical antiseptics. In the first place, they are all un- stable organic compounds, and they may undergo such changes . in the gastro-intestinal tract as to have completely altered their properties. In the second place, they are diluted by the food and gastro-intestinal secretions to such an extent as to render them practically inert, and if employed in sufficient concentra- tion, act injuriously, not only on the bacteria, but also on the se- creting cells. It therefore appears irrational to depend much on intestinal antiseptics, the ever-increasing number of which in itself proves their comparative worthlessness. It would seem far more rational to prevent the entrance of harmful bacteria into the gastro-intestinal tract, than to permit them to enter into the deep recesses of our internal anatomy, and then hunt them down with yard-long synthetic formulae. The animal parasites which are found in the gastro-intestinal tract, and which may be productive of diseases of these organs, are protozoa and vermes. Of the former, the Amoeba coli, a unicellular animal organism, is concerned in the production of tropical dysentery and hepatic abscesses. However, later in- vestigations by Shiga (of Japan), Kruse (of Germany), Flex- ner and his pupils, Vedder and Duval, in this country, have 936 THE GASTRO-INTESTINAL CLINIC shown that certain cases of sporadic and epidemic dysentery are caused by a specific bacillus, first isolated and described by Shiga. Another protozoan belonging to the Ciliata, Balan- tidium coli, causes severe diarrhea. In all nine different bacilli have been recognized as causes of the numerous cases of"' dysentery observed among the returning pilgrims at Tor, Egypt. The vermes, Cestoda and Nematoda, are commonly found in the intestinal tract. They cause pathologic changes, either me- chanically, by occluding cavities, producing obstruction, or chemically, by generating irritating poisons. In the case of the tapeworm, the large size of the parasite, which obtains its food by absorption, may interfere with nutrition; the tape- worm, Bothriocephalus latus, producing in addition a systemic poison. The round worms are extremely irritating, and diar- rhea, vomiting, and other gastro-intestinal disturbances are the result of their irritating action. The seat- worm, on account of its very irritating properties and migratory habits, is liable to lead to masturbation, either by direct irrita- tion of the genitals, or by indirect reflex irritation of the anus. Recently, Metchnikoff advanced the theory that the Nematoda, or round worms, are frequently the cause of appendicitis, which they are said to produce by irritating the appendix and favor- ing bacterial infection. This theory seems to be supported by his own observations, as well as the experience of some other observers, although the subject has been investigated by a number of men who failed to substantiate it. The vermes, which may be found in the intestinal tract, are Ascaris lumbri- coides, Oxyuris vermicularis, Trichocephalus dispar, Anky- lostoma duodenale. Tenia solium, Tenia saginata, and Both- riocephalus latus. They are considered more in detail in the following section. THE INTESTINAL PARASITES These are described with sufficient fullness in most of the text-books on Practice, but a brief account of them will be in place here. The diagnosis of worms should rest on one thing BACTERIA, ETC., IN THE GASTRO-INTESTINAL TRACT gT,^ only, and that is the finding of either the worms or their eggs in the feces. Intestinal parasites act primarily as irritants, and the symptoms of reflex irritation do not, as a rule, differ from those produced by any other irritant. Moreover, the symp- toms are extremely variable, and lack altogether in uniformity or constancy, except in the case of ankylostoma duodenale. Between 'pruritus ani, or the irritation due to pinworms, and severe digestive disturbances caused by tapeworms, there is a variety of conditions produced by the various parasites, con- ditions in no way differing from those due to other factors. To make a diagnosis of worms without a careful examination of the feces, is to do the patient harm by mistaking the true setiologic factor involved. In cases of persistent symptoms referable either to the nerv- ous or digestive system, especially in children, you should think of worms and look for them. In all such suspicious cases, in- struct the patient to evacuate his or her bowels in a vessel partly filled with tepid water, and then carefully examine each evacuation for anything which looks like worms. As a rule, any layman will detect readily a roundworm or a tapeworm, though mucus is sometimes mistaken for them, nor does the detection of oxyuris or pinworms present much difficulty. The suspected worm, if found, should be placed in a bottle contain- ing alcohol or formalin for further examination. The Principal Varieties of Tapeworms, etc. — The identifi- cation of the adult parasite presents little difficulty. Of the more common ones, the tapeworm, the round worm, and the threadworm, are of interest in this country. Of the tapeworm (cestodes) the Tenia solium and Tenia medio- canellata or saginata are the most prevalent varieties, while the Tenia echinococcus is comparatively rare, and the bothriocepha- lus latus is only found in European immigrants, especially those coming from Switzerland, Germany, and the Baltic countries. The T. solium develops in the lower part of the small intes- tines, the infection being derived from insufficiently cooked measly pork, where the parasite exists in the form of encysted 938 THE GASTRO-INTESTINAL CLINIC larvae called cysticerci. The adult worm is distinguished by the proglottides or segments being 8 to lo mm. long, and 6 to 7 mm. broad, and the branchings of the uterus, which are from seven to ten in number and divide peripherally. (See Fig. 106, T. S.) The T. saginata is distinguished by being larger than the preceding. The segments measure 18 mm. by 7 to 9 mm., their number being about 1200 to 1600, The uterus possesses from 20 to 30 branches, which divide dichotomously (Fig. 106, T. Sg.). The segments are frequently evacuated spontaneously, apart from defecation. The bothriocephalus latus is the largest tapeworm in man. It results from eating infected fish, as a rule. Its segments, of which there are from 2400 to 3500, measure 3 to 5 mm. in length and 12 mm. in breadth. The uterus forms a rosette in the middle of the segment. (Fig. 106, B. L-) In order to distinguish the uterus, the segments may be pressed between two slides and held up to the light, or they may be placed in oil of cloves until translucent, and mounted permanently in balsam. It is often important to know whether the head of the para- site has been removed. The heads of the parasites above men- tioned are distinguished by the following characteristics : T. Solium. — The head is about imm. in diameter and fur- nished with a rostellum and 26 booklets, behind which are 4 sucking discs. (Fig. 106, H. T. S.) T. Saginata. — The head is 1.5 to 2.5 mm. in diameter; has neither rostellum nor hooks, and possesses 4 large discs or suckers which are surrounded by a line of pigment. Seg- mentation of the neck cjuite evident. (See Fig. 106, H. T. Sg.) Bothriocephalus latus. — The head is very small and flat, looking like an enlargement of the thin neck. It is marked by two deep furrows or suckers arranged longitudinally. (See Fig. 106, H. B. L.) Of the nematodes, the ascaris lumbricoides and oxyuris ver- micularis (threadworm) are the most common. BACTERIA, ETC., IN THE GASTRO-INTESTINAL TRACT 939 //. 7!5p. H.B.L, BL % i Fig. 106. — The more common intestinal parasites. H.T.Sg., Head of T. Saginata; T.Sg., Segments and, i.sg., egg of T. Saginata; H.T.S., Head, T.S., A I Segments, and, /.J., eggs of T. Solium; B.L., Seg- '*■ ^' ments, H.B.L., Head, and, b.l., egg of Bothrioceph- alus latus; O. V. and 'o.v., Oxyuris vermicularis (male and female) and eggs; A.L. and aj., Ascaris lumbricoides (male and female) and egg; yi./)., Various forms of Amoeba dysenteriae. 940 THE GASTRO-INTESTINAL CLINIC Ascaris lumhricoidcs is represented by both sexes. The male is about 250 mm. and the female about 400 mm. long. The cylindric body tapers toward each end, presenting four longi- tudinal and many cross stripes. It is pale red, the head being slightly different in color. The intestinal canal runs through the entire worm. The female possesses a thread- like twisted double uterus which may contain rnany millions of eggs. Oxyuris verinicularis is a small, white, thread-like w^orm. The male is about 3-4 mm. and the female 8-12 mm. long, the tail of the former being rolled up, while that of the latter is tapering. The mouth end is provided with three lips, and the intestinal canal is straight and in the mid-line. It frequently happens that the adult worms are not found in a particular specimen of feces, and the urgency of the case de- mands an immediate examination, or it may be that the adult forms are not sufficiently numerous to be excreted with the feces in numbers which may be readily detected. Under these circumstances, an effort should be made to detect the eggs in the feces by a careful microscopic examination. Diagnosis of the Ova. — The following differential points will aid in distinguishing the eggs of the various para- sites: T . Solium. — Eggs ovoid, about 35 microns long. They de- velop into the cysticerci cellulosi, which are often found in man. By tearing open the cyst the scolex or larvae may be ob- served on the inner wall. (Fig. 106, t. s.) T. Sagiiiata. — Eggs more oval than T. solium ; possess a thick shell and lining membrane. They develop into cysticerci which do not occur in man. (Fig. 106, t. sg.) Bothriocephahis latus. — Eggs oval, 0.07 mm. long and 0.045 ^^^^- thick. Surrounded by a thin brown shell, the upper pole of which is marked in the form of a lid. In fresh water they develop into a ciliated, freely moving spherical embryo. (Fig. 106, b. 1.) Oxyuris verinicularis. — Eggs oval, 0.05 mm. long, contain- BACTERIA^ ETC.^ IN THE GASTRO-INTESTINAL TRACT 94 1 ing an embryo with a sharp posterior end. The shell is flat- tened on one side, and surrounded by an albuminous substance. (Fig. 106, o. V.) Ascaris lunibricoidcs. — Eggs oval, about twice as large as t-he preceding; possess a thick double shell, surrounded by a layer of an albuminous substance. (Fig. io6, a. 1.) The treatment required for the expulsion of the various kinds of intestinal parasites will be described at the end of the entire section devoted to such parasites. Amoeba Dysenteriae — While dysentery occurring in this country is usually due to some one of various bacilli, includ- ing that isolated and described by Shiga, yet there are also cases of that affection caused by an amoeba. This protozoon may be found in large numbers in the lesions as well as the feces. The latter are best examined when fresh, or at least not over twenty- four hours old. The Amoeba dysenteriae, or more commonly called Amoeba coli, is a round, oval, or irregular protoplasmic body, varying in size from lo to 50 microns. It is pale or faint green in color, refractile, with sharply outlined borders, and contains a large r Fig. 107. — Amoeba coli mitis or vulgaris. (After Rocs.) vacuole, and in some cases a nucleus. The greater central portion of the parasite contains the vacuoles, and is known as the endoplasm ; this is surrounded by a narrow, clear layer, known as ectoplasm. The parasite is, as a rule, actively motile, throwing out psaudopodia. It frequently contains within its endoplasm foreign substances, such as various granules and 942 THE GASTRO-INTESTINAL CLINIC fresh or disintegrated red blood cells. The smear may be stained with alkaline meth3-lene blue for about five minutes and then washed in distilled water. Amoeba dysenteries is distinguished with difficulty from Amoeba coli vulgaris, which is a harmless inhabitant of the human intestines. It is, therefore, well in all cases to cor- roborate the diagnosis by feeding young cats on the feces con- taining the amcjebas. If the amoebae are of the pathogenic variety, dysentery will result in the experimental animals. Amoebic dysentery, the disease produced by this organism, is described in Lecture LXXII. Ankylostotna Duodenale, or Uncinaria Duod This para- site has been comparatively unknown in the 'United States until very recently. It has been long familiar to physicians on the continent of Europe, and has passed in some quarters under the name of Egyptian chlorosis. It is endemic in Egypt and the southern parts of Europe, and prevails chiefly among the men employed in brick yards or tile works, but also, to some extent, among farmers who work much in moist earth. The parasite has, in recent years, been seen in this country among Italians and othgr immigrants from the South of Europe, but a form of it, which is a little smaller, and differs in other respects to some* degree from the foreign type, is now encountered frequently among the negroes and other laborers, as well as the barefooted children in our Southern States, and has been named by Stiles (1902) Uncinaria americana, ac- cording to Henry B. Ward, who contributes the article on Nematoda to the new edition of Wood's " Reference Hand- book," vol. vi., page 205.^ Drs. Herman B. Allyn and M. Behrend contributed to American- Medicine of July 13, 1901, a paper on Ankylosto- miasis in the United States, with report of a case treated by them in the Philadelphia Hospital. Their paper contains an ex- cellent illustration of both the male and female parasite, which, by their courtesy and that of the editor of American Medicine, iSee also Stiles' Bulletin, Bureau Pub. Health and Marine Hosp. Service. Fig. 108. — Ankylostoma duodenale. The larger one at th^ left is the fe- male; A, Head, showing teeth- and glands; B, Esophagus; C, Mouth glands; D, Intestines; E, Genital opening; F, Uterus and oviducts; G, Anal orifice. The figure on the right is the male. The teeth and glands show more distinctly. S, Spermatic ducts containing cells; Z, The bursa copula- trix. (From a paper by Herman B. Allyn and M. Behrend in Am. Mea, of Jnly 13, 1901, By permission.) 944 THE GASTRO-INTESTINAL CLINIC I am permitted to reproduce here. (See illustration, Fig. io8.) I have had made, also, an accurate representation of the ova of Uncinaria americana, which it is even more important that you should be able to recognize, since they may be discovered under the microscope, even when the parasites themselves can- not be found. (See illustration. Fig. 109.) Ward thus describes the well-known Uncinaria duod., or as formerly called most frequently, Ankylostoma duod. : " Body cylindric ; buccal cavity, with two pairs of uncinate ventral teeth, and one pair of dorsal teeth, directed forward; Fig. 109. — Eggs of Uncinaria americana from feces, x. 330. (After Stiles.) dorsal rib not projecting into capsule. Female, 10-18 mm. long, by 0.5-0.6 mm. wide; vulva at or near posterior third of body ; eggs 52 by 32 /^. segmenting when deposited with direct development. Male, 8- 11 mm. long, by 0.4-0.5 mm. wide; caudal bursa, with dorso-medial lobe, dividing at two-thirds the distance from base, each branch being tridigitate, and with prominent lateral lobes united by a ventral lobe ; spicules long, slender." This form of parasite is found in many parts of Europe, Asia, and Africa, as well as in the West Indies, and not in- frequently of late in the United States. BACTERIA^ ETC.^ IN THE GASTRO-INTESTINAL TRACT 945 The Uncinaria americana, described by Stiles and quoted by Ward, presents the following characteristics : Ventral recurved uncinate teeth absent from mouth, one pair prominent dorsal semilunar plates, and an inconspicuous ventral pair being present ; dorsal median conical tooth, pro- jecting prominently into buccal capsule. Female, 9-1 1 mm. long, by 0.31-0.35 mm. wide; vulva near middle of body, but in front of it; eggs (Fig. 109) 64-72 /<, by 36-40 /O seg- menting, or with well-developed embryos when deposited. 'Male, 7-9 mm. long by 0.29-0.31 mm. wide; dorsal ray of caudal bursa divided to the base, each branch bipartite to tip. Species otherwise similar to U. duodenalis. Symptoms of Ankylosfoma, etc. — The chief S}TTiptoms are anaemia and debility, which are often very marked and are caused by the blood-sucking habit of the parasite ; also certain ofastro-intestinal disturbances. The red-blood cells ha^-e some- times fallen below 1,000,000. These include especially nausea with often vomiting, flatulence, constipation, or diarrhea, se- vere gastric or colicky pain, and marked changes in appetite. There -are likely to be also dyspnoea, vertigo, dropsy of the lower limbs, cold hands and feet, and occasionally hemorrhages. Afternoon fever may sometimes be observed, and extreme drowsiness may develop. There is occasionally leucocytosis, and almost invariably marked eosinophilia. Pathologically the disease causes the changes to be expected from a long and severe anaemia, with much congestion and evidences of hemorrhage in the intestinal mucosa. The heart is often enlarged. The diagnosis turns upon the observance of the above- described symptoms in connection with the presence of either the parasite or its characteristic ova in the evacuations. The prognosis of ankylostoma duod. is good if appropriate treatment is begun early, and in persons not infested with too great a number of the parasites. Otherwise, it runs a pro- longed and serious course and often terminates fatally. Treatment of Ankylostoma duod. — Any of the remedies for tapeworm may be hopefully employed, but the greatest success 94^ THE GASTRO-IXTESTINAL CLINIC has been achieved with thymol, and with the male fern. Allyn and Behrend report favorably of thymol, lo to 30 grns. in water at 8 a. m. (fasting-) and repeated at 10 a. m.^ followed in two hours by castor oil, or Epsom salt. Treatment of Tenia, Round and Seat Worms. — In the treat- ment of tapczi'onn, regardless of the variety, the most success- ful method has been found to be the following : First, to empty the alimentary canal by purgatives, then limit the diet strictly to a few very simple articles for one day. The Germans insist that it is well to select for this special pre- liminary diet articles of food which are believed to act in- juriously upon the worm. These include onions and garlic, with salt herring, all chopped finely and mixed into a form of salad. Striimpell attributes to strawberries, cranberries, and bilberries a similar disturbing action upon the parasite. After the preliminary evacuations of the bowels and such a diet as above mentioned for one day, some writers advise evacuating the bowels again at bedtime, and then the next morning to take no food whatever, unless it be a cup of black coffee, which, however, may be sweetened, — though the maximum doses of male fern are safer after a meal. Then, it is in order to admin- ister the special teniafuge or teniacide. There are a number of such remedies which have been employed with success. These include the ethereal extract or oleof esin of male fern, which you may give in doses of f 3 ss. to f 3 ii, though the Germans carry the dosage as high as f 3 iiss., especially for tenia solium; koosso, in the form usually of an infusion, one-half ounce of the dried flowers in a pint of water ; tannate of pelletierine in doses of 5 to 10 grains, usually effective, but very expensive; infusion of pomegranate, 2 to 3 ounces of the bark in a pint of water; and last, but by no means least, a mixture of pumpkin seeds chopped up finely with sugar. Of the last-mentioned mixture as much as a teacupful may be given to adults, and in propor- tion to children. It is a safe and not very unpleasant remedy to take, and often efficient. Another remedy recently recom- mended, concerning which I have had no experience, is the oil BACTERIA_, ETC.^ IN THE GASTRO-INTESTINAL TRACT 947 of pine needles, given in half-dram doses, either in a capsule or in emulsion. These remedies usually either kill or benumb the worm so that a brisk cathartic, given two to three hours later, effects its expulsion. In some instances, only a part of the parasite is thus expelled, and, if the head should be retained, it soon reproduces itself. Hence the importance of the directions already given in this lecture for passing the stools after such a treatment into tepid water so that it may be readily determined whether the entire worm, including the head, has been removed. Tapeworm remedies need to be fresh and fully active in order to succeed. Probably the most successful of all the different remedies is the male fern — filix mas — and a very efficient and convenient way of administering it is in capsules, on account of its un- pleasant taste. It is especially eft'ective when given in milk, which tapeworms prefer as a food. The drug is not entirely safe, and cases of poisoning from it are on record, one of them fatal ; but it is believed that the lethal result was in consequence of the fact that castor oil was administered with it, thus greatly increasing its absorption into the system. No cathartic should be administered with it, but two hours after it some other one than castor oil. ' ^Mlenever, in any case, the examination shows that the head of the parasite has not been passed, there will be reason to ex- pect a recurrence of all the symptoms in a short time ; but it is better to wait until evidences appear that the worm has re- produced itself before repeating the administration of remedies to expel it.° To repeat the violent course of remedies required to expel a tapeworm within a few days is never desirable, and it is particularly -unsafe to repeat- so soon a full dose of male fern. In the frcafincut of round zcornis santonin is the only drug that need be considered. Half-grain doses of it are prepared in troches, which are now official in the United States Phar- macopeia. For a child under two years, one of these, or the same dose as a powder with sugar, may be given at night, and 948 THE GASTRO-INTESTINAL CLINIC again the next morning", upon an empty stomach, followed an hour later by a dose of castor oil, rhubarb, or calomel. A child five years old will need doses of one grain, and adults from 3 to 4 grains, administered in the same way. The effect of all anthelmintics is much enhanced by restrain- ing the patient to the simplest, and preferably liquid, food for a few days, before the remedy is begun, and you should see to it that during the same time the bowels are especially open — that there are at least two soft or liquid stools daily. Tlic treatment of seat- or thread-zvornis requires the fre- quent irrigation of the colon with some mild disinfectant so- lution — it matters little what one, so that it be mild enough not to irritate the mucosa. An infusion of quassia or simple olive oil injected every few days for several weeks has often succeeded in my own experience. In female children es- pecially it is well to have a few grains of zinc ointment, or un- guentum hydrargyri cinerei, smeared about the anus once a day, to prevent the migration of the worms into the vagina. Weak solutions of quinine, or boracic acid, etc., have also proved effective. In stubborn cases the administration of santonin has been recommended as directed for round worms. Whitaker,^ how- ever, doubts the efficiency of any remedies administered by the mouth, but insists that enemas of soapy water, after a pre- liminary irrigation to empty the colon completely, are as ef- ficient as any other. He advises one such enema every week for three weeks. Since- the worms inhabit the upper colon and cecum, as well as the rectum, it is important that the enemas should be caused to pass entirely through the colon, and this is best effected by having the patient either in the knee-chest position during the injection, or lying on the left side for a short time at first, and afterward on the right side. ' Wood's " Reference Handbook," vol. vii, p. 794, New York, 1889. BACTERIA_, ETC.^ IN THE GASTRO-INTESTINAL TRACT 949 TRICHINA SPIRALIS AND TRICHOCEPHALUS DISPAR Trichina occurs frequently in pork — very rarely in the meat of other animals. It exists in two forms or stages of its de- velopment : ( I ) in a sexually mature form, when its habitat is the»intestine, and (2) in a larval or immature form, when it is found in the muscles, usually encapsulated. When portions of meat containing the encapsulated larvae of trichinae are eaten, the latter are liberated within a few hours after reaching the stomach, by the opening of the capsules, and develop with great rapidity. By the end of forty to forty-eight hours the imma- ture larvae have fully matured in the intestine, and impregnation of the females takes place. The birth of a new progeny occurs by the end of a week from impregnation, and in two weeks more the embryos have migrated from the intestine to the muscles of the infected person. The fully developed female trichinae are 3 to 4 mm. long, while the males are only half so long. At this stage the para- site can be seen by the unaided eye. Illustrations of trichinae are shown on page 950. Trichinosis is the name given to the acute febrile disease produced by these parasites. It is rather a disease of the mus- cles than of the gastro-intestinal tract, and therefore shall be only briefly considered here. However, a few days after eat- ing meat infected with trichinae, the victim is likely to com- plain of certain indigestion symptoms — loss of appetite, nausea, vomiting, and diarrhea, with usually pain of a colicky kind, besides much flatulency. By the end of a few days, or a week after the larvae have reached the muscles, there is de- veloped fever with pains, and usually decided stiffness in the muscles as the predominant symptoms. There is marked eosinophilia during the acute stage, and possibly bronchitis, and pneumonia. Involvement of the respiratory muscles causes a marked form of dyspnoea. When the infection is severe, and the fever high, there is often delirium. Some- times oedema of the face and eyelids is an early symptom. 950 THE GASTRO-INTESTINAL CLINIC The diagnosis must be made from typhoid fever, muscular rheumatism, etc., and may be established with an approxima- tion to positiveness in marked cases by the oedema and the mus- cular symptoms — pain and stiffness — especially when dyspnoea ^ •J' •'^ Fig, ho. — Trichina spiralis (after Leuckardt); a, female; b, male of intestinal trichina; c, muscle-trichinae in capsule. results from involvement of the respiratory muscles; but the recognition of the parasite in a piece of excised muscle affords the "only certain evidence of the disease, except when the adult trichiucie can be found in the stools. The mortality from the disease differs widely in different epidemics — from o to 30 per cent. Treatmeyit. — Meat, especially pork, should never be eaten raw, or insufficiently cooked, if trichinae and teniae, as well as BACTERIA^ ETC.^ IN THE GASTEO-INTESTINAL TRACT 95 1 Other parasites which infest the flesh of animals, are to be avoided. For the curative treatment of an attack of trichinosis at an early stage, while there is still a probability that a part of the parasites remain in the intestines, the most effective method is prompt and energetic cleansing of the alimentary canal by purgatives and colon douches, followed by full doses of intesti- nal antiseptics. Santonin, also, has often proved effective. When the migration is over, and the muscles have been fully infected, there is little to be done, except to sustain the strength and vital powers in every way possible. Meanwhile you will, Z^ Fig. III. — Trichocephalus dispar. (From " Krankheiten des Darms u. des Bauchfells," von Prof. Dr. C. A. Ewald.) of course, alleviate the pain and insomnia by anodynes and emollient local applications. The open-air treatment, now uni- versally recommended and largely employed for tuberculosis, will add much to the patient's chances in the combat with such an inaccessible enemy, and moderate tonic doses of quinine, iron, etc., are beneficial. Trichocephalus Dispar. — This parasite frequently occurs in the cecum or adjacent parts of the intestine, but produces usu- ally few or no symptoms. Ewald speaks of it as harmless, though other authors^ mention that diarrhea, or reflex nervous symptoms, may sometimes result from its presence in man. In- fection is caused by taking the eggs in uncooked food or in 952 THE GASTRO-INTESTINAL CLINIC water. Raw fruit, lettuce, and other green vegetables are es- pecially liable to convey them into the alimentary canal unless carefully washed. The parasite is 4 to 5 cm. long. It is shown in the illustra- tion on page 943, the two smaller figures, to the right of the large one, representing the worm, life-size. *The ova, which are not killed by either cold or drying, are of a peculiar oval, with a knobbed projection at either end. Fig. 112. — Ovum of Trichocephalus dispar. They are about 50 f^ long, of a brown color, and have a hard shell. They develop in wet earth or water, but very slowly^ — in several months. An illustration of one of them is here given. The trichocephalus dispar, or more frequently its eggs, may be recognized in the stools by a careful microscopic examina- tion. It is seldom, however, that the wonns themselves can be found in the stools. As to treatment, various anthelmintics and teniafuges have been used successfully. Male fern and thymol internally are especially recommended. Douches of the colon with antiseptic solutions are useful adjuvants. LECTURE LXXXI GASTRO^INTESTINAL AFFECTIONS IN RELATION TO OTHER DISEASES A FULL and adequate discussion of the interrelations be- tween the gastro-intestinal tract and other organs or systems, as to their functions and diseases, would fill a large volume alone. But they call for some consideration here, even though it must be less extended than the subject demands. We know that in many febrile affections, and as a rule in high fever from any cause, the digestion is disturbed, the ap- petite is impaired, and the tongue heavily coated; constipation or diarrhea develops in most cases, and nausea and vomiting may occur at times as complications. In the advanced stages of most organic diseases the digestive functions are likely to be markedly lowered, and in certain affections of the skin, in- cluding nearly all those not dependent upon local irritations or general exogenous infections, the intestinal digestion espe- cially is usually impaired and the metabolism deranged. We know, too, that derangements of the functions of digestion and assimilation affect directly or indirectly all the other functions of the body. Thus mu^ch can be said with a good degree of certainty, but when we go further and seek for a definite relation between the diseases of other organs and the amount of secretion or degree of motor power in the stomach, as has been done, we often meet with disappointment. No such uniform relation has been demonstrated to exist be- tween any of the gastro-intestinal functions and the different general or local diseases involving other parts, especially as re- gards the influence of these diseases upon such functions. The nearest approach to such uniformity is the tendency of 953 954 THE GASTRO-INTESTINAL CLINIC advanced disease in the heart and arteries to lower both the secretory and motor fnnctions of the digestive organs; and also the tendency of movable kidney as well as some of the other ptoses, gall-bladder affections, etc., to excite the gastric glands and cause hyperchlorhydria reflexly. Again defeca- tion is likely to be disturbed in either one way or the other in nearly every serious general disease, as well as in a large pro- portion of the local ones, and most frequently by depressing it, producing constipation. Diarrhea is more common in typhoid fever and in some of the more severe forms of sep- ticaemia, and often results secondarily from the irritation pro- duced by hard fecal masses in chronic constipation. The foregoing general statement must suffice with regard to the relation of most other diseases to those of the stomach and intestines and to the functions of the digestive system. However, the relation of the maladies of a few of the prin- cipal organs and systems to the digestive functions deserves special mention. ANiEMIA AND CHLOROSIS The results of experiments and observations are scarcely more uniform here. Influence of Displacements of the Viscera upon the Blood. — There is, however, a preponderance of evidence to the fact that chlorosis is unusually prevalent in girls who have displace- ments of the stomach or other viscera — gastroptosis, or splanchnoptosis. In these cases there should certainly be a particularly careful examination of the abdomen to determine the position of the viscera, so that displacements may be remedied. But in chlorosis, too, the proportion of HCl may vary much and be normal, excessive, or deficient. Riegel con- siders that in simple chlorosis the secretion and motor power of the stomach are not as a rule decreased — more frequently, in- deed, increased. On the other hand, in the anaemias, although here also the RELATION OF GASTRO-INTESTINAL TO OTHER DISEASES 955 findings have been various, and no uniform rule holds, there is a rather greater probability that the production of HCl will be diminished, especially when it is remembered that there is a peculiarly close relation between some of the more profound types of anaemia and the total absence of secretion in the stomach — achylia gastrica. The motor function of the stomach is rarely under normal in either ansemia or chlorosis, and it occasionally happens, espe- cially in the latter, that there is a marked excess of HCl. Influence of Constipation and Other Gastro-intestinal Affec- tions. — Judging from my own experience, constipation is al- most constantly associated with chlorosis, and is very likely to complicate ansemia. You should always remember, however, that constipation may easily pass over into diarrhea by a proc- ess already explained. Gastric and intestinal affections nearly all tend finally to impair the crasis of the blood. Dyspeptics rarely have a good healthy color. THE RELATION OF THE GASTRO-INTESTINAL FUNC- TIONS TO TUBERCULOSIS Since tuberculosis is an infectious disease from which the healthy and robust are comparatively immune, and to which the debilitated are especially prone, you should readily under- stand how any seriously depressing affection in the gastro- intestinal tract can pave the way for it. HCl has been shown to exert a decided influence in inhibiting the development of the tubercular bacilli, and it is probable that persons whose gastric glands secrete abundantly are in less danger of becom- ing infected through their food or drink, but are not appar- ently in much less danger of infection through the respiratory tract, though some recent contributions uphold the view that the infection always occurs through absorption, from the in- testinal mucosa, being carried by the blood and lymph to the lungs. 956 THE GASTRO-INTESTINAL CLINIC A paper entitled Stomach Conditions in Early Tuberculosis, 'read by me before the American Climatological Association in Washington in May, 1900, and subsecjuently published in the Philadelphia Medical Journal, considered fully the relations of this most important disease to the digestive functions, and I here append the larger part of it : Impaired Digestion Conducive to Tuberculosis " In what has been incorrectly styled the pretuberculous, but should be called the incipient, stage of consumption, the most noticeable symptoms are often those of flatulent dyspepsia, with eructa- tions and pyrosis or heartburn, with or without gastric pain, nausea, and even stubborn vomiting. These are sometimes symptoms merely of a lowered nerve-tone, and at other times evidences of actual gastric involvement. " All the possible affections of the stomach may, of course, precede tuberculosis. Indeed, its development must be favored by gastric dilatation, the various forms of chronic gastritis, and a failure or persistently depressed activity of the peptic glands, from whatever cause, nutrition being lowered in this way to a degree which may render infection possible. " Moreover, it is probable that, contrary to general belief, hypersthenic conditions in the stomach, such as hyperchlor- hydria and acid gastric catarrh, are quite as compatible with tubercular infection through the lungs as are the asthenic types of gastric disease. For it is now known that a large propor- tion of the cases of early phthisis — a preponderance of them, according to some observers — has an excessive secretion of HCl. Free HCl Often Present — " Though not a very large num- ber of reports of analyses of the stomach contents in the early stages of tuberculosis are to be found in medical literature — and this question, therefore, cannot, be said to have been posi- tively decided — the evidence so far available points to the con- clusion that, except in advanced cases with continuous fever, there is at least quite as likely to be an abundant secretion as a deficiency of HCl in the stomach. RELATION OF GASTRO-INTESTINAL TO OTHER DISEASES 957 " Van Valzah and Nisbet/ in 47 cases of incipient phthisis, found in 10 no signs or symptoms of any gastric derange- ment. Three out of the same series had chronic gastritis, with an absence of free HCl, a diminished proportion of combined HCl, etc. In 18 of the cases there were traces only of free HCl and diminution of secretion otherwise. In 13 of this last number there was mild, and in 5 severe, stagnation, with fer- mentation. " Among the 16 remaining of the 47 cases, 3 were found to have acid gastric catarrh — i. e., the sthenic form of chronic gastritis, with an augmented secretion of HCl; 7 had the same acid in excess, with motor insufficiency, stagnation, and de- layed evacuation; and in the other 6 there was also hyperchlor- hydria, with fermentation in all; while in 2 of them the stom- ach was unable to empty itself even during the night. " In 26 cases, first examined by the same authors during the stage of consolidation, 4 were normal as to gastric juice, 5 had chronic asthenic gastritis, one had a trace only of free HCl, and in 13 the secretion was variable, which means that some- times it was in excess, and at other times normal or deficient. " Thus in 47 incipient cases there were 26, or 55 per cent., with either a normal or overacid gastric juice; and of the 26 in the stage of consolidation, in 4, or 15 per cent., the secretion was normal constantly, and in 50 per cent, more it was variable, that is normal or above, a part of the time. In 65 per cent., therefore, of the y^) comparatively early cases studied by Van Valzah and Nisbet, the secretion of HCl was normal, or above, at least a part of the time. The Motor Function Mostly Depressed — " Riegel ^ quotes Klemperer as thus summing up the results of his observations in 14 cases, 10 of early and 4 of more advanced phthisis. In the beginning the secretory capacity of the stomach was mostly increased, often normal, seldom lowered ; in the final stage 1 " The Diseases of the Stomach," Philadelphia, W. B. Saunders & Co., 1898 ; page 646, et seq. 2 " Erkranktingen des Magens," Wien, Alfred Hoelder, 1897, pp. 946-947. 958 THE GASTRO-INTESTINAL CLINIC markedly lessened. Klemperer found, however, that in all the forms of dyspepsia associated with tuberculosis the motor function of the stomach was depressed. " Brieger/ cjuoted by Riegel, studied 64 cases of tubercu- losis, all except 6 of which were in a more or less advanced stag-e. In such a series there would naturally be a preponder- ance of depression in all the gastric functions. Still in 16 per cent, of even the more severe cases, Brieger found a normal condition of the gastric juice, while the same was observed in 33 per cent, of the cases classed as moderately severe. In the 4 incipient cases, he found 2 with normal secretion, and 2 with disturbed chem.ism, the inference being that in the latter there was a variable condition. " Riegel - states that the results of his own observations ac- cord in the main with those of Klemperer and Brieger. " Croner ^ in 36 cases of early phthisis found in only 5 a complete failure of HCl. The total acidity varied from 21 to 80, but it was in most cases normal.* " Unforunately for the cause of medical science, and for the best interests of patients, physicians in general practice rarely make, themselves, or have made, analyses of the stomach con- tents except when cancer is suspected, and the pulmonary specialists, I fear, have been in the past almost equally in- different to the modern exact methods of studying the gastric functions. Frequent Intolerance of the Usual Remedies. — " The series 1 Loc. cit. ^Loc. cit. ^Deutsche Med. Woch., 1898, No. 48. 4 At the Pottenger Sanatorium for Diseases of the Throat and Lungs at Monrovia, Cal., it is now the rule to test the feces in all cases having serious gastro-intestinal complications, and also the stomach contents in such cases when a tube can be safely used. In a recent series of 55 tuber- culous cases there, of 11 in the first stage 3 showed by the Mintz method free HCl to the amount of 40 or more, the remainder being below that figure ; of the 4 in the second stage free HCl was less than 40 in all ; and the remaining 40 cases, all in the third stage, showed 36 with free HCl, under 40, 4 with free HCl over 40 and one of these 64, which was the only one in the whole series over 60. RELATION OF GASTRO-INTESTINAL TO OTHER DISEASES Qt^Q of cases reported by Van Valzah and Nisbet, by Brieo-er and by Klemperer, show that in early tuberculosis there is present very frequently — and probably in a majority of cases — a con- dition of the peptic glands which contra-indicates the adminis- tration of any considerable doses, by the stomach at least, of highly stimulating remedies, such as carbolic acid, creosote and its derivatives, the mineral acids, and most of the familiar stomachics. That is, in these cases when the gastric function is not entirely normal, there is usually either an excess of HCl, or a very impressionable and variable condition of the secre- tion — a condition in which the exhibition of stimulating drugs produces harmful irritation, resulting often in hyperchlor- hydria, or acid gastric catarrh, which complicates the treat- ment of the tuberculosis and lessens the prospects of cure. Riegel's experience agrees with that of the authors cited, and my own case well illustrates the point just made, besides show- ing how tuberculosis for a long time may masquerade in the guise of a stomach trouble. " In the light of these facts, it is easy to understand why such directly opposite views are held by clinicians of equal ability as to the value of large doses of creosote and of other irritant drugs in tuberculosis. Whether the remedy does good or harm depends mainly upon the condition of the stomach, and, it not having become yet the settled practice, as it ought to be, always to ascertain the state of the gastric functions be- fore instituting active drug treatment in any chronic disease, a confusing contrariety of results follows such modes of treat- ment. " For exactly the same reason the profession is divided as to the value of cod-liver oil in pulmonary phthisis. Recent ex- periments prove that the oils markedly lessen the secretion of HCl in the stomach.^ In the cases, therefore, in which the gastric functions are almost always depressed, as in the later stages of phthisis, cod-liver oil, or much fat of any kind, im- iBachman, " Experimentelle Stttdien iiber die diatetische Behandlung bei Su-pev&ciditat," A rc/a'v/. Verdauungskrankheiten, B. v., Hft. 3. 960 THE GASTRO-INTESTINAL CLINIC pairs digestion and injures the patient; whereas, in the cases of hyperchlorhydria, which are so often found in the earlier stages, the same remedy exerts a double influence for good, since here it tends to correct the injurious hypersecretion at the same time that it helps to fatten and strengthen the patient. In ^e cases between these extremes — cases in which there is a nearly normal gastric secretion — a moderate amount of oil may prove helpful for a time, and by means of an occasional analysis of the stomach contents to see when it has begun to depress secretion unduly, advantage may safely be taken of its valuable medicinal and nutrient qualities. " Let me turn aside right here to advise that, in doubtful cases, in which an analysis of the stomach-contents is not prac- ticable, as well as in cases in which the gastric juice has been found to be about normal, it would be well to combine creo- sote or one of its congeners with cod-liver oil, so as to have the stimulating properties of the former neutralize the depressing influence of the latter upon the gastric glands. Need of Strengthening the Motor Function. — " It is gen- erally conceded that the motor function of the stomach, which is always seriously lowered in advanced phthisis, is very apt to be depressed somewhat in even the earlier stages. That is, the muscular walls of the organ lose their tone, and there re- sults a tardy evacuation of the contents, with consequent stag- nation and fermentation. This weakened motility must be overcome before tuberculous patients can get well. " Drugs are of little avail for this condition. * * * We should avoid in such cases overloading the stomach, and little or no liquids should be taken with the meals. * * * Massage of the abdomen can do great good, except when the gastric glands are irritable and inclined to overaction; then it can overstim- ulate and do much harm, as has been pointed out by me in a previous paper.^ Intragastric faradism is also most helpful, but must be used with discretion. ^Massage of the Abdomen, by Boardman Reed, M. D., Internat. Med. Mag., January, 1898. RELATION OF GASTRO-INTESTINAL TO OTHER DISEASES 961 " The points emphasized in this paper may be thus sum- marized : Conclusions — i. " In early tuberculosis, the secretion of HCl in the stomach is very frequently excessive, the peptic glands being in a condition of irritability, which causes stimu- lant remedies of the creosote class to disagree and act inju- riously. 2. " Oils tend to depress the secretory function of the stom- ach, and in consequence, cod-liver oil is likely to help the cases which drugs of the creosote class hurt; but, on the other hand, hurts the cases in which the gastric secretion is inactive, the very one in which creosote and the like often do good. 3. " Therefore it ought to be the rule to ascertain the condi- tion of the secretory function of the stomach before pushing either class of remedies. 4. " When analysis of the gastric contents cannot be made, it is safer to combine creosote with cod-liver oil, so as to let one neutralize the other in its influence upon the stomach. 5. " The motor function is very generally depressed in tuber- culosis, and must be restored before a cure can be brought about. Drugs avail little in this direction, but diet, exercise,^ especially in the open air, faradism, and abdominal massage — except when hyperchlorhydria complicates — are all valuable means of effecting the result." 1 Experience at the Pottenger Sanatorium, in which more cases of tuberculosis are treated than in any other private institution in America, has seemed to demonstrate that much exercise is not conducive to the cure of such cases. Only the gentler forms of exercise are encouraged there for even patients in the early stage, while advanced cases are con- fined to bed either entirely in freely ventilated tent cottages, virtually in the open air constantly, or kept at rest the larger part of the time in such cottages. Much attention is given to the selection of a careful dietary suited to the needs of each patient as shown by examinations of the stomach contents, feces, etc , and appropriate doses of tuberculin have proved conducive to the cure in most of the cases. My regular visits to that institution in the capacity of consulting gastro-enterologist, have enabled me to bear emphatic testimony on these points. B. R. 962 THE GASTRO-INTESTINAL CLINIC CATARRHAL AFFECTIONS OF THE RESPIRATORY TRACT Specialists in diseases of the nose, throat, etc., are coming more and more to the conviction that the catarrhal affections of this region, as well as of the bronchial tubes, are determined largely by a faulty metabolism. The chief predisposing condi- tion is what was formerly known as the uric acid diathesis, an obscure vice of nutrition due in part to inheritance, and in part to eating excessively, especially of meats and sweets, by per- sons who lead a sedentary life and exercise little — i. e., a con- dition of suboxidation. My own observations have convinced me that this explanation of the aetiology of such catarrhs has much in its favor and have led to the suspicion that the mucous membranes may have for one of their functions the excretion of certain of the products of a faulty metabolism. I have seen numerous cases of chronic nasopharyngeal catarrh, as well as of chronic bronchitis, which were not only associated with indig'estion and lithsemia, but could only be relieved or improved by remedies which favored the elimina- tion of the uratic products, xanthin bases, etc., though some- times the combination of such remedies — chiefly alkalies — with antiseptics like the benzoates, salicylates, etc., proved still more effective. NERVOUS DERANGEMENTS, NEURASTHENIA, INSOMNIA, ETC. The sympathy between the digestive and nervous systems is particularly marked. Neurasthenia. — It is certain that all the forms and grades of nerve weakness or depression — neurasthenia — tend strongly to derange the digestive functions and metabolism, and it is no less a fact that diseases of the stomach and intestines, as well as most of the more serious disturbances of the digestion and assimilation, influence adversely the nervous functions so that a vicious circle is formed. They impair sleep, producing often insomnia, lower the capacity for sustained physical or mental RELATION OF GASTRO-INTESTINAL TO OTHER DISEASES 963 effort, and develop an irritability of temper. These effects are in some instances due to a reflex irritation conveyed to the nervous centers, and in others, to an autotoxic influence upon those centers and the nerve structures generally through an impoverishment or depravation of the blood. Insomnia is particularly often dependent upon some form of indigestion. Any of the painful gastro-intestinal diseases, such as cancer, ulcer, colic, or even marked flatulency, will naturally disturb or wholly prevent the sleep by the actual pain or dis- comfort produced by them. But you should not overlook the curious and interesting fact that an excess of HCl in the gas- tric juice — hyperchlorhydria — will often greatly impair the sleep, even when it gives rise to no pain or conscious discomfort in the stomach. So common is this that in any case of stub- born insomnia, not due to pain or other manifest cause, }^ou should test the stomach contents to see if there is not an ex- cess of HCl, or if this cannot be done, try the effect of one or two teaspoonfuls of sodium bicarbonate, administered, well diluted, at bedtime. It will sometimes, in such cases, accom- plish much more than the usual hypnotics. Auto-intoxication, resulting indirectly from the more se- rious and persistent derangements of digestion, besides being able to disturb the nervous functions in the ways mentioned, is capable, doubtless, also of injuring ultimately the nerve struc- tures themselves, and setting up organic lesions in the nervous system, just as it can in the circulatory system and the kid- neys. DISEASES OF THE LIVER AND GENITAL ORGANS The liver is another organ which can be damaged seriously by prolonged gastro-intestinal disease. There is no longer room for doubt that various hepatic lesions, including a form of cirrhosis, can have such an origin. Boix has written a book entitled " The Liver of Dyspeptics," in which this subject is discussed at much length.^ ^ G. P. Putnam's Sons, New York, 1897. 964 THE GASTRO-INTESTINAL CLINIC Conversely, too, hepatic affections can greatly derange the functions of both the stomach and intestines. Colecystitis and colelithiasis are particularly likely to give rise to dyspeptic S}Tnptoms and many a sufferer from one or both of them has been dosed ad nauscmn for " stomach trouble," very often, too, with hydrochloric acid and pepsin, when, as usual in the earlier stages at least, of such cases, there has been a large excess in- stead of a deficiency of that acid in the gastric juice. But space is lacking for as full a consideration of these interesting relations of the stomach and liver as their importance deserves. The interrelations between the stomach and intestines on the one hand, and the genital organs on the other, are very inti- mate. The functions of the one are rarely much deranged without some sympathetic disturbance in those of the other. This is as might be expected, considering the fact that the nerve supply of the two systems is in large part from closely associated centers — particularly the vaso-motor nerves, which control the caliber of the arterioles in each set of organs, and thus regulate the blood supply to them. I have already referred (Lecture XLIX.) to the marked ef- fect of movable kidney in setting up hyperchlorhydria by re- flexly exciting gastric secretion, and have dwelt at some length, in Lecture XLIIL, upon the frequent dependence of pelvic troubles, such as displacements of the uterus and ovaries, upon gastroptosis or enteroptosis. Then, hyperchlorhydria by the irritating effect of the excessive acid upon the intestinal mu- cosa is a prolific cause of flatulence, and I have seen many cases in both sexes in which flatulence has reflexly irritated the sexual organs, producing at night painful erections in men, with unrefreshing sleep, and analogous disturbances in women. Most gastrologists have observed that women having stomach trouble will often secrete during their menstrual periods more or less HCl than usual; there is no uniformity as to the kind or amount of the aberration from the normal, but it may be in either direction, and either slight or very marked. The fact is well known that various forms of gastric derangement may RELATION OF GASTRO-INTESTINAL TO OTHER DISEASES 965 result from disease or displacement of the uterus or ovaries- but it is not so well known that disease of the prostate gland in men may disturb the digestion/ DISEASES OF THE HEART Cardiac affections, involving a lowered blood pressure — /. e., valvular defects not well compensated — and dilatation of the heart, or decided weakness of the cardiac muscle from any cause, generally lessen the secretion of HCl in the stomach, and of the bile in consequence of the stasis, with resulting slow digestion and constipation. Riegel notes that in these cases the stomach often secretes sufficiently for the small test breakfast, but not enough for the heartier test dinner, and I have observed that in analogous con- ditions, resulting from neurasthenia, there may be sufficient secretion in the morning, when the patient is rested, but not enough in the latter part of the day, when he has become fatigued. These facts should teach us something as to the management of such patients. It is a manifest inference that numerous small feedings will best nourish patients with fail- ing circulation, and that more rest — less exhaustion of the vital force by the usual activities — will do most for neurasthenics. Flatulence directly disturbs the heart, causing palpitation, ir- regular pulse, etc., besides probably reflexly increasing the blood pressure according to a series of observations by me in the succeeding lecture — Lecture LXXXII. Quite as interesting and worthy of study as the effects of other diseases upon the digestive processes are the effects of impaired digestion and faulty assimilation upon the other functions, and even upon the tissues of the organism. 1 At the meeting of the American Medical Association in Boston June 5 to 8, 1906, a physician from Memphis, Tenn., remarked in substance dur- ing the discussion of a paper before the section of Practice of Medicine that we hear much of hepatic insufficiency, renal insufficiency, cardiac in- sufficiency, etc., but that gastro-intestinal insufficiency is really the alma mater of all the other insufficiencies. This is to a very large extent true, and it is a truth very strikingly expressed. 966 THE GASTRO-INTESTINAL CLINIC How Digestive Faults Injure the Heart, — Certain of the products of a faulty metabolism tend to increase the labor of the heart by contracting and probably also roughening the inner coats of the smaller arteries and capillary vessels gen- erally, besides increasing the viscosity of the blood as claimed by Haig. Croftan ^ has reported experiments proving that some of the xanthin bases can produce both hypertrophy of the heart, and chronic nephritis in animals. Haig has reported many clinical observations which tend to show increased arterial tension under dietetic methods which produce an ex- cess 0/ uric acid, and he has built upon these observations his well-known theory as to the toxic effects of uric acid upon the nervous system and various organs. His results are now ex- plicable on the hypothesis that the alloxuric or xanthin bases, substances of the uratic group, and probably not uric acid it- self, were responsible for the results observed by him. To go a step further back, the digestive processes need to be perfectly performed in order that the metabolism may be com- plete, though when one overeats and underexercises, there may be, easily enough, a disturbed metabolism in spite of a naturally sound digestion. An excessive secretion of HCl (hyperchlor- hydria) tends to exercise a very irritating effect upon the mu- cosa of the intestines, with the result in many cases of setting up catarrhal inflammation, with constipation, etc. Few things tend more surely to produce a deranged metabolism, with the production of excessive fermentation and putrefaction, than intestinal catarrh and a sluggish intestinal peristalsis. These conditions increase enormously the absorption of toxins from the intestinal tract. You will readily understand that what is true of hyperchlor- hydria is still more true of the same condition of HCl excess, plus an open sore in the stomach or duodenum, such as we have in the round or peptic ulcer of these parts. Still greater and more profound is the disturbance of metabolism in such a se- rious disease as cancer of the stomach, pancreas, or any other '^Joiir. A))icr Med. Assji , July 8, 1S99 RELATION OF GASTRO-INTESTINAL TO OTHER DISEASES 967 of the digestive organs. The same is true in the case of a very markedly weakened motor power in either the stomach or intestines, or the downward displacement of any of the viscera. All these diseases and derangements seriously affect nutrition and impair the metabolism with a double resulting injury to the heart — an impairment of the nutrition of its muscular fibers and an increase of its work, in very many cases, through the contraction of the smaller vessels throughout the body by the toxic products of incomplete metabolism as above explained. When there exists for long periods a marked deficiency of secretion on the part of any of the important digestive glands, whether this deficiency coincides with a catarrhal process in the mucous membrane or depends merely upon nervous or reflex influences, the metabolism may be affected almost as injuriously as in the cases of HCl excess. A deficiency of the gastric juice is very frequently found with an excess of indican in the urine, and though my own experience has been that hyperchlorhydria most frequently coincides with indicanuria, I can well believe that either departure from the normal, when pronounced, can so far derange intestinal digestion as to in- crease fermentation and putrefaction in that part of the ali- mentary canal. Increased fermentation, and especially putre- faction of the proteids, go with incomplete oxidation, and if the theories of various foreign investigators, which have been con- firmed and extended by observers in this country, are accepted, we must believe that in such conditions the work of the heart is notably increased through a contraction of the peripheral blood- vessels. Summary. — To sum up, then, disorders of the digestive or- gans, and especially the imperfect metabolism which results from them, are capable of injuring the heart in at least two ways: (i) By impairing the nutrition of the muscular tissues of the heart itself through imperfect digestion and assimila- tion of the food; (2) by increasing the work of the heart through a narrowing of the peripheral blood-vessels — also by a roughening of their lining membrane — as a result of the 968 THE GASTRO-INTESTINAL CLINIC toxic action of certain products of incomplete oxidation of the proteids, and perhaps other faulty metabolic processes. (See Lecture LXXXII.) Therapeutics of Secondary Cardiac Affections. — Degenera- tive myocardial changes, with hypertrophy often at first, but later usually some degree of dilatation, are the forms of dis- ease which are most likely to result from the digestive and nu- tritional disorders just described. Manifestly, when a contrac- tion of the peripheral vessels has played a large part in causing the trouble, the curative measures which will be most promis- ing are the mildest forms of exercise and the hydriatic pro- cedures which tend to dilate the capillaries, rather than any medicinal remedies which exert a contrary effect, valuable as the latter are in more serious conditions of cardiac dilatation with an extremely low blood pressure. The Nauheim method of treatment usually suits well in the latter cases, as is fully explained in Lecture LXXXIL It is equally obvious that the primary faults in the digestive apparatus need to be first of all removed, and such a regimen instituted as shall prevent their recurrence. DISEASES OF THE KIDNEYS AND DIABETES These have been much studied as to their influence on di- gestion, but with contradictory results. In early or mild cases, there may be a normal, increased, or diminished proportion of HCl, but in severe or advanced cases, naturally, there is a diminution. Riegel, however, reports having frequently found a normal amount of HCl in even old chronic cases of renal disease. Influence of Bright's and Diabetes on Digestion. — My own experience has shown a like variability in results as to both Bright's disease and diabetes, except that diabetes is often de- pendent on disease of that most important of the digestive glands, the pancreas. There is no constant relation between the gastric secretion and the amount of albumin or sugar passed, but in the later stages, when the general health has RELATION OF GASTRO-INTESTINAL TO OTHER DISEASES 969 become seriously damaged, gastric secretion suffeFs, as does 'doubtless that of all the glands. In all such cases it is important, therefore, to make tests oc- casionally of the gastric contents, since both medicines and the diet prove most effective when suited to the condition of the stomach. Persisting long with alkaline treatment in full doses when there is no free HCl, cannot help but destroy what little digestion is left, and on the other hand, administering mineral acids with a diet rich in soups and meats, or meat extracts in any form, would soon play havoc with a case of diabetes com- plicated with hyperchlorhydria. As in the case of the heart, disease of the kidneys may ulti- mately result from certain of the products of indigestion and the consequent deranged metabolism. In a medical paper written by me ^ concerning autotoxic forms of nephritis, eighteen cases were reported showing al- bumin and casts which had developed apparently as a result of digestive disorders. All but one were cured, or markedly benefited, by a persistent employment of the static wave and static induced currents. 1 The Effects of the Secondary Static Currents in Removing Albumin and Casts from the Urine, with Reports of Cases, A7n. Med., vol. vi. No. 22. LECTURE LXXXII ARTERIOSCLEROSIS AND ITS RELATIONS TO THE AFFECTIONS OF THE GASTRO-INTESTINAL TRACT The relations of arteriosclerosis with gastro-intestinal affec- tions are reciprocally so intimate and so exceedingly important that it has been decided to discuss them somewhat fully and at length in this new lecture which is now added to the third edition of this volume. A study of the literature which has appeared on arterio- sclerosis during the last two decades, forcibly impresses one with the increasing appreciation of its great importance. Directly or indirectly, it probably causes a majority of all deaths in adults. Recent investigations indicate that not only are both the arteries and arterioles more or less generally in- volved sooner or later, in the inflammatory and degenerative processes commonly grouped under this name, but also in many cases the veins, venules, and capillaries, so that the term angio- sclerosis more nearly expresses the actual pathologic condition. The disease is easily diagnosed by even a tyro in medicine, when far advanced and hopeless. To recognize it in its in- cipiency, when a cure is often practicable, is very difficult and the diagnosis then is doubtless rarely made. The symptoms of fully-established arteriosclerosis are fa- miliar to most physicians, and those of the advanced stages, such as the arcus senilis, thickened, hardened, and tortuous surface arteries, apoplectic or apoplectiform attacks and paralyses, as well as dropsies and uremic convulsions, when the kidneys have become seriously involved, are known even to many of the laity. The earlier, and especially the premonitory, 970 ARTERIOSCLEROSIS AND GASTRO-INTESTINAL AFFECTIONS 9/1 symptoms are by no means so well known. They are fre- quently overlooked or neglected in spite of the fact that their prom.pt recognition and persistent energetic treatment mean the saving of lives that must otherwise be wrecked — allowed to drift helplessly on to the rocks of apoplexy, Bright's disease, heart failure, etc., with a resulting early death, or what is worse, a useless prolongation of life after all capacity for serviceable or pleasurable activity has been lost. Among the earliest symptoms which signify that the ar- terial walls are being irritated and their integrity endangered by some toxic agent, whether it be a poison from the outside as in the case of syphilis, lead, and tobacco, or one from within (endogenous) as in gout, lithemia, or a chronic autotoxemia of any kind, must be mentioned especially as the most im- portant of all, increased tension in the arteries with augmented blood pressure as revealed by the sphygmomanometer and much less certainly by the finger on the pulse. By this valu- able instrument of precision, which every family physician should now possess and use as regularly on occasion as his clinical thermometer or specula, increased blood pressure can be certainly detected in a few minutes in any patient, while all the other early symptoms, except the findings in an examina- tion of the eyeground, are likely at times to elude or mislead us. Yet, while (apart from the changes in the eyeground) no other single symptom of threatened, or actually existing, arterial disease is so generally present up to the time when the heart has yielded to the overstrain and become unequal to its task, it has been apparently established that cases of arteriosclerosis do occur and run their course to the inevitable fatal termina- tion with the blood pressure always subnormal. Therefore, the common mistake of failing to recognize the disease because the blood pressure remains low, should never be made. As will be shown later on, it is likely that the pressure in many of these cases might be found to be abnormally high early in the morning immediately after arising from bed, especially after eating imprudently the previous day. My observations of 972 THE GASTRO-IXTESTINAL CLINIC numerous early cases have generally shown a pressure ten to thirty points higher just after arising than in the afternoon, or even in the late forenoon. The normal systolic pressure in men is 120 to 140, according to age, and in women, no to 130 mm. of mercury. Dr. A. L. Macleish ^ of Los Angeles has emphasized the importance of an ophthalmological examination of the eye- ground in every case of suspected arteriosclerosis, reminding us that the disease can usually be thus detected long before signs of it are apparent elsewhere. Another significant symptom which can often be seen early is a pallor of the skin not due to a true anemia, the blood count being at or near the normal figures. This, being a result of a spasmodic contraction, of the vessels, would generally be confirmed by finding at the same time an abnormally high blood pressure and swollen vessels in the retina. Other symptoms to be noted in a later stage are often vertigo, tinnitus aurium, impaired memory and sleep, and mental depression and also intermittent claudication; failing nutrition with loss of weight, and unusual proneness to infec- tions and to attacks of gastric and intestinal indigestion; but it is cjuestionable whether these last are not rather the results of nutritional and metabolic faults, which are themselves the real causes of the arterial disease. This leads us to the con- sideration of a special form of the disease, which has only within the last few years been receiving much attention, viz : Arteriosclerosis of the Abdominal Vessels Stengel ^ of Philadelphia in 1904 referred to cases of an intestinal form of arteriosclerosis studied by him in hospital, and considered that the intractable cases of chronic colitis so often encoun- tered are probably thus explained. The early symptoms of this form seem not to be dis- tinguishable from the familiar ones of indigestion and chronic ^So. Calif. Prac, January, 1907. 2 "The Clinical Course and Diagnosis of Arteriosclerosis," Wis. M-ed. four., vol. iii, No. 3, 1904. ARTERIOSCLEROSIS AND GASTRO-INTESTINAL AFFECTIONS 973 catarrh, but Buch ^ mentions repeated severe attacks of pain resembling gastralgia felt near the navel as characteristic of it. They may recur several times a day and last usually a few minutes only, seldom half an hour or more. They may be pro- voked by any muscular effort as walking upstairs, by a purga- tion, or by mental strain — sometimes merely by lying down — and though usually they appear to have no relation to food or eating, they seem sometimes to be superinduced by an extra- heavy meal. Buch maintains very positively that the diagnosis may be made by a therapeutic test; the administration of three or four grams daily of diuretin or five to eight drops of the tincture of strophanthus three times a day, he says, will stop the attacks within two or three days or at least greatly dimin- ish them, and sometimes the first day, if they are due to arteriosclerosis, but be otherwise without effect. The same observer found the aortic second sound accentu- ated in every one of his cases and also the abdominal aorta, sensitive on pressure. The latter symptom, however, I have observed in a great variety of digestive troubles even in young dyspeptics in whom there was no suspicion of fault in the arteries. Buch describes two distinct forms of pain which he ascribes to abdominal arteriosclerosis, ( i ) one in which there is no involvement of the thoracic organs in the painful attacks, although, when the heart is also at fault, there may be anginal pain in that region at other times; and (2) a form in which the pain may begin in the epigastrium and then extend to the heart, producing there a true stenocardial attack, or z'ice versa, the pain beginning in the cardiac region and extending to the abdomen. More recently Mueller - of Buda-Pest has reported the results of an elaborate study of abdominal arteriosclerosis, in which he confirms most of Buch's previous findings. He quotes Hasenfeld as having proved by histological researches that arteriosclerosis of the abdominal viscera is not only much more frequent than generally supposed, but is also the chief 1 Sf. Petersburgh Med. Woch., No. 27, 1904. ^ Allg. IVzetier Med. Zeitung, Nos. 37 to 40, 1909. 974 THE GASTRO-INTESTINAL CLINIC cause of cardiac h3qDertrophy, and cites Kuemmel as holding, as a result of extensive in^'estigations, that sclerosis of the abdominal vessels is very common. He also reports communi- cations from various other writers concerning ulceration and thrombosis in the gastro-intestinal tract leading to fatal hemor- rhage in some of the cases. Mueller explains the sclerotic pains of the abdomen as a neuralgia of the lumbar sympathetic and believes that very many of the ailments commonly classed as neuroses of the stomach and intestines are really results of arteriosclerosis of the gastro-intestinal tract. .Etiology. — Daland ^ of Philadelphia holds that in this coun- try the order of frequency of the causes of arteriosclerosis is as follows : (i) excessive muscular work; (2) alcoholism; (3) syphilis; (4) excess in food, especially of the nitrogenous variety; (5) gout; (6) intestinal toxemia; (7) uremia; (8) excessive mental work, especially in those possessing a neurotic temperament; (9) various infections such as rheumatism, chronic septicemia, typhoid fever, etc.; (10) plumbism; (11) nicotinism; (12) long-continued excess in fluids; (13) con- genitally weak vascular apparatus, (a) syphilis, (b) offspring of senile parent or parents, (c) unknown causes. This is the most complete list of such causes that I have seen; yet my own observations indicate that there are prob- ably still a few others, which shall be mentioned later. They also suggest some question as to the order of frequency. While the records of the hospitals and clinics from which most of our published statistics are drawn, would doubtless warrant the placing of muscular strain, alcohol, and syphilis very high up in the list of causes, since such statistics deal with a class of patients in whom these are prevalent far above the average, there can be little doubt that among private patients, even in cities and especially among the people generally who live out- side of the large cities, the three setiologic factors named belong lower down on the list in the order of frequency; also that, among the well-to-do classes at least, the various forms of ^Monthly Cyclopedia of Pract. Medicine, vol. x. p. 145, 1907. ARTERIOSCLEROSIS AND GASTRO-INTESTINAL AFFECTIONS 975 autotoxemia resulting from high Hving — overeating or over- burdening the digestive and ehminating organs with both food and drink, particularly alimentation out of proportion to oxygenation — demand first place. The role of alcohol in this connection calls for special men- tion. Probably a majority of both American and foreign authors agree with Daland in considering it one of the most frequent causes of arteriosclerosis, but Cabot of Boston has reported that a study of the inmates of a large hospital for inebriates showed only 6 per cent, affected with arteriosclerosis — less than the average among adults generally. Clifford All- butt has suggested that probably alcoholic beverages have been an astiologic factor chiefly by conducing to overeating, which all now concede to be one of the principal causes of arterial disease. At all events, the beers and wines that are so largely drunk abroad, tend more to produce fermentation and flatu- lency which, according to my experience, increase blood pres- sure, while the spirits predominantly consumed in this country, especially by most heavy drinkers and hospital inmates, actu- ally lower the blood pressure, pernicious as is their effect other- wise on the liver, nerve tisues, etc. A recent exhaustive paper by Pottenger of Los Angeles con- cerning the effects of tuberculosis on the circulation proves that this, the most widespread of all infections, like various other ones, can set up gradually the lesions of arteriosclerosis. The cases studied particularly numbered 162. Of 28 patients who had been ill less than a year, one-half had thickened radial arteries; in 41 ill between one and two years, 20 had the same; while in 93 ill over two years, 60, or nearly two-thirds, had palpably thickened radials. The blood pressure was constantly subnormal in all, thus revealing one condition capable of caus- ing those cases of arteriosclerosis in which the blood pressure remains always low. Puerperal fever is another of the acute infections which have been shown to be capable of causing arteriosclerosis. Pathology. — Viewing the disease for our purposes here in 9/6 THE GASTRO-INTESTINAL CLINIC its practical relations chiefly, with regard to its prevention and its possible cure in the earlier stages, as well as retarding its fatal course in later stages, the patliology of arteriosclerosis need be only broadly and briefly discussed. The vessels be- come very gradually altered so that their walls are thicker and stiffer, their lumen lessened and their lining membrane rough- ened, while the blood generally has an increased viscosity. Local dilatations follow in the arteries, as well as in the heart itself; aneurisms may result even in the smallest vessels, w4tli later rupture and hemorrhage often lethal,- especially when in the brain. In a large proportion of cases the renal vessels are eventually — sometimes early — involved with the development of Bright' s disease. The vessels which supply the digestive organs including the pancreas (less frequently the liver), the stomach, and intestines are now known to be often primarily affected — perhaps in all the very large proportion of cases in which dietetic faults have been the cause — and in any case be- come ultimately and increasingly involved so that the digestive secretions diminish and the glands and muscles both atrophy until finally, even when ruptures of vessels or other more seri- ous accidents have been escaped, death results from marasmus or toxemia through failure of the kidneys, liver, etc., to clear the system. The exact nature of the earlier changes in the vessels — the minuter histology of the morbid processes — is of far less im- portance, to express Allbutt's opinion in different phrase, than the causes, the results, and the means by which they can be prevented, stopped, or at least retarded. Diagnosis. — Continued high blood pressure in a person under forty, or in any except the very old, would alone warrant the diagnosis of either existing or threatened presenile arterio- sclerosis. When found together with superficial vessels visibly or palpably thickened the condition cannot well be referred to anything else except physiologic or senile arteriosclerosis. In the form of the disease which runs its course without ever showing an excessive blood pressure, and in the later stages ARTERIOSCLEROSIS AND GASTRO-INTESTINAL AFFECTIONS 977 of the more usual fonn, after cardiac insufficiency and low blood pressure have resulted, the diagnosis must rest upon the thickened condition of the superficial vessels discoverable by the unaided eye and touch, and especially by an ophthal- mologic examination of the eyeground. The mental, nervous, and renal symptoms usually also present, make up a picture which is unmistakable for even cases in only a moderately advanced stage. In the earlier stages the condition of the blood pressure and the ophthalmologic findings often afford the only reliable means of deciding and when the increased blood pressure is wanting the latter findings may be the only depend- ence. As Macleish forcibly puts it, " a man is as old as his arteries; how old his arteries are, the ophthalmologist is in a position to discover before brain or heart or even kidney tells the tale." ^ When there are suspicions of a combination of tuberculosis with disease in the arteries, the tuberculin test and eyeground findings must join in helping to an early diagnosis, since then the blood pressure is usually subnormal. It is important to distinguish secondary from primary low blood pressure. The former has always been preceded by a period of high pressure at a time when there should have been comparative vigor accompanied by the symptoms of hyper- tension, a history which careful inquiry should be able to elicit. Clinical Observations on Blood Pressure by the Author — A summary of observations carried out in part with the as- sistance of Dr. F. E. Corey at his. Sanatorium in Alhambra, Cal., will appropriately precede here a discussion of the treatment. Besides routine examinations in a large number of other case's, there were made on four persons who volunteered for the purpose, several hundred obser\^ations of the systolic blood pressure by means of the Riva Rocci sphygmomanometer, before and after exercises of various kinds and degrees of activity, before and after meals, and different forms of hydri- atic procedures, electric treatments, etc. ; also at various hours "^Loc. cit. gyS THE GASTRO-INTESTINAL CLINIC of the day and night, especially on retiring and on arising after a night's sleep. One of the four was a professional man 68 years old, who had had somewhat atonic gastro-intestinal viscera and moderate arteriosclerosis for over ten years with always, for years, a high pressure in the morning. Another of them was a lady aged 65 who, though possessed of a first- class digestion, showed signs of beginning arteriosclerosis with high pressure, especially in the early morning. The third, a merchant aged 29, had a low arterial tension and various nervous symptoms, due probably, in part at least, to tobacco. The fourth was a lady of 23, in whom a tuberculous infiltration of one lung had been arrested by the tuberculin treatment. Her blood pressure and pulse rate were variable. The results of these observations may be briefly summarized as follows : I. Exercise of all kinds, from the gentlest to the most active and vigorous, is followed, after a brief rise of blood pressure and increase in the pulse rate (which can be made very slight and transient), by a decided fall of from 5 to 50 mm. of mercury, according to the severity and duration of the exercise and the condition of the patient. Generally the pulse rate increases as the pressure falls, but the gentler exercises, especially those against resistance (Widerstandgyninastik) car- ried out in accordance with the rules of the Schott brothers of Nauheim, will leave the pulse rate unchanged, or when very rapid before,^ slowed and strengthened. As a rule, the higher the pressure before, the greater is the fall after, the exer- cise. It is possible that cases complicated by serious renal disease may prove exceptions in this respect, but I have not had an opportunity of testing such a case thoroughly. The elaborate Schott rules are not necessary to obtain very favorable results, except in the weakest patients. Ten to twenty minutes spent in making a variety of muscular move- ments, not more than two to ten or twenty of each kind, the number depending upon the degree of the cardiac tone (the weaker the heart the fewer and the more slowly to be made). ARTERIOSCLEROSIS AND GASTRO-INTESTINAL AFFECTIONS 979 will nearly always produce decided results. An attendant is not necessary after the patient has been taught to resist him- self by contracting moderately the muscle opposed to the one in action. Pulleys also can be adapted so as to give the proper amount of resistance, but the patient needs to be cautioned always not to overexert in any of these ways. The gentlest exercises do the most good in feeble patients. 2. Mental exertion has produced varying results, but never in my experience a lowering effect on the blood pressure unless after exhaustion. When very severe or exciting it tends to raise the pressure, but otherwise is likely to leave it unchanged. 3. During the period of digestion, from one to three hours after a simple ordinary meal, not including tea, coffee, or alcoholics, I have found the blood pressure usually lowered, often decidedly, though it has sometimes been transiently raised before falling, as happens with exercise. Whenever, however, a flatulent distention of the intestines has resulted, as especially during the night in dyspeptics, the pressure has been raised. The pulse rate has been always higher after meals. 4. The cumulative effect of any special diet is a different matter. An exclusive milk or meat diet has generally lowered the pressure in arteriosclerotics when previously high, — in one of my cases, markedly, — but the ultimate effect of the meat diet has been aggravation of the disease in the vessels as shown by the nervous and other serious symptoms. Thus the almost universal advice of writers that these patients should eat meat very sparingly, if at all, is justified by my observations. 5. In the great majority of my observations, as before men- tioned, the blood pressure has been found very much higher shortly after rising than later in the day, especially in patients not confined to bed. This rise has been particularly marked in patients troubled with "flatulence, but by no means confined to them. Various causes probably contribute to this result. The reflex stimulation of the heart by the distention is pos- sibly one; the absence of the pressure-lowering influence of 980 THE GASTRO-INTESTINAL CLINIC digestion and the other activities of the day and evening is probably another, and the tonic effect of prolonged rest and sleep upon the heart must also be a factor. No other observer seems to have noted this usually marked difference between the evening and morning blood pressures, and it is always to be borne in mind in managing important cases of arteriosclerosis. The particular directions for the treatment of arteriosclerosis were very fully given in the paper presented by me to the American Climatological Association, at its meeting at Old Point Comfort in 1909, and they are reproduced here in part with such changes and additions as newer developments have suggested. Prophylaxis and Treatment — The prophylaxis of arterio- sclerosis demands the avoidance of the causal conditions al- ready mentioned or the removal of them, in so far as is possible, when they are already in existence. To prevent a premature hardening of the arteries with its usual consequences, one needs to have, first, a good inheritance, and then to live hy- gienically in all ways — to be temperate in eating and drinking especially, but also in everything. And the more strenuous the life in regard to the mental and emotional activities, in par- ticular, the greater the importance of not overtaxing the diges- tive system. Then, after middle age, if not before, one should be examined at least once a year, as to the blood pressure and condition of the kidneys especially, if not a more general ex- amination, so as to combat any signs of the trouble in its incipiency. The treatment will need to vary with the nature of the cause. The cases due to poisons coming from outside the body de- mand especially medicinal antidotes and eliminants — in par- ticular the iodides for syphilis and lead. Those dependent upon physical, mental, or emotional overstrain may require more complete rest from the offending cause — from the par- ticular form of over-activity — sometimes even a rest cure in bed, but otherwise much the same treatment as the more ARTERIOSCLEROSIS AND GASTRO-INTESTINAL AFFECTIONS 98 1 prevalent autotoxic cases, except that the diet may not need to be so much restricted. For the remaining cases due mainly to autotoxemia and comprising the great bulk of all the cases of arteriosclerosis, the treatment must depend upon the stage of the affection. The stage in which the disease is usually first recognized is that of cardiac hypertrophy, when the blood pressure is per- sistently high as a rule, though often easily and rapidly lowered by even gentle exercise, fasting, or low diet, the nitrites, car- diac depressants, tepid or warm baths, bleeding or particularly by prolonged active exercise but, as a rule, not carried to the point of fatigue. Finally, we have the stage of broken compensation with gen- erally low blood pressure, the heart having yielded to the pro- longed overstrain, so that unaided it is no longer equal to the task of forcing a sufficient supply of blood through the ob- structed vessels. The general principles to be kept ever in mind and made the dominant features of the treatment are these two : 1. To spare in every way possible the vital organs involved, i.e., the circulatory, digestive, and eliminating organs, espe- cially the heart and kidneys. 2. To assist any of these organs found to be flagging in their indispensable work. When they flag or begin to fail, the important principle of sparing them, in so far as practicable, rather than urging them harder, should never be overlooked. Before bringing to bear our stimulant remedies — our whips and spurs — we should try to lessen their work — relieve them of part of the burden. E.g., we can and should spare all the organs concerned by keeping the total amount of the ingesta of all kinds strictly within the needs of the system, and also by avoichng or restricting the quantity of those kinds of food and drink which either unduly tax the digestive and eliminating functions. Or introduce poi- sons from without which the excretory organs must then cast out, in addition to excreting the toxic matters constantly 982 THE GASTRO-INTESTINAL CLINIC formed within the body. When, notwithstanding the utmost care of the diet, the kidneys show signs of being unequal to their task, we should call upon the bowels to do more, and, above all, compel that great, but often neglected, emunctory,. the skin, to do better work by prescribing some of the many procedures, or drugs, which will increase the perspiration. When the heart begins to be embarrassed and all unneces- sary demands upon it have been stopped by lessening the amount of the ingesta to within the quantities actually required to maintain nutrition, and by placing the patient at either com- plete or partial rest, much more can still be done in the way of relieving it. We can widen the blood paths by means of the various practicable mechanical measures for increasing the activity of the peripheral circulation, as well as by the adminis- tration of drugs which tend to dilate the vessels. Failing these remedies, or in urgent cases, simultaneously with them, drugs of the digitalis group may need to be also administered. When indigestion is a feature of the case, a careful diagnosis should be made of the exact fault and the proper remedy then be applied. 1. Should we be fortunate enough to recognize an incipient case of arteriosclerosis, of the prevalent autotoxic type, before the heart has hypertrophied, we can very hopefully apply the principle of economizing the vital forces. We have only as a rule to prevent overdoing, overeating, and overdrinking — ^to regulate the patient's diet both as to quantity and quality — to correct any digestive or other setiologic fault and see to it that the eliminating organs do their full duty in order to spare the heart and arteries further embarrassment and effect a cure. In this stage, constipation will very often be found, and, before matters have progressed too far, an earnest effort to cure it radically should always be made, by means of a laxative diet, special exercises, etc. (See Lecture LXX.) But complete daily bowel movements must be secured even with laxative drugs, if not obtainable otherwise. 2. In the stage of cardiac hypertrophy the same things need ARTERIOSCLEROSIS AND GASTRO-INTESTINAL AFFECTIONS 983 to be done still more thoroughly and perseveringly, and, be- sides, whatever further is required to keep the blood pressure within the limits normal for the patient's age, say from 120 to 140 or 150 Hg. We must then secure for the patient as much physical and mental rest as is necessary and practicable, pre- scribe a diet appropriate to the gastro-intestinal findings, with a minimum of flesh food and no meat extractives or stimulants, besides ordering massage and Swedish movements, or other passive exercises; or, in the milder cases, the gentler forms of active exercise. If need be, we may add general faradization or d'Arsonvalization (perhaps now the most effective single remedy for high tension) and spongings with hot salt water, or even short, warm tub baths, or salt rubs followed by prolonged brisk toweling; in short, whatever forms of baths or local treatment will best keep the skin active and lower the blood pressure, without weakening the heart. If these meas- ures fail, as they sometimes will, especially when the kidneys are involved, we must push drug remedies, such as the nitrites, besides purging or even bleeding in serious cases in which the tension remains obstinately high, to any extent necessary, while at the same time keeping the heart up to its work by giving cardiac tonics cautiously, if required. 3. When the heart has dilated, the problem is more com- plicated. Besides the sparing, eliminating, and tonic measures already described, the saline baths of Nauheim, Germany, and the resisted movements first introduced by the Schott brothers there, may be resorted to hopefully in cases not too far ad- vanced. They are, of course, well known to most physicians. The baths in the natural, carbonated, saline water, together with the Widersfandgymnastik, as carried out by the trained attendants there, are very effective in appropriate cases, as I can personally testify, having spent a season there once with a patient; but the artificial, carbonated saline baths given at some of the sanatoria in this country as a substitute, serve the purpose well in skillful hands, and it should not be very diffi- cult for any person to learn in a short time how to assist a 984 THE GASTRO-INTESTINAL CLINIC patient to make the resisted movements with the requisite care and skill. In the severer cases, however, it will often be neces- sary to push boldly some active cardiac tonic in addition to the mechanical measures mentioned. In prescribing the diet only a few general rules can be laid down, since so much depends upon the condition of the diges- tiv*e organs. When there is dilatation or marked atony of the stomach or intestines, large amounts of licjuid disagree and are therefore doubly contra-indicated. In these cases the carbohy- drates need to be as much restricted as practicable, since they are very prone to ferment and produce flatulence, which, as my experience shows, raises the blood pressure and generally im- pairs the sleep. When there is hyperchlorhydria, the metabolism will be so seriously disordered thereby, that little progress toward an improvement of the circulation can be expected until this com- plication (or possibly the chief causal condition) has been removed by the appropriate diet and other treatment. When there is a displacement of any of the abdominal viscera, espe- cially of the stomach and kidneys, little can usually be accom- plished until the fault has been corrected. So with gall- stones, chronic pancreatitis, and all the other manifold dis- orders which affect the gastro-intestinal tract and are believed to play a prominent part in the aetiology of many cases of arteriosclerosis. The majority of writers hold that certain kinds of food and drink and so-called food accessories, as, e.g. the flesh foods, the alcoholic beverages and other stimulants, particularly tea and coffee, because their alkaloids are practically identical with some of the toxic purin bases, and tobacco, which seems to be worst of all, have an especially injurious effect in arterio- sclerosis. I am convinced that an excessive quantity of food and drink taken regularly day after day, is even more harm- ful in this respect than a moderate amount of some one or more of the incriminated articles above mentioned. That such an excess tends to produce hypertention is certain, and pro- ARTERIOSCLEROSIS AND GASTRO-INTESTINAL AFFECTIONS 985 longed hypertention has been shown to be a very prominent cause of arteriosclerosis. It remains to speak of climatotherapy in arteriosclerosis. Climate can help much in the treatment. Moderate warmth and dryness promote the action of the skin, and joined with equability afford the arteriosclerotic the most favorable exter- nal conditions for attaining a high old age in spite of his dis- abilities. Many places in our great Southwest suit well, espe- cially for the winter months. When the patient can live all the year round in such a com- paratively dry and equable climate as that of Southern Cali- fornia, at nearly the sea level, his chances for improvement will be greatly increased. This is especially true for the more favored localities of that region near the coast. The blood pressure is not disturbed in this region by either altitude or violent storms, cold waves or extreme changes of temperature, such as prevail so much of the time in many parts of our country. For patients who are difficult to control or whose environ- ment is unfavorable for whatever cause, and especially for advanced cases with secondary low arterial tension, in which the heart unaided is no longer equal to the task of maintain- ing the circulation, sanatorium treatment in a good climate, with sometimes a Weir Mitchell rest-cure, offers the best pos- sible remedy. In this way only can a suitable hygienic and mechanical treatment by diet, massage, resisted movements, baths, including in appropriate cases the Nauheim baths, elec- tricity, etc., be systematically carried out. LECTURE LXXXIII THE SURGERY OF THE STOMACH AND INTESTINES In this lecture attention is called to some of the leading indications for surgical interference in a certain class of gastro-intestinal diseases. No attempt will be made to de- scribe minutely each operation and the technicjue employed, but since the general practitioner often has not the time and opportunity to keep fully informed concerning all the advances in surgery, a brief outline will be given of some of the oper- ative methods usually adopted by the best surgeons. SURGERY OF THE STOMACH Gastric Ulcer. — A great many ulcers of the stomach can be cured if they are systematically treated by means of rest, diet, good hygiene, and careful medication. It is a mistake, how- ever, to persevere too long with palliative measures, and surgical aid should always be sought whenever the patient grows gradually worse in spite of treatment, or continues to vomit blood and ingesta. Perforations, chronic indurated ulcers, and perigastric adhesions are conditions that are prac- tically never cured except by an operation. As soon as a probable diagnosis of a perforation is established, the abdomen should be opened and careful search made for the point of rupture. It is generally quickly found, for in the majority of cases it is located on the anterior wall near the lesser curva- ture and is easily accessible. A perforation on the posterior wall should be approached through an opening in the trans- verse mesocolon; this opens up the lesser peritoneal cavity and gives free access to the whole posterior surface of the THE SURGERY OF THE STOMACH AND INTESTINES 987 stomach. The method of closing the perforation depends upon the size of the opening and the condition of the surrounding tissue. If it is small, a purse-string suture reenforced by a few interrupted Lambert sutures is all that is necessary. The large ragged openings should be treated by first carefully excising the ulcerated area, and then uniting the freshened edges with a double layer of sutures. Should the perforation happen at a time when the stomach is empty and there is not sufficient leakage to soil the peritoneal cavity, it is possible to close the abdomen without drainage, but, if in doubt, it is safer to make a stab wound above the pubis and insert a rubber drainage tube into the cul-de-sac of Douglas. The reported mortality from perforations is gradually becoming less, the result largely of an increasing number of operations done early and before the onset of peritonitis. Perigastric Adhesions — When these are extensive enough to cause serious trouble with the stomach and intestines, the only rational treatment is to open the abdomen and break them up; all raw spaces should be covered with peritoneum and omentum so as to prevent the adhesions from forming again. Chronic indurated ulcers of the stomach and all those not favorably influenced by medical treatment demand surgical interference. The operation of choice is a gastro-jejunostomy, for it provides the affected area with rest and good drainage, which are the two essential principles in effecting a cure. It is not considered necessary in all cases to excise the ulcer at the time of the operation and this should only be done when it is situated at some easily accessible point. Cicatricial Stenosis of the Cardiac Opening of the Stomach. — Spasmodic strictures and organic strictures the result of traumatic, chemical, or thermal irritation should be treated, when possible, by passing down the esophagus from time to time graduated bougies, but if this cannot be accomplished, the abdomen must be opened, the stomach incised, and an attempt made to overcome and dilate the stricture by passing bougies from below upward. Strictures which result from 988 THE GASTRO-INTESTINAL CLINIC malignant growths and all those not benefited by the bougie treatment frequently require a gastrostomy in order to pre- vent the patient from starving to death. The object of this operation is to form a permanent gastric fistula, one which will not leak and through which the patient may be fed. The three operations known by the names of the men who first suggested them — Senn, Franck, and Witzell — are the ones generally followed and all admirably accomplish the purpose for which they were designed. After such an operation the patient can be fed on any easily assimilated liquid food, or upon sohds, if the precaution is taken to first masticate the food thoroughly in the mouth before it is introduced through the tube into the stomach. The operation of gastrostomy is not a dangerous one, provided of course it is performed, as should always be the case, before the patient reaches a stage of extreme cachexia. The results from the operation are generally satisfactory — in the non-malignant cases life may be preserv'ed indefinitely, and in the malignant ones the relief from pain and other distressing symptoms is sufficient to more than justify the procedure. Cicatricial Stenosis of the Pylorus. — The operation of pylo- rectomy has given such a high mortality that it is no longer considered advisable except in cases where the radical cure of carcinoma is to be attempted. The choice of operation depends largely on the conditions as they reveal themselves at the time of the operation, but as a rule a radical one like gastro-jejunostomy or gastro-duodenostomy will give the best results, and unless contra-indicated should always be given the preference over the plan of cutting the stricture (pylo- roplasty), or stretching it (pylorodiosis). The operation of gastro-jejunostomy, as now performed with sutures and spe- cially devised clamps for holding the stomach and intestines, can be c^uickly and easily done. If the proper technique is observed, regurgitant vomiting and the formation of the so- called vicious circle are not so frequently encountered as in former days. The mortality from the operation should not THE SURGERY OF THE STOMACH AND INTESTINES 989 be over 4 per cent. The operation of gastro-duodenostomy as perfected by Finney and Kocher has much to recommend it, but it is more difficuh to perform and gives a higher mor- tahty than gastro-enterostomy. Hour-Glass Stomactu — This is usually caused by the ad- hesions following a gastric ulcer, — occasionally it is congenital or the result of syphilitic gumma or cancer. The treatment is entirely surgical — in many cases all that is required is a plastic operation to relieve the constriction (gastro-plasty). In other cases it is better to join the two sacs, by an anasta- motic opening (gastro-gastrotomy) and at the same time, if necessary, do a gastro-jejunostomy. Cancer and Sarcoma of the Stomach — Primary sarcoma of the stomach is hardly rare enough to be considered a patho- logical curiosity, the literature containing the report of 50 or more cases, and it is probable that there are many more, sarcoma not infrequently being mistaken for carcinoma. Gas- tric carcinoma on the other hand is very common, the stomach standing third in the order of frequency among the organs of the body most frequently attacked by this disease. In these conditions of the stomach surgery can occasionally offer the hope of a complete and permanent cure, and in a number of cases which are too far advanced to attempt radical work a palliative operation like gastro-enterostomy will sometimes prolong life, relieve pain, vomiting, and other distressing- symptoms, thereby rendering the patient's latter days decid- edly more comfortable. The value of an early diagnosis cannot be too strongly emphasized, for if the object of the operation is to be attained and a complete cure effected, it is abso- lutely necessary that the work be done before extensive metastasis has taken place and at a time when every particle of diseased tissue can be removed. If the tumor is situated in the body of the stomach, a radical operation necessitates the removal of almost the entire organ, only enough of the cardiac end being left to form an anastomosis with the jeju- 990 THE GASTRO-INTESTINAL CLINIC num. The mortality from this operation is high and but few cases come to the operating-table early enough to justify attempting it. When the growth involves the pyloric orifice, as it does in the majority of cases, excision is easier and it is not considered necessary to remove so much of the stomach, but precaution should always be taken to extend the incision high enough toward the cardiac orifice to assure the removal of the entire chain of glands along the lesser curvature. Dilatation of the Stomach. — Acute dilatation is a very fatal disease, but fortunately it is not often encountered. We do not fully understand its pathogenesis, but from a clinical standpoint know that it is very closely allied to ileus and paresis of the bowel. In about 40 per cent, of the reported cases it has come on, generally within a few days, after some abdominal operation performed under general anaesthesia. Some other causes which are supposed to predispose to it are over-eating, chronic wasting diseases, and injuries to the head and spine. Treatment so far has proven of little avail — early and fre- quent lavage is recommended, but unless this affords prompt relief, it will probably be better to perform a gastrostomy. Chronic Dilatation (Gastrectasis). — Constriction at the pylo- ric orifice, atrophy of the tunica muscularis, and continual ex- cessive ingestion of food and drink are the most frequent causes of this condition. Treatment. — Conservative measures should first be given a thorough trial, but if they fail to afford relief, an operation is the ' only alternative. The usual surgical procedure is to overcome the constriction at the pyloric orifice (pyloroplasty) and at the same time do a gastro-enterostomy. If the stomach is enormously enlarged a row of interrupted sutures should be placed through the anterior abdominal wall in order to tuck in some of the excessive tissue (gastroplication). Gastroptosis. — A downward displacement of the stomach may result from some congenital deformity or may accom- pany a general relaxation of all the abdominal organs. The THE SURGERY OF THE STOMACH AND INTESTINES 99I ligaments and various mesenteric attachments are lengthened, thus permitting the liver to extend below the costal margin and the stomach below the umbilicuS. This condition fre- quently exists without producing any marked disturbance of the digestive process; on the other hand it will often render life miserable. A great many cases can be entirely relieved by wearing an abdominal belt made so as to lift up and sup- port the depressed viscera, at the same time proper attention being given to rest, diet, exercise, etc. Surgical interference should be a last resort and advised only after persistent and repeated failure of all palliative means. The operation de- vised by Dr. Harry D. Beyea of Philadelphia is the most ra- tional one and the one which up to the present time has afforded the greatest number of cures. The abdomen is opened through the middle line and the gastro-hepatic omentum shortened by passing through it from above down- ward a series of interrupted sutures. The sutures are intro- duced close to the border of the liver and each bite of the needle takes up about one inch of tissue, finally emerging at a point just above the border of the stomach. When these sutures are tied, the effect is to draw up the stomach and fix it in its normal position. Foreign Bodies in the Stomach. — A great many of the for- eign bodies swallowed intentionally or accidentally cause no harm or injury; they find their way naturally through the pyloric orifice and are discharged with the feces. But there are some which cannot be so eliminated and as long as they remain in the stomach are a serious menace to health and life. Before any operative procedure is attempted, an x-ray picture should be taken so as to render the diagnosis abso- lutely certain; a simple gastrotomy can then be performed and the substance removed. Wounds of the Stomach.^Stab and gun-shot wounds of the abdomen frequently penetrate the peritoneal cavity and injure the stomach. Whenever from the position of the wound there is suf^cient 992 THE GASTRO-IXTESTIXAL CLINIC evidence to render this likely, an exploratory operation should be immediately made, and the anterior and posterior walls carefully examined. SURGERY OF THE INTESTINES Duodenal Ulcers. — These ulcers pathologically and symp- tomatically are closely allied to gastric ulcers, but differ in that they are more frequent (six to one) in men than in women. The surgical treatment of the two conditions is the same. When a patient suffers from localized tenderness in the right epigastrium, with pain coming on from one to three hours after eating, has vomiting, blood in the stools, eructa- tions of gas, and withal a gradual and progressive loss of weight, the diagnosis of duodenal ulcer is justifiable. The treatment should first be conservative and palliative, every effort being made to effect a cure by means of rest, massage, diet, and judicious medication, but, if after the patient has been under observation for a reasonable time, (two to four weeks), and there is no improvement noted, operative work should be advised. One of the most important factors in pre- venting the ulcer from healing is the constant passing of the chyme over it; a gastro-enterostomy obviates this by providing means of diverting the food directly into the jejunum. The most serious complication of duodenal ulcer is per- foration, which may be expected in from 25 to 30 per cent, of cases. It is often the first clinical manifestation of the disease, and its prompt recognition is of the greatest impor- tance. The favorite seat of rupture is in the first portion of the duodenum, on the anterior wall and within one inch of the pyloric orifice. It is not necessary before operation to waste time trying to locate the exact point of rupture; if the history points towards duodenal ulcer and one finds the patient suf- fering from profound shock, severe pain in the epigastrium with a rigid scaphoid abdomen and, possibly, diminution of the liver dullness, he should not hesitate to urge immediate THE SURGERY OF THE STOMACH AND INTESTINES 993 operation. The reported cases prove conclusively that suc- cess or failure depends upon the time elapsing between per- foration and operation — those cases operated upon under twelve hours nearly all recover, whereas if there is a delay of twenty-four hours or more nearly all of them die. In operating for suspected duodenal ulcer the abdomen should be opened above the umbilicus through the right rectus muscle and a careful and systematic search instituted in order to find the seat of trouble. A small opening with but little surrounding induration may be closed by a continuous Lam- bert or a purse-string suture. If, however, one finds a large puncture surrounded by a ring of indurated, friable tissue, he will have to exercise con- siderable ingenuity to successfully close it without seriously narrowing the lumen of the bowel — if possible, two rows of interrupted Lambert sutures should be used and over this a graft of omentum placed. Tuberculosis of the Intestines. — Probably not more than one-tenth per cent, of the adults who suffer from tuberculosis are infected primarily along the intestinal tract; in children it is much more frequent (variously estimated at from i to 4 per cent.). Secondary involvement of the intestines following pulmonary tuberculosis is, on the other hand, a common oc- currence both in adults and children. Treatment from a surgical standpoint centers particularly about the primary infections localized along an accessible por- tion of the intestinal tract, chiefly those involving the region in and around the ileo-cecal valve. A tumor-like mass gradu- ally developing in the peritoneal cavity and accompanied by the symptoms of intestinal obstruction demands an explora- tory operation. The abdomen should be opened, preferably through the median line, and a resection done in all cases where it seems possible to remove the entire tubercular mass. The reported resuks from this operation are highly satisfac- tory, a number of complete cures having been effected. If it does not seem feasible to attempt a radical operation, then 994 THE GASTRO-INTESTINAL CLINIC a temporary procedure such as enteroplasty, or the formation of an artificial anus, may succeed in prolonging life and ren- dering the patient more comfortable. Intestinal Tumors. — The benign tumors are exceedingly rare and practically limited to adenomas, fibrous growths, and liporjias. They are of surgical interest chiefly because they seem to predispose to intussusception. Sarcomas are of oc- casional occurrence, the lympho-sarcoma being the most usual form of it. Carcinomas are common along the whole intes- tinal tract, especially so in the duodenum and colon. There is no more difficult and important diagnosis in medicine than the early recognition of intestinal carcinoma. If it is delayed until the mass grows large enough to be palpated through the abdominal wall, the probabilities are that a radical operation will be impossible. The rule should be that if the symptoms point strongly toward carcinoma an operation is indicated, eveii though the confirmatory presence of the mass is absent. The abdomen should be opened through the middle line and a careful in- vestigation made to determine the nature of the trouble. If a tumor is found in some accessible portion of the intestinal tract, it must first be carefully studied in order to ascertain w^hether or not its complete removal is possible. In case a resection is decided upon, the diseased loop of bowel is drawn through the abdominal wound and walled off from the peri- toneal cavity by gauze sponges. Precaution should always be taken to see that the line of incision both above and below the mass is through perfectly healthy tissue, even though this may necessitate the removal of cjuite an extensive amount of bowel. The form of anastomosis depends upon the conditions as they reveal themselves at the time of the operation — the simplest and easiest method is to close the ends by a purse- string suture and invert them into the bowel with a continu- ous Lambert suture, the operation being completed by making a lateral anastomosis. If a colostomy is decided upon, it can be performed in sev- THE SURGERY OF THE STOMACH AND INTESTINES 995 eral ways, and the method selected depends upon the patho- logical conditions necessitating the operation. Unless contra- indicated the point of election is the left inguinal region — • the abdomen is opened by splitting the muscles, the highest portion of the sigmoid drawn into the wound and fixed there either by passing a glass rod through the mesocolon, or by the use of the Ward stitch tied over a small piece of drainage tube. If there is no necessity for haste, a dressing should be applied and the bowel left from two to four days before opening. But in case immediate evacuation is called for, it is better to stitch the bowel all around to the peritoneum, make a small opening at the crest of the loop, and insert a Paul's tube — by so doing the dangers of infection are mini- mized. In cases where it is certain the fistula is to be per- manent, some surgeons prefer to divide the bowel, close the distal end, and drop it back into the peritoneal cavity; the proximal end being fastened to the peritoneum and fascia with catgut sutures, and a glass drainage tube introduced into the bowel to drain the fecal matter away from the wound. Intestinal Obstruction. — There are many mechanical condi- tions originating either within or without the bowel which may give rise to various degrees of obstruction, and it may also result from an intestinal paralysis which follows some local or general disease. Mention has already been made of a few of the mechanical causes demanding surgical attention, such as cicatricial contraction, pressure, and distortion from tumors, etc., etc. Other causes of obstruction which will be considered here are biliary' calculi, intestinal concretions, ascarides, accumulation of feces, intussusception, volvulus, flexures, and strangulation by ligamentous bands. Biliary Calculi. — As a rule, these are small and pass through the intestines without causing any serious harm, but now and then an unusually large one will lodge along the intestinal tract and cause trouble. As soon as the diagnosis of obstruction is made, the abdomen should be opened and the position of the stone determined. If the calculus is soft it 996 THE GASTRO-INTESTINAL CLINIC may sometimes be crushed with the fingers, but, unless this can be done without injuring the bowel, it is better to incise the gut at once and remove it. A method recommended by Tait consists in piercing and breaking up the enterolith with a strong needle passed obliquely through the intestinal wall, the ^mall wound being afterwards closed by a few interrupted sutures. If the operation has been delayed too long and the intestinal wall at the site of the stone has become gangrenous, a resection must be performed. Obstruction due to intestinal concretions, an accumulation of feces, masses of ascarides or other worms, resisting all simple and ordinary methods of treatment, must be subjected to operation in a manner similar to that advised for obstruc- tion caused by gall-stones. Intussusception. — The older methods of attempting a reduc- tion by means of inflation, injections, etc., are now generally regarded as a waste of valuable time; consequently, they are being abandoned. The invariable rule should be, unless there is some strong contra-indication, to do a laparotomy as soon as possible after the diagnosis is made. The intussusception can generally be reduced easily by gentle traction on the bowel, and a recurrence prevented by fixing it with a few interrupted sutures, or, if necessary, shortening the mesentery at the site of the intussusception. In case the invagination cannot be reduced and the bowel is gangrenous, recourse must be had to a resection followed by either an end-to-end or lateral anastomosis. In chronic cases with the bowel in good condition, a short-circuiting operation is all that is necessary. Volvulus is characterized by a rapid onset, profound shock, and all the symptoms of complete obstruction. The abdomen should be opened without delay and the affected loop un- twisted. There is great danger of recurrence and conse- quently every precaution should be taken to guard against it. It may be necessary to shorten the mesentery, to stitch the bowel to the anterior abdominal wall or to the side of the THE SURGERY OF THE STOMACH AND INTESTINES 997 pelvis. If the affected loop is gangrenous, a complete resec- tion is demanded. Intestinal Flexure. — The bowel should be straightened out, and to prevent a recurrence a V-shaped piece should be re- moved from the wall of the affected loop and the wound closed by sutures. Adhesions and Ligamentous Bands. — These should be cut between two ligatures and, if large, the raw ends covered with peritoneum. Meckel's Diverticnlum. — This anatomical anomaly will oc- casionally cause intestinal strangulation. It should be removed in the same way that an appendectomy is done. Hernia. — Strangulation of any internal hernia demands an immediate laparotomy as soon as the diagnosis is made. A strangulated external hernia protruding under the skin can frequently be reduced by taxis, but one should not persevere with this form of treatment longer than ten or fifteen min- utes — operative intervention is generally required. INDEX Abdomen, contra-indications for mas- sage of, 274 indications for massage of, 273 inspection of, 76 splashing sounds in, 186 strapping for displacements, 423 Abdominal cavity, anatomy of, 31 displacements as causes of pelvic disease, 462 organs, how mapped out, 70 tumors, differential diagnosis of gastric cancer from, 628 tympany, 187 Abram's method of treatment through the spine, 311 method of treatment of consti- pation, 783 Abscess, ischiorectal, 912 of rectum,, gii subphrenic, 541 Absorption, 59 defecation and digestion, physi- ology of, 54 Acetone and diacetic acid, 158 iodoform test for, 159 Achylia gastrica, symptoms of, 833 Acid, diacetic, 158 gastric catarrh, diagnosis of, 509 gastric catarrh, diagnosis from ulcer, 511 gastric catarrh, aetiology of, 504 gastric catarrh, microscopic help in, diagnosis of, 512 gastric catarrh, pathology of, 505 gastric catarrh, symptoms of, 506 gastritis, 485 gastritis and HCl excess, diet in, gastritis and HCl excess, medic- inal treatment in, 522 Acid gastritis and HCl excess, treat- ment of, 514 hydrochloric, an injurious rem- edy in certain cases, 2^3 hydrochloric, does not prevent fermentation, 334 hydrochloric, valuable effects of, 335 lactic, test for, 127 uric, tests for, 153 Acids, administration of, 331 organic, excess of, 531 organic, tests for, 128 Acute appendicitis, treatment of the severer forms, 757 catarrhal appendicitis, treatment of, 755 •catarrh of the intestines, aetiology of, 707 enteritis, diagnosis of, 710 enteritis, diet in, 714 enteritis, pathology of, 708 enteritis, prognosis of. 711 enteritis, symptomatology of, 709 enteritis, treatment of, 711 gastrectasis, 387 gastritis, simple, diagnosis of, 473 gastritis, treatment of, 474 Adhesions, surgical treatment, 987 perigastric, 987 Administration of acids, 331 Advantages claimed for mechanical vibration, 305 Etiology, incidence, etc., of sarcoma of the stomach, 617 After-treatment of membranous ca- tarrh of the intestines, 819 Age and sex, incidence of ulcer as to, 534 Air passages, upper, blood from, 600 999 lOOO INDEX Albumin, tests for, 131 Alcohol and food accessories, 195 rarely necessary, 355 Alcoholic gastritis, 481 liquors, effects of, 230 Alimentation, rectal, technique of, 248 Alkalies and alkaline spring waters in hyperchlorhydria, 531 for acid gastritis, 522 effect of, given before and after meals, 330 in gastro-intestinal disease, 348 Alkaline mineral waters, 349 American surgery, tribute to, 462 Amceba coli, 941 dysenterise, illustration of, 803 Amoebic dysentery, complications, 804 dysenterjs diagnosis of. 804 dysentery, setiology of, 802 dysentery, pathology of, 803 dysentery, prognosis of, 805 dysentery, symptoms of, 804 dysentery, treatment of, 805 Ammonium benzoate as an antisep- tic, 362 Anacidity of the stomach, nerv- ous, 833 Anadenia, gastrica, 833 Analyses, fees for, 143 quantitative, indispensable to di- agnosis of acid gastritis, 514 Anaemia and chlorosis, 954 as predisposing cause of gastric ulcer. 550 pernicious, from septic mouth, 825 Anatomy of abdominal cavity, 31 of cecum, 42 of digestive tract, 29 of duodenum, 41 of intestinal canal, 41 of intestines, liver, etc., 41 minute, of the stomach, 37 of pharynx, 29 Aneurismal and atheromatous changes in the arteries, 545 Animal parasites in feces, 168 Ankylostoma duodenale, 942 Anomalous course of first portion of ascending colon, 445 direction of transverse colon, 452 Anorexia and hyperkoria, 848 (impaired appetite), 179 Antiseptic drugs for fermentation, 827 Anus, fissure of, 909 Apparatus for lavage, 314 Appendicitis, chronic catarrhal, T})"] chronic catarrhal, symptoms, 738 chronic catarrhal, diagnosis, 739 chronic, as a source of flatulency, 824 clinical course of, 736 complicated by peritonitis, 734 conservative surgical method in, 743 diet in, 746 different forms of, 728, 729 diagnosis of, 735 setiology of, 729 fulminating form of, ^2)7 latent chronic cases of, 738 lavage in, 745 management of, 762 non-operative treatment of, often the only kind practicable, 758 nutritive enemas for, 746 Ochsner's description of his method in, 745 Ochsner's plan of treating, 744 operative treatment for, 747 pathology of, 730 perforation in, 734 physical signs of, 736 prognosis of, 740 radical surgical method in, 743 rectal temperature in, most sig- nificant, 734 report of author's case of, 760 report of Babcock's operations for, 749 report of Deaver's work in, 750 Richardson's results in, 748 salicylic enemas for, 765 simple classification of, 729 INDEX lOOI Appendicitis, symposium on, 754 symptoms of, 732 the pulse in, 734 treatment of acute catarrhal, 755 treatment of chronic catarrhal, 759 treatment of the severer forms of, 757 Appendix, glands and lymphoid tis- sue from, 42 often involved in diarrhea, 788 directions for palpating, 739 removal of, during first 36 hours, 742 surgery of, 743 thickening of, in chronic enteri- tis, 719 Appetite, excessive, 180, 845 excessive, causes of, 845 impaired (anorexia), 179 normal excitants of, 196 Applications to abdomen in intestinal colic, 8go to epigastrium in nervous vom- iting, 861 Approximate quantitative test for in- dican, 151 Area of tympany in gastrectasis with gastroptosis, 401- of tympany in gastroptosis, 434 Arnold's claims for manual ther- apy, 307 Aromatic sulphates in the urine, 149 Arrangement of meals with relation to rest and exercise, 211 Arsenite of copper as a remedy in gastro-intestinal affections, 366 Arteriosclerosis and its relations with gastro-intestinal affec- tions, 970; climatotherapy in, 985; diagnosis of, 976; eti- ology of, 974; of the ab- dominal vessels, 972 ; pathol- ogy of, 975 ; prophylaxis and treatment of, 980. Astringents, 362 Atonic and spastic constipation, 771 Atonic conditions, diet in, 219 constipation, differential diagno- sis between spastic and, 769 constipation, Penzoldt's diet for, 778 dilatation of stomach, treatment of, 410 Atony, gastric, 378 of stomach, aetiology of, 381 of stomach, diagnosis of, 383 of stomach, nervous, 865 of stomach, symptomatology of, 382 of stomach, symptoms of, 381 relative importance of dilatation and, 379 various degrees of, 380 Atropine, great value of, in acute ileus, 700 Atrophy of the mucous membrane of stomach with polyposis, 490 of the stomach, diagnosis of can- cer from, 626 Auscultation and percussion, 85 Author's case of appendicitis, 760 method of determining the state of the gastric motor func- tion, 90 method of outlining the stom- ach, go results from mechanical treat- ment of abdominal displace- ments, 666, 668 Auto-intoxication as a cause of in- somnia, 967 Autotoxic nephritis treated by elec- tro-static currents, 283 Babcock's operations for appendi- citis, 749 paper on coloptosis, 440 Bacillary dysentery, aetiology of, 798 dysentery, complications and sequels of, 799 dysentery, definition of, 798 dysentery, diagnosis of, 799 I032 INDEX Bacillary dysentery, pathology of, 798 dysentery, treatment of, 800 Bacillus butyricus, 141 Flexner, of dysentery, 808 Shiga-Kruse, 808 Bacteria and animal parasites in gas- tro-intestinal tract, 931 Baths of warm milk, 252 Bead test, Einhorn's, 134 Bedford Spring water, 350 Belched gas from the intestines, 823 Benedict effervescent test for gastric acidity, 132 effervescent test, further develop- ment of, 132 Benign tumors of the rectum, 923 tumors of the stomach, 618 Beverages allowed in chronic gastric catarrh. 498 helpful in treatment of chronic gastritis, 498 Bile, 58 blood, feces, or pus in the stom- ach contents, 123 Biliary calculi, treatment of, 995 pigments and acids, 156 Bismuth and its combinations in ex- cessive eructations, 827 and cerium oxalate, 359 in chronic asthenic gastritis, 502 preparations in gastric ulcer, 359 preparations used in gastro-in- testinal affections, 362 treatment of gastric ulcer, 555 Bland oils, 360 Blood cells, red, in feces, 168 counts, 176 diseased conditions that may be diagnosed by, 178 examinations not conclusive in stomach cases, 173 found in the stools, source of, 597 from stomach and that from lungs or air passages, 600 in both vomit and stools, 598 in gastric carcinoma, 174 in gastro-intestinal diseases, 173 Blood in stomach contents, 123 in vomit and stools, significance •of, 595 iron test for, 599 specimen of, to obtain, 175 the, in gastric cancer, 606 Blood-vessels in the stomach, 38 Boas bacilli in gastric cancer, 613 Boas' explanation of aetiology of constipation, 768 formula for a nutritive enema, 250 Bodenhamer's bivalve speculum, 898 Bothriocephalus latus, 938 Boundary, mapping out the, 97 Bowel, measures to combat collapse from sudden emptying of, 291 hydro-electric curents within, 288 Bowels, relief of pain or insomnia produced by disease of, 355 Breakfast, Ewald, 117 Breath, fetor of, or foul taste in mouth, 179 Bright's disease and diabetes, influ- ence on digestion, 968 Bromides, large doses of, in cardio- spasm, 855 Bronzing, jaundice or discolorations of skin, 181 Buccal reflex, 846 Bulimia and akoria, 845 (excessive appetite), 180 Burette for quantitative analysis, il- lustration of, 135 Caird, F. M., cases of tuberculosis of cecum, reported by, 705 Calculi, biliary, surgical treatment of, 995 Cancer and sarcoma of the stomach, surgical treatment of, 989 as affected by its location, symp- toms of, 613 gastric, differential diagnosis from other abdominal tumors, 629 INDEX 1003 Cancer, gastric, hemorrhage from, 616 ■gastric, histologic changes in, 623 gastric, indications for an ex- ploratory incision in, 643 gastric, operative treatment of, 641, 989 gastro-intestinal, early diagnosis most important, 639 of body of stomach, 616 of cardia, 614, 615 of cardia differentiated from ul- cer, 631 of gastric walls, 616 of stomach, complications, se- quels, etc., 606 of stomach, diffuse, 605 of stomach, frequency and inci- dence of, 602 of posterior wall of the stomach, 604 of pylorus, 614 of stomach, pathology of, 603 of stomach, varieties of, 603 of stomach. X-rays, radium, etc., in, 636, 641, 642, 643 Capacity and motor -power of the stomach, 103 of the stomach, tests of, 103 Capillaries in villus of injected in- testine, 41 Carbolic acid and creosote for eruc- tations, 827 safe only when gastric se(5retion not excessive, 361 Carbon dioxide in diseases of the rec- tum and colon, 296 in intestinal diseases, 296 Carcinoma and sarcoma of intestines, aetiology of, 652 gastric symptomatology of, 609 and other tumors of the stomach; medicinal and palliative treat- ment of, 644 intestinal metastases of, 653 of the cecum, differential diagno- sis between tuberculosis and, 663 of stomach developed in site of ulcer, 542 of stomach, treatment, 645 of stomach, treatment with X- rays, 636-639 strictures from, obstructing the bowels, 674, 701 Carcinomatous stenoses, symptoms of, 701 ulcer, 633 ulcer of duodenum, illustration of, 564 ulcer of stomach, 625 ulcer of stomach, therapeutic test for, 634 Cardia, cancer of, 614 cancer of, diffei»entiated from ul- cer, 631 spasm of, 852 Cardiac glands from a dog's stomach, 34 end of stomach, glands from, 35 Catarrhal appendicitis, acute, treat- ment of, 755 appendicitis, chronic, ^yj appendicitis, chronic, treatment of, 759 dysentery, diagnosis of, 796 dysentery, aetiology of, 794 dysentery, pathology of, 794 dysentery, prognosis of, 796 dysentery, saline laxatives, best remedies for, 363 dysentery, symptoms of, 795 dysentery, treatment of, 796 ulcers of intestines, 586 Catarrh, chronic gastric, prognosis of, 495 chronic intestinal, from cardiac or hepatic disease, 716 chronic intestinal, diagnosis of, 720 chronic intestinal, pathology of, 716 1004 INDEX Catarrh, chronic intestinal, prog- nosis of, 721 chronic intestinal, symptomatol- ogy of, 717 chronic intestinal, treatment of, 772 gastric, diagnosis of, from ner- vous dyspepsia, 875 of intestines, chronic, eetiology of, 71S of intestines, acute, aetiology of, 707 of intestines, membranous, af- ter-treatment of, 819 of intestines, membranous, diag- nosis of, 812 of intestines, membranous, aetiol- ogy of, 810 of intestines, membranous, pa- thology of, 812 of intestines, prognosis of, 814 of intestines, membranous symp- toms of, 811 of intestines, membranous, symp- tomatic treatment of. 814 of intestines, membranous, treat- ment of, 814 Causal treatment of membranous ca- tarrh of intestines, 815 Causation of peristaltic unrest, 851 Causes of dilatation of stomach, 388, 389 of meteorism. 884 Cecum, anatomy of. 42 carcinoma of, differential diagno- sis between tuberculosis and, 663 catarrh of, splashing sound in, 719 Cells, border, and parietal or oxyntic cells, 36 chief or central. 36 goblet, and glands from the colon, 43 red blood, in feces, 168 vegetable, in feces, 167 Central galvanization, illustration of, 279 Cerium oxalate, and bismuth prepara- tions, 359 Chair exercise for arm and trunk muscles, illustration of, 263 Chlorides, importance of estimating, 145 Chloride waters (saline), 351 Cholera, diagnosis of the forms of acute enteritis from, 711 Chronic appendicitis as a source of flatulency, 824 catarrhal appendicitis, ']2)'j catarrh of the intestines, setiology of, 715 dilatation of the stomach, 388 diarrhea, diet in, 790 dysentery, complications of, 806 dysentery, diagnosis of, 806 dysentery, pathology of. 805 dysentery, prognosis of, 806 dysentery symptoms of, 805 dysentery, treatment of, 806 gastric catarrh, beverages al- lowed in, 498 gastric catarrh, prognosis of, 495 gastric catarrh, treatment, die- tetic and hygienic, 496 gastritis, diagnosis of, 492 gastritis, diagnosis of cancer from. 625 gastritis, different forms of, 485 gastritis in general, pathology of, 4S8 gastritis, symptomatology of, 489 gastritis, syphilitic, 579 intestinal catarrh, treatment of, "722, intussusception, 701 Cicatricial stenosis of the pylorus, 972 Clapotement in the examination of the stomach, 96 Classes of cases for which certain diet lists are indicated, 240 INDEX 1005 Classification of diseases, 371 of diseases with regard to dietetic treatment, 216 of foods, 197 of intestinal obstruction, 668 Cleaves' method of applying hydro- electric treatment in the bow- els, 289 Climatic changes for constipation, 780 and hygienic measures in tuber- cular ulcerations of the gastro- intestinal tract, 575 Clinical course of appendicitis, 736 Cod-liver oil in tuberculosis of stom- ach, 576 Coffee and tea, 231 Cohn's method of applying static elec- tricity in constipation, 286 Cold and heat as remedies, 309 Coldness of hands and feet indicates, derangement of circulation, TJ^ Colica mucosa, associated oftenest with hyperchlorhydria, 810 mucosa. Da Costa's early study of, 809 mucosa, Nothnagel's view con- cerning, 810 mucosa. Von Noorden's mono- graph on, 809 mucosa in true enteritis, treat- ment of, 820 Colic form of intussusception, treat- ment of, 683 intestinal, 882 Colitis, bismuth and oil enemas for, 303 treatment of, per rectum, 789 Colloid cancer and tubercle of cecum, 703 Colon, anatomy of, 43 carbon dioxide in, 296 flushing the, 301 inflation of, 99 stomach, etc., reports of cases of displacements of, 464 Turck's method of doing mas- sage of, 301 Colonic irrigation for colitis, 714 Coloptosis, 440 diagnosis of, 454 seven cases cited with diagram- matic illustrations, 444 symptoms of, 453 treatment of, 454 Columnar cells and yeast fungi, il- lustration of, 508 Combination of external methods, gi Comments on the Von Noorden method, 818 Comparison of results from surgi- cal and mechanical treatment, 468 Complications and consequences of gastric dilatation, 394 and course of tumors of the in- testines, 660 and sequels of bacillary dysen- tery, 799 and sequels of gastric ulcer, treatment of, 556 and sequels of round ulcer of the duodenum, 563 of amcEbic dysentery, 804 of chronic dysentery, 806 of gastric ulcer, 540 sequels, etc., of cancer of the stomach, 606 Compounds, useless pepsin, 347 Concerning test meals, 117 Concretions, intestinal obturation by, 673 Conditions, diseased, that may be di- agnosed by the blood, 178 Congenital anomalies of the stomach, 438 stenosis of the pylorus, 438 stenosis of the pylorus generally fatal, 439 Congo-red paper not a reliable test for free HCl, 529 Consequences and complications of gastric dilatation, 394 Conservative surgical method in ap- pendicitis, 743 ioo6 INDEX Constriction of loop of intestine by adhesion, 686 of intestine by club-shaped diver- ticulum, 688 Constipation, i8o ^Etiology of, 766 and diarrhea, alternating, 717 as a symptom of rectal diseases, 894 atonic and spastic, differential di- agnosis between, 769 atonic, Penzoldt's diet for, 778 atonic and spastic forms of, 767 causes of, in rectum, etc., 901 complicated by enteritis, mucus in, ITi complicated by enteritis, treat- ment of, 776 dietetic treatment of, 778 diet in, 222 dependent on displaced right kid- ney, 690 from organic obstructions, 772 gastric functions in, 782, 783 in nervous dyspepsia, 878 influence of, upon the blood, 955 intra-rectal vibration for, ']'j'] prognosis of, 774 rectal relations of, 901 stools in atonic and spastic, 771 symptomatology of, 767 treated by spring water and sa- line laxative drugs, 776 ■ treatment of, 775 treatment of, in nervous dyspep- sia, 878 Continuous current (galvanism), 278 hypersecretion (Reichmann's dis- ease), 528 Contra-indications for the stomach tube, 114 Contra-indications for massage of the abdomen, 274 Contraction, hour-glass, 436 Corset, the, as cause of atony and dilatation of the stomach, 382 Corset, the, as cause of displacements of stomach, 382 Counter-irritants, 308 Course and complications of tumors of the intestines, 660 and direction of the spinal nerves, 49 Creosote and cod-liver oil in phthisis, 959 minute doses of, in irritable stomach, of tuberculosis, 574 Crystals, hemin, examination for, 599 in feces, 172 Cupric arsenite in gastro-intestinal affections, 366 Curative treatment of gastric ulcer, S5I Currents, action of faradic on gastric secretion discovered acciden- tally, 326 continuous, 278 high-frequency, 283 induced, 280 polyphase, 285 Cylindric cells in gastric mucosa, 36 Dangers in over-restriction of diet, 224 Deardorff's antiseptic enema, 724 method of treating chronic colitis, 302 Deaver's statistics in appendicitis, 741, 750 Debility, 181 in carcinoma, measures against, 648 Deductions from statistics of appen- dicitis, 751 Defecation, 61 absorption and digestion, physi- ology of, 54 painful, 181 Definition of bacillary dysentery, 798 of dysentery, 793 Depression, mental or nervous, 182 Derangements of the appetite, 844 INDEX 1007 Determination of the gastric motor power, 98 Detritus in feces, 172 Diagnosis and symptoms of sarcoma of the stomach, 617 differential, between atonic and spastic constipation, 769 differential, of acute ileus, 693 differential, between carcinoma and ulcer of stomach, 630 differential, of dilatation of stom- ach, 402 differential, of gastric cancer from other abdominal tumors, 628 differential, between gastric ulcer and the diseases which resem- ble it, 546 differential, between tuberculosis and carcinoma of cecum, 663 differential, between various forms of intestinal obstruc- tion, 698 early, indispensable in the treat- ment of gastro-intestinal can- cers, 639 of acid gastric catarrh, 509 of acid gastric catarrh from ul- cer, SI I of achylia gastrica, 834 of acute enteritis, 710 of amoebic dysentery, 804 of anorexia, 849 of appendicitis, 735 of atony of stomach, 383 of bacillary dysentery, 799 of carcinoma of the rectum, 926 of cardiospasm, 853 of catarrhal dysentery, 796 of chronic dysentery, 806 of chronic gastritis, 492 of chronic intestinal catarrh, 720 of coloptosis, 454 of dilatation of the stomach, 396 of fistula in ano, 914 of gastralgia, 837 Diagnosis of gastric hypersesthesia, 842 of gastric phlegmon, 483 of gastroptosis, 433 of hemorrhage from stomach and intestines, 598 of intestinal ulceration, 590 of ischiorectal abscess, 913 of membranous catarrh of the in- testines, 812 of meteorism, 885 of movable kidney, 421 of nervous dyspepsia, 874 of nervous dyspepsia from gas- tric catarrh, 875 of nervous dyspepsia from hyperchlorhydria, anacidity, or hypochlorhydria, 875 of nervous vomiting, 861 of Reichmann's disease from gas- tric ulcer, 529 of round ulcer of the duodenum, 562 of simple acute gastritis, 473 of stricture of the rectum, 920 of toxic gastritis, 480 of tubercular ulcers in the stom- ach and intestines, 570 of trichinosis, 950 of tumors of intestines, 661, 664 of ulcer of the stomach from ulcer of the duodenum, 545 symptomatic guide to, 179 Diaphragmatic hernia, 684 Diarrhea, 181 aetiology of, 784 appendix often involved in, 788 as a symptom of constipation, 769 as a symptom of rectal disease, 89s astringents harmful in early stages of, 714 chief symptom of acute intestinal catarrh, 709 chronic, diet in, 790 colon flushing in treatment of, 787 ioo8 INDEX Diarrhea complicated by chronic appendicitis, treatment of, 791 complicating conditions in, 787 diet in, 222 diet for, judged by results on stopls, 791 foods which aggravate most, 790 need of examining stomach con- tents and urine in, 787 nervous forms of, 792 opium and astringents not often needed in, 787 small doses of podophyllin in, 788 treatment of, 785 laxatives in treatment of, 786 Diathesis, uratic, diet in, 225 Dietaries, American, 199 Diet and dietotherapy, 204 dangers in over-restriction of, 224 directions of Leube and Pen- zoldt, 242 in acid gastritis and HCl excess, 515 in acute enteritis, 714 in atonic conditions, 219 in appendicitis, 746 in cardiospasm, 854 in cases of movable kidney, 427 in chronic diarrhea, 790 in chronic intestinal catarrh, 722 in chronic asthenic gastritis, 496 lists, classes of cases for which certain, are indicated, 240 in constipation, 778 in diarrhea and constipation, 222 in dilatation from pyloric spasm, 406, 408 in excessive eructations, 827 in gastric ulcer, 551 in irritative conditions, 217 in nervous vomiting, 861 in the treatment of gastric dila- tation, 388, 406, 407, 408 Diet in the uratic diathesis, 225 non-stimulating, best for sthenic gastritis, 516 normal, table of, 198 Penzoldt's, for atonic constipa- tion, 778 scheme, Leube' s, 242 tables, Penzoldt's, 244 Dietetic and hygienic treatment of chronic gastric catarrh, 496 faults, frequent cause of gastro- intestinal disease, 207 sins, how to detect, 68 treatment, classification of dis- eases with regard to, 216 treatment of carcinoma of the stomach, 645 treatment of membranous catarrh of the intestines, 815, 816, 817 Dietetics, relative importance of, 205 Different mechanical methods, simi- larity of effects of, 310 Differential diagnosis of acute ileus, 693 diagnosis of dilatation of stom- ach, 402 diagnosis of gastric cancer from other abdominal tumors, 628 diagnosis of gastric ulcer and diseases which resemble it, 546 diagnosis between atonic and spastic constipation, 769 diagnosis between tuberculosis and carcinoma of the cecum, 663 diagnosis between various forms of intestinal obstruction, 698 Difficulty of diagnosing chronic gas- tritis, 494 Digestants, 345 Digestive capacity, Penzoldt's diet tables for gradual training of, 244 Digestion, absorption, and defecation, physiology of, 54 gastric, 55 INDEX 1009 Digestion, impaired, conducive to tuberculosis, 956 influence of Bright's and diabetes on, 968 intestinal, 57 salivary, 54 salivary, tests for, 129 Digestive tract, anatomy of, 29 Digital examination of diseases of rectum and anus, 897 Dilatation, atonic, of stomach, treat- ment of, 410 from pyloric spasm, treatment of, 406 gastric, complications and conse- quences of, 394 of stomach, setiology of, 388 of stomach, cured by intragastric electricity, 327 of stomach, diagnosis of cancer from, 627 of stomach, diagnosis of, 396 of stomach, differential diagnosis of, 402 of stomach, lavage for, 313 of stomach, prognosis of, 405 of stomach, treatment of, 405 relative importance of atony and, 379 Dilated stomach, its surgical treat- ment, 975 Dilator, Kelly's, 921 Dinner, test, 118 Dioxy-diamido-arseno-benzol ( Ehr- lich's "606"), for syphilis, 584 Diphtheritic dysentery, secondary, 799 Directions for a nutritive enema, Ewald's, 249 for treating membranous catarrh of the intestines. Von Noor- den's, 816 Discolorations of the skin, jaundice or bronzing, 181 Disease, gastro-intestinal, alkalies in, 348 Reichmann's, 528 Diseased stomachs need rest, 205 Diseases, classification of, 372 classification of, with regard to dietetic treatment, 216 functional, 372, 373 gastro-intestinal, the blood in, 173 of rectum and anus, 892 of rectum and colon, carbon di- oxide in, 296 of stomach and intestines not al- ways separable, ^il^ of stomach, place of HCl in treatment of, 332 Displaced organs, tumors external, etc., as causes of obstruction, 689, Displacements, abdominal, as causes of pelvic disease, 462 and distortions of the stomach, 429 lateral, of stomach, frequent, 429 of abdominal viscera, 460 of intestines, treatment of, 459 of the liver, 456 of stomach often result of cor- set, 429 of stomach, colon, etc., reports of cases of, 464 strapping abdomen for, 423 visceral, importance of correct- ing, 428 ; effect upon blood, 954 of the small intestine, 457 some statistics of, 460 Distortions of stomach from cancer, 607 Diverticulum,- Meckel's, intussuscep- tion of, 676 Dorkin's results from long-continued rectal feeding, 552 Dosage of alkalies, 348, 349 Doses, minute, modus operandi of, minute, of certain drugs, z^y Douche, intragastric, 318 Doumer's application of galvanism in chronic intestinal catarrh, 726 Downward displacement of liver and intestines, illustration of, 458 lOIO INDEX Drinking, hygiene of, 194 Drinkers and smokers, difficulty of passing stomach tube in, 11 1 Dropsy a late development of gastric cancer, 607 Drug treatment for nervous dyspep- sia, 877 Drugs, usefulness of, in minute doses, 366 Dunin on central anomalies in nerv- ous system, as causes of consti- pation, yd"} Duodenal ulcer, 559 ulcer, jaundice in, 561 ulcer, surgical treatment of, 975 ulcer, symptoms of, 560 Duodenum, anatomy of, 41 diagnosis of round ulcer of, 562 prognosis of round ulcer of, 564 round ulcer of, aetiology and pa- thology, 559 round ulcer of, complications and sequels of, 563 ulcer of, diagnosis from ulcer of stomach, 545 Dynamic obstruction of intestines, symptoms of, 670 Dysentery, 793 aetiology of, 793 amoebic, complications of, 804 amoebic, aetiology of, 803 amoebic, diagnosis of, 804 amoebic, pathology of, 803 amoebic, prognosis of, 805 amoebic, quinine enemas for, 805 amoebic, symptoms of, 804 amoebic, treatment of, 805 bacillary, aetiology of, 798 bacillary, complications and se- quels of, 799 bacillary, diagnosis of, 799 bacillary, definition of, 798 bacillary, ipecac treatment of, 800 bacillary, Shiga's goat serum for, 802 bacillary, pathology of, 794 bacillary, symptoms of, 799 Dysentery, bacillary, tendency of to relapse, 800 bacillary, treatment of, 800 catarrhal, aetiology of, 794 catarrhal diagnosis of, 796 catarrhal, pathology of, 794 catarrhal, prognosis of, 796 catarrhal, symptoms of, 795 catarrhal, treatment of, 796 catarrhal, milk diet in, 797 chronic, complications of, 806 chronic, diagnosis of, 806 chronic, pathology of, 805 chronic, prognosis of, 806 chronic, symptoms of, 805 chronic, treatment of, 806 chronic, small doses of mercuric chloride for, 807 definition of, 793 diphtheritic, secondary, 799 Epsom or Rochelle salt in, 797 forms of, 794 Dyspepsia, diagnosis of nervous, 874 nervous, 871 nervous, constipation in, 878 nervous, diagnosis of, 874 nervous, diagnosis of, from gas- tric catarrh, 875 nervous, diagnosis of, from hyperchlorhydria, anacidity, or hypochlorhydria, 875 nervous, drug treatment for, 877 nervous, electricity for, 877 nervous, prognosis of, 876 nervous, symptomatology of, 872 nervous, treatment of, 876 prognosis of nervous, 876 symptomatology of nervous, 872 treatment of nervous, 876 Early diagnosis, importance of, in gastro-intestinal cancers, 639 Eating, excessive, cause of acid gas- tritis, 515 hygiene of, 194 INDEX lOII Eating, regularity in times of, essen- tial, 214 Ebstein's views regarding relaxation of the pylorus, 868 Edebohls' view as to movable kidney and enteroptosis, 463 on aetiology of appendicitis, 739 Efifect of alkalies given before and after meals; 349 of intragastric electricity upon secretion, 324 Effervescent test, further develop- ment of Benedict's, 132 Eggs of Uncinaria Americana, 944 in treatment of gastritis, 497 Ehrlich's " 606 " for syphilis, 584 Einhorn's bead test, 134 electrode, Reed's modification, 323 gastrodiaphane, 86 intragastric spray apparatus, 319 statistics of movable kidney, 419 Electric gastroscope, 88 Electricity, 278 efifect of intragastric, upon secre- tion, 324 faradic (induced current), 280 for regurgitation and rumination, 867 for nervous dyspepsia, 877 in acid gastritis, methods of ap- plying, 521 in chronic asthenic gastritis, 501 in nervous vomiting, 862 intragastric, 409 intragastric, for acid gastritis, 520 intragastric, for stubborn case of acid gastritis, 520 intragastric, in gastric fermenta- tion, 826 intragastrically, technique of ap- plying, 329 static, 280 Electrode, Reed's modification of the Einhorn, 323 Electrodes, intragastric, 322 Electrodes, for zinc-and-mercury cataphoresis in rectal opera- tions, 929 Elimination and rest in treatment of acute enteritis, 711 Elongation and displacement of the sigmoid flexure, 447 Emaciation, 182 Embolism or thrombosis, obstruction of intestines from, 669 Emminghaus on degenerative changes in splanchnics, 767 Enema, Boas' formula for a nutritive, 250 nutritive, recommended by Ewald, 552 nutritive, in appendicitis, 746 nutritive, in gastric ulcer, 552 oil, technique of administering, 302 Enteralgia, 880 Enteritis, acute, diagnosis of, 710 acute, diet in, 714 acute, laxatives for, 712 acute, pathology of, 708 acute, prognosis of, 711 acute, symptomatology of, 709 acute, treatment of, 711 chronic, from cardiac or hepatic disease, 716 chronic, objective, symptoms of, 719 chronic, varieties of, 716 hydro-electric method in muco- membranous, 293 treatment of colica mucosa in, 820 Enteroliths, obstruction by gall- stones, etc., 691 Enterospasm, 882 Enzymes, gastric, 56 Epigastrium, tenderness on pressure over, 187 Epithelium, in feces, 167 Erosions of stomach, symptoms of, 557 of stomach, treatment of, 558 Eructations, 182 I0I2 INDEX Eructations, excessive, antiseptic drugs for, 827 excessive, intragastric electricity for, 826 nervous, 859 Esophagus, anatomy of, 30 Estimate of hemoglobin, 177 Ewald breakfast, 117 Prof. Dr. C. A., early recogni- tion of anacidity of the stom- ach by, 833 Ewald's clinic, experiments carried out by the author in, 93 directions for a nutritive enema, 249 opinion of pyloric insufificiency, 868 test breakfast, 117 view as to sympathetic gastritis, 479 Exaggerated and displaced sigmoid loop, illustration of, 449 V-shaped course of transverse colon, 451 Examination of abdominal muscles, 78 of blood, technique of, 176 of blood not conclusive in stom- ach cases, 173 of feces, 162 of feces, macroscopic, 163 for hemin crystals, 599 macroscopic, of stomach contents, 121 microscopic, of feces, 166 microscopic, of stomach contents, 141 of abdominal muscles, 78 of the spine, how made, by Ham- mond, 82 partial, of urine better than none, 148 physical, of the patient, T:}, of stomach, best made when emp- ty, 95 Excess of organic acids, 531 Excessive appetite, 845 Excessive appetite (bulimia), 180 secretion of HCl, effects of, 57 Excitability, undue, 182 Exercise and rest, arrangement of meals with relation to, 211 especially of trunk muscles, 192 in chronic enteritis, 726 indispensable, 259 passive, 268 various kinds of, 260 Exercises, gymnastic, in gastric cases, 412 Experiments as to the proper food ration, 847 carried out by the author in Ewald's clinic, 93 concerning food requirements, 199 series of, with digestants, 334 with sweet foods, 227 Expression of stomach contents con- demned, 120 External method of testing for gas- tric acidity, 132 methods, a combination of, 91 tumors and displaced organs, causes of obstruction, 689 Extracting sample of stomach con- tents, 108 Eyestrain a probable cause of chronic sthenic gastritis, 505 as cause of gastro-intestinal neu- roses, 826 Paradic currents, action of, on gas- tric secretion discovered, 326, 412 Fasting, for chronic catarrh of the intestines, 722 indications and contra-indica- tions for, 209, 752 Fat in feces, 167 Fattening as a remedy for movable kidney, 426 Fatty acids, quantitative test for, 140 Fecal impaction, 903 segregators, 164 INDEX lOI Feces, chemical reaction of, in enteri- tis, 710 examination of, 162 hardened, obturation by, a cause of bowel obstruction, 673 illustrations of microscopic find- ings in, 172 in health, 162 in stomach contents, 123 microscopic examination of, 166 Feeding by other routes than the mouth, 248 Femoral hernia, 684 Fermentation, antis-eptic drugs for, 827 from chronic gastric catarrh, treatment of, 826 hydrochloric acid does not pre- vent, 334 Ferruginous mineral waters, 357 Fetor of breath, or foul taste in mouth, 179 Fever and chills in appendicitis, 72,2, in acute catarrh of intestines, 710 Fibers, muscle in feces, 167 Fibrosis in gastric catarrh, illustra- tion of, 491 Finsen light treatment, 309 Fissure of the anus, 909 Fistula in ano, 914 gastrocolic, 607 gastrocolic, setiology of, 607 gastrocolic, symptoms of, 607 Fistulas, a majority non-tubercular, 916 Flatulency, chronic appendicitis as a source of, 824 excessive, a result of numerous different gastro-intestinal dis- orders, 823 gastric or intestinal, 182 its reflex influence upon the sex- ual organs, 964 treatment of, 826 Flexner's bacillus as a cause of dys- entery, 794, 808 Fletcher, on buccal reflex, 846 Flexure, intestinal, surgical treatment of, 997 Flies as cause of dysentery, 793 Fluidity of stomach contents, 123 Flushing the colon, 301 Folin-Hopkins method of determin- ing the amount of uric acid, 154 Food articles, proportions of the sev- eral ingredients in, 209 accessories, and alcohol, 195 definition of, 193 injection of, subcutaneously, 251 requirements, recent experiments concerning, 199 requirements under different conditions, 199 Foods, classification of, 197 Foreign bodies in the stomach, 619 bodies, obturation by, as a cause of bowel obstruction, 673 Forms of appendicitis, 728 of chronic gastritis, 485 of intestinal ulceration, 585 of micro-organisms in the gastro- intestinal tract, 932 of treatment, mechanical, in chronic gastritis, 499 Formula, Boas', for a nutritive ene- ma, 250 Formulas for acute enteritis, 713 Forward and backward body bend- ing, illustration of, 264 Foul taste in mouth, 179 Free HCl often present in tubercu- losis, 956 Frequency and incidence of cancer of the stomach, 602 Freund and Topfer's test for urinary acidities, 156 Fruits, the more acid, objectionable in acid gastritis, 517 Further development of the Benedict effervescent test, 132 IOI4 INDEX Gall-stones, obturation by, as a cause of intestinal obstruction, 672 Galvanism for chronic intestinal ca- tarrh, 726 (continuous current), 278 in acid gastritis, 521 in treatment of gastralgia, 839 Gangrene in strangulation ileus, 687 Gas, belched, often from the intes- tines, 823 Gastralgia, aetiology and symptoms of, 836 Gastrectasis, acute, 387 lavage for, 313 pronounced, 466 Gastric acidity, external method of testing for, 132 atony, 378 cancer, differential diagnosis from other abdominal tumors, 628 cancer, hemorrhage from, 616 cancer, histologic changes in, 623 cancer, indications for an explo- ratory incision in, 640 cancer, operative treatment of, 641 carcinoma, symptomatology of, 609 cases secondary to Bright's dis- ease, 413 cases secondary to heart disease, 413 catarrh, acid, aetiology of, 504 catarrh, acid, diagnosis of, 509 catarrh, acid, symptoms of, 506 catarrh, acid, microscopic help in, 512 catarrh, acid, pathology of, 505 catarrh, chronic, beverages al- lowed in, 498 catarrh, chronic, prognosis of, 495 catarrh, chronic, treatment of, dietetic and hygienic, 496 catarrh, diagnosis of nervous dyspepsia from, 875 Gastric catarrh, fatty degeneration of the glands, illustration of, 489 digestion, 55 dilatation, complications and con- sequences of, 394 enzymes, 56 flatulency,, 182 glands, anatomy of, 36 glands, best stimulant for, HCl, 355 hemorrhages, source of the larger, 596 hypergesthesia, most frequent in hyperchlorhydria, 840 hypersesthesia, Riegel's defini- tion of, 841 Inflammations, pathology of, 471 juice, normal percentage of HCl in, 56 motility, salol test of, 104 motility, simple tests for, 383 motor power, determination, 98 motor function, author's method of determining state of, 90 muscles, modes of stimulating, SOI neuroses, secretory and sensory, 830 phlegmon, diagnosis of, 483 phlegmon, symptoms of, 482 phlegmon, treatment of, 483 surgery, 986 tetany, treatment of, 413 ulcei-, complications of, 540 ulcer, curative treatment of, 551 ulcer, diagnosis of, from Reich- mann's disease, 529 ulcer, diet in, 551 ulcer, differential diagnosis, 546 ulcer, hemorrhage of the stomach in, 544 ulcer, massage in, 554 ulcer, medicinal treatment in, 554 ulcer, nutritive enemas in, 552 . ulcer, pathology of, 535 INDEX Gastric ulcer, prophylactic treatment of, 549 ulcer, sequels of, 541 ulcer, surgery of, 986 ulcer, symptomatology of, 536 ulcer, syphilitic, 580 ulcer, treatment of complications and sequels of, 556 Gastritis acida, 485 acid, and HCl excess, diet in, 515 acid, and HCl excess, medicinal treatment in, 522 acid, and HCl excess, treatment of, 514 acid, quantitative analyses neces- sary to diagnosis of, 514 acute and subacute, 471 acute, diagnosis of, 473 acute, report of case of, 474 acute, symptoms of, 473 acute, treatment of, 474 alcoholic, early resumption of feeding in, 481 chronic, different forms of, 485 chronic, difficulty of diagnosing, 494 chronic, diagnosis of, 492 chronic hypertrophic, 486 chronic, Homburg, Kissingen, and Wiesbaden waters for, 500 chronic, lavage most useful remedy for, 499 chronic, sthenic, 504 chronic, syphilitic, 579 chronic, symptomatology of, 489 complicating carcinoma, 647 fibrinous, 483 mycotic, 483 infectious and parasitic, 483 mucous, 486 in general, pathology of, 488 polyposa, 489 purulent or phlegmonous, 482 septic, from oral sepsis, 825 simple acute, 472 subacute, 477 sympathetic, 479 IO15 Gastritis, toxic, 479 toxic, necessity of emptying the stomach in, 481 toxic, treatment of, 481 Gastrocolic fistula, aetiology of, 607 fistula, symptoms of, 607 Gastrodiaphane, Einhorn's, 86 Gastro-intestinal affections, uranaly- sis indispensable in, 143 cancers, early diagnosis most im- portant, 639 disease, alkalies in, 348 disease, dietetic faults the most frequent cause of, 207 diseases, the blood in, 173 diseases, their relation to other diseases, 953 functions in relation to tubercu- losis, 955 neurasthenia, 871 tract, bacteria and animal para- sites in, 931 Gastroptosis, aetiology of, 430 surgical treatment of, 990 symptomatology of, 432 treatment of, 434 Gastroscope, electric, 88 Gastrospasm, 851 Gastrosuccorrhea chronica continua, symptoms of, 528 chronica periodica, symptoms of, 528 Gastroxynsis, symptoms of, 530 treatment of, 530 Gavage in anorexia, 849 General massage for acid gastritis, 522 Genital organs, relation of diseases of, to gastro-intestinal diseases, 963 Glands, cardiac, from a dog's stom- ach, 34 and lymphoid tissue from ap- pendix, 42 from colon and goblet cells, 43 from cardiac end of the stomach, 35 ioi6 INDEX Glands from pyloric end of stomach, 36 gastric, anatomy of, zl pyloric, from a dog's stomach, 34 Glenard on displacements as causes of constipation, 767 Glenard's disease, 415 Glenard's theory as to cause of dis- placements of stomach, 430 Glycerophosphates and hypophos- phites in nervous dyspepsia, 354 Goblet cells and glands from the colon, 43 Gould, Dr. George M., views of, re- garding ocular faults as causes of neuroses, 826 Gradual dilatation for stricture of the rectum, 921 Gymnastic exercises in gastric cases, 412 Gymnastics, special forms of, recom- mended, 262 rowing, etc., for abdominal dis- placements, 459 Gyromele, Turck's, 87 Hair balls in the stomach, 619 Hardened feces a cause of intestinal obstruction, 673 Hay's test for the bile acids, 157 Headache, 183 Health, feces in, 162 Heart disease, in relation to gastro- intestinal affections, 965 enlarged by digestive faults, 966 Heat and cold, as remedies, 309 Hematemesis from other causes than ulcer, 544 less frequent causes of, 597 in carcinoma, 648 Hemin crystals, examination for, 599 Hemoglobin, to estimate the, 177 Hemorrhage from gastric cancer, 616 from perforation of duodenal ulcer, 56s Hemorrhage from stomach and intes- tines, diagnosis of, 598 from stomach and intestines, symptoms of, 598 from stomach and intestines, treatment of, 600 from stomach in gastric ulcer, 544 from stomach, most important symptom of ulcer, 544 gastric, source of the larger, 596 in gastric ulcer, 540 or loss of blood or altered blood by mouth or rectum, 183 Hemorrhoids, capillary, 905 fibrous, 90s internal, 905 thrombotic, 90S varicose, 90S varieties of, 904 Henry's observations concerning the blood in gastric cancer, 174 Hepatoptosis, 456 Hernia, diaphragmatic, 684 femoral, 684 inguinal, 684 intestinal obstruction by, 684 inverted position for, 688 obturator, 68s retroperitoneal, 684 sacrosciatic, 685 taxis in, 688, 997 through slits in mesentery, 684 umbilical, 684 Herschell-Dean triphase apparatus, illustration of, 284 High-frequency currents, 283 Histologic changes in gastric cancer, 623 History, importance of a full, 6s Homburg and Kissingen waters, 351 Kissingen and Wiesbaden waters in chronic .gastritis, 500 Hookworm disease, eosinophilia in, 178 Horseback riding, 261 Hot-water cure, meat and, in ca- tarrhal conditions, 221 INDEX IOI7 Hour-glass contraction, 436 contraction of the stomach, 607 stomach as a result of gastric ulcer, 542 stomach, diagnostic signs of, 542 stomach, treatment of, 989 Hydriatic procedures, 309 Hydrochloric acid, absence of, not a proof of cancer. 612 an injurious remedy in certain cases. 333 best stimulant for the gastric glands, 355 cases showing use of, 338-341 does not prevent fermentation, 334 and bitter tonics, good remedies for anorexia, 849 effects of excessive secretion of, 57 excess, meats in, 218 for eructations with deficient se- cretion, 827 later experience with, 342 place of, in the treatment of gas- tric diseases, 332 secretion, relation between uri- nary acidity and, 144 stimulating effects upon secre- tion, 343 secretion increased by massage, 270 secretion, what constitutes a normal, 510 simpler tests for, 126 valuable effects of, 335 Hydro-electric applications for chronic intestinal catarrh, 727 applications within the bowel, 288 method in muco-membranous enteritis, 293 method, prerequisites for, and limitations of, 294 Hygiene of eating and drinking, 194 personal, 192 Hygienic and climatic measures in tubercular ulcerations of the gastro-intestinal tract, 575 and dietetic treatment of chronic gastric catarrh, 496 Hypersesthesia, gastric, 840 Hypertrophic stenosis of the pylorus, 620 Hyperassthesia, gastric, as cause of motor neuroses of stomach, 830 Hyperchlorhydria, a cause of excess- ive appetite, 846 case of, aggravated by massage, 271 as cause of motor neuroses of stomach, 830 medicinal remedies in, 531 mistaken for hypochlorhydria, 832 oxygen peroxide, an efficient remedy for, 524, 531 prognosis of, 530 symptomatology of, 527 tendency to, among intellectual people, 215 treatment of, 525 Hypnotic drugs, harmfulness of, 194 Hypnotics in gastro-intestinal dis- eases, 356 Hypochlorhydria, nervous, 831 Hypochondriac region, pain referred to, 185 Ileocecal intussusception, 675 Ileocolic intussusception, 674 and ileocecal intussusception, 675 Ileus, acute, differential diagnosis of, 693 obturation, relatively good prog- nosis in, 699 obturation, symptoms of, 692 prognosis of acute, 697 strangulation, symptoms of, 685 strangulation, treatment of, 688 symptoms of, 670 ioi8 INDEX Illustration of mechanical vibrator, 306 Illustrations of microscopic findings in feces, 172 Incidence of gastric ulcers in differ- ent parts of stomach, 536 Incision, indications for an explora- tory, in gastric cancer, 640 Indican, approximate quantitative test for, 151 quick test for, 150 Indications for lavage, 313 for massage of the abdomen, 273 for treatment in carcinoma, 645 Induced current (faradic electricity), 280 Induction of premature labor in per- nicious vomiting of pregnancy, 864 Infection of alimentary tract from mouth, nose, and throat, 825 Infectious and parasitic gastritis, 483 Inflammations, gastric, pathology of, 471 Inflation of stomach and colon, 99 Inguinal hernia, 684 Injected intestine, showing central lacteal and arrangement of ca- pillaries in villus, 41 Injection treatment of hemorrhoids, 907 Impaction, fecal, 903 Insomnia, neurasthenia, etc., relation of, to gastro-intestinal affec- tions, 962 produced by disease of stomach or bowels, relief of, 355 Inspection of abdomen, 74 of anus, 896 thorough, importance of, 196 Instrumental tests in diagnosing gas- tric dilatation, 400 Instruments for determining the size and position of the viscera, 85 required in rectal work, 897 Insufficiency, motor (mechanical), of the stomach, 378 Insufficiency of cardia, 866 of pylorus, 868 Internal hemorrhoids, 905 Interrogation of the patient, 65 Intestinal antiseptics, 935, 936 canal, anatomy of, 41 catarrh, chronic, diagnosis' of, 720 catarrh, chronic, pathology of, 716 catarrh, chronic, prognosis of, 721 catarrh, chronic, treatment of, 722 catarrh, purpetrol, a remedy for, 360 colic, 882 concretions, obturation by, d^Z digestion, 57 fermentation, from causes in ap- pendix, 826 flatulency, 182 flexure, surgical treatment of, neurosis, treatment of, 888 obstruction, acute, treatment of, 699 obstruction by hernia, 684 obstruction, classification of, 668 obstructions from calculi, worms, etc., 995 obstruction generally, 668, 995 obstruction, pathology of, 693 surgery, 992 tumors, surgery of, 994 ulceration, diagnosis of, 590 ulceration, symptoms of, 588 ulceration, treatment of, 591 ulceration, various forms of, 585 Intestine, volvulus of, 683 Intestines, aetiology of acute catarrh of, 707 anatomy of, 41 chronic catarrh of, aetiology, 715 diagnosis of tubercular ulcers in, 570 INDEX IOI9 Intestines, displacements of small, 457 gas belched from the, 823 hemorrhage from stomach and, 594 membranous catarrh of, aetiology of, 810 membranous catarrh of, after- treatment of, 819 membranous catarrh of, diag- nosis of, 812 membranous catarrh of, pathol- ogy of, 812 membranous ^.atarrh of, prog- nosis of, 814 membranous catarrh of, symp- toms of, 811 membranous catarrh of, treat- ment of, 814 neuroses of, 879 prognosis of tubercular ulcers in, 572 stenosis of, from carcinoma, 657 stomach and, diagnosis of hemor- rhage from, 598 stomach and, diseases of, not al- ways separable, 376 stomach and, symptoms of hem- orrhage from, 598 stomach and, treatment of hem- orrhage from, 600 strangulation by knotting, etc., 685 symptoms of displacements of small, 459 treatment of displacements of, 459 treatment of syphilitic disease in, 584 treatment of tubercular ulcers in, 572 tubercular ulcers of, 567 tumors of, course and complica- tions of, 660 tumors of. diagnosis of. 661 tumors of, other diagnostic points in, 664 tumors, pathology of, 653 Intestines, tumors of, prognosis and treatment, 665 tumors of, symptomatology of, 654 Intragastric douche and spray, 318 electricity, 409 electricity a remedy for excess- ive appetite, 846 electricity, administration of, as easy as lavage, 321 electricity, as simple as lavage, 321 electricity in fermentation from chronic gastric catarrh, 826 electricity, effect of, upon secre- tion, 324 electricity for acid gastritis, 520 electricity, indications for, 321 electricity in fermentation from deficient gastric motility, 826 electrode for gastric hypersesthe- sia, 842 electrodes, 322 faradization, for gastrectasis, 408, 409 faradization, technique of, for acid gastritis, 520 Introducing the tube, iii Intussusception as cause of intestinal obstruction, 672 chronic, 701 ileocolic and ileocecal, 675 of jejunum, illustration of, 673 of Meckel's diverticulum, 676 surgical treatment of, 996 treatment of, 682, 996 treatment of colic form of, 683 varieties of, ^'j6 Invaginated Meckel's diverticulum, illustration of, 677 Iodoform test for acetone, Leiben's, 159 Iron and its principal preparations, 356 chloride of, as an antiseptic, 361 test for blood, 599 waters of the United States, 358 ^ I020 INDEX Irritability of temper, 184 Irritative conditions, diet in, 217 Irritable throats, training, 112 Ischiorectal abscess, 912 Jaundice in duodenal ulcer, 561 or discolorations of skin, 181 Jones' (Allen A.) contributions con- cerning gastralgia of syphilitic origin, 582 (Allen A.), observations of, as to diarrhea from hypochlor- hydria, 708 Juvenile vomiting, 860 Kelly, A. O. J., on origin and de- velopment of appendicitis, 730 Kelly's dilator, 921 Kidney displaced as cause of intesti- nal obstruction, 689 movable, aetiology of, 418 movable, as cause of intestinal obstruction, 670 movable, diagnosis of, 421 movable, dilated stomach, etc., 467 movable, symptomatology of, 419 movable, treatment of, 423 prognosis of movable, 422 Kidneys, diseases of, and diabetes, in relation to gastro-intestinal af- fections, 968 how located by bimanual palpa- tion, 79 movable. 416 Kissingen and Homburg waters, 351 Homburg and Wiesbaden waters in chronic gastritis, 500 Knife, fistula, Martin's, 916 Klemperer's statistics as to the motor function in tuberculosis, 961 Knapp's theory of the pylorus, 868 Knotting of the intestines by stran- gulation, etc., 68s Kussmaul-Fleiner treatment of gas- tric ulcer, 555 Kuttner aspirator, 114 Lack of appetite, 848 Lactic acid-free meal, 118 acid, quantitative test for, 140 acid, test for, 127 Lane, Arbuthnot, on displaced kidney as cause of constipation, 690 Laparotomy, immediate, the treat- ment of volvulus, 684 Later experience with HCl, 342 Lavage, apparatus for, 314 best time for, 314 compared with intragastric elec- tric treatment, 321 for chronic gastrectasis, 314 for gastrectasis, 313 in atonic dilatation of the stom- ach, 413 in the treatment of fermentation, 826 indication for, 313 most useful of curative measures in chronic gastritis, 499 of stomach, illustration of, 316 often helpful in ileus, 700 useful in sthenic gastritis, 519 Laxatives and purgatives in gastro- intestinal affections, 363 Lenhartz treatment of ulcer, 555 Leube's diet scheme, 242 Leucocytes in feces, 168 Levico iron water, 358 Liquors, alcoholic, effects of, 230 spirituous, objectionable in acid gastritis, 518 Liver, anatomy of, 45 displacements of, 456 functions of, 59 the, its relation to gastro-intesti- nal affections, 963 various degrees of ptosis of, 457 Lower edge of liver, pain referred to, 185 INDEX I02I Lungs, blood from, 600 Lymphadenoma, 619 Lymphatics, veins and, 39 Macroscopic examination of feces, 163 examination of the stomach con- tents, 121 Magnesium phosphate-crystals in case- of hyperchlorhydria, 527 Magnetic oxide for X-ray work, 89 Malignant tumors of the rectum, 925 Management of appendicitis, 762 Manual replacement of prolapsed organs, 459 therapy, 307 Mapping out the boundaries, 97 Marginal abscess of rectum. 912 Martin's conical speculum, 898 fistula knife. 916 Massage and Swedish movements, 268 case of hyperchlorhydria pro- duced by, 271 general, for acid gastritis, 522 HCl increased by, 270 in gastric ulcer, 554 of abdomen, 459 of abdomen, contra-indications for, 274 of abdomen, indications for, 273 of abdomen, valuable in chronic asthenic gastritis, 501 of colon, Turck's method of, 301 Massey's method in cancer of the in- testines, 665 method in malignant rectal tu- mors, 928 Mastication, insufficient, cause of acid gastritis, 515 thorough, 223 Meals, arrangement of, with relation to rest and exercise, 211 effect of alkalies given before and after, 350 Measures to combat possible collapse from sudden emptying of the bowel, 291 Meat and hot-water cure for ca- tarrhal conditions, 221 and hot-water treatment of chronic enteritis, 722 diet not the best in excessive HCl cases, 515 Meats in HCl excess. 218 Mechanical forms of treatment, 499 insufficiency of the stomach, 378 obstructions as cause of gastrec- tasis, 391 obstruction of intestines, 670 treatment for movable kidney, 427 vibration, advantages claimed for, 30s vibration, in treatment of gas- tralgia, 839 Meckel's diverticulum, a cause of in- testinal strangulation, surgical treatment, 997 diverticulum, intussusception of, 676 diverticulum invaginated into its own lumen, 679 diverticulum invaginated into the ileum, 678 Medicinal and palliative treatment of carcinoma, and other tumors of the stomach, 644 remedies for acute gastritis, 476 remedies in hyperchlorhydria, 531 treatment in acid gastritis and HCl excess, 522 treatment in gastric ulcer, 554 treatment of gastritis, 502 Membranous catarrh of the intes- tines, causal treatment of, 815 catarrh of the intestines, aetiology of, 810 catarrh of the intestines, diag- nosis of, 812 catarrh of the intestines, dietetic treatment of, 815 I022 INDEX Membranous catarrh of the intes- tines, Ewald on, 8io catarrh of the intestines, pathol- ogy of, 812 catarrh of the intestines, prog- nosis of, 814 catarrh of the intestines, rest treatment for, 816 catarrh of the intestines, slime masses in, 813 catarrh of the intestines, symp- tomatic treatment of, 814 catarrh of the intestines, symp- toms of, 811 catarrh of the intestines, theories as to nature of, 809 catarrh of the intestines, treat- ment of. 814 catarrh of the intestines, von Noorden's after-treatment of, 819 catarrh of the intestines, von Noorden's treatment of, 814 catarrh of the intestines, von Noorden's views concerning, 809 Mental depression, 182 or nervous strain in chronic sthenic gastritis, 505 strain to be avoided in sthenic gastritis. 518 Merycism, 866 Mesenteric infarct as cause of intes- tinal obstruction, 672 Metabolism, faulty, as cause of heart disease, 955 Metastases in gastric cancer, 606 of intestinal tumors, 653 Meteorism, tympanites, or flatulency, 883 Method, external, of testing fer gas- tric acidity, 132 hydro-electric, in enteritis. 294 objectionable, of getting the stomach contents, 120 radical surgical, in appendicitis, 743 Method, summary of the author's, 100 Turck's, of doing massage of the colon, 301 von Noorden's, in colica mucosa, comments on, 818 Methods, external, a combination of, for outlining boundaries, 91 of testing the motility of stom- ach, 105 therapeutic, 255 Microgastria, 437 Microscopic examination of feces, 166 examination of stomach con- tents, 141 findings in feces, illustrations of, 172 help in acid gastric catarrh, 512 Milk as an article of diet for dyspep- sia, 22,2 water, etc., 232 Mineral waters, alkaline, 349 waters, ferruginous, 357 Minute anatomy of the stomach, 37 Modes of dress productive of gas- tric atony, 382 of stimulating the gastric mus- cles, 501 INIodification of the Einhorn elec- trode. Reed's, 323 Morphin and narcotics in nervous dyspepsia, 354 with atropine, large doses often needed for intestinal colic, 889 Morris, Robert T., paper by, on In- testinal Fermentation, 825 ]\Iotility, gastric, salol test of, 104 gastric, simple tests for, 383 methods of testing, 105 Motor function of stomach, 56 function of stomach, importance of strengthening in phthisis, 964 insufficiency of stomach, 378 neuroses of stomach, 851 INDEX 1023 Motor power of stomach, capacity and, 103 Mouth, foul taste in, 179 infectious in gastric cases, 825 nose and throat, infection from, 82s Movable kidney predisposing cause of sthenic gastritis, 505 kidney, etiology of, 418 kidney, as a cause of intestinal obstruction, 6go kidney, diagnosis of, 421 kidney, dilated stomach, etc., 467 kidney, fattening a remedy for, 426 kidney, how palpated, 79 kidney (nephroptosis), 416 kidney often a cause of hyper- chlorhydria, 420 kidney, palpation of, illustration, 422 kidney, prognosis of, 422 kidney, rest treatment of, 427 kidney, symptomatology of, 419 kidney, treatment of, 423 spleen, 457 Movements, bowel, 70 Mucoid and cystic degeneration of gastric mucosa, 487 Muco-membranous enteritis, hydro- electric method in, 293 Murphy's method of operating in complicated appendicitis, 748 Muscle fibers in feces, 167 Muscles, gastric, modes of stimu- lating, SOI Musser's treatment of hyperchlor- hydria with large doses of nux vomica, 524 Myxoneurosis intestinalis membra- nacea (Ewald), 810 Narcotics for acute ileus, 700 Natural position of the stomach, 32 Nausea, 843 Nausea and vomiting, not common results of passing stomach tube, 112 in chronic asthenic gastritis, how best controlled, 502 or vomiting, 184 Nephritis, autotoxic, treated by elec- tro-static currents, 969 Nephroptosis (movable kidney), 416 Nerve tonics, 354 Nerves, secretory, 47 spinal, course and direction of, 49 spinal, course of, 50-51 vaso-motor, 48 vaso-motor, points of emergence of, 51 Nervous anacidity of the stomach, 833 and reflex vomiting, 859 atony of the stomach, 865 depression, 182 derangements, relation of, to gastro-intestinal affections, 962 dyspepsia, 871 dyspepsia, attributed to eye- strain, 826 dyspepsia, constipation in, 878 dyspepsia, diagnosis of, 874 dyspepsia, drug treatment for, 877 _ dyspepsia, electricity for, 877 dyspepsia, prognosis of, 876 dyspepsia, remedies for, 843 dyspepsia, symptomatology of, 872 dyspepsia, treatment of, 876 eructation. 859 forms of diarrhea, 792 hypochlorhydria, 831 secretory derangements of stom- ach, 830 Neurasthenia, gastro-intestinal, 871 insomnia, etc., relation of, to gastro-intestinal affections, 962 Neuroses in gastro-intestinal affec- tions, 272 I024 INDEX Neuroses of digestive system from reflex causes, 825 of the- intestines, 879 of the stomach, motor, 851 Nitrous oxide, the preferred .anaes- thetic in divulsion of the anal sphincter, 902 Nori-operative measures for gastric dilatation. 406 Normal diet table, 198 HCl secretion, author's view as to, 510 percentage of HCl in gastric juice, 56 Nose and nasopharynx, harmfulness of catarrh of, 193 throat, and mouth, infection from, 825 Nutritive enema. Boas' formula for, 250 enema, Ewald's directions for, 249 enemas in gastric ulcer, 552 Obstruction by a sharp flexure, 672 by displaced organs, etc., treat- ment of, 691 by gall stones, 573 by gall stones, enteroliths, etc., 691 by the Murphy button. 692 from displaced organs, etc., symptoms of, 690 from external tumors, symp- toms of, 690 from external tumors, treatment of, 691 hernial, symptoms of, 685 intestinal, acute, treatment of, 699 intestinal, by hernia, 684 intestinal, by obturation rarely complete at first, 695 intestinal, classification of, 668 intestinal, diliferential diagnosis Jjetwep.o various forms, 698 Obstruction, intestinal generally, symptoms of, 668 intestinal, pathology of, 693 mechanical, of intestines, 672, 995 of bowels from cancer, 661 of intestines from thrombosis, 669 of the cardia in gastric cancer, 606 tubercular ulcers and growths as causes of chronic, 705 Obturation by hardened feces, as a cause of bowel obstruction, 673 by intestinal concretions. 673 by polypi, as a cause of intestinal obstruction, 673 by worms, as a cause of intes- tinal obstruction, 673 Obturator hernia, 685 ileus, symptoms of, 692 Ochsner's description of his method in appendicitis, 745 plan, or surgico-starvation meth- od in appendicitis, 744 statistics in appendicitis, 741, 750 CEdema of lower extremities in can- cer of the intestines, 661 Oil enemas, technique of administer- ing, 302 Oils, bland, 360 mineral, for constipation, 782 Olive-oil treatment of constipation, 782 Operation of divulsion of anal sphincter, 901 Operative treatment of gastric can- cer, 641 Opiates and narcotics as remedies in gastro-intestinal affections, 355 Oppression or weight in stomach, 185 Oral cavity, importance of inspect- ing, 75 Organic acids, excess of, 531 acids, tests for, 128 INDEX 102: Outlining the stomach, authors method of, 90 Ova of intestinal parasites, 940 Overdosing and overdoing in thera- peutics, 257 Overeating, danger of, 195 Oxyuris vermicularis, 940 Pain and insomnia from disease of stomach or bowels, relief of, 355 in carcinoma, measures to re- lieve, 649 referred to the region of stom- ach, 185 referred to the right hypochon- driac region or lower edge of liver, 185 where felt in strangulation ileus, 687 Palliative and medicinal treatment of carcinoma and other tumors of stomach, 644 for bleeding in cases of hemor- rhoids, 909 Pallor of skin, 185 Palpation, Tj of appendix, -739 of movable kidney, illustration of, 422 over the spine, 81 Pancreas, anatomy of, 46 Pancreatic preparations, 347 Paralysis of intestines, 887 of intestines, treatment of, 890 Parasites, animal, in feces, 168 intestinal, eosinophilia a sign of. 178; descriptions of, 936 Parasitic gastritis, infectious, 483 Pathogenic micro-organisms in feces, illustration of, 169 Pathology and aetiology of round ulcer of the duodenum, 559 of acid gastric catarrh, 505 of acute enteritis, 708 of amoebic dysentery, 803 Pathology of appendicitis, 730 of bacillary dysentery, 798 of catarrhal dysentery, 794 of cancer of stomach, 603 of chronic dysentery, 805 of chronic gastritis in general, 488 of chronic intestinal catarrh, 716 of gastric inflammations, 471 of gastric ulcer, 535 of membranous catarrh of the intestines, 812 of intestinal obstruction, 693 of phlegmonous or purulent gas- tritis, 482 of toxic gastritis, 480 of tumors of the intestines, 653 of tubercular ulcers of the stom- ach, 568 Patient, interrogation of, 65 physical examination of, TZ preparation of, 109 Pawlow's experiments with HCl on dogs, 342 Penzoldt, diet directions of, 242 Penzoldt's diet for atonic constipa- tion, 778 diet tables for gradual training of digestive capacity, 244 Pepsin and its action, 56 compounds, useless, 347 tests for, 130 Peptones, tests for, 131 Percussion, auscultation and, 85 in diagnosing gastric dilatation, 399-400 note before and after drinking a solution of soda, 133 Perforation of intestines from ca- tarrhal ulcers, 586 in strangulation ifeus, 687 of stomach in gastric ulcer, S40 particularly frequent in duodenal ulcer, 565 Perigastric adhesions, 987 Perigastritis, surgical treatment, 975 Periodic vomiting, 860 I026 INDEX Peristaltic restlessness, 857 unrest of the intestines, 885 unrest of the intestines, treat- ment of, 890 Pernicious anaemia from septic mouth, 825 vomiting of pregnancy, 863 Personal hygiene, 192 Pharynx, anatomy of, 29 Phlegmonous or purulent gastritis, 482 or purulent gastritis, pathology of, 482 Phototherapy (the Finsen light treat- ment), 309 Physical examination of the patient, signs of appendicitis, 736 Physiology of digestion and absorp- tion, 54 Pigments, biliary, 156 Pleximeter, Reed's, 96 Podophyllin, value of, in diarrhea, 364, 366, 367 Points of emergence from the spine of special vaso-motor nerves, 51 Poland spring water, 350 Polypi as cause of intestinal obstruc- tion, 673 Polypi, obturation by. as a cause of bowel obstruction, 673 Pottenger's new method of outlin- ing organs, 103 Pregnancy, pernicious vomiting of, 863 Preparation of the patient, 109 Preparations, pancreatic, 347 Prerequisites for, and limitations of, hydro-electric method, 294 Procedures, hydriatic, 309 Proctoscope, pneumatic, Tuttle's, 899 Prolapse of the rectum, 917 Propeptone. tests for, 131 Prophylactic treatment of gastric ulcer, 549 Prophylaxis, 191 Proportions of different foods in normal diet, 198 of several ingredients in food ar- ticles, 209 Pruritus ani, 910 Psychic conditions a cause of ano- rexia, 849 Ptyalism, or salivation, 186 Pulley exercise for arm and trunk muscles, illustration of, 265 Pulse, the, in strangulation ileus, 687 Purgatives for intestinal colic, 889 Purpetrol in constipation and intes- tinal catarrh, 360 Purulent or phlegmonous gastritis, 482 Purulent processes in the mouth, 75 Pus in the stomach contents, 123 Pylorectomy, indications for, 988 mortality rate of, 988 Pyloric cancer, 614 cramp, pylorospasm, 855 glands from a dog's stomach, 34 glands from end of stomach, 36 insufficiency, symptoms of, 869 insufficiency, treatment of, 870 obstruction as a cause of dilata- tion of the stomach, 391 Pylorus, cicatricial contraction of, 972 congenital, stenosis of, 438 hypertrophic stenosis of, 620 insufficiency of, 868 spasm of, 507 stenosis of, in gastric ulcer, 541 thickening of, 619 Quantitative test, approximate, for indican, 151 test for fatty acids, 140 test for lactic acid, 140 tests of stomach contents, the more important, 135 Questioning, systematic, 6rj INDEX 1027 Radiographs of the viscera, 102 Radium, X-rays, etc., in cancer of the stomach, 636 Rapid eating a predisposing cause of sthenic gastritis, 505 Ration, proper food, 847 Rectal alimentation as an auxiliary to other feeding, 251 alimentation, technique of, 248 examination and treatment, in- struments for, 897 relations of constipation, goi Rectum, anatomy of, 44 and anus, diseases of, 892 benign tumors of, 923 carbon dioxide in diseases of, 296 prolapse of, 917 ulceration of, 922 Red blood cells in feces, 168 Reed's electrode, illustration of, 324 modification of the Einhorn elec- trode, 323 Reflex causes of flatulency, 825 vomiting, 859 Regularity in times of eating essen- tial, 214 Regurgitation, or rumination, 186 rumination, etc., 866 Reichmann's disease, 403 disease (continuous hypersecre- tion), 528 disease, diagnosis of, 529 disease, treatment of, 530 Relation between urinary acidity and HCl secretion, 144 of gastro-intestinal to other dis- eases, 953 of respiratory aflfections to gas- tro-intestinal diseases, 962 Relative importance of atony, dilata- tion, etc., 379 Relief of pain and insomnia, from disease of stomach or bowels, 355 Remedies, antiseptic, 361 Remedies, medicinal, for acute gas- tritis, 476 medicinal, in hyperchlorhydria, 531 Rennet ferment, tests for, 130 Rennin zymogen, 56 Reports of cases of coloptosis, 444- 453 of cases of displacements of stomach, colon, etc., 464 of cases illustrating abdominal displacements, 464-467 of cases treated by HCl, 337 of two cases showing effects of intragastric faradization, 326 Resorcin in chronic asthenic gas- tritis, 502 thymol, etc., as antiseptics, 362 Respiratory affections, relations of, to gastro-intestinal diseases, 962 Rest after lavage, 318 arrangement of meals with rela- tion to, 211 cure, the, for certain cases of chronic intestinal catarrh, 726 essential in treatment of gastric dilatation, 409 treatment, 276 treatment in atonic dilatation of the stomach, 411 treatment, special, for gastric ulcer, 554 treatment for movable kidney, 427 treatment in anorexia, 850 Restlessness, peristaltic, 857 Results must decide in appendicitis, 748 Retroperitoneal hernia, 684 Rib, floating tenth, 419 Richardson's statistics in appendicitis, 740, 741, 748 view as to time for operation, 754 Riegel's classification of nervous and functional diseases, 374 definition of gastric hyperses- thesia, 841 1028 INDEX Riegel's view as to hour-glass con- traction, 437 view as to the relation of chloro- sis to gastro-intestinal condi- tions, 955 Rigidity over right rectus muscle in appendicitis, T22, Rose's apparatus for generating car- bonic dioxide, 297 carbon dioxide method for chronic intestinal catarrh, T2'j method of strapping the ab- domen for displacements, 423 Rosewater's views as to results of enteroptosis, 420 Rotary movement of the trunk while sitting, illustration of, 265 Round worms, 940 Routes, other, for feeding, 248 Ruheman's uricometer, 153 Rumination, or regurgitation, 186 regurgitation, etc., 866 Sahli's Dermoid Test, 134 Salicylates, 361 Saline laxatives in catarrhal dysen- tery, 363 laxatives in treatment of dysen- tery. 797 Saline waters, von Noorden's book on effects of, 352 or chloride waters, 351 Salivary digestion, 54 digestion, tests for, 129 Salivation, or ptyalism, 186 Salol test of gastric motility, 104 Sample of stomach contents easily obtained, 108 Saratoga Kissingen and Vichy waters, 350 Sarcoma and benign tumors, treat- ment of, 650 and carcinoma of intestines, setiology of, 652 of intestines, differential diag- nosis of, from cancer, 661 Sarcoma of intestines runs a more rapid course than cancer, 661 of rectum, 930 of stomach, 616 of stomach, setiology, incidence, etc., of, 617 Sarcinte ventriculi, 141 Schmidt's test of proteid digestion by examination of feces, 134 Scirrhus of gastric walls, diffuse, 606 Seat worms, 940 Secondary diphtheritic dysentery, 799 intussusception of ileum, 679 Secretion, effect of intragastric elec- tricity upon, 324 excessive in stomach, 526 HCl, relation between urinary acidity and, 144 Secretory derangements of the stom- ach, nervous, 830 nerves, 47 Section from carcinoma of the pylorus, illustration of, 624 Segregators, fecal, 164 Selection of stomach tube, 109 Sensory disturbances of the stomach, 835 Sequels of gastric ulcer, 541 Series of experiments with digest- ants, 345 Sexual excitement harmful in acid gastritis, 519 Sigmoid flexure, anatomy of, 44 loop touching left kidney, illus- tration of, 448 Significance of blood in vomit and stools. 595 of symptoms in diseases of rec- tum and anus. 893 Silver nitrate as an antiseptic, 361 nitrate combination for acid gas- tritis. 524 nitrate in chronic asthenic gas- tritis, 501 Similarity of effects of different mechanical methods, 310 INDEX 1029 Simple acute gastritis, 472 Simpler tests for HCl, 126 Skin, pallor of, 185 Skirts hung from waist, harmfulness of, 469 Sleeplessness, remedies for, 356 Small intestine, displacements of, 457 intestines, symptoms of displace- ments of, 459 Smokers and drinkers, difficulty of passing the tube in, 11 1 Sodium benzoate as an antiseptic, 362 bromide as a remedy in gastro- intestinal afifections, 354 bromide with tincture of chloride of iron in gastro-intestinal afifections, 354 Solids, test for total amount of, 152 Solution of soda, percussion note be- fore and after drinking, 133 Source of blood found in the stools, 597 of the larger gastric hemor- rhages, 596 Spasm of cardia, 852 » of entire stomach, 851 pyloric, dilatation from, 406 of pylorus, 507, 855 Spastic and atonic constipation, stools in, 771 constipation, differential diag- nosis between atonic and, 769 constipation, treatment of, 781 Special forms of gymnastics recom- mended, 262 vaso-motor nerves, points of emergence of, from spine, 51 Specimen of blood, to obtain a, 175 Speculum vivalve, Bodenhamer's, 898 Martin's, conical, 898 Spices, etc., drugs not foods, 229 Spinal irritation, as described by Hammond, 81 nerves, course of, 50-51 Spine, and the vaso-motor nerves, 48 points of emergence from, of special vaso-motor nerves, 51 Spirits of chloroform as an antisep- tic, 362 Spirochsetas in syphilis, 578 Spivak's fecal segregator, 165 Splanchnoptosis, 415 Splashing sounds in abdomen (suc- cussion), 186 sounds in catarrh of cecum, 719 sounds in intestines, 709 sounds in stomach, 96 Spleen, movable, 457 Spondylotherapy, Abram's, 311 Spray, intragastric, 318 Spraying with nitrate-of-silver solu- tion for gastric hyperaesthesia, 842 Spring waters, alkaline and alkalies, in hyperchlorhydria, 531 Starch, need of having it well dex- trinized, 218 Static electricity, 280 in treatment of gastralgia, 840 Statistics of displacements, 460 Stenosis, cicatricial, of the cardiac opening of stomach, 987 cicatricial, of the pylorus, 988 congenital, of pylorus, 438 hypertrophic, of the pylorus, 620 of intestines from carcinoma, 657 of pylorus in gastric cancer, 606 of pylorus in gastric ulcer, 541 or strictures as causes of in- testinal obstruction, 673 symptoms of carcinomatous, 701 Stiller's sign, floating tenth rib, 419 Stimulants, harmfulness of, 197 Stockton's prescription for excessive HCl, 523 views regarding gastric syphilis, 582 acute dilatation of, relations of, to surgery, 990 Stomach, anaiomy of, 31 and iiuestines, diagnosis of neiiioirhage from, 598 and mtestines, diseases of, not always separable, 376 I030 INDEX Stomach and intestines, hemorrhage from, 594 and intestines, symptoms of hemorrhage from, 598 and intestines, syphilis of, 578 and intestines, treatment of syph- ihtic disease in, 584 setio|ogy of atony of, 381 benign tumors of, 618 blood from, and from lungs or upper air passages, 600 blood-vessels of, 38 cancer of, complications, sequels, etc., 606 cancer of, frequency and inci- dence of, 602 cancer of, pathology, 603 cancer of the body of, 616 cancer of, use of X-rays, radium, etc., in, 636, 641, 642, 643 cancer of, varieties of, 603 capacity and motor power of, 103 carcinoma and other tumors of, medicinal and palliative treat- ment of, 644 carcinoma of, dietetic treatment of, 645 carcinoma of, treatment with X-rays, etc., 636-639 carcinomatous ulcer of, 625 chronic dilatation of, 388 colon, etc., reports of cases of displacements of, 464 congenital anomalies of, 438 contents, bile, blood, feces, or pus in, 123 contents, expression of con- demned, 120 contents, fluidity of, 123 contents, importance of examin- ing in chronic asthenic gas- tritis, 493 contents, macroscopic examina- tion of, 121 contents, microscopic examina- tion of, 141 Stomach contents, more important quantitative tests of, 135 contents, objectionable method of getting, 120 contents, quantitative -tests of, 135 contents, tests of, 126 diagnosis of atony of, 383 diagnosis of tubercular ulcers in, 570 diagnosis of ulcer of, from ulcer of the duodenum, 545 differential diagnosis of dilata- tion of, 402 dilatation, prognosis of, 405 dilated, illustration of, 399 dilated, movable kidney, etc., 467 diseases of, place of HCl in treatment of, 332 examination of, best made when empty, 95 foreign bodies in, 991 hemorrhage from, in gastric ulcer, 544 how to introduce a tube into, most easily, 108 inflation of, 99 in natural position, illustration of, 2,2 methods of testing the motility of, 105 nervous atony of, 865 or bowels, relief of pain or in- somnia from disease of, 355 pain referred to region of, 185 prognosis of tubercular ulcers of, 572 sarcoma of, 616, 989 sarcoma of, setiology, incidence, etc., of, 617 symptomatology of atony of, 382 symptoms and diagnosis of sar- coma of, 617 tests of the capacity of, 103 treatment of dilatation of, 405, 990 treatment of tubercular ulcers of, 572 INDEX IO3I Stomach tube, how to determine when passed in sufficiently far, 113 tube, selection of, 109 tube sometimes impracticable, 91 tubercular ulcers of, pathology of, 568 ulcer of, aetiology of, 533 volvulus of, 435 washing the, downward, 500 when and how to wash out, 312 Stomachs, abnormally small, 437 diseased, need rest, 205 Stools always small in organic stric- ture of bowel, 772 and vomit, blood in both, 59 and vomit, significance of blood in, 595 in atonic and spastic constipa- tion, 771 fetid, in diarrhea, 786 may be variable in spastic con- stipation, 771 scybalous, in the course of diar- rhea, 786 source of blood found in, 597 the, in chronic enteritis, 720 Strangulation ileus, symptoms of, 685 ileus, treatment of, 688 of the intestines by knotting, etc., 685 Strapping the abdomen, 423 Strassburger's fermentation tube, 166 Strengthening the abdomen in colop- tosis, 455 Stricture or stenosis as cause of in- testinal obstruction, 673 of rectum, 919 Strictures from carcinoma, as causes of intestinal obstruction, 674 from scars of ulcers, as causes of bowel obstruction, 673 from healed ulcers and carci- noma obstructing the bowels, 701 Structure of the stomach and intes- tine, 44 Subacidity, nervous gastric, 831 Subacute gastritis, 477 Subphrenic abscess, 541 Succussion, or splashing sounds in abdomen, 186 Sugar in chronic gastritis, 497 place of, most difficult point in dietetics, 226 Sulphates, aromatic, in the urine, 149 ' Summary of the author's method, 100 Surgery, American, tribute to, 462 newest gastro-intestinal, 981 of the appendix, 980 of the stomach and intestines, 986 the only effective resource in tuberculous stricture of intes- tine, 706 Surgical intervention in displace- ments of the colon, 455 intervention necessary in cica- tricial contraction of either gastric orifice, 557 intervention necessary for per- foration of ulcer, 557 method, conservative, in appen- dicitis, 743 method, radical, in appendicitis, 743 treatment of obstructions of the gastric orifices, 987 Swedish movements, massage and, 268 Sweets often disagree after a dinner, why, 228 Sympathetic gastritis, 479 Syphilis of stomach. 578 Ehrlich's "606" for, 584 Syphilitic chronic gastritis, 579 disease in stomach and intestines, treatment of, 584 gastric ulcer, 580 Systematic questioning, 67 Symposium on appendicitis, 754 Symptomatology of nervous dyspep- sia, 872 I032 INDEX Table showing percentages of the various symptoms in different forms of ileus, 697 Talquist's hemoglobin scale, 177 Tapeworms, 937 etc., treatment of, 946 Tea and coffee, 231 Technique of administering oil enemas, 302 of applying electricity intragas- trically, 329 of blood examination, 176 of examination in rectal diseases, 895 of rectal alimentation. 248 of strapping the abdomen, 424 Teeth and gums, importance of care of, 191 importance of inspecting, 75 Temper, irritability of, 184 Tenderness on palpation in enteritis, 719 on pressure a symptom of gastric ulcer, 538 on pressure over epigastrium, 187 Tenesmus, 187 Tenia saginata, 938 solium, 938 Test, for indican, 151 dermoid, 134 dinner, 118 for blood, iron, 599 for lactic acid, 127 for total acidity, 155 for total amount of solids, 152 for urinary acidities, Freund and Topfer's. 156 iodoform, for acetone, 159 meal, single one not conclusive, 119 meals, concerning, 117 quantitative, for fatty acids, 140 quantitative, for lactic acid, 140 therapeutic, between cancer and ulcer of the stomach, 634 quick, for indican. 150 salol, of gastric motility. 104 Testing for gastric acidity, external method, 132 vomitus in gastric ulcer, 539 Tests for albumin, propeptone and peptones, 131 for pepsin and the rennet fer- ment, 130 for the other organic acids, 128 for the salivary digestion, 129 for uric acid, 153 of capacity of the stomach, 103 of gastric contents and feces in tubercular cases, 958 of gastric motility, 383 of stomach contents, 126 Tetany from cancer of the stomach, 607 gastric, treatment of, 413 Therapeutic methods, 255 test of carcinomatous ulcer of the stomach, 634 Therapeutics of secondary cardiac af- fections, 968 overdosing and overdoing In, 257 Therapy, manual, 307 Thickening of the pylorus, 619 Throat, etc., infection from, 825 Throats, training irritable, 112 Tongue coated or furred, 187 Tonics, bitter, and HCl, remedies for anorexia, 849 nerve, 354 Total acidity, test for, 155 amount of solids, test for, 152 Toxic gastritis, 479 gastritis, diagnosis of. 480 gastritis, pathology of, 480 gastritis, symptoms of, 480 gastritis, treatment of, 481 Tract, digestive, anatomy of, 29 Training irritable throats, 112 Treatment, after, of membranous catarrh of the intestines, 819 prognosis and, of tumors of the intestines. 665 classification of diseases with re- gard to dietetic, 216 INDEX Treatment, comparison of results from surgical and mechanical, 468 curative, of gastric ulcer, 551 dietetic, of carcinoma of the stomach, 645 dietetic, of membranous catarrh of the intestines, 815 mechanical forms of, in chronic gastritis, 499 medicinal and palliative, of car- cinoma and other tumors of the stomach, 644 medicinal, in acid gastritis and HCl excess, 522 medicinal, in gastric ulcer, 554 medicinal, of gastritis, 502 of achylia gastrica, 834 of acid gastritis and HCl excess, S14 of acute catarrhal appendicitis, 755 of acute dilatation of the stom- ach, 387-388 of acute enteritis, 711 of acute gastritis, 474 of acute intestinal obstruction, 699 of amoebic dysentery, 805 of ankylostoma duod., 945 of anorexia, 849 of atonic dilatation of stomach, 410 of bacillary dysentery, 800 of benign tumors in the stom- ach, 619 of benign tumors of the intes- tines, 667 of benign tumors of the rectum, 916 of bulimia, 846 of cancer of stomach, 636, 651 of carcinoma of the stomach with X-rays, etc., 636 of cardiospasm, 854 of catarrhal dysentery, 796 1033 Treatment of chronic catarrhal ap- pendicitis, 759 of chronic dysentery. 806 of chronic gastric catarrh, dietetic and hygienic, 496 of chronic intestinal catarrh, 722 of colica mucosa in true enter- itis, 820 of coloptosis, 454 of complications and sequels of gastric ulcer, 556 of complications of rectal ab- scess, 913 of congenital stenosis of the pylorus, 439 of constipation, 775 of constipation in nervous dys- pepsia, 878 of diarrhea, 785 of dilatation of stomach, 405 of diseases of stomach, place of HCl in, 332 of displacements of intestines, 459 of duodenal ulcer, 564 of erosions of stomach, 558 of fecal impaction, 903 of fissure of anus, 910 of fistula in ano, 915 of flatulency, 826 of foreign bodies in stomach, 619 of gastric atony, 384 of gastric hypersesthesia, 842 of gastric phlegmon, 483 of gastric tetany, 413 of gastritis, chronic, 496 of gastro-intestinal cancers, early diagnosis indispensable for, 639 of gastroptosis, 434 of gastrospasm, 851 of hyperchlorhydria, 525, 530 of hemorrhage from the stomach and intestines, 600 of hemorrhoids, 906-907 of intestinal neuroses, 888 I034 INDEX Treatment of intestinal ulceration, 591 of intussusception, 682 of ischiorectal abscess, 913 of membranous catarrh of the in- testines, 814 of movable kidney, 423 of nervous vomiting, 861 of obstruction from external tumors, displaced organs, etc., 691 of paralysis of the intestines, 890 of peristaltic restlessness, 858 of peristaltic unrest of the in- testines, 890 of pernicious vomiting of preg- nancy, 863 of pruritus ani, 910 of pyloric insufificiency, 870 of rectal prolapse, 918 of regurgitation and rumination, 867 of sarcoma and benign tumors, 650 of spasm of the pylorus, 857 of strangulation ileus, 688 of stricture of the rectum, 920 of syphilitic disease in the stom- ach and intestines. 584 of tapeworms, round worms, etc., 946 of the colic form of intussuscep- tion, 683 of the severer forms of acute appendicitis, 757 of toxic gastritis, 481 of trichinosis, 950 of trichocephalus dispar, 952 of tubercular ulcers of the stom- ach and intestines, 572 of tumors of the rectum, 927 of ulceration of the rectum, 92J of volvulus, 684 Treatments through the spine and spinal nerves, 305, 783 Trichina spiralis, 949 Trichinosis, 949 Trichocephalus dispar, illustration of, 951 Tube, how to introduce most easily, 108 mode of introducing, iii stomach, best kind for lavage, 315 stomach, contra-indications for, 114 stomach, sometimes imprac- ticable, 91 Tubercular ulcerations of the gastro- intestinal tract, climatic and hygienic measures in, 575 ulcers and growths as causes of chronic obstruction, 705 ulcers in stomach and intes- tines, 573 ulcers of intestines, special site of, 568 ulcers, symptomatology of, 569 Tuberculin treatment of tubercular ulcers in stomach and intes- tines, 573 Pottenger's method of adminis- tering, 573 Tuberculosis of intestines generally a secondary process, 568 of intestines, palpation in, 568 of intestines, secondary, a hope- less condition, 572 of intestines, surgery of, 993 relations of, to the gastro-intes- tinal functions, 955 Tuberculous ulcer of the stomach, frequency of, 569 stricture of ileum, 702, 704 Tuholske's description of strangula- tion ileus, 686 Tumor sometimes palpable in gastric ulcer, 540 Tumors, abdominal, differential diag- nosis of gastric cancer from, 628 benign, of intestines, treatment of, 667 INDEX 1035 Tumors, benign, or foreign bodies in stomach, treatment of, 619 external, displaced organs, etc., as causes of obstruction, 689 external, symptoms of obstruc- tion by, 690 intestinal, surgery of, 992 of intestines, complications and course of, 660 of intestines, diagnosis of, 661 of intestines, diagnostic points in, 664 of intestines, how located, 662 of intestines, pathology of, 653 of intestines, prognosis and treatment of, 665, 995 of intestines, symptomatology of, 654 of rectum, benign, 923 of rectum, malignant, 925 of s!:omach, benign, 618 Turck's apparatus for pneumatic gymnastics, illustration of, 299 gyromele, 87 gyromele as an aid in diagnosing gastrectasis, 402 gyromele as an electrode, 324 lavage of colon for chronic in- testinal catarrh, 727 method of doing massage of the colon, 301 stomach sprinkling tube, 318 Tuttle's formula for injection treat- ment of hemorrhoids, 907 Tuttle's pneumatic proctoscope, 899 Tympanites, 880 meteorism, or flatulency, 883 Tympany, abdominal, 187 Typical symptoms of cancer rarely all present, 610 Ulcer, carcinomatous, 633 carcinomatous, of stomach, 625 carcinomatous, of stomach, therapeutic test for, 634 Ulcer, diagnosis from acid gastric catarrh, 511 differentiated from cancer of the cardia, 631 duodenal, constipation in, 561 duodenal, jaundice in, 561 duodenal, symptoms of, 560 gastric, complications of, 540 gastric, curative treatment of, , 551 gastric diagnosis of, from Reich- mann's disease, 529 gastric, diet in, 551 gastric, hemorrhage in, 540 gastric, massage in, 554 gastric, nutritive enemas in, 552 gastric, pathology of, 535 gastric, perforation of, 9S6 gastric, prophylactic treatment of, 549 gastric, sequels of, 541 gastric, symptomatology of, 536 gastric, syphilitic, 580 gastric, treatment of complica- tions and sequels of, 556 incidence of, as to sex and age, 534 latent, a cause of failure in treatment of supposed hypcr- chlorhydria by electricity, 330 to be suspected in cases of stub- born hyperchlorhydria or hy- persecretion, 539 medicinal treatment in gastric, 554 of duodenum, diagnosis of, from ulcer of stomach, 545 of pyloric end of stomach, 535 of stomach, diagnosis of from ulcer of the duodenum, 545 of stomach, aetiology of, 533 of stomach, spontaneous healing of, 549 of stomach, therapeutic test, 543 perforation in gastric, 540 round, of duodenum, diagnosis of, 562 1036 INDEX Ulcer, round, of duodenum, aetiology and pathology of, 559 round, of duodenum, prognosis of, 564 round, of duodenum, treatment of, 566, 992 Ulcerating carcinoma of the rectum, 659 Ulceration, intestinal, diagnosis of, 590 intestinal, symptoms of, 588 intestinal, treatment of, 591 intestinal, various forms of, 585 of the rectum, 922 Ulcers, amyloid, 588 embolic and thrombotic, 587 gouty, 588 healed, strictures from, obstruct- ing the bowels, 701 of the intestines, catarrhal, 587 peptic, 981 scars of, as causes of intestinal obstruction, 674 stercoral, 587 strictures from scars of, as causes of bowel obstruction, 673 toxic, 587 tubercular, as causes of chronic obstruction, 705 tubercular, diagnosis of, in the stomach and intestines, 570 tubercular, of the intestines, 567 tubercular, of the stomach and intestines, prognosis of, 572 tubercular, of the stomach and intestines, treatment of, 572 tubercular, of the stomach, pa- thology of, 568 Umbilical hernia, 684 Uncinaria americana, 942 Undigested milk curds in feces, 167 Upper part of abdomen, position of organs in, 33 Uranalysis indispensable in gastro- intestinal affections, 143 Uratic diathesis, diet in, 225 Urea, 154 largely produced in the liver, 59 Uric acid excess, 150 acid, Folin-Hopkins method of determining the amount of, 154 acid, tests for, 153 Urinary acidities', Freund and Topfer's test for, 156 acidity and HCl secretion, rela- tion between, 144 Urine, partial examination better than none, 148 the, in enteritis, 710 V-shaped transverse colon, illustra- tion of, 450 Valuable effects of hydrochloric acid, 335 Van Valzah and Nisbet, statistics of, as to the gastric secretions in incipient phthisis, 957 Vaso-constrictors and vaso-dilators, their origin in the spine, 49 Vaso-motor nerves and the spine, 48 nerves, points of emergence of, 51 Varieties of cancer of the stomach, 603 Vegetable cells in feces, 167 diet, 203 Veins and lymphatics, 39 Vessels, blood, of the stomach, 38 Vertical stomach, 403 Vertigo, 187 Vichy and Kissingen waters, Sara- toga, 350 water, French, 350 Villi, intestinal, 60 Viscera, instruments for determin- ing the size and position of, 8S radiographs of, 102 Volvulus of intestine, 683 of stomach, 435 surgical treatment of, 996 INDEX 1037 Volvulus, S3'mptoms of, 683 treatment of, 684, 996 Vomit and stools, blood in both, 598 and stools, significance of blood in, 595 Vomiting, a symptom of gastric ulcer, 538 an important symptom of pyloric cancer, 611 in obturation ileus, 696 in gastric ulcer, 538 nausea and, not common results of passing stomach tube, 112 nervous and reflex, 859 of pregnancy, pernicious, 863 or nausea, 184 Von Noorden's book about Effects of Saline Waters on IMetabo- lism, 352, 532 Wet compress over stomach for acute gastritis, 475 Whittaker's method of administering tuberculin, 574 Wiesbaden, Homburg, and Kissingen waters in chronic gastritis, 500 Withholding of food advised in acute gastritis, 475 Worms as a cause of excessive appe- tite, 846 obturation by, as a cause of in- testinal obstruction, 673 Wrinkle, practical, for carrying out lavage, 318 practical, for lavage in sthenic gastritis, 519 Wylie's views as to frequent cause of pelvic displacements, 462 Washing out the stomach, 312, 500 Wassermann serum test for syphi- lis, 578 Water drinking in dyspeptic condi- tions, 233 free drinking of warm, as a remedy for acute gastritis, 476 milk, etc., dietetically considered, 232 Waters, ferruginous mineral, 357 medicinal, in chronic enteritis, 726 mineral, alkaline, 349 saline or chloride, 351 spring, in hj'perchlorhydria, 531 Weber's modified test for occult blood, 599 Weight in stomach, 185 X-rays, etc , treatment of carcinoma of the stomach with, 636-639 radium, etc., in cancer of the stomach, 636, 641, 642, 643 radium, etc., in tumors of the in- testines, 665 Yeast fungi and columnar epithelium from a case of acid gastritis, 509 illustration of, 141 Z'inc-mercury cataphoresis in cancer of the intestines, 665 cataphoresis in malignant tumors of the rectum, 928 THE END !i i